Future directions in residential segregation and health research: a multilevel approach

A matter of measurement? A Swedish register-based study of migrant residential segregation and all-cause mortality

Background

In recent decades, Sweden has become an increasingly diverse society by origin, but one in which residential segregation by migrant background has also increased. This study examines how different aspects of migrant residential segregation are associated with all-cause mortality among native-born and migrant populations.

Methods

Using Swedish population-based registers, this longitudinal open cohort study assessed associations between four local level indices of migrant residential segregation and all-cause mortality among adult migrant and native-born residents of Sweden's three largest metropolitan areas (Stockholm, Gothenburg, and Malmö) between 2004 and 2016. Multilevel Poisson regression models, adjusted for individual-level sociodemographic and socioeconomic factors as well as area-level socioeconomic conditions, were used to estimate associations between these indices and all-cause mortality.

Results

Moderate decreased mortality risks were observed among migrants in residential areas with higher levels of migrant density, isolation, and exposure in fully adjusted models. However, isolation and exposure effects could not be distinguished due to a high degree of correlation between the isolation and exposure measures. In fully adjusted models mortality gradients were largely unobserved among native-born individuals in relation to migrant residential segregation. The evenness dimension of segregation showed limited relevance for mortality risk in both groups.

Conclusions

This study provides evidence that higher migrant density is associated with lower mortality risks among migrants, suggesting that residential areas with higher proportions of migrants may offer health benefits for migrants. These findings highlight the importance of residential contexts in shaping migrant health outcomes.

Impact of Residential Segregation on Healthcare Utilization and Perceived Quality of Care Among Informal Caregivers in the United States

This study aimed to investigate the impact of racial residential segregation on healthcare utilization and perceived quality of care among informal caregivers in the US. It further assessed potential variations in the estimated impact across caregivers' race and socioeconomic status. We used data from the Health Information National Trends Survey Data Linkage Project (fielded in 2020) for a sample of 583 self-identified informal caregivers in the US. Fitting a series of regression models with the maximum likelihood estimation, we computed the beta coefficients (β) of interest and their associated Wald 95% confidence limits (CI). Caregivers who resided in areas with higher segregation, compared to those living in lower segregated areas, were less likely to visit a healthcare professional [β =  - 2.08; Wald 95%CI - 2.093, - 2.067] (moderate); [β =  - 2.53; Wald 95%CI - 2.549, - 2.523] (high)]. Further, caregivers residing in moderate [β =  - 0.766; Wald 95%CI - 0.770, - 0.761] and high [β =  - 0.936; Wald 95%CI - 0.941, - 0.932] segregation regions were less likely to perceive a better quality of care compared to those located in low segregation areas. Moreover, as segregation level increased, Black caregivers were less likely to see a health professional, less frequently used healthcare services, and had poorer perceived healthcare quality when compared to Whites. Our findings indicate that higher residential segregation is associated with lower healthcare utilization, such as visiting a healthcare professional, and poorer perceived healthcare quality among informal caregivers. Given the essential role of informal caregivers in the current healthcare system, it is vital to investigate and address challenges associated with access to and quality of essential healthcare services to improve caregivers' health and well-being, specifically for caregivers of minority backgrounds.

Structural Racism-Related State Laws and Healthcare Access Among Black, Latine, and White U.S. Adults

Racialized healthcare inequities in the USA remain glaring, yet root causes are understudied. To address this gap, we created a state-level structural racism legal index (SRLI) using the Structural Racism-Related State Law Database and analyzed its association with racialized inequities in four outcomes (lacking health insurance coverage, lacking a personal doctor, avoiding care due to cost, lacking a routine check-up) from the 2013 Behavioral Risk Factor Surveillance System (N = 454,834). To obtain predicted probabilities by SRLI quartiles (Q1 = less structural racism, Q4 = more structural racism) and racialized group, we fit survey-weighted multilevel logistic models adjusted for individual- and state-level covariates. We found substantial healthcare access inequities across racialized groups within SRLI quartiles and less pronounced, but still meaningful, inequities within racialized groups across SRLI quartiles. For example, the predicted probabilities of lacking health insurance coverage across SRLI quartiles ranged from 13 to 20% among Black adults, 31 to 41% among Latine adults, and 8 to 11% among White adults. Across racialized groups in Q4 states, predicted probabilities ranged from 11% among White adults to 41% among Latine adults. Similar patterns were observed for lacking a personal doctor and avoiding care due to cost. Findings underscore the need to address structural racism in laws and policies to mitigate these inequities.

Segregation in hospital care for Medicare beneficiaries by race and ethnicity and dual-eligible status from 2013 to 2021

OBJECTIVE

To examine the extent of segregation between hospitals for Medicare beneficiaries by race, ethnicity, and dual-eligible status over time.

DATA SOURCES AND STUDY SETTING

We used Medicare inpatient hospital provider data for fee-for-service (FFS) beneficiaries, and the Dartmouth Atlas of Health Care from 2013 to 2021 nationwide, for hospital referral regions (HRRs), and for and hospital service areas (HSAs).

STUDY DESIGN

We conducted time trend analysis with dissimilarity indices (DIs) for Black (DI-Black), Hispanic (DI-Hispanic), non-White (including Black, Hispanic, and other non-White) (DI-non-White), and dual-eligible (DI-Dual) beneficiaries. DIs between hospitals were contextualized and correlated with population compositions and residential DIs.

DATA COLLECTION/EXTRACTION METHODS

We included 3177 hospitals with more than 250 Medicare FFS beneficiaries discharged per year. We cross-linked data on hospital-level patient race, ethnicity, and dual-eligible status with geographic data and examined time trends using linear mixed models.

PRINCIPAL FINDINGS

Nationwide DIs ranged from 0.23 to 0.53. HRRs and HSAs generally had low segregation (DI medians: 0.08-0.19, highest among Black, then non-White, Hispanic, and dual-eligible beneficiaries). However, some HRRs and HSAs had moderate or high segregation (DI-Black >0.30 in 19.1% of HRRs and 5.8% of HSAs; DI-non-White >0.30 for two HRRs with high American Indian/Alaska Native populations). Time trends indicated small declines in segregation from 2013 to 2021 (0.15%-0.30% per year; all p < 0.001). DI-Dual correlated moderately with non-White populations.

CONCLUSIONS

For Medicare FFS, we observe generally low and slightly declining levels of segregation across HRRs and HSAs, with notable exceptions. Improving race reporting and contextualizing select areas of higher segregation with their hospital and residential population compositions can help frame and understand health inequities. Interpretation of HRR-level DI may require additional historical, demographic, and spatial context due to its potential to oversimplify, overstate, or obscure segregation. Future work should identify drivers and mitigators of segregation, including sorting patterns among health systems.

Caste Inequality in Occupational Exposure to Heat Waves in India

India is a leading global hot spot for extreme heat waves induced by climate change. The social demography of India is centered on its caste hierarchy rooted in endogamous occupational groups. We investigate the association between caste and climate inequality by studying occupational exposure during the 2019 and 2022 heat waves. We combine high spatiotemporal resolution heat stress information from satellite imagery with a large nationally and regionally representative labor force survey with rich socioeconomic and demographic information (n > 100,000 individuals). The slope of the heat stress dose-workhours curve corresponding to the marginalized caste groups is between 25% and 150% steeper than that for dominant caste groups for UTCI (Universal Thermal Climate Index) thresholds between 26°C and 35°C. Our models control for other economic-demographic confounders, including age, gender, education, and economic status, besides political-geographic controls and fixed effects. Our robust evidence for the association between caste identity and exposure to heat stress shows why adaptation and mitigation plans in India must account for the hierarchical social order characterized by the "division of laborers" along caste lines rather than the mere division of labor. Methodologically, our analysis demonstrates the utility of pairing satellite imagery and detailed demographic data.

The effects of residential segregation on cognition among U.S. older adults: a systematic review based on the social determinants of health model

OBJECTIVES

This systematic review aims to advance the understanding of the complicated effects of segregation on older adults' cognition and provide guidance for future research.

METHOD

A systematic review using the Social Determinants of Health framework to examine the relationship between segregation and cognition across the selected literature.

RESULTS

Eight papers met the criteria for inclusion. All selected studies examined the influence of living in a segregated area on older adults' cognition, covering older adults from different racial/ethnic groups. The association between segregation and cognition was found in different directions across different racial/ethnic groups. The effects can be varied depending on race/ethnicity, level of education, neighborhood socioeconomic status, or social context.

CONCLUSION

This review identified existing gaps in understanding the relationship between segregation and cognition. Future studies should carefully adopt the segregation measures, acknowledge the varying segregation experience among different racial/ethnic groups, and consider more social determinant factors in research.

Uncovering the Biological Toll of Neighborhood Physical Disorder: Links to Metabolic and Inflammatory Biomarkers in Older Adults

Background

Neighborhood physical disorder has been linked to adverse health outcomes, yet longitudinal assessments of its relationship with metabolic and inflammatory biomarkers in older adults remain limited. This study examined the association between patterns of neighborhood physical disorder exposure and biomarkers among older adults.

Methods

We included community-dwelling Medicare beneficiaries with 2017 biomarker data from the National Health and Aging Trends Study (n = 4,558). Neighborhood physical disorder from 2011 to 2016 was assessed using interviewer reports of neighborhood characteristics. Latent class analysis was employed to identify longitudinal patterns of exposure. Inverse probability weighted linear regression models were used to examine associations between physical disorder patterns and five biomarkers, including body mass index (BMI), waist circumference, hemoglobin A1C (HbA1c), high-sensitivity C-reactive protein (hsCRP), and interleukin-6 (IL-6).

Results

Four classes of neighborhood physical disorder emerged: stable low exposure (85%), increased exposure (4%), decreased exposure (8%), and stable high exposure (3%). Regression findings indicate that residing in neighborhoods with stable high exposure was significantly associated with higher levels of BMI (b = 0.06, p<0.05), HbA1c (b = 0.09, p<0.05), hsCRP (b = 0.21, p < 0.05), and IL-6 (b = 0.22, p < 0.05), compared to those with stable low exposure. Older adults with increased exposure and decreased exposure also exhibited elevated risks in multiple metabolic and inflammation biomarkers.

Conclusions

Persistent exposure to neighborhood physical disorder is associated with higher levels of metabolic and inflammatory biomarkers, underscoring the need for targeted clinical screening and neighborhood initiatives to promote healthy aging in place.

Influence of structural racism on cancer health disparities: Tailoring measures relevant to multiple myeloma

This commentary highlights a need for comprehensive measures of structural racism tailored to cancer health disparities, in particular Black-White disparities in multiple myeloma (MM). Recent political and social calls and advances in the ability to quantitate structural racism have led to rapidly growing research on the health consequences of structural racism. However, to date, most studies have used unidimensional measures of structural racism that do not capture cumulative influences or enable the identification of factors most responsible for driving disparities. Furthermore, measures may not reflect aspects of structural racism most relevant to underlying disease processes and risks. This study proposes a multifaceted approach to measuring structural racism relevant to MM that includes comprehensive, disease- and at-risk population-tailored social and environmental data and biomarkers of susceptibility and progression related to underlying biological changes associated with structural racism. Such novel measures of structural racism may improve the ability to assess the influence of structural racism on cancer health disparities, which may advance understanding of disease etiology and differences observed by racialized groups.

Understanding the Intersection Between Racial Segregation, Social Isolation and Safety Perceptions on Health for an Economically Disadvantaged Urban Community

Safety concerns continue to be challenging amid racially segregated communities of urban concentrated disadvantage. Although contributing factors to crime in such neighborhoods have been described, there is a lack of knowledge regarding how social isolation and perceptions of safety impact community health. This qualitative study explored how minoritized residents (N = 23) from an urban community of economic disadvantage perceived the influence of environmental and residential conditions on their health. Use of the grounded theory method produced conceptual insights into the process of how safety concerns led to fear, which created stress and prevented residents from using outdoor public spaces. Additionally, results indicated how the cyclical nature of such physical withdrawal reinforced social isolation and stigma by those outside the community, ultimately affecting residents' ability to maintain healthy living. Implications include implementing a multi-pronged public health policy that addresses safety perceptions, crime exposure, and social inclusion to improve health conditions in low-income communities.

Lasting Legacy: The Enduring Relationship Between Racially Restrictive Housing Covenants and Health and Wellbeing

Racially restrictive covenants in housing deeds, commonplace in Minnesota for houses built from the 1910s to the 1950s, provided a foundation for the myriad of policies that made it difficult for people of color to obtain housing. Though covenants were ruled illegal in 1968, their legacy continues to shape neighborhoods. The Mapping Prejudice Project's efforts in Hennepin County, Minnesota, produced the first systematic documentation of racially restrictive covenants. We use this novel data set to explore the relationship between historic covenants and current health and wellbeing outcomes. Using regression analysis to control for neighborhood level covariates, we compare previously covenanted neighborhoods to neighborhoods without covenants. Today, previously covenanted neighborhoods have higher life expectancy and lower rates of obesity, diabetes, coronary heart disease, and asthma than neighborhoods without racially restrictive covenants. Additionally, previously covenanted neighborhoods have less upward mobility for children from poorer households, and there are larger gaps in upward mobility between white and Black children. These findings contribute to a growing literature that shows racist policies, even decades after they are legally enforceable, leave an imprint on neighborhoods. Using the novel data from the Mapping Prejudice Project, we provide statistical analysis that confirms qualitative and anecdotal evidence on the role of racial covenants in shaping neighborhoods.

Is racism a barrier to HIV care continuum engagement among Black People in the United States? A scoping review to assess the state of the science and inform a research agenda

People living with HIV can achieve viral suppression through timely HIV care continuum (HCC) engagement (ie, diagnosis, linkage to HIV care, retention in care, and adherence to prescribed treatment regimens). Black populations have poorer viral suppression, suboptimal HCC engagement, and higher levels of racism-related mistrust. The state of the evidence linking suboptimal HCC engagement to racism among US Black populations is assessed in this article. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 6 English language databases were searched using 3 sets of key terms related to HCC engagement (eg, HIV diagnosis), racism (eg, discrimination), and the population (eg, Black people). To exclude articles, 3 rounds of reviews were conducted and results assessed for interrater reliability (κ = 99.00%; P < 0.00). From 2027 articles initially retrieved, the final set of analyses (n = 32) included clinical and nonclinical samples of people living with or at risk for HIV. Overall, the evidence was conceptually robust but methodologically simple. Studies primarily targeted intrapersonal and interpersonal racism and the late stage of HCC engagement: adherence. Sample-specific prevalence of racism ranged considerably; for example, 20% to 90% of sample members in clinical settings perceived or experienced interpersonal forms of racism. To date, the evidence suggests the relationship between racism and HCC engagement is mixed. Racism is salient among Black people living with or at risk for HIV. It appears not to impede HIV testing, though it may limit retention in HIV care, especially among men who have sex with men.

[Is socioeconomic residential segregation associated with sleep problems? Insights from ELSA-Brasil]

Several factors influence sleep, which is essential for health. While the role of neighborhood socioeconomic context on sleep health has been studied in recent years, results are inconsistent. The study aimed to investigate the association between socioeconomic residential segregation and sleep problems, using data from the second evaluation (2012-2014) of 9,918 public servants participating in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Socioeconomic residential segregation was assessed using the Getis-Ord Local Gi* statistic. Sleep duration and deprivation, complaints of insomnia, and daytime sleepiness were obtained through interviews. Binomial and multinomial logistic regression models were used to estimate the odds ratio (OR). Regarding sleep, 49% had short duration and 3% long duration, 23% reported complaints of insomnia, 45% sleep deprivation, 42% daytime sleepiness, and 48% reported ≥ 2 sleep problems. In the model adjusted for demographic and socioeconomic variables, there was an association between high socioeconomic residential segregation and short sleep duration (OR = 1.22; 95%CI: 1.07; 1.40), sleep deprivation (OR = 1.20; 95%CI: 1.05; 1.37), daytime sleepiness (OR = 1.17; 95%CI: 1.03; 1.34) and ≥ 2 associated sleep problems (OR = 1.24; 95%CI: 1.08; 1.41). Individuals living in neighborhoods with high socioeconomic residential segregation are more likely to have short sleep duration, sleep deprivation, daytime sleepiness, and ≥ 2 associated sleep problems. This information reinforces that public policy measures to reduce socioeconomic inequalities can improve the population's sleep health.

Industry of employment and occupational class in relation to cardiovascular health by race/ethnicity, sex/gender, age and income among adults in the USA: a cross-sectional study

Background

Racially minoritised groups tend to have poorer cardiovascular health (CVH) than non-Hispanic (NH)-White adults and are generally more likely to work in labourer or support service positions where job strain-associated with cardiovascular disease-is often high. Yet, few studies have included racially/ethnically diverse samples.

Methods

Using 2004-2018 National Health Interview Survey cross-sectional data, we investigated standardised occupational classifications in relation to 'ideal' CVH using a modified 'ideal' CVH (mICVH) metric among US adults (n=230 196) by race/ethnicity, sex/gender, age, and income. mICVH was defined as a report of 'yes' to the following: never smoked/former smoker; body mass index (≥18.5-25 kg/m2); physical activity (≥150-300 min/week moderate or ≥75-150 min/week vigorous); sleep duration (7-9 hours/night); and no prior diagnosis of dyslipidaemia, hypertension, or diabetes/pre-diabetes. Adjusting for sociodemographic, clinical factors, and health behaviour confounders, we used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% CIs of mICVH overall and by race/ethnicity and performed Wald tests for interaction.

Results

Latinx (53%) and NH-Black (37%) adults were more likely than NH-White adults (29%) to report labourer positions and had the lowest prevalence of mICVH (5.2% (Latinx) and 3.9% (NH-Black)). Labourer versus professional/management occupational class positions were associated with a lower mICVH prevalence among NH-Asian (PR=0.60 (0.46-0.79)), NH-White (PR=0.80 (0.74-0.87)) and NH-Black (PR=0.77 (0.58-1.01)), but with no evidence of an association among Latinx (PR=0.94 (0.78-1.14) adults; p interaction <0.001).

Conclusions

In conclusion, working in labourer versus professional/management positions was associated with lower mICVH, except among Latinx adults. Given the higher likelihood of labourer occupations and lower prevalence of mICVH among minoritised racial/ethnic groups, social determinants related to occupational class should be considered in future studies of racial and ethnic disparities in CVH.

Understanding the roles of state demographics and state policies in epidemiologic studies of maternal-child health disparities

Disparities in maternal-child health outcomes by race and ethnicity highlight structural differences in the opportunity for optimal health in the United States. Examples of these differences include access to state-level social policies that promote maternal-child health. States vary in their racial and ethnic composition as a result of the complex history of policies and laws related to slavery, Indigenous genocide and relocation, segregation, immigration, and settlement in the United States. States also vary in the social policies they enact. As a result, correlations exist between the demographic makeup of a state's population and the presence or absence of social policies in that state. These correlations become a mechanism by which racial and ethnic disparities in maternal-child health outcomes can operate. In this commentary, we use the example of 3 labor-related policies actively under consideration at state and federal levels (paid parental leave, paid sick leave, and reasonable accommodations during pregnancy) to demonstrate how correlations between state demographics and presence of these state policies could cause or exacerbate racial and ethnic disparities in maternal-child health outcomes. We conclude with a call for researchers to consider how the geographic distribution of racialized populations and state policies could contribute to maternal-child health disparities.

Where Does the Black-White Life Expectancy Gap Come From? The Deadly Consequences of Residential Segregation

The disparity in life expectancy between white and black Americans exceeds five years for men and three years for women. While prior research has investigated the roles of healthcare, health behaviors, biological risk, socioeconomic status, and life course effects on black mortality, the literature on the geographic origins of the gap is more limited. This study examines how the black-white life expectancy gap varies across counties and how much of the national gap is attributable to within-county racial inequality versus differences between counties. The estimates suggest that over 90% of the national gap can be attributed to within-county factors. Using a quasi-experimental research design, I find that black-white residential segregation increases the gap by approximately 16 years for men and five years for women. The segregation effect loads heavily on causes of death associated with access to and quality of healthcare; safety and violence; and public health measures. Residential segregation does not appear to operate through health behaviors or individual-level factors, but instead acts primarily through institutional mechanisms. Efforts to address racial disparities in mortality should focus on reducing racial residential segregation or reducing inequalities in the mechanisms through which residential segregation acts: public services, employment opportunities, and community resources.

Building a Culture of Health Through the Built Environment: Impact of a Cluster Randomized Trial Remediating Vacant and Abandoned Property on Health Mindsets

Changing built environment conditions to impact health mindsets and health equity may be a promising target for public health interventions. The present study was a cluster randomized controlled trial to test the impact of remediating vacant and abandoned properties on factors related to health mindset-including well-being, health interconnectedness, social capital markers, neighborhood disorder and worry-as well as direct and indirect violence experiences and the moderating role of racial and income segregation on outcomes. A residential cohort of 405 participants from 194 randomly assigned geographic clusters were surveyed over five waves from 2019 to 2023. Compared to clusters with no treatment, participants in clusters where both vacant lots and abandoned homes were treated experienced significant increases in sense of community (83%, 95% CI=71 to 96%, p=0.01). Among participants in randomization clusters where only vacant lots were treated, there were declines in perceived neighborhood disorder (-55%, 95% CI=-79 to -5, p=0.06) and worry about community violence (-56%, 95% CI=-58 to - 12, p=0.06). There was also a moderating effect of racial and income spatial polarization, with the greatest changes in sense of community observed among more deprived areas with both homes and lots treated; and the largest changes in neighborhood worry and disorder were seen in more deprived areas with only lots treated. Remediation of vacant and abandoned properties may be one approach to change some but not all mindsets around health, and the effects may depend on the type of remediation as well as larger neighborhood conditions such segregation.

Lessons Learned from Immigrant Health Cohorts: A Review of the Evidence and Implications for Policy and Practice in Addressing Health Inequities among Asian Americans, Native Hawaiians, and Pacific Islanders

The health of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) is uniquely impacted by structural and social determinants of health (SSDH) shaped by immigration policies and colonization practices, patterns of settlement, and racism. These SSDH also create vast heterogeneity in disease risks across the AANHPI population, with some ethnic groups having high disease burden, often masked with aggregated data. Longitudinal cohort studies are an invaluable tool to identify risk factors of disease, and epidemiologic cohort studies among AANHPI populations have led to seminal discoveries of disease risk factors. This review summarizes the limited but growing literature, with a focus on SSDH factors, from seven longitudinal cohort studies with substantial AANHPI samples. We also discuss key information gaps and recommendations for the next generation of AANHPI cohorts, including oversampling AANHPI ethnic groups; measuring and innovating on measurements of SSDH; emphasizing the involvement of scholars from diverse disciplines; and, most critically, engaging community members to ensure relevancy for public health, policy, and clinical impact.

Mobilizing knowledge about urban change for equity and sustainability: developing 'Change Stories', a multi-country transdisciplinary study

Background

Health-focused research funders increasingly support multi-country research partnerships that study health, urban development and equity in global settings. To develop new knowledge that benefits society, these grants require researchers to integrate diverse knowledges and data, and to manage research-related aspects of coloniality, such as power imbalances and epistemic injustices. We conducted research to develop a transdisciplinary study proposal with partners in multiple middle and high income countries, aiming to embed equity into the methodology and funding model.

Methods

Parallel to literature review, we used participatory and social research methods to identify case study cities for our primary study and to inform our study design. We conducted semi-structured interviews with informed and consented sustainable urban development experts in the USA (n=23). We co-developed our research approach with our global advisory group (n=14) and conducted a participatory workshop (n=30) to identify case study sites, also informed by conversations with international academic experts in sustainable development (n=27).

Results

Through literature review we found that there is a need to study the contextual pre-conditions of urban transformation, the influence of coloniality on understandings of how cities can change and the failure of standard development practices to meet the needs of all residents and the planet. Through expert input and literature we found that decolonial and storytelling methods may help us show the complexities behind stories of urban transformation, particularly the role of marginalized populations in creating long-term change.

Conclusions

There are multiple benefits of conducting research to develop an equitably designed multi-country research collaboration. We built new partnerships and co-developed our research approach, creating new understanding of diverse collaborators' disciplinary perspectives and institutional requirements. By investigating the informational needs of U.S. sustainable development actors and designing our study to meet these needs, we have increased the likelihood that our research will create impact.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

The Impact of Neighborhood-Level Factors on Perceived Quality of Hospice Service Satisfaction: A Geographic Information System Study

Racial/ethnic minorities are underrepresented in hospice care in the United States, despite this being the standard of care for terminally ill individuals. Research indicates that location of services (e.g., rural vs. urban) plays a role in the differences in quality and quantity of services observed. However, the influences of neighborhood structural characteristics on quality of hospice services have not been explored. The purpose of this study was to explore the relationship between hospice neighborhood characteristics and caregiver-rated satisfaction with services in Florida. Data were derived from the Consumer Assessment of Healthcare Providers and Systems Hospice Survey and American Community Survey; ArcGIS was used to generate heat maps to provide visual representations. Findings showed that higher neighborhood immigrant density predicted lower family satisfaction with timely care, communication, spiritual support, and likelihood to recommend the agency services. The U.S. population is projected to continue to grow in its diversity, and thus understanding neighborhood characteristics associated with racial/ethnic minorities' perception of care quality are important for shaping care improvements.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

Socio-spatial health disparities in Covid-19 cases and deaths in United States skilled nursing facilities over 30 months

BACKGROUND

This study investigated whether socio-spatial factors surrounding United States skilled nursing facilities related to Covid-19 case counts among residents, staff, and facility personnel and deaths among residents.

METHODS

With data on 12,403 United States skilled nursing facilities and Census data we estimated multilevel models to assess relationships between facility and surrounding area characteristics from June 2020 to September 2022 for cumulative resident and facility personnel case counts and resident deaths.

RESULTS

Facilities with more Black or Latino residents experienced more cases incident rate ratios (IRR = 1.005; 1.004) and deaths (IRR = 1.008) among residents during the first 6 months of the pandemic but were no different thereafter. Facilities with more racial and ethnic heterogeneity and percent Black or Latino in the surrounding buffer experienced more Covid-19 cases and deaths in the first 6 months, but no such differences were observed in the subsequent 24 months. Facilities surrounded by higher percent Latino consistently experienced more cases among staff and facility personnel over the study period (IRR = 1.006; 1.001).

CONCLUSIONS

Findings indicated socio-spatial health disparities in cases among residents, staff, and facility personnel in the first 6 months of the pandemic, with some disparities fading thereafter. This pattern likely suggests the importance of the adoption and adherence to pandemic-related safety measures in skilled nursing facilities nationwide.

Traveling Together: A Road Map for Researching Neighborhood Effects on Population Health and Health Inequities

As evidence of the relationship between place and health mounts, more epidemiologists and clinical science researchers are becoming interested in incorporating place-based measures and analyses into their examination of population health and health inequities. Given the extensive literature on place and health, it can be challenging for researchers new to this area to develop neighborhood-effects research questions and apply the appropriate measures and methods. This paper provides a road map for guiding health researchers through the conceptual and methodological stages of incorporating various dimensions of place into their quantitative health research. Synthesizing across reviews, commentaries, and empirical investigations, the road map consists of 4 broad stages for considering place and health: 1) why?: articulating the motivation for assessing place and health and grounding the motivation in theory; 2) what?: identifying the relevant place-based characteristics and specifying their link to health to build a conceptual framework; 3) how?: determining how to operationalize the conceptual framework by defining, measuring, and assessing place-based characteristics and quantifying their effect on health; and 4) now what?: discussing the implications of neighborhood research findings for future research, policy, and practice. This road map supports efforts to develop conceptually and analytically rigorous neighborhood research projects.

Neighborhood-level Residential Isolation and Neighborhood Composition: Similar but Different

Residential segregation has been considered as a potential cause of racial and/or ethnic disparities in health. Among the five dimensions of residential segregation, the isolation dimension has been conceived to play an essential role in disproportionately shaping the health of racial and ethnic minorities, particularly in urban or metropolitan areas. However, a noticeable amount of research studies has been using informal measures of neighborhood composition (i.e., proportions or percentages), which do not capture any of the five dimensions of residential segregation. Since the inappropriateness of measurement may obstruct a meaningful interpretation and an effective dissemination of research findings, a combination of graphical and non-graphical techniques was used to demonstrate the similarities and differences between formal measures of neighborhood-level residential isolation and informal measures of neighborhood composition. These were intended to provide intuitive and mutual understandings across academic disciples (e.g., city or urban planning, geography, public health, and sociology) and practitioners or professionals in multiple fields (e.g., community development workers, health service providers, policymakers, and social workers). Conceptual and methodological explanations with analytical discussions are also provided to differentiate and/or distinguish the two types of measures. While the concepts, methodologies, and research implications discussed herein are most relevant for research studies in urban or metropolitan areas of the United States, the general framework is also applicable to those of other industrialized counties.

Association between Racial Residential Segregation and COVID-19 Mortality

This study investigates the impact of racial residential segregation on COVID-19 mortality during the first year of the US epidemic. Data comes from the Center for Disease Control and Prevention (CDC), and the Robert Wood Johnson Foundation's and the University of Wisconsin's joint county health rankings project. The observation includes a record of 8,670,781 individuals in 1488 counties. We regressed COVID-19 deaths, using hierarchical logistic regression models, on individual and county-level predictors. We found that as racial residential segregation increased, mortality rates increased. Controlling for segregation, Blacks and Asians had a greater risk of mortality, while Hispanics and other racial groups had a lower risk of mortality, compared to Whites. The impact of racial residential segregation on COVID-19 mortality did not vary by racial group.

The Contribution of Neighborhood Characteristics to Psychological Symptom Severity in a Cohort of Injured Black Men

BACKGROUND

Traumatic injury is not evenly distributed by race and class in the USA. Black men are marginalized in the society, often reside in disadvantaged neighborhoods, and are at higher risk for injury mortality and ongoing physical and psychological problems following injury. Post-traumatic stress disorder (PTSD) and depressive symptom severity are among several problematic and disabling conditions faced by injury survivors. While much research has examined individual factors that lead to increased post-injury psychological symptom severity, the contribution of the social and physical environment has been relatively understudied.

OBJECTIVE

To examine the contribution of neighborhood characteristics to PTSD and depressive symptom severity in Black men following traumatic injury.

DESIGN

Prospective cohort study. Participant data were linked via GIS to neighborhood characteristics (constructs established by factor analysis) to spatially model factors associated with increased post-injury psychological symptom severity using a GEE regression analysis, adjusting for injury mechanism and severity, age, and insurance.

PARTICIPANTS

Four hundred fifty-one adult Black males hospitalized for traumatic injury.

RESULTS

The 4 constructs were neighborhood disconnectedness, concentrated disadvantage/deprivation, crime/violence/vacancy, and race/ethnicity. High depressive and PTSD symptom severity was reported by 36.8% and 30.4% of participants, respectively. Higher PTSD symptom severity was associated with crime/violence/vacancy, and higher depressive symptom severity was associated with neighborhood disconnectedness. PTSD and depressive symptom severity were associated with intentional injury mechanisms and Medicaid/no insurance. Higher injury severity was associated with depressive symptoms.

CONCLUSION

Neighborhood characteristics are associated with psychological symptom severity after injury.

Cause-specific mortality by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities

BACKGROUND

Large disparities in mortality exist across racial-ethnic groups and by location in the USA, but the extent to which racial-ethnic disparities vary by location, or how these patterns vary by cause of death, is not well understood. We aimed to estimate age-standardised mortality by racial-ethnic group, county, and cause of death and describe the intersection between racial-ethnic and place-based disparities in mortality in the USA, comparing patterns across health conditions.

METHODS

We applied small-area estimation models to death certificate data from the US National Vital Statistics system and population data from the US National Center for Health Statistics to estimate mortality by age, sex, county, and racial-ethnic group annually from 2000 to 2019 for 19 broad causes of death. Race and ethnicity were categorised as non-Latino and non-Hispanic American Indian or Alaska Native (AIAN), non-Latino and non-Hispanic Asian or Pacific Islander (Asian), non-Latino and non-Hispanic Black (Black), Latino or Hispanic (Latino), and non-Latino and non-Hispanic White (White). We adjusted these mortality rates to correct for misreporting of race and ethnicity on death certificates and generated age-standardised results using direct standardisation to the 2010 US census population.

FINDINGS

From 2000 to 2019, across 3110 US counties, racial-ethnic disparities in age-standardised mortality were noted for all causes of death considered. Mortality was substantially higher in the AIAN population (all-cause mortality 1028·2 [95% uncertainty interval 922·2-1142·3] per 100 000 population in 2019) and Black population (953·5 [947·5-958·8] per 100 000) than in the White population (802·5 [800·3-804·7] per 100 000), but substantially lower in the Asian population (442·3 [429·3-455·0] per 100 000) and Latino population (595·6 [583·7-606·8] per 100 000), and this pattern was found for most causes of death. However, there were exceptions to this pattern, and the exact order among racial-ethnic groups, magnitude of the disparity in both absolute and relative terms, and change over time in this magnitude varied considerably by cause of death. Similarly, substantial geographical variation in mortality was observed for all causes of death, both overall and within each racial-ethnic group. Racial-ethnic disparities observed at the national level reflect widespread disparities at the county level, although the magnitude of these disparities varied widely among counties. Certain patterns of disparity were nearly universal among counties; for example, in 2019, mortality was higher among the AIAN population than the White population in at least 95% of counties for skin and subcutaneous diseases (455 [97·8%] of 465 counties with unmasked estimates) and HIV/AIDS and sexually transmitted infections (458 [98·5%] counties), and mortality was higher among the Black population than the White population in nearly all counties for skin and subcutaneous diseases (1436 [96·6%] of 1486 counties), diabetes and kidney diseases (1473 [99·1%]), maternal and neonatal disorders (1486 [100·0%] counties), and HIV/AIDS and sexually transmitted infections (1486 [100·0%] counties).

INTERPRETATION

Disparities in mortality among racial-ethnic groups are ubiquitous, occurring across locations in the USA and for a wide range of health conditions. There is an urgent need to address the shared structural factors driving these widespread disparities.

FUNDING

National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research, US National Institutes of Health.

Residential Segregation and Depressive Symptoms in Older Chinese Immigrants: The Mediating Role of Social Processes

BACKGROUND AND OBJECTIVES

Older Chinese immigrants are at risk for depression due to acculturative stress and language barriers. Residential segregation with respect to language use plays an important role in the mental health of historically marginalized populations. Previous research provided mixed evidence about the segregation effect among older Latino and Asian immigrants. Guided by a model of social processes, we examined the direct and indirect effects of residential segregation on depressive symptoms via multiple mechanisms of acculturation, discrimination, social network, social support, social strain, and social engagement.

RESEARCH DESIGN AND METHODS

Four waves of depressive symptoms were assessed in the Population Study of Chinese Elderly (2011-19, N = 1,970), and linked to the 2010-14 American Community Survey estimates of neighborhood context. Residential segregation was measured by the Index of Concentrations at the Extremes which simultaneously assesses Chinese and English language use within a given census tract. Latent growth curve models with adjusted cluster robust standard errors were estimated after controlling for individual-level factors.

RESULTS

Residents of segregated Chinese-speaking neighborhoods had fewer baseline depressive symptoms but a slower rate of symptom reduction than those living in neighborhoods segregated with English-only speakers. Racial discrimination, social strain, and social engagement partially mediated the association between segregation and baseline depressive symptoms; social strain and social engagement partially mediated the association with long-term reduction in depressive symptoms.

DISCUSSION AND IMPLICATIONS

This study demonstrates the importance of residential segregation and social processes in shaping mental well-being among older Chinese immigrants and suggests potential mechanisms to alleviate mental health risks.

Segregation and Childhood Blood Lead Levels in North Carolina

BACKGROUND AND OBJECTIVES

Using a local measure of racial residential segregation, estimate the association between racial residential segregation and childhood blood lead levels between the early 1990s and 2015 in North Carolina.

METHODS

This population-based observational study uses individual-level blood lead testing records obtained from the NC Department of Health and Human Services for 320 916 children aged <7 years who were tested between 1992 and 1996 or 2013 and 2015. NC childhood blood lead levels were georeferenced to the census tract. Neighborhood racial residential segregation, assessed using a local, spatial measure of the racial isolation of non-Hispanic Blacks (RINHB), was calculated at the census tract level.

RESULTS

From 1990 to 2015, RINHB increased in 50% of 2195 NC census tracts, although the degree of change varied by geographic region. In 1992 to 1996 blood lead testing data, a 1-standard-deviation increase in tract-level RINHB was associated with a 2.86% (95% confidence interval: 0.96%-4.81%) and 2.44% (1.34%-3.56%) increase in BLL among non-Hispanic Black and non-Hispanic White children, respectively. In 2013 to 2015 blood lead testing data, this association was attenuated but persisted with a 1-standard-deviation increase in tract-level RINHB associated with a 1.59% (0.50%-2.70%) and 0.76% (0.08%-1.45%) increase in BLL among non-Hispanic Black and non-Hispanic White children, respectively. In the supplemental information, we show the change in racial residential segregation across the entire United States, demonstrating that RINHB increased in 69% of 72 899 US census tracts.

CONCLUSIONS

Racially isolated neighborhoods are associated with higher childhood lead levels, demonstrating the disproportionate environmental burdens borne by segregated communities and warranting attention to providing whole child health care.

Racial residential segregation and child mortality in the southern United States at the turn of the 20th century

A growing body of research considers racial residential segregation to be a form of systemic racism and a fundamental cause of persistent racial disparities in health and mortality. Historical research examining the impact of segregation on health and mortality, however, is limited to a few studies with poor data and inconsistent results. In this study, we examine the association between racial residential segregation and child mortality in the South at the turn of the 20th century. We rely on the new IPUMS 1900 and 1910 complete-count databases to estimate child mortality in the 5 years before each census and construct segregation measures at the census enumeration district (ED), the lowest level of geography consistently available in the census. We calculate the proportion of households headed by Black individuals in each ED, and the Sequence Index of Segregation (SIS), which is based on the racial sequencing of household heads within each district. We construct models of child mortality for rural and urban areas, controlling for a wide variety of demographic and socioeconomic variables. The results indicate that proportion Black and SIS were strongly and positively associated with the mortality of Black children in most models and in both rural and urban areas. Proportion Black was also positively but more moderately correlated with the mortality of White children, while SIS was not correlated or negatively correlated. These results suggest that racial segregation was a long-standing fundamental cause of race disparities in health and mortality in the United States.

Geospatial Associations between Female Breast Cancer Mortality Rates and Environmental Socioeconomic Indicators for North Carolina

In North Carolina, over 6000 women will be diagnosed with breast cancer yearly, and over 1000 will die. It is well known that environmental conditions contribute greatly to health outcomes, and many of these factors include a geographic component. Using death data records from 2003-2019 extracted from North Carolina Vital Statistics Dataverse, a spatial database was developed to map and analyze female breast cancer mortality rates at the ZIP code scale in North Carolina. Thirty-nine hot spots and thirty cold spots of age-adjusted death rates were identified using the Getis-Ord analysis. Two-tailed t-tests were run between each cohort for environmental socioeconomic-related factors associated with breast cancer progression and mortality. The median age and household income of individuals who resided in ZIP codes with the highest breast cancer mortality were significantly lower than those who lived in ZIP codes with lower breast cancer mortality. The poverty rate, percentage of SNAP benefits, and the percentage of minorities were all significantly higher (p < 0.05, p < 0.001, and p < 0.001) in ZIP codes with high breast cancer rates. High-quality (ZIP code) granular cancer data were developed for which detailed analysis can be performed for future studies.

Relationships Between Patient Race and Residential Race Context With Missed Human Immunodeficiency Virus Care Visits in the United States, 2010-2015

BACKGROUND

Racial inequities exist in retention in human immunodeficiency virus (HIV) care and multilevel analyses are needed to contextualize and address these differences. Leveraging data from a multisite clinical cohort of people with HIV (PWH), we assessed the relationships between patient race and residential characteristics with missed HIV care visits.

METHODS

Medical record and patient-reported outcome (PRO; including mental health and substance-use measures) data were drawn from 7 participating Center for AIDS Research Network of Integrated Clinical Systems (CNICS) sites including N = 20 807 PWH from January 2010 through December 2015. Generalized estimating equations were used to account for nesting within individuals and within census tracts in multivariable models assessing the relationship between race and missed HIV care visits, controlling for individual demographic and health characteristics and census tract characteristics.

RESULTS

Black PWH resided in more disadvantaged census tracts, on average. Black PWH residing in census tracts with higher proportion of Black residents were more likely to miss an HIV care visit. Non-Black PWH were less likely to miss a visit regardless of where they lived. These relationships were attenuated when PRO data were included.

CONCLUSIONS

Residential racial segregation and disadvantage may create inequities between Black PWH and non-Black PWH in retention in HIV care. Multilevel approaches are needed to retain PWH in HIV care, accounting for community, healthcare setting, and individual needs and resources.

The impact of ethnic segregation on neighbourhood-level social distancing in the United States amid the early outbreak of COVID-19

The COVID-19 pandemic has been argued to be the 'great equaliser', but, in fact, ethnically and racially segregated communities are bearing a disproportionate burden from the disease. Although more people have been infected and died from the disease among these minority communities, still fewer people in these communities are complying with the suggested public health measures like social distancing. The factors contributing to these ramifications remain a long-lasting debate, in part due to the contested theories between ethnic stratification and ethnic community. To offer empirical evidence to this theoretical debate, we tracked public social-distancing behaviours from mobile phone devices across urban census tracts in the United States and employed a difference-in-difference model to examine the impact of racial/ethnic segregation on these behaviours. Specifically, we focussed on non-Hispanic Black and Hispanic communities at the neighbourhood level from three principal dimensions of ethnic segregation, namely, evenness, exposure, and concentration. Our results suggest that (1) the high ethnic diversity index can decrease social-distancing behaviours and (2) the high dissimilarity between ethnic minorities and non-Hispanic Whites can increase social-distancing behavior; (3) the high interaction index can decrease social-distancing behaviours; and (4) the high concentration of ethnic minorities can increase travel distance and non-home time but decrease work behaviours. The findings of this study shed new light on public health behaviours among minority communities and offer empirical knowledge for policymakers to better inform just and evidence-based public health orders.

Traumatic Life Events and Stressors: Associations With Substance Use Problems of Men Under Community Supervision

This study aims to determine associations between sources of stress and substance use problems among men under community supervision programs. We used ordinary least squares regression models to test the hypotheses that the traumatic life events and stressors of men under community supervision and their partners, respectively, were associated with the substance use problems of men under community supervision. The sample included 230 men involved in community supervision programs in New York City and 230 women who were their intimate partners. We found that the traumatic events and the depression and anxiety of men under community supervision and partner's substance use problems were associated with the substance use problems of the men. These findings underscore the importance of addressing trauma in substance use treatment for men under community supervision. Future research can explore how stressful events impact substance use, sources of coping for couples, and the association between racism, traumatic events, stress, and substance use. Clinical Trial Registration: NCT01690494.

County-Level Segregation and Racial Disparities in COVID-19 Outcomes

CONTEXT

Segregation has been linked to unequal life chances. Individuals from marginalized communities experience more crime, higher levels of poverty, poorer health, and less civic engagement. In addition, segregated metropolitan regions have been found to display inequality in access to basic services. This article builds on these findings by linking segregation to infection and deaths from COVID-19.

METHODS

Using census data matched to COVID infection and death statistics at the county level, this article offers a theoretical basis for the researchers' choice of segregation measures and predictions for different racial groups. It analyzes the relationship between two dimensions of segregation-racial isolation and racial unevenness-and COVID outcomes for different racial and ethnic groups.

FINDINGS

In counties where Black and Latino residents lived in more racially isolated neighborhoods, they were much more likely to contract COVID-19. This pattern was exacerbated in counties with a high proportion of frontline workers. In addition, racial segregation increased COVID-19 death rates for Black, Latino, and white residents.

CONCLUSIONS

These findings suggest that devastating outcomes of the coronavirus pandemic were linked to a long history of racial marginalization and entrenched discrimination produced by structural inequalities embedded in our geographies. This knowledge should be used to inform public health planning.

Principles to operationalize equity in cancer research and health outcomes: lessons learned from the cancer prevention and control research network

Reflecting their commitment to advancing health equity, the Cancer Prevention and Control Research Network (CPCRN) established a Health Equity Workgroup to identify and distill guiding principles rooted in health equity, community-engaged participatory research (CBPR), social determinants of health, and racial equity frameworks to guide its collective work. The Health Equity Workgroup utilized a multi-phase, participatory consensus-building approach to: (1) identify recurrent themes in health and racial equity frameworks; (2) capture perspectives on and experiences with health equity research among CPCRN members through an online survey; (3) engage in activities to discuss and refine the guiding principles; and (4) collect case examples of operationalizing equity principles in cancer research. Representatives from all CPCRN centers endorsed nine core principles to guide the Network's strategic plan: (1) Engage in power-sharing and capacity building with partners; (2) Address community priorities through community engagement and co-creation of research; (3) Explore and address the systems and structural root causes of cancer disparities; (4) Build a system of accountability between research and community partners; (5) Establish transparent relationships with community partners; (6) Prioritize the sustainability of research benefits for community partners; (7) Center racial equity in cancer prevention and control research; (8) Engage in equitable data collection, analysis, interpretation, and dissemination practices; and (9) Integrate knowledge translation, implementation, and dissemination into research plans. Dissemination products, such as toolkits and technical assistance workshops, reflecting these principles will foster knowledge transfer to intentionally integrate health and racial equity principles in cancer prevention and control research.

Without Affordable, Accessible, and Adequate Housing, Health Has No Foundation

Policy Points Today's housing disparities are rooted in the increasing commodification of housing that has taken precedence over the need for shelter, a basic human right. With rising housing costs across the country, more residents are finding their monthly income going to rent, mortgage payments, property taxes, and utilities, leaving little for food and medication. Housing is a determinant of health, and with increasing housing disparities, action must be taken to ensure no individual is displaced, communities remain intact, and cities continue to thrive.

Assessing community-level exposure to social vulnerability and isolation: spatial patterning and urban-rural differences

BACKGROUND

Environmental health disparity research involves the use of metrics to assess exposure to community-level vulnerabilities or inequities. While numerous vulnerability indices have been developed, there is no agreement on standardization or appropriate use, they have largely been applied in urban areas, and their interpretation and utility likely vary across different geographies.

OBJECTIVE

We evaluated the spatial distribution, variability, and relationships among different metrics of social vulnerability and isolation across urban and rural settings to inform interpretation and selection of metrics for environmental disparity research.

METHODS

For all census tracts in North Carolina, we conducted a principal components analysis using 23 socioeconomic/demographic variables from the 2010 United States Census and American Community Survey. We calculated or obtained the neighborhood deprivation index (NDI), residential racial isolation index (RI), educational isolation index (EI), Gini coefficient, and social vulnerability index (SVI). Statistical analyses included Moran's I for spatial clustering, t-tests for urban-rural differences, Pearson correlation coefficients, and changes in ranking of tracts across metrics.

RESULTS

Social vulnerability metrics exhibited clear spatial patterning (Moran's I ≥ 0.30, p < 0.01). Greater educational isolation and more intense neighborhood deprivation was observed in rural areas and greater racial isolation in urban areas. Single-domain metrics were not highly correlated with each other (rho ≤ 0.36), while composite metrics (i.e., NDI, SVI, principal components analysis) were highly correlated (rho > 0.80). Composite metrics were more highly correlated with the racial isolation metric in urban (rho: 0.54-0.64) versus rural tracts (rho: 0.36-0.48). Census tract rankings changed considerably based on which metric was being applied.

SIGNIFICANCE

High correlations between composite metrics within urban and rural tracts suggests they could be used interchangeably; single domain metrics cannot. Composite metrics capture different facets of vulnerabilities in urban and rural settings, and these complexities should be examined by researchers applying metrics to areas of diverse urban and rural forms.

Inclusion of Race and Ethnicity With Neighborhood Socioeconomic Deprivation When Assessing COVID-19 Hospitalization Risk Among California Veterans Health Administration Users

Importance

Despite complexities of racial and ethnic residential segregation (hereinafter referred to as segregation) and neighborhood socioeconomic deprivation, public health studies, including those on COVID-19 racial and ethnic disparities, often rely on composite neighborhood indices that do not account for residential segregation.

Objective

To examine the associations by race and ethnicity among California's Healthy Places Index (HPI), Black and Hispanic segregation, Social Vulnerability Index (SVI), and COVID-19-related hospitalization.

Design, Setting, and Participants

This cohort study included veterans with positive test results for COVID-19 living in California who used Veterans Health Administration services between March 1, 2020, and October 31, 2021.

Main Outcomes and Measures

Rates of COVID-19-related hospitalization among veterans with COVID-19.

Results

The sample available for analysis included 19 495 veterans with COVID-19 (mean [SD] age, 57.21 [17.68] years), of whom 91.0% were men, 27.7% were Hispanic, 16.1% were non-Hispanic Black, and 45.0% were non-Hispanic White. For Black veterans, living in lower-HPI (ie, less healthy) neighborhoods was associated with higher rates of hospitalization (odds ratio [OR], 1.07 [95% CI, 1.03-1.12]), even after accounting for Black segregation (OR, 1.06 [95% CI, 1.02-1.11]). Among Hispanic veterans, living in lower-HPI neighborhoods was not associated with hospitalization with (OR, 1.04 [95% CI, 0.99-1.09]) and without (OR, 1.03 [95% CI, 1.00-1.08]) Hispanic segregation adjustment. For non-Hispanic White veterans, lower HPI was associated with more frequent hospitalization (OR, 1.03 [95% CI, 1.00-1.06]). The HPI was no longer associated with hospitalization after accounting for Black (OR, 1.02 [95% CI, 0.99-1.05]) or Hispanic (OR, 0.98 [95% CI, 0.95-1.02]) segregation. Hospitalization was higher for White (OR, 4.42 [95% CI, 1.62-12.08]) and Hispanic (OR, 2.90 [95% CI, 1.02-8.23]) veterans living in neighborhoods with greater Black segregation and for White veterans in more Hispanic-segregated neighborhoods (OR, 2.81 [95% CI, 1.96-4.03]), adjusting for HPI. Living in higher SVI (ie, more vulnerable) neighborhoods was associated with greater hospitalization for Black (OR, 1.06 [95% CI, 1.02-1.10]) and non-Hispanic White (OR, 1.04 [95% CI, 1.01-1.06]) veterans.

Conclusions and Relevance

In this cohort study of US veterans with COVID-19, HPI captured neighborhood-level risk for COVID-19-related hospitalization for Black, Hispanic, and White veterans comparably with SVI. These findings have implications for the use of HPI and other composite neighborhood deprivation indices that do not explicitly account for segregation. Understanding associations between place and health requires ensuring composite measures accurately account for multiple aspects of neighborhood deprivation and, importantly, variation by race and ethnicity.

Objectively measured external building quality, Census housing vacancies and age, and serum metals in an adult cohort in Detroit, Michigan

BACKGROUND

Residentially derived lead pollution remains a significant problem in urban areas across the country and globe. The risks of childhood residence in housing contaminated with lead-based paint are well-established, but less is known about the effects of housing quality on adult lead exposure.

OBJECTIVE

To evaluate the effects of residential-area housing age, vacancy status, and building quality on adult lead exposures.

METHODS

We evaluated the effect of Census block group housing vacancy proportion, block group housing age, and in-person survey evaluated neighborhood building quality on serum levels of lead, mercury, manganese, and copper among a representative cohort of adults in Detroit, Michigan, from 2008-2013 using generalized estimating equations.

RESULTS

Participants in Census block groups with higher proportions of vacant and aged housing had non-significantly elevated serum lead levels. We identified similar positive associations between residence in neighborhoods with poorer objectively measured building quality and serum lead. Associations between Census vacancies, housing age, objectively measured building quality, and serum lead were stronger among participants with a more stable residential history.

SIGNIFICANCE

Vacant, aged, and poorly maintained housing may contribute to widespread, low-level lead exposure among adult residents of older cities like Detroit, Michigan. US Census and neighborhood quality data may be a useful tool to identify population-level lead exposures among US adults.

IMPACT

Using longitudinal data from a representative cohort of adults in Detroit, Michigan, we demonstrate that Census data regarding housing vacancies and age and neighborhood survey data regarding housing quality are associated with increasing serum lead levels. Previous research has primarily focused on housing quality and lead exposures among children. Here, we demonstrate that area-level metrics of housing quality are associated with lead exposures among adults.

Neighborhood segregation, socioeconomic status, and cognitive function among older Chinese immigrants

BACKGROUND

The fast-growing population of older Chinese immigrants and their segregated residences highlight the importance of understanding the role of neighborhood context in cognitive health. The segregation-cognition association is equivocal based on a limited number of studies among Hispanic and Asian Americans. To close the knowledge gap, this study examined the associations of neighborhood segregation and socioeconomic status (NSES) with cognitive functioning among older Chinese immigrants.

METHODS

Four waves of cognitive performance tests were conducted in the Population Study of Chinese Elderly in Chicago (2011-2019) and linked to the 2010 to 2014 American Community Survey estimates of neighborhood contexts. NSES was a summary z-score of six census variables of education, income/wealth, and occupation. Neighborhood segregation was measured by the Index of Concentrations at the Extremes (ICE), which simultaneously assesses Chinese and English language use within a given census tract. There were 170 census tracts in the present sample of 2044 participants. Latent growth curve models with adjusted cluster robust standard errors were estimated.

RESULTS

On average, cognitive functioning declined over time (B = -0.07, p < 0.001). After adjusting for individual-level predictors, living in high-NSES neighborhoods was associated with slower cognitive decline (B = 0.003, p = 0.04). ICE was not associated with cognitive functioning, but boosted the protective effect of high NSES on cognitive decline (B = 0.006, p = 0.05).

CONCLUSIONS

Neighborhood socioeconomic advantage was related to slower cognitive decline among older Chinese immigrants, especially among those living in neighborhoods with more English speakers or less segregation. This finding suggests complex associations between neighborhood context and cognitive health among Chinese immigrants.

The Residential Environment and Health and Well-Being of Chinese Migrant Populations: A Systematic Review

China's internal migrants suffer from marginalised housing conditions, poor neighbourhood environments and residential segregation, which may have significant implications on health and well-being. Echoing recent calls for interdisciplinary research on migrant health and well-being, this study examines the associations and mechanisms of the impact of the residential environment on the health and well-being of Chinese migrants. We found that most of the relevant studies supported the "healthy migration effect", but the phenomenon was only applicable to migrants' self-reported physical health rather than mental health. The subjective well-being of migrants is lower than that of urban migrants. There is a debate between the effectiveness of residential environmental improvements and the ineffectiveness of residential environmental improvements in terms of the impact of the neighbourhood environment on migrants' health and well-being. Housing conditions and the neighbourhood's physical and social environment can enhance migrants' health and well-being by strengthening place attachment and social cohesion, building localised social capital and gaining neighbourhood social support. Residential segregation on the neighbourhood scale affects the health outcomes of migrant populations through the mechanism of relative deprivation. Our studies build a vivid and comprehensive picture of research to understand migration, urban life and health and well-being.

Association of neighborhood segregation with 6-year incidence of metabolic syndrome in the Hispanic community health study/study of Latinos

PURPOSE

Examine the association between neighborhood segregation and 6-year incident metabolic syndrome (MetSyn) in the Hispanic Community Health Study/Study of Latinos.

METHODS

Prospective cohort of adults residing in Miami, Chicago, the Bronx, and San Diego. The analytic sample included 6,710 participants who did not have MetSyn at baseline. The evenness and exposure dimensions of neighborhood segregation, based on the Gini and Isolation indices, respectively, were categorized into quintiles (Q). Racialized economic concentration was measured with the Index of Concentration at the Extremes (continuously and Q).

RESULTS

Exposure, but not evenness, was associated with higher disease odds (Q1 (lower segregation) vs. Q4, OR = 1.53, 95% CI = 1.082.17; Q5, OR = 2.29, 95% CI = 1.493.52). Economic concentrationprivilege (continuous OR = 0.87, 95% CI = 0.770.98), racial concentrationracialized privilege (Q1 (greater concentration) vs. Q2 OR = 0.75, 95% CI = 0.541.04; Q3 OR = 0.68, 95% CI = 0.441.05; Q4 OR = 0.68, 95% CI = 0.451.01; Q5 OR = 0.64, 95% CI = 0.420.98)(continuous OR = 0.93, 95% CI = 0.821.04), and racialized economic concentrationprivilege (i.e., higher SES non-Hispanic White, continuous OR = 0.86, 95% CI = 0.760.98) were associated with lower disease odds.

CONCLUSION

Hispanics/Latino adults residing in neighborhoods with high segregation had higher risk of incident MetSyn compared to those residing in neighborhoods with low segregation. Research is needed to identify the mechanisms that link segregation to poor metabolic health.

Supermarket Proximity and Risk of Hypertension, Diabetes, and CKD: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

Living in environments with low access to food may increase the risk of chronic diseases. We investigated the association of household distance to the nearest supermarket (as a measure of food access) with the incidence of hypertension, diabetes, and chronic kidney disease (CKD) in a metropolitan area of the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

777,994 individuals without hypertension, diabetes, or CKD at baseline within the HealthLNK Data Repository, which contains electronic health records from 7 health care institutions in Chicago, Illinois.

EXPOSURE

Zip code-level average distance between households and nearest supermarket.

OUTCOME

Incidence of hypertension, diabetes, and CKD based on presence of ICD-9 code and/or blood pressure≥140/90mm Hg, hemoglobin A1c≥6.5%, and eGFR<60mL/min/1.73m², respectively.

ANALYTICAL APPROACH

Average distance to nearest supermarket was aggregated from street-level metrics for 56 Chicagoland zip codes. The cumulative incidence of hypertension, diabetes, and CKD from 2007-2012 was calculated for each zip code in patients free of these diseases in 2006. Spatial analysis of food access and disease incidence was performed using bivariate local indicator of spatial association (BiLISA) maps and bivariate local Moran I statistics. The relationship between supermarket access and outcomes was analyzed using logistic regression.

RESULTS

Of 777,994 participants, 408,608 developed hypertension, 51,380 developed diabetes, and 56,365 developed CKD. There was significant spatial overlap between average distance to supermarket and incidence of hypertension and diabetes but not CKD. Zip codes with large average supermarket distances and high incidence of hypertension and diabetes were clustered in southern and western neighborhoods. Models adjusted only for neighborhood factors (zip code-level racial composition, access to vehicles, median income) revealed significant associations between zip code-level average distance to supermarket and chronic disease incidence. Relative to tertile 1 (shortest distance), ORs in tertiles 2 and 3, respectively, were 1.27 (95% CI, 1.23-1.30) and 1.38 (95% CI, 1.33-1.43) for diabetes, 1.03 (95% CI, 1.02-1.05) and 1.04 (95% CI, 1.02-1.06) for hypertension, and 1.18 (95% CI, 1.15-1.21) and 1.33 (95% CI, 1.29-1.37) for CKD. Models adjusted for demographic factors and health insurance showed significant and positive association with greater odds of incident diabetes (tertile 2: 1.29 [95% CI, 1.26-1.33]; tertile 3: 1.35 [95% CI, 1.31-1.39]) but lesser odds of hypertension (tertile 2: 0.95 [95% CI, 0.94-0.97]; tertile 3: 0.91 [95% CI, 0.89-0.92]) and CKD (tertile 2: 0.80 [95% CI, 0.78-0.82]; tertile 3: 0.73 [95% CI, 0.72-0.76]). After adjusting for both neighborhood and individual covariates, supermarket distance remained significantly associated with greater odds of diabetes and lesser odds of hypertension, but there was no significant association with CKD.

LIMITATIONS

Unmeasured neighborhood and social confounding variables, zip code-level analysis, and limited individual-level information.

CONCLUSIONS

There are significant disparities in supermarket proximity and incidence of hypertension, diabetes, and CKD in Chicago, Illinois. The relationship between supermarket access and chronic disease is largely explained by individual- and neighborhood-level factors.

Historic Redlining Practices and Contemporary Determinants of Health in the Detroit Metropolitan Area

Objectives. To examine how redlining, a historical racially discriminatory housing policy implemented by the Home Owners' Loan Corporation (HOLC), is associated with current neighborhood determinants of health in the Detroit Metropolitan Area. Methods. We analyzed associations between census tract‒level HOLC color grades (red = "hazardous"; yellow = "declining"; blue = "desirable"; and green = "best") and a developed neighborhood determinants of health index (DOHI) consisting of 8 indicators of economic, social, governance, and physical environment characteristics using spatial regression analysis and controlling for change in the census tract's percentage of White residents. Results. A total of 484 Detroit Metropolitan Area census tracts had HOLC grades. The mean redlining score across all census tracts was 3.02 (min = 1.0; max = 4.0). The mean contemporary DOHI was 19.11 (min = 8.0; max = 36.0). Regression models show significantly higher DOHI scores in yellowlined (b = 2.71; 95% confidence interval [CI] = 1.52, 3.91), bluelined (b = 5.33; 95% CI = 3.65, 7.01), and greenlined (b = 9.25; 95% CI = 6.86, 11.64) neighborhoods compared with redlined neighborhoods. Conclusions. Historical redlined neighborhoods experience contemporary determinants of health conditions that are less conducive to health compared with those in nonredlined neighborhoods. These differences also reflect the accumulation of resources essential for health in greenlined neighborhoods. Public Health Implications. Neighborhood development initiatives should consider the impacts of historical redlining on contemporary neighborhood conditions. (Am J Public Health. 2023;113(S1): S49-S57. https://doi.org/10.2105/AJPH.2022.307162).

Neighborhood segregation and cancer prevention guideline adherence in US Hispanic/Latino adults: Results from the HCHS/SOL

Background

Adherence to the American Cancer Society (ACS) guidelines for cancer prevention is associated with a lower risk of cancer and mortality. The role of neighborhood segregation on adherence to the guidelines among Hispanic/Latino adults is relatively unexplored.

Materials and methods

The Hispanic Community Health Study/Study of Latinos is a community-based prospective cohort of 16,462 Hispanic/Latino adults, ages 18-74 years enrolled in 2008-2011 from the Bronx, Chicago, Miami and San Diego. Dimensions of neighborhood segregation were measured using 2010 United States' census tracts:-evenness (the physical separation of a group), exposure (the propensity for contact between groups), and their joint effect (hypersegregation). ACS guideline adherence levels - low, moderate, high - were created from accelerometry-measured physical activity, dietary intake, alcohol intake, and body mass index. Weighted multinominal logistic regressions estimated relative risk ratios (RRR) and 95% confidence intervals (CI) for guideline adherence levels and its components.

Results

Hispanic/Latino adults were classified as low (13.7%), moderate (58.8%) or highly (27.5%) adherent to ACS guidelines. We found no evidence of an association between segregation and overall guideline adherence. Exposure segregation associated with lower likelihood of moderate adherence to alcohol recommendations (RRR_{moderate vs. low}:0.86, 95%CI:0.75-0.98) but higher likelihood for diet recommendations (RRR_{moderate vs. low}:1.07, 95%CI:1.01-1.14). Evenness segregation associated with lower likelihood of high adherence to the physical activity recommendations (RRR_{high vs. low}:0.73, 95%CI:0.57-0.94). Hypersegregation was associated with individual guideline components.

Conclusion

We found evidence of a cross-sectional relationship between neighborhood segregation and ACS cancer prevention guideline components, but not with overall ACS guideline adherence.

Association between Gentrification and Health and Healthcare Utilization

There is tremendous interest in understanding how neighborhoods impact health by linking extant social and environmental drivers of health (SDOH) data with electronic health record (EHR) data. Studies quantifying such associations often use static neighborhood measures. Little research examines the impact of gentrification-a measure of neighborhood change-on the health of long-term neighborhood residents using EHR data, which may have a more generalizable population than traditional approaches. We quantified associations between gentrification and health and healthcare utilization by linking longitudinal socioeconomic data from the American Community Survey with EHR data across two health systems accessed by long-term residents of Durham County, NC, from 2007 to 2017. Census block group-level neighborhoods were eligible to be gentrified if they had low socioeconomic status relative to the county average. Gentrification was defined using socioeconomic data from 2006 to 2010 and 2011-2015, with the Steinmetz-Wood definition. Multivariable logistic and Poisson regression models estimated associations between gentrification and development of health indicators (cardiovascular disease, hypertension, diabetes, obesity, asthma, depression) or healthcare encounters (emergency department [ED], inpatient, or outpatient). Sensitivity analyses examined two alternative gentrification measures. Of the 99 block groups within the city of Durham, 28 were eligible (N = 10,807; median age = 42; 83% Black; 55% female) and 5 gentrified. Individuals in gentrifying neighborhoods had lower odds of obesity (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.81-0.99), higher odds of an ED encounter (OR = 1.10; 95% CI: 1.01-1.20), and lower risk for outpatient encounters (incidence rate ratio = 0.93; 95% CI: 0.87-1.00) compared with non-gentrifying neighborhoods. The association between gentrification and health and healthcare utilization was sensitive to gentrification definition.

Redlining and Neighborhood Walking in Older Adults: The 2017 National Household Travel Survey

INTRODUCTION

In the 1930s, Black, working-class, and immigrant neighborhoods were color coded on maps (i.e., redlining) indicating investment risk, which negatively impacted mortgage attainment/homeownership for these groups and led to long-standing segregation by race/ethnicity and socioeconomic status. Limited studies have investigated the health impacts of redlining, particularly among older adults who tend to stay closer to their residences. This study examines whether older adults in historically redlined neighborhoods report less neighborhood walking and whether associations vary by race/ethnicity and income.

METHODS

The sample included 4,651 individuals aged ≥65 years from the 2017 U.S. National Household Travel Survey. U.S. Census tract‒based redlining scores were 1=best, 2=still desirable, 3=definitely declining, and 4=hazardous. Multivariable negative binomial regression tested the associations between redlining and neighborhood walking/day in the overall sample and with stratification by poverty status (analyzed in 2022).

RESULTS

Participants were on average aged 73 years, and 11% were African/American Black, 75% were White, 8% were Hispanic/Latinx, and 6% were of other race/ethnicity. Participants reported a mean of 7.1 neighborhood walking minutes/day (SD=20.6), and 60% lived in definitely declining or hazardous neighborhoods. Individuals in hazardous neighborhoods (versus those in best neighborhoods) reported less neighborhood walking (prevalence ratio=0.64; 95% CI=0.43, 0.97). Among those living in poverty, living in definitely declining and hazardous neighborhoods was associated with less neighborhood walking (prevalence ratio=0.39 [95% CI=0.20, 0.79] and 0.39 [95% CI=0.18, 0.82], respectively).

CONCLUSIONS

Less neighborhood walking was reported among individuals living in neighborhoods with a historic redlining score of definitely declining or hazardous. Future studies using larger, more diverse cohorts may elucidate whether associations differ by race/ethnicity and geographic location/city.

Racial-Ethnic Residential Clustering and Early COVID-19 Vaccine Allocations in Five Urban Texas Counties

Previous research has indicated that racial-ethnic minority communities lack a wide variety of health-related organizations. We examine how this relates to the early COVID-19 vaccine rollout. In a series of spatial error and linear growth models, we analyze how racial-ethnic residential segregation is associated with the distribution of vaccine sites and vaccine doses across ZIP codes in the five largest urban counties in Texas. We find that Black and Latino clustered ZIP codes are less likely to have vaccine distribution sites and that this disparity is partially explained by the lack of hospitals and physicians' offices in these areas. Moreover, Black clustering is also negatively related to the number of allocated vaccine doses, and again, this is largely explained by the unequal distribution of health care resources. These results suggest that extant disparities in service provision are key to understanding racial-ethnic inequality in an acute crisis like the COVID-19 pandemic.