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11
What Makes a Place Healthy? Neighborhood Influences on Racial/ Ethnic Disparities in Health over the Life Course

Jeffrey D. Morenoff and John W. Lynch


Our main purpose in this chapter is to suggest a conceptual framework for better understanding how characteristics of neighborhoods can affect racial/ethnic differences in health, with a special emphasis on health in aging populations. At the outset we should recognize that the specific studies in this field are sparse. However, we will try to draw from the more diverse sociological and epidemiological literature on neighborhoods and health to illustrate the potential for certain characteristics of neighborhoods to affect racial/ethnic health differences in aging.

In recent years, epidemiologists and sociologists have become increasingly interested in studying the effects of local context on individual health and well-being. Although a long history of research shows that health status varies strongly across local, state, regional, and national settings (Murray, Michaud, McKenna, and Marks, 1998), what distinguishes the new generation of research on neighborhoods and health is its attention to investigating the multilevel causation of these differences. The basic premise is that both individual and contextual characteristics play a role in health. This concern is captured by the search for so-called “neighborhood effects,” which generally refers to the study of how local context influences the health and well-being of individuals in a way that cannot be reduced to the properties of the individuals themselves.

Most of the research on neighborhood effects has focused on social and behavioral outcomes, including child cognitive and behavioral development, school dropout, educational attainment, crime and delinquency, substance use, sexual activity, contraceptive use, childbearing, income, and



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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 11 What Makes a Place Healthy? Neighborhood Influences on Racial/ Ethnic Disparities in Health over the Life Course Jeffrey D. Morenoff and John W. Lynch Our main purpose in this chapter is to suggest a conceptual framework for better understanding how characteristics of neighborhoods can affect racial/ethnic differences in health, with a special emphasis on health in aging populations. At the outset we should recognize that the specific studies in this field are sparse. However, we will try to draw from the more diverse sociological and epidemiological literature on neighborhoods and health to illustrate the potential for certain characteristics of neighborhoods to affect racial/ethnic health differences in aging. In recent years, epidemiologists and sociologists have become increasingly interested in studying the effects of local context on individual health and well-being. Although a long history of research shows that health status varies strongly across local, state, regional, and national settings (Murray, Michaud, McKenna, and Marks, 1998), what distinguishes the new generation of research on neighborhoods and health is its attention to investigating the multilevel causation of these differences. The basic premise is that both individual and contextual characteristics play a role in health. This concern is captured by the search for so-called “neighborhood effects,” which generally refers to the study of how local context influences the health and well-being of individuals in a way that cannot be reduced to the properties of the individuals themselves. Most of the research on neighborhood effects has focused on social and behavioral outcomes, including child cognitive and behavioral development, school dropout, educational attainment, crime and delinquency, substance use, sexual activity, contraceptive use, childbearing, income, and

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life labor force participation (see recent reviews by Gephart, 1997; Leventhal and Brooks-Gunn, 2000; Sampson, Morenoff, and Gannon-Rowley, 2002). Until recently, health outcomes had been noticeably absent from this list, but multilevel studies are becoming increasingly popular in health research. This new multilevel research on local social context and health has garnered wide attention in social epidemiology, as evidenced by the publication of four reviews of this literature in the past 3 years (Diez-Roux, 2002; Ellen, Mijanovich, and Dillman, 2001; Pickett and Pearl, 2001; Robert, 1999). One of the reasons that public health scientists have become so interested in local context is to better understand the striking and persistent racial and ethnic differences across a range of health outcomes that have eluded most efforts to explain them using data at the individual level (Krieger, 1994; Williams and Collins, 1995a). There are large racial/ethnic differences across many causes of morbidity and mortality, and even through casual observation it seems obvious that perhaps some of this health inequality is related to the different types of contexts, or “ecological niches,” into which different racial/ethnic groups are born, and within which they grow up, live, and work. As research on residential segregation demonstrates (Acevedo-Garcia, 2000; Cooper et al., 2001; Ellen, 2000; LaVeist and Wallace, 2000; Massey and Denton, 1993; Polednak, 1996) place-based disparities are of central importance to understanding race-based health disparities in the United States. Moreover, a better understanding of why place and context matter also promises to yield new insights and intervention strategies for addressing racial/ethnic inequalities in health. Thus, the potential of place-based research to inform health intervention strategies that target places as well as people has given further impetus to this research in public health (Macintyre, MacIver, and Sooman, 1993; Sooman, Macintyre, and Anderson, 1993). At this point, research on local context and health remains somewhat disengaged from recent theoretical and methodological developments in the sociological literature on neighborhoods. For example, whereas the sociological literature on neighborhood effects has taken a “process turn” in recent years and begun to focus more on the mechanisms that explain why neighborhoods matter (Sampson et al., 2002), most research on the neighborhood context of health is still attempting to establish that context matters. This is partly because most health research is framed in a paradigm where individual-level proximal influences—such as behaviors or biomarkers of pathogenic processes—take precedence over contextual factors (Krieger, 1994; Palloni and Morenoff, 2001; Schwartz, Susser, and Susser, 1999; Susser, 1998).1 To some extent neighborhood effects research on health remains mired in a “poverty paradigm” (Rowley et al., 1993) focusing mostly on the

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life association between Census-based indicators of community socioeconomic position and individual health outcomes, with a heavy emphasis on the deleterious effects of concentrated poverty and other forms of disadvantage. The main thrust of such studies has been to show that poorer places are associated with worse health outcomes, above and beyond the characteristics of the individuals who live there (Robert, 1999). This emphasis on disadvantage, to the exclusion of other facets of neighborhood environments, is partly the result of a lack of appropriate data, but we argue that it also reflects a paucity theory that can inform questions about how neighborhoods may affect specific types of health outcomes. In this chapter we discuss both the promises and shortcomings of this growing literature on local context and health. In doing so, we bring together epidemiological perspectives concerned with exposure measurement and mechanisms—what are the measurable characteristics of neighborhoods (exposures) that can plausibly influence different types of health-related outcomes (specific causal pathways)—with sociological concerns about how to conceptualize and analyze neighborhoods. Rather than engaging in a comprehensive literature review—excellent reviews already exist (e.g., Diez-Roux, 2001; Ellen et al., 2001; Pickett and Pearl, 2001; Robert, 1999; Yen and Syme, 1999)—in this chapter we will focus on issues relating to the current state of research on neighborhoods and health, the dimensions of neighborhood environments that may be related to health, the pathways through which neighborhoods translate into specific types of health outcomes, how neighborhood effects intersect with the study of aging and the life course, and selection processes relating to the sorting of individuals into neighborhoods. We also present an empirical analysis of the neighborhood context of mortality in Chicago neighborhoods and conclude by suggesting new directions for neighborhood research on health. THE CONCEPT OF NEIGHBORHOOD Robert Park and Ernest Burgess laid the foundation for urban sociology by defining local communities as “natural areas” that developed as a result of competition between businesses for land use and between population groups for affordable housing. A neighborhood, according to this view, is a subsection of a larger community—a collection of both people and institutions occupying a spatially defined area influenced by ecological, cultural, and sometimes political forces (Park, 1916). Suttles (1972) later refined this view by recognizing that local communities do not form their identities only as the result of free-market competition. Instead, some communities have their identity and boundaries imposed on them by outsiders. Suttles also argued that the local community is best thought of not as a single entity, but rather as a hierarchy of progressively more inclusive resi-

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life dential groupings. In this sense, we can think of neighborhoods as ecological units nested within successively larger communities. In practice, most social scientists and virtually all studies we assess rely on “statistical” neighborhoods that depend on geographic boundaries defined by the Census Bureau or other administrative agencies (e.g., school districts, police districts). Although administratively defined units such as Census tracts and block groups are reasonably consistent with the notion of overlapping and nested ecological structures, they offer imperfect operational definitions of neighborhoods for research and policy. However, the term “neighborhood” has been defined quite broadly in health research, encompassing units as small as block groups and as large as counties. Thus far there has been little systematic research into how geographic scale affects contextual estimates, although there is some evidence that estimates of place effects are stronger when using smaller geographic areas (Boyle and Willms, 1999). Increasingly, researchers have become interested in new methods that might help define neighborhoods in such a way that is more respectful of the logic of street patterns and possibly more reflective of the social networks of “neighboring” behavior (Coulton, Korbin, Chan, and Su, 2001; Grannis, 1998). One important avenue for future research is to explore whether and how such neighboring patterns vary across demographic subgroups. For example, children and the elderly may both face more geographical constraints on the range of social networks and routine activity patterns that could make the more proximate neighborhood environment more consequential in their daily lives (Booth, Owen, Bauman, Clavisi, and Leslie, 2000; Carstensen, Isaacowitz, and Charles, 1999). Race/ethnicity may also play a role in shaping the geographic reach of routine activities and social networks. Understanding how the concept of neighborhood varies across these demographic groups is critical in advancing research on neighborhood environments as sources of group disparities in health. WHAT DO WE KNOW ABOUT NEIGHBORHOODS AND HEALTH? One of the hallmarks of neighborhood effects research is its attention to the potentially confounding influences of individual-level attributes in making neighborhood-level inferences, either through the use of multilevel research designs and statistical methods, or through randomized experimental designs. Investigations in this field have attempted to unravel the extent to which characteristics of neighborhoods (contextual effects) influence health outcomes after accounting for the fact that neighborhoods are composed of people with different individual characteristics (compositional effects), who in some cases choose to live in different types of neighborhoods, or more likely are sorted into them by economic, political, and other

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life social processes. As we will discuss later, this beguilingly simple framing of the research objective raises important conceptual problems as to what should be considered a contextual or compositional effect. For example, at any one point in time an individual may “possess” a certain level of education, which could be considered an individual-level predictor of that person’s health status. Yet educational attainment is also the complex product of prior influences of the individual (e.g., innate characteristics), family (e.g., educational expectations), and social context (e.g., quality of schooling). Thus, the association between individual educational attainment and health could, in part, reflect the effects of prior social context, and yet its effect on health typically would be attributed to compositional rather than contextual factors. Thus, the line between compositional and contextual is conceptually very fuzzy, and is simultaneously a problem of not having appropriate data, appropriate methodology, and perhaps most importantly, appropriate sociological and epidemiological theory. The literature on neighborhood effects and health is expanding rapidly. One recent review (Pickett and Pearl, 2001) identified 25 multilevel studies of neighborhood effects on health, 23 of which reported significant associations between health and at least one measure of neighborhood socioeconomic status. Even in the 2 years since the publication of that review, the literature has grown substantially. We have identified more than 60 multilevel studies of health that encompass the following array of outcomes: Mortality: Specific outcomes include all-cause mortality (Anderson, Sorlie, Backlund, Johnson, and Kaplan, 1997; Bond Huie, Hummer, and Rogers, 2002; Bosma, van de Mheen, Borsboom, and MacKenbach, 2001; Ecob and Jones, 1998; Haan, Kaplan, and Camacho, 1987; Kaplan, 1996; LeClere, Rogers, and Peters, 1997; Malmstrom, Johansson, and Sundquist, 2001; Sloggett and Joshi, 1994, 1998; Veugelers, Yip, and Kephart, 2001; Waitzman and Smith, 1998a; Yen and Kaplan, 1999) and mortality due to specific causes, including heart disease, cancer, kidney disease, and injury (Alter, Naylor, Austin, and Tu, 1999; Cubbin, LeClere, and Smith, 2000; Garg, Diener-West, and Powe, 2001; LeClere et al., 1998; Waitzman and Smith, 1998a). Adult physical health status: This category includes studies of blood pressure (Davey Smith, Hart, Watt, Hole, and Hawthorne, 1998; Diez-Roux et al., 1997; Krieger, 1992; Merlo et al., 2001; Wilson, Kliewer, Plybon, and Sica , 2000), cholesterol (Davey Smith et al., 1998; Diez-Roux et al., 1997), coronary heart disease (Diez-Roux et al., 1997; Lee and Cubbin, 2002), respiratory function (Ecob, 1996; Humphreys and Carr-Hill, 1991), height and waist-hip ratio (Ecob, 1996; Krieger, 1992), indicators of obesity (Davey Smith et al., 1998; Ecob, 1996; Marmot et al., 1998; Robert, 1998; Sundquist, Malmstrom, and Johansson, 1999), lead expo-

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life sure among older adults (Elreedy et al., 1999), and survey-reported conditions such as functional limitations, chronic conditions, and self-rated health (Balfour and Kaplan, 2002; Chandola, 2001; Ecob, 1996; Humphreys and Carr-Hill, 1991; Malmstrom et al., 2001; Malmstrom, Sundquist, and Johansson, 1999; Shouls, Congdon, and Curtis, 1996; Stafford, Bartley, Mitchell, and Marmot, 2001). Infant and child health: Most of these studies are of birthweight (Buka, Brennan, Rich-Edwards, Raudenbush, and Earls, 2003; Ellen, 2000; Gorman, 1999; Morenoff, 2003; O’Campo, Xue, and Wang, 1997; Pearl, Braveman, and Abrams, 2001; Rauh, Andrews, and Garfinkel, 2001; Roberts, 1997; Sloggett and Joshi, 1998), but there are also some on infant mortality (Matteson, Burr, and Marshall, 1998), childhood asthma and respiratory illness (Morgan and Chinn, 1983), accidental injuries (Reading, Langford, Haynes, and Lovett, 1999), and emotional and behavioral problems (Caspi, Taylor, Moffitt, and Plomin, 2000; Kalff et al., 2001) among young children. Mental health: This category includes measures of depression, anxiety, and various other outcomes (Aneshensel and Sucoff, 1996; Katz, Kling, and Liebman, 2001; Marmot et al., 1998; Reijneveld and Schene, 1998; Ross and Jang, 2000; Schulz et al., 2000). Health behaviors: Outcomes in this group include substance use (Boardman et al., 2001; Diehr et al., 1993; Diez-Roux et al., 1997; Duncan, Jones, and Moon, 1998; Ecob and Macintyre, 2000; Finch, Vega, and Kolody, 2001; Ganz, 2000; Hart, Ecob, and Smith, 1997; Kleinschmidt, Hills, and Elliott, 1995; Krieger, 1992; Lee and Cubbin, 2002; Reijneveld and Schene, 1998; Robert, 1998; Schroeder et al., 2001; Sundquist et al., 1999), dietary practices (Diehr et al., 1993; Ecob and Macintyre 2000; Hart et al., 1997; Karvonen and Rimpela, 1996; Lee and Cubbin, 2002), and physical activity (Ecob and Macintyre, 2000; Lee and Cubbin, 2002; Robert, 1998; Ross, 2000b; Sundquist et al., 1999). Health services: Some studies use multilevel data to examine neighborhood differences in the availability of health services, including cardiopulmonary resuscitation (Iwashyna, Christakis, and Becker, 1999), cardiac procedures (Alter et al., 1999), and kidney transplants (Garg et al., 2001). With only a few exceptions (e.g., Sloggett and Joshi, 1994; Veugelers et al., 2001), nearly all of the multilevel studies we reviewed found that after controlling for individual-level characteristics, there is still an association between neighborhood environments and health outcomes. However, these studies varied widely in the way they operationalized the concept of neighborhood and measured neighborhood characteristics, making it difficult to reach a conclusion about the magnitude and substantive importance of these effects. The vast majority of the studies we reviewed focus on the deleterious effects of socioeconomic disadvantage using Census-based measures of local

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life area socioeconomic composition. The most common way to measure neighborhood socioeconomic status (SES) is through an index of socioeconomic deprivation/disadvantage (e.g., Boardman et al., 2001; Bosma et al., 2001; Caspi et al., 2000; Cubbin et al., 2000; Diez-Roux et al., 1997; Duncan et al., 1998; Ecob, 1996; Ecob and Jones, 1998; Ecob and Macintyre, 2000; Hart et al., 1997; Hart, Hole, and Smith, 2000; Malmstrom et al., 1999; Marmot et al., 1998; Morgan and Chinn, 1983; Reading et al., 1999; Reijneveld and Schene, 1998; Roberts, 1997; Sloggett and Joshi, 1994, 1998; Stafford et al., 2001; Sundquist et al., 1999; Wilson et al., 2000; Yen and Kaplan, 1999). However, some studies eschew the single index approach in favor of using single- or multiple-item indicators of neighborhood disadvantage, such as measures based on income, poverty, unemployment, public assistance, education, and occupational status (e.g., Ganz, 2000; Humphreys and Carr-Hill, 1991; Kaplan, 1996; Karvonen and Rimpela, 1996, 1997; LeClere et al., 1998; LeClere, Rogers, and Peters, 1997; Lee and Cubbin, 2002; O’Campo et al., 1997; Pearl et al., 2001; Robert, 1998; Ross, 2000a; Veugelers et al., 2001). Other studies take a categorical approach to measuring neighborhood disadvantage by constructing neighborhood typologies, such as the distinction between “poverty” and “nonpoverty” areas (Geis and Ross, 1998; Haan et al., 1987; Humphreys and Carr-Hill, 1991; Waitzman and Smith, 1998a). A smaller number of studies have analyzed other neighborhood compositional/structural factors such as racial/ethnic composition (Bond Huie et al., 2002; Cubbin et al., 2000; LeClere et al., 1997, 1998; Lee and Cubbin, 2002; Roberts, 1997), family structure (Cubbin et al., 2000; LeClere et al., 1997, 1998; Lee and Cubbin, 2002; Ross, 2000a; Veugelers et al., 2001), residential stability (Cubbin et al., 2000; Kaplan, 1996; Lee and Cubbin, 2002; Roberts, 1997; Ross, Reynolds, and Geis, 2000), population density/ urbanization (Cubbin et al., 2000; Iwashyna et al.,1999; Lee and Cubbin, 2002), and housing condition/owner occupancy (Kaplan, 1996; Karvonen and Rimpela, 1997; Lee and Cubbin, 2002; O’Campo et al., 1997; Roberts, 1997; Stafford et al., 2001). However, the evidence on how these factors affect health is much less consistent across studies. Neighborhood Context and Racial/Ethnic Disparities in Aging Health Given that race/ethnic minority groups are disproportionately exposed to disadvantaged social environments, it is not surprising that many researchers have looked to neighborhood environmental factors, such as residential segregation and the concentration of poverty, as potential explanations for racial/ethnic disparities in health (e.g., Williams and Collins, 1995b). To this point, however, only a few studies have explicitly made this connection. Two such studies track the mortality of respondents to the

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life National Health Interview Survey (NHIS) using the National Death Index (NDI). In the first of these studies, LeClere and colleagues (1997) used tract-level contextual data from the 1990 Census to explain racial/ethnic disparities in all-cause mortality among NHIS respondents from 1986 to 1990. The authors found that after adjusting for individual-level indicators of SES (i.e., income, education, and marital status), neighborhood characteristics fully explain the remaining mortality differential between African Americans and non-Hispanic whites, but not the mortality differential between Mexicans and whites. (Mexicans had lower mortality rates than whites, and neighborhood characteristics do not explain Mexicans’ mortality advantage.) In this study, the main contextual factor driving the convergence in the mortality differential between African Americans and whites was neighborhood racial/ethnic composition. In a follow-up study, Bond Huie and colleagues (2002) modified the NHIS-NDI data set by expanding the number of years of NHIS respondents (1986-1997), adding more individual-level control variables, and changing the definition of neighborhood from Census tracts to very small areas (VSAs). They found that the introduction of contextual variables reduced the mortality risk for African Americans and Puerto Ricans by 12 and 14 percent, respectively, but significant mortality disparities remained even after adjusting for neighborhood characteristics. As was the case in the study by LeClere and colleagues (1997), neighborhood characteristics explained fewer of the mortality disparities between whites and either Mexicans or other Hispanics.2 Although differences in model specification make it difficult to compare the results of the two NHIS-NDI studies, it does appear that neighborhood characteristics contribute substantially to the explanation of black-white mortality disparities in both studies, but less so to Mexican-white mortality differences. Another issue that has also received relatively little attention is whether neighborhood context is more predictive of health outcomes for certain age groups. Most of the available evidence on this topic also comes from multilevel studies of mortality. Two of these studies (Haan et al., 1987; Waitzman and Smith, 1998a) show that residence in a poverty area is more predictive of mortality among younger age groups than older age groups. Using data from the National Health and Nutrition Examination Survey (1971-1974), Waitzman and Smith (1998a) found that poverty area residence is associated with elevated mortality risk among 25- to 54-year-olds, but reduced mortality risk among 55- to 74-year-olds. The authors attribute the counterintuitive effect of poverty in the older age group to a “crossover” effect in which elderly survivors living in poverty areas may be selectively less frail than their counterparts in nonpoverty areas. In another study showing that neighborhood effects on mortality may be less pronounced among the elderly, LeClere and colleagues (1997) found that con-

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life textual characteristics account for a greater reduction in racial/ethnic mortality disparities within younger age groups (18 to 44 and 45 to 64) than within the oldest group (65 and over). However, this study does not report the results of age-specific regression coefficients for neighborhood covariates, so it is not clear whether the neighborhood effects themselves are stronger among the younger groups. Other mortality studies using the NHIS-NDI data set have failed to replicate the finding that neighborhood effects on mortality are weaker among the elderly. In one of these, Waitzman and Smith (1998b) showed that the metropolitan area-level concentration of poverty was associated with an elevated risk of mortality among respondents to the 1986-1994 NHIS in both the 30 to 44 and 65 and over age groups. In a more recent study using smaller geographic units to measure contextual effects (VSAs) and a longer time series of respondents to the NHIS (1986-1997), Bond Huie and colleagues (2002) found that most contextual covariates have slightly larger effects among the older age group (45 to 64) compared to the younger group (18 to 44). They also found interactions between age and some neighborhood covariates, such as immigrant composition, which is protective against mortality for the older group, but a risk factor for the younger group. Thus, the empirical evidence is mixed on the question of how contextual effects on mortality vary by age. The view that neighborhood context may be more salient for the elderly is corroborated by multilevel research focusing on health outcomes other than mortality. For example, Balfour and Kaplan (2002) found that self-reported neighborhood problems, such as excessive noise, inadequate lighting, and heavy traffic, were strongly associated with functional loss among participants aged 55 and over in their sample of adults from Alameda County, California. In perhaps the most extensive investigation of age variation in neighborhood effects thus far, Robert and Li (2001) hypothesize that neighborhood effects should actually be stronger among older adults because they may be more vulnerable to negative exposures such as pollution, crime, and weak social and medical services. In keeping with this hypothesis, their findings show that the association between neighborhood socioeconomic characteristics and health (survey reports of self-rated health and the number of chronic conditions) is weakest in young adulthood, but becomes progressively stronger in successively older age groups, peaks between ages 60 and 69, then gets weaker again at ages 70 and older. In sum, although there is relatively little research on how the relation between neighborhood environments and health may vary across demographic subgroups, the available evidence suggests that racial/ethnic differences in neighborhood context may account for a large proportion of racial/ethnic disparities in health (focusing primarily on mortality), but there is more disagreement on whether and how neighborhood effects vary across

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life age groups. A common limitation of the studies that have analyzed the connection between neighborhood environments and racial/ethnic health disparities is that they do not consider interactions between race/ethnicity and age. This is especially problematic in the case of mortality, where a large number of studies have found a black-white crossover in mortality curves at older ages (Hummer, Rogers, and Eberstein, 1998), implying that racial/ethnic disparities are not fixed entities, but moving targets that vary depending on which age groups are being compared. We will consider such interactions in an analysis of racial/ethnic disparities in mortality using multilevel data on all-cause mortality in Chicago neighborhoods. UNDERSTANDING WHY NEIGHBORHOODS MATTER Most of the previous research on neighborhood environments and health has been concerned with the question of whether neighborhoods, and specifically socioeconomic characteristics of neighborhoods, matter for the health of individuals. The overwhelming majority of these studies indicate that lower neighborhood socioeconomic status does appear to be related to poor health, net of individual characteristics. Without neglecting the importance of this question, we believe that research should begin to pay more attention to the question of why neighborhoods matter—what does the association between area socioeconomic status and individual health, even net of all other individual-level factors, mean? One way to answer this question is to explore interactions between neighborhood- and individual-level factors that might explain the individual circumstances under which neighborhoods influence individual health—or, considered another way, the neighborhood conditions under which individual-level factors influence health. Some studies have explored such “cross-level” interactions (e.g., Diez-Roux et al., 1997; Ecob and Macintyre, 2000; O’Campo et al., 1997; Rauh et al., 2001). Another strategy is to directly measure the neighborhood “mechanisms” that might explain the relationship between neighborhood SES and health (Morenoff, Sampson, and Raudenbush, 2001; Sampson et al., 2002). This calls for an infusion of new theory and new data. One problem with the current state of this research is that neighborhood characteristics are used somewhat interchangeably and with little theoretical justification in the search for neighborhood effects. Whereas many frameworks have been proposed for organizing individual-level predictors of health status into conceptual categories and for determining the order in which they should be entered into statistical models, health researchers are much less accustomed to thinking about neighborhood-level mechanisms and how they are interrelated. We propose a conceptual framework, consistent with a stress and adaptation perspective on how social

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life environments come to affect health (House, 2002; Lin and Ensel, 1989), that highlights the importance of stressful neighborhood conditions that may deleteriously affect health and the availability of resources from social relations that may counteract or buffer the impact of contextual stressors on health. Structural/Physical Environment Structural characteristics refer to properties of a neighborhood’s population composition that are typically measured as aggregations of individual-level attributes. In the health literature, the most commonly studied structural measures are indicators of socioeconomic and racial/ethnic composition. In the case of socioeconomic composition, concentrated poverty may be a marker of institutional abandonment. For example, poor neighborhoods may lack access to quality health services, nutritional food, and well-maintained recreational areas (Sooman et al., 1993). Disadvantaged neighborhoods may also expose residents to more dilapidated housing, pollutants, and sources of stress that include crime, violence, and overcrowding. In contrast, affluent areas may offer access to better health care, stores with nutritional food, recreational areas, and other institutional resources that promote good health. Thus, measures of socioeconomic composition could be proxies for a bundle of health risks associated with the concentration of disadvantage and protective factors associated with the concentration of affluence. The relationship between neighborhood racial/ethnic composition and health is more complex. On the one hand, measures of racial/ethnic composition are markers for residential segregation, and previous research demonstrates that segregation imposes multiple health risks on members of poor minority areas (Cooper et al., 2001; Ellen, 2000; LaVeist, 1993; Massey and Denton, 1993; Polednak, 1996). The health consequences of segregation are likely to overlap with those of concentrated disadvantage, but segregation could impose additional risks. For example, individuals who face barriers to residential mobility because of their race could face psychological risks associated with discrimination (Williams and Collins, 1995b). Moreover, studies have shown that African-American neighborhoods are more likely to suffer from institutional risk factors such as the proliferation of liquor stores and insufficient supplies of prescription drugs at local pharmacies (LaVeist and Wallace, 2000; Morrison, Wallenstein, Natale, Senzel, and Huang, 2000). On the other hand, ethnically homogeneous neighborhoods could also be havens for group resources. For example, some scholars have argued that Mexican culture emphasizes strong family support and reinforces healthy behaviors (Balcazar, Aoyama, and Cai, 1991; Scribner, 1996). Mexican women may be more likely to adhere

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life both individuals and their neighborhoods. Some existing data sets offer these possibilities, including national studies, such as the Panel Study of Income Dynamics (http://www.isr.umich.edu/src/psid/), and local area studies, such as the Project on Human Development in Chicago Neighborhoods (http://phdcn.harvard.edu/). Spatial perspectives on health: To gain a fuller appreciation of contextual effects on health it is also necessary to widen the geographic lens beyond the often arbitrary boundaries of statistically defined neighborhoods. A wider spatial perspective on health may also shed new light on racial/ethnic health disparities. For example, if African-American neighborhoods are embedded in more disadvantaged environments than are similarly endowed white neighborhoods, then the consequences of racial segregation may be greater and more systemic than previously thought (Morenoff et al., 2001). Patillo-McCoy’s (1999) ethnographic study of “Groveland,” a community in Chicago, suggests that black middle-class families face such a spatial (and structural) disadvantage. Despite networks of social control, she found that black middle-class families must constantly struggle to escape the problems of drugs, violence, and disorder that spill over from neighboring communities. Finally, from a public health viewpoint, understanding how and why spatial externalities occur may be critical in designing community intervention strategies. These findings carry with them both a caution that treating neighborhoods as “islands unto themselves” for the purposes of intervention is potentially misguided, but also the promise that if interventions can foster protective factors, such as social resources, they may spawn positive spatial externalities and thus benefit a wider geographic area. ENDNOTES 1.   Some public health researchers also use neighborhood variables, such as Census tract income, as proxies for unmeasured characteristics at the individual level, such as socioeconomic status (Alter et al., 1999; Geronimus and Bound, 1998; Krieger, 1992). 2.   In the Bond Huie et al. study (2002), Mexicans have significantly higher mortality than non-Hispanic whites in all models, while other Hispanics have significantly lower mortality than non-Hispanic whites. 3.   There are, however, two studies from the Project on Human Development in Chicago Neighborhoods (PHDCN) researchers relating neighborhood social processes to health (Buka et al., 2003; Morenoff, 2003). 4.   The idea of using Tilly’s (2002) classification theories to illustrate the theoretical importance of selection processes comes from Winship (2002), who refers to Tilly’s first type of theory as “substantive theory” and his second type as “methodological theory.” 5.   By merging the vital statistics data from death certificates with population data from the Census, we encounter several sources of measurement error. First, because the vital statistics data track death over the entire year, 1990, it is possible that some people who died were not recorded in the Census population counts, which represent a snapshot at one point in

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life     time. It is also possible that some people who were recorded in the Census population data may have died during 1990, but their deaths were not recorded in the vital statistics data. Empirically, we found that in several sociodemographic strata there were more deaths than population. Therefore it was necessary to add a constant of 15 people to each of the strata so that the numerator never exceeded the denominator. However, adding fictional people to the denominator necessarily lowers the mortality rate of each stratum. To check how this may have affected our results, we reran the models by adding higher numbers of people to the denominator (20, 25, and 30). We found that our findings were robust to all specifications, but that the magnitude of the mortality rates was sensitive to the number of people we added to the denominator. Thus we caution against making generalizations based on the absolute levels of mortality represented in our data. 6.   The project team cluster analyzed 1990 Census data in order to determine which tracts could be combined to form relatively homogeneous neighborhood clusters (NCs) with respect to distributions of racial/ethnic mix, SES, housing density, and family structure. Then they fine-tuned these combinations to ensure that the final NC boundaries would be consistent with major ecological barriers (e.g., railroad tracts, parks, and main thoroughfares) and local knowledge of neighborhood borders. The average NC contains 7,950 people. In comparison, the average Census tract contains 3,156 people, while the Local Community Area, another commonly used geographic unit in Chicago that is aggregated from Census tracts, has an average of 35,415 people. More details about the PHDCN sample design are available in previous publications (e.g., Sampson et al., 1997). Although the vital statistics data were geocoded to the level of the Census tract, we chose to use the somewhat larger neighborhood clusters in order to obtain more stable estimates of mortality within each neighborhood. 7.   We also ran models where age was specified with dummy variables for 17 of the 18 categories, and this yielded very similar findings. We present the linear, quadratic, and cubic specifications in the interest of parsimony. REFERENCES Aboderin, I., Kalache, A., Ben-Shlomo, Y., Lynch, J.W., Yajnik, C.S., and Kuh, D. (2002). Life course perspectives on coronary heart disease, stroke and diabetes. The evidence and implications for policy and research. Geneva, Switzerland: World Health Organization. Acevedo-Garcia, D. (2000). Residential segregation and the epidemiology of infectious diseases. Social Science and Medicine, 6(1), 45-72. Alter, D.A., Naylor, C.D., Austin, P., and Tu, J.V. (1999). Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction. New England Journal of Medicine, 341, 1359-1367. Anderson, R.T., Sorlie, P., Backlund, E., Johnson, N., and Kaplan, G.A. (1997). Mortality effects of community socioeconomic status. Epidemiology, 8, 42-47. Aneshensel, C.S., and Sucoff, C.A. (1996). The neighborhood context of adolescent mental health. Journal of Health and Social Behavior, 37, 293-310. Anselin, L. (2001). Spatial externalities, spatial multipliers, and spatial econometrics. Unpublished manuscript, University of Illinois, Urbana-Champaign. Axinn, W.G., and Yabiku, S.T. (2001). Social change, the social organization of families, and fertility limitation. American Journal of Sociology, 106, 1219-1261. Balcazar, H., Aoyama, C., and Cai, X. (1991). Interpretative views on Hispanics’ perinatal problems of low birth weight and prenatal care. Public Health Reports, 106, 420-426. Balfour, J.L., and Kaplan, G.A. (2002). Neighborhood environment and loss of physical function in older adults: Evidence from the Alameda County study. American Journal of Epidemiology, 155, 507-515.

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