Structural racism in the built environment: Segregation and the overconcentration of alcohol outlets.

Structural racism, evidenced in practices like residential racial segregation, has been linked to health inequities. We examined the relationship between an adverse environmental factor (alcohol outlet overconcentration), segregated neighborhoods, and county alcohol policy in Louisiana and Alabama to investigate this link. Multilevel analysis revealed high outlet density associated with segregated counties and predominantly black census tracts in counties with restrictive alcohol policy. This inverse association between policies designed to limit alcohol availability and overconcentration of outlets in black neighborhoods warrants consideration by policymakers given links between outlet density and health inequities. Consideration of these findings in historical context suggests these policies may function as a contemporary actualization of the historical use of alcohol policy to subjugate black people in the South, now over-concentrating instead of prohibiting access.

Neighborhood disadvantage and racial disparities in colorectal cancer incidence: a population-based study in Louisiana.

PURPOSE: Colorectal cancer (CRC) continues to demonstrate racial disparities in incidence and survival in the United States. This study investigates the role of neighborhood concentrated disadvantage in racial disparities in CRC incidence in Louisiana. METHODS: Louisiana Tumor Registry and U.S. Census data were used to assess the incidence of CRC diagnosed in individuals 35 years and older between 2008 and 2012. Neighborhood concentrated disadvantage index (CDI) was calculated based on the PhenX Toolkit protocol. The incidence of CRC was modeled using multilevel binomial regression with individuals nested within neighborhoods. RESULTS: Our study included 10,198 cases of CRC. Adjusting for age and sex, CRC risk was 28% higher for blacks than whites (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.22-1.33). One SD increase in CDI was associated with 14% increase in risk for whites (RR = 1.14; 95% CI = 1.10-1.18) and 5% increase for blacks (RR = 1.05; 95% CI = 1.02-1.09). After controlling for differential effects of CDI by race, racial disparities were not observed in disadvantaged areas. CONCLUSION: CRC incidence increased with neighborhood disadvantage and racial disparities diminished with mounting disadvantage. Our results suggest additional dimensions to racial disparities in CRC outside of neighborhood disadvantage that warrants further research.

The Social Determinants of Health Core: Taking a Place-Based Approach.

INTRODUCTION: There is growing recognition that health disparities research needs to incorporate social determinants in the local environment into explanatory models. In the transdisciplinary setting of the Mid-South Transdisciplinary Collaborative Center (TCC), the Social Determinants of Health (SDH) Core developed an approach to incorporating SDH across a variety of studies. This place-based approach, which is geographically based, transdisciplinary, and inherently multilevel, is discussed. METHODS: From 2014 through 2016, the SDH Core consulted on a variety of Mid-South TCC research studies with the goal of incorporating social determinants into their research designs. The approach used geospatial methods (e.g., geocoding) to link individual data files with measures of the physical and social environment in the SDH Core database. Once linked, the method permitted various types of analysis (e.g., multilevel analysis) to determine if racial disparities could be explained in terms of social determinants in the local environment. RESULTS: The SDH Core consulted on five Mid-South TCC research projects. In resulting analyses for all the studies, a significant portion of the variance in one or more outcomes was partially explained by a social determinant from the SDH Core database. CONCLUSIONS: The SDH Core approach to addressing health disparities by linking neighborhood social and physical environment measures to an individual-level data file proved to be a successful approach across Mid-South TCC research projects.

Racial/Ethnic Disparities in Health-Related Quality of Life among Participants with Self-Reported Diabetes from NHANES 2001-2010.

PURPOSE: The purpose of this study is to investigate the racial/ethnic disparities in health-related quality of life (HRQOL) among adults with self-reported diabetes and identify the different risk factors related to HRQOL for specific racial/ethnic groups in the United States. METHODS: National Health and Nutrition Examination Survey (NHANES) 2001-2010 participants (ages 20 years and older) who were self-identified as non-Hispanic white, non-Hispanic black, or Hispanic and with self-reported diabetes were included in the analysis (n = 2594). The Centers for Disease Control and Prevention's HRQOL-4 was used to assess factors associated with HRQOL through multivariate logistic regression models with survey weighting. Stepwise model selection was applied to select the most significant factors for HRQOL in each racial/ethnic group. RESULTS: Hispanic participants were less likely to report 14 or more mentally unhealthy days and activity-limited days compared to non-Hispanic white counterparts, adjusting for age, sex, education, marital status, family poverty-income ratio (PIR), body mass index, smoking status, insurance coverage, and diabetes duration. Current smoking status and obesity were significantly associated with worse HRQOL among whites and blacks. Marital status predicted better HRQOL only among Hispanics. Having insurance coverage predicted better HRQOL among both blacks and Hispanics. Increased family PIR had a favorable association with the 4 HRQOL domains consistently among all races/ethnicities. CONCLUSION: Minimal racial/ethnic disparities in HRQOL were observed among US adults with self-reported diabetes. Support is offered for more individualized health care and communication with patients to target care and interventions that improve health and quality-of-life indicators.

Multilevel spatiotemporal change-point models for evaluating the effect of an alcohol outlet control policy on changes in neighborhood assaultive violence rates.

Many previous studies have suggested a link between alcohol outlets and assaultive violence rates. In 1997 the City of New Orleans adopted a series of policies, e.g., increased license fee, additional enforcement staff, and expanded powers for the alcohol license board. The policies were specifically enacted to address the proliferation of problem alcohol outlets believed to be the source of a variety of social problems including assaultive violence. In this research, we evaluate the impact of a city level policy in New Orleans to address the problem alcohol outlets and their influence on assaultive violence. The spatial association between rates of assaultive violence at the census tract level (n=170) over a ten year period raises a challenge in statistical analysis. To meet this challenge we developed a hierarchical change-point model that controls for important covariates of assaultive violence and accounts for unexplained spatial and temporal variability. While our model is somewhat complex, its hierarchical Bayesian analysis is accessible via the WinBUGS software program. Keeping other effects fixed, the implementation of the new city level policy was associated with a decrease in the positive association between census tract level rates of assaultive violence and alcohol outlet density. Comparing several candidate change-point models using the DIC criterion, the positive association began decreasing the year of the policy implementation. The magnitude of the association continued to decrease for roughly two years and then stabilized. We also created maps of the fitted assaultive violence rates in New Orleans, as well as spatial residual maps which, together with Moran's I's, suggest that the spatial variation of the data is well accounted for by our model. We reach the conclusion that the implementation of the policy is associated with a significant decrease in the positive relationship between assaultive violence and the off-sale alcohol outlet density.

Misspecification of the effect of race in fixed effects models of health inequalities.

The purpose of this study is to characterize the different results obtained when analyzing health inequalities data in which individuals are nested within their neighborhoods and a single level model is used to characterize risk rather than a multilevel model. The inability of single level models to characterize between neighborhood variance in risk may affect the level of risk attributed to black race if blacks are differentially distributed in high risk neighborhoods. The research replicates in Los Angeles an approach applied by a different group of researchers in Massachusetts (Subramanian, Chen, Rehkopf, Waterman, & Krieger, 2005). Single level and multilevel models were used to analyze Los Angeles County, California, US all-cause mortality data for the years 1989-1991, modeled as 29,936 cells (deaths and population denominators cross-tabulated by age, gender, and race/ethnicity) nested within 1552 census tracts. Overall blacks had 1.27 times the risk of mortality compared to whites. However, multilevel models demonstrated considerable between census tract variance in mortality for both blacks and whites which was partially explained by neighborhood poverty. Comparing the results of equivalent single level and multilevel models, the mortality odds ratio for blacks compared to the white reference group reversed itself, indicating greater risk for blacks in the single level model and lower risk in the multilevel model. Adding an area based socioeconomic measure (ABSM) to the single level model reduced but did not remove the discrepancy. Predictions of mortality risk for the interaction of race and age group demonstrate that all single level models exaggerated the mortality risk associated with black race. We conclude that characterizing health inequalities in mortality for blacks using single level models, which do not account for the cross level interaction created by the greater likelihood of black residence in neighborhoods where the risk of mortality is greater regardless of race, can exaggerate the risk of mortality attributable to the individual level effects of black race.

Neighbourhood alcohol availability and gonorrhea rates: impact of social capital.

Social capital and income inequality have been proposed as important mediators of the relation between the material environment and health outcomes. We determined whether indicators of social capital are (i) associated with neighbourhood gonorrhea rates, and (ii) mediate the relation between alcohol outlet density and gonorrhea rate. Longitudinal analyses of age- and sex-adjusted gonorrhea cases reported from 1990 to 1996 in the 445 census tracts affected by the 1992 civil unrest in Los Angeles, California was conducted. The role of alcohol outlets was assessed both as tracts with surrendered off-sale outlets due to the civil unrest and annual off-sale alcohol outlet density rates. Tract level voting rates were used as one indicator of social capital, while neighbourhood structure conducive to social organization was used as another. Neighbourhoods with greater voting over time and greater endogenous social organization experienced 1.9 and 67.2 fewer gonorrhea cases per 100,000. Results also reveal a partial mediating role of social capital on the relationship between alcohol outlet density and gonorrhea rate. The alcohol environment may have a direct or partially mediated role in infectious disease outcomes such as gonorrhea. Our findings support the importance of continuing controls and limits on off-premise alcohol outlet density, as a potential means of reducing gonorrhea rates and increasing social capital.

Determinants of social capital indicators at the neighborhood level: a longitudinal analysis of loss of off-sale alcohol outlets and voting.

OBJECTIVE: Neighborhoods represent a unique level of analysis where social and material determinants of social capital may be lodged. The 1992 civil unrest in Los Angeles following the Rodney King verdict provided an opportunity to determine if a change in the material environment (i.e., the loss of off-sale alcohol outlets) resulted in a subsequent change in a potential indicator of social capital-civic engagement-as measured by voting rates. METHOD: Longitudinal analyses of voting rates between 1990 and 1996 for the 480 census tracts affected by the civil unrest were conducted. Tracts that lost and did not lose off-sale alcohol outlets were compared using piecewise hierarchical models that accounted for both time-varying and census-tract-level confounders, as well as for spatial autocorrelation. RESULTS: In the post-unrest period, the increase in voting was significantly greater in tracts where there was a loss of alcohol outlets (beta = 0.393, p < .05). Findings remained after taking into account time-varying effects of the changes in ethnicity, gender, and age; and baseline effects of voting, potential for social organization, outlet density, and deprivation. The loss of alcohol outlets was associated with an average 3.0% increase in voting rate in the postunrest period, translating into an average increase of 50-212 voters per tract, depending on the size of the tract. CONCLUSIONS: Loss of off-sale alcohol outlets in the 1992 civil unrest was associated with increased voting at the census tract level. Findings support the concept that loss of alcohol outlets in the neighborhood environment may contribute to the development of social capital, possibly through social network expansion.