Redlining Linked to Experience with SDOH, Higher Stroke Prevalence

Social determinants of health like educational attainment, poverty, language barriers, and provider workforce shortages are linked to the impact redlining has on clinical outcomes, underscoring how institutional racism drives these social factors, according to researchers from Montefiore Medical Center in New York.

Particularly, the study found a link between redlining and incidence of stroke, adding that the other SDOH are factors linked between redlining and health outcomes. Said otherwise, because redlining determines resources in certain neighborhoods, those who live there are more likely to experience lower educational attainment, poverty, language barriers, and provider workforce shortages, the researchers wrote in JAMA Network Open.

This study follows others that outline the link between redlining and health outcomes. Redlining is a 20th Century practice that designated many inner-city, mostly Black neighborhoods as hazardous for housing investment. This left many financial resources, plus other social goods, out of reach for those living in low-rated neighborhoods.

“While the practice officially ended in 1968 with the passage of the Fair Housing Act, the socioeconomic impacts remain,” the researchers explained in the study’s introduction. “Formerly redlined neighborhoods have less access to quality housing stock, transportation, schools, green space, sanitation services, and employment opportunities in the present day.”

This latest study looked foremost at whether stroke disparities line up with the original redlining designations—best, desirable, declining, and hazardous. It also looked at how redlining designations were linked with common social determinants of health.

Using data for 2,117 census tracts in New York City, plus data about stroke prevalence from the CDC 500 Cities Project from between 2014 and 2018, the researchers found a clear link between redlining and stroke. A neighborhood’s historical redlining score, which the researchers called HRS, was independently linked with community-level stroke incidence.

“While further research is needed, these results suggest that there may be residual effects of HRS on community stroke risk in certain New York City communities that are additive to classic SDOH defined by the Healthy People Framework,” the researchers said.

Moreover, the researchers identified a link between certain social determinants of health and historically redlined neighborhoods. Key social determinants of health associated with higher stroke incidence included educational attainment, poverty, language barriers, and provider workforce shortages.

These SDOH may be the result of the disinvestment that happened under redlining; a neighborhood that has been divested may not have high-performing schools, well-paying jobs, or hospitals to employ healthcare professionals. The researchers noted that historical redlining score helped create the social determinants of health that drive stroke incidence.

The researchers also acknowledged the plausibility of the weathering hypothesis, which states that the stress that compounds from exposure to interpersonal and structural racism can impact health outcomes, including risk for stroke. That theory may also apply to the stress of living in a disinvested community, the team said.

Notably, the researchers observed a lower stroke prevalence among Black and Hispanic people after adjusting for risk factors, SDOH, and historical redline score. This indicates that race is not a biological indicator of health outcomes, but rather an “identifier of social position,” the researchers said. Race is social, not biological.

These findings add to the literature about the impact redlining has had on health outcomes. In July 2022, researchers reported that historically redlined neighborhoods now see a higher level of cardiometabolic risk factors. A separate June 2022 study found a link between relined districts and asthma.

Uncovering these links cannot un-do the racist practices in America’s history. However, it can help identify areas for tailored health and social welfare interventions, experts have indicated.