Understanding Neighborhood, Redlining as Social Determinants of Health

Built environment

Built environment refers to the human-made structures that occupy a certain space. In terms of neighborhood, this includes things like sidewalks and walkability, green space, public transportation, playgrounds, and other structures that can influence patient health.

“Many people in the United States live in neighborhoods with high rates of violence, unsafe air or water, and other health and safety risks,” according to Healthy People 2030. “Racial/ethnic minorities and people with low incomes are more likely to live in places with these risks. In addition, some people are exposed to things at work that can harm their health, like secondhand smoke or loud noises.”

These factors all have a downstream impact on patient health. Individuals living in neighborhoods with high levels of secondhand smoke, for example, may experience poorer air quality, as might individuals living in urban areas.

Neighborhood violence

Neighborhood violence is a critical public health and population health topic. Sometimes referred to as community violence, neighborhood violence often impacts younger people and people of color, according to the Centers for Disease Control & Prevention.

“Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home,” CDC wrote on its website. “Examples include assaults or fights among groups and shootings in public places, such as schools and on the streets.”

Neighborhood or community violence has a direct impact on patient health, most experts agree. Instances of community violence, like a school shooting, represent a significant public health crisis, leading some medical trade groups like the American Medical Association to adopt policies advocating violence—and particularly firearm violence—prevention.

The acute physical impacts of neighborhood violence are clear and staggering; however, healthcare experts have also zeroed in on the long-term mental health consequences of high levels of neighborhood violence.

For example, 2019 data published in Health Affairs found that kids exposed to moderate or high neighborhood violence went on to have mental and physical health challenges, with the greater the childhood exposure the worse the health impacts. It is also worth mentioning the link between neighborhood violence, gun violence, and mortality.

Geographic barriers to care

Geographic barriers to care—literally living so far away from a healthcare provider that one does not end up accessing treatment unless symptoms are particularly dire—is an understood social determinant of health that most acknowledge affects those living in rural areas.

But neighborhood can also be an upstream indicator of geographic barriers to care, especially in the context of area walkability, access to public transportation, and neighborhood income.

For example, 2020 data in Health Affairs showed care access limitations by neighborhood income. Low-income neighborhoods typically only had hospitals with fewer ICU beds when compared to high-income neighborhoods, presenting a steep challenge for someone looking to get treatment when a hospital is facing high patient volumes.

Getting to a bigger hospital with more beds might be challenging if a patient does not have access to public transportation, their own ride, or walkable space.

Access to nutritious food, food security

Neighborhood can also be linked to another key social determinant of health: food security. Neighborhood can often determine the businesses that individuals visit; someone may not travel long distances to go to a certain business to buy a certain product.

In terms of food security, this means living a long distance from a bigger grocery store that stocks nutritious food options could sway food security and ultimately health.

And, conversely, the closer someone lives to a fast food restaurant or seller of junk food, the more likely they are to access that and see its health, according to 2019 data from NYU Langone.

“Our study indicates that living very close to food outlets with a lot of unhealthy, junk food choices is likely not good for reducing the risk of children being overweight or obese,” study senior investigator Brian D. Elbel, PhD, MPH, said in a statement.

“Just having food outlets a block farther away—and potentially less convenient or accessible—can significantly lessen children’s chances of being obese or overweight,” Elbel added.

How redlining impacts health disparities

Finally, racial segregation has molded neighborhood composition such that even decades-old policies like redlining can impact health outcomes.

By and large, living in a mostly-Black neighborhood—composition that likely stems from mid-century redlining—adversely impacts health outcomes. That may be due to other forms of structural racism, implicit bias from healthcare providers, and intersection with other social determinants of health listed above.

Redlining is a 20th Century mortgage practice of denying a loan based on the “desirability” of the neighborhood in which an individual wishes to purchase. Low-desirability neighborhoods tended to have a higher proportion of Black people living in them, setting off decades of disinvestment from these areas and perpetuating structural racism.

Now, in the 21st Century, the impacts of redlining can be seen across the social spectrum, including in health outcomes. For example, redlining has been linked to poor asthma outcomes and racial health disparities, according to researchers from UPMC.

Redlined districts have higher levels of air pollution, a key part of climate as a social determinant of health, which can exacerbate a chronic illness like asthma. Being that mostly Black, previously redlined neighborhoods have higher levels of air pollution, the researchers were able to identify a connection between redlining and racial health disparities.

“Air pollution induces structural changes in the lungs, causes inflammation, and damages cells lining the airway, all of which can exacerbate asthma,” said Sally Wenzel, MD, chair of Pitt Public Health’s Department of Environmental and Occupational Health.

“We are still seeing the long-term effects of the loss of generational capital and neighborhoods labeled as ‘toxic,’” added Wenzel, who is also the director of Pitt’s Asthma and Environmental Lung Health Institute at UPMC. “Institutional racism is something we, as clinicians, have to recognize as a real, continued threat to the health of our patients and one we must fight against.”

Neighborhood is a difficult social determinant of health to mitigate because of its intersection with several other social determinants of health. Moreover, healthcare providers often find themselves without the resources to truly address neighborhood as a social determinant of health.

On the provider level, screening for related SDOH like food security and referring to social services may quell the effect of neighborhood on overall wellness. However, it will likely take efforts in concert with public policymakers to truly move the needle. Investment in urban development, public safety, and better healthcare access will be key moving forward.