Access to health care: does neighborhood residential instability matter?

Many Americans do not have access to adequate medical care. Previous research on this problem focuses primarily on individual-level determinants of access such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed medical care, however, has not received much attention. We address this gap in the literature by investigating the association between neighborhood residential instability and access to health care. Using individual-level data from the 2000 Medical Expenditure Panel Survey and block-group level data from the 2000 decennial census, we find that individuals who live in neighborhoods with high residential turnover have worse health care access than residents of other neighborhoods. This association persists even when the prevalence of poverty, the supply of health care, and a variety of individual characteristics are held constant. We offer explanations for these findings and suggest directions for future research.     

Neighborhood disadvantage, disorder, and health.

We examine the question of whether living in a disadvantaged neighborhood damages health, over and above the impact of personal socioeconomic characteristics. We hypothesize that (1) health correlates negatively with neighborhood disadvantage adjusting for personal disadvantage, and that (2) neighborhood disorder mediates the association, (3) partly because disorder and the fear associated with it discourage walking and (4) partly because they directly impair health. Data are from the 1995 Community, Crime, and Health survey, a probability sample of 2,482 adults in Illinois, with linked information about the respondent's census tract. We find that residents of disadvantaged neighborhoods have worse health (worse self-reported health and physical functioning and more chronic conditions) than residents of more advantaged neighborhoods. The association is mediated entirely by perceived neighborhood disorder and the resulting fear. It is not mediated by limitation of outdoor physical activity. The daily stress associated with living in a neighborhood where danger, trouble, crime and incivility are common apparently damages health. We call for a bio-demography of stress that links chronic exposure to threatening conditions faced by disadvantaged individuals in disadvantaged neighborhoods with physiological responses that may impair health.     

Neighborhood disadvantage, stress, and drug use among adults

This paper explores the relationships among neighborhood disadvantage, stress, and the likelihood of drug use in a sample of adults (N = 1,101). Using the 1995 Detroit Area Study in conjunction with tract-level data from the 1990 census, we find a positive relationship between neighborhood disadvantage and drug use, and this relationship remains statistically significant net of controls for individual-level socioeconomic status. Neighborhood disadvantage is moderately associated with drug related behaviors, indirectly through increased social stressors and higher levels of psychological distress among residents of disadvantaged neighborhoods. A residual effect of neighborhood disadvantage remains, net of a large number of socially relevant controls. Finally, results from interactive models suggest that the relationship between neighborhood disadvantage and drug use is most pronounced among individuals with lower incomes.     

Neighborhood disadvantage and anger among older adults: social comparisons as effect modifiers

Using data from a sample of 1,136 adults ages 65 and older in the District of Columbia and two adjoining counties in Maryland, we examine the association between neighborhood structural disadvantage and levels of anger. In addition, we test whether subjective financial comparisons with neighbors modify those effects differently for elders at different levels of income. We find that the association between neighborhood disadvantage and anger is positive among lower-income elders who feel financially advantaged relative to their neighbors. In contrast, the association between neighborhood disadvantage and anger is positive among higher-income elders who feel financially disadvantaged relative to their neighbors. Irrespective of income, neighborhood disadvantage is unrelated to anger among people who feel financially similar to their neighbors. We discuss the implications of our findings for the study of neighborhood context and health, underscoring interrelationships among inequality, social comparisons, and the stress process.     

Neighborhood Effects in Temporal Perspective

Theory suggests that neighborhood effects depend not only on where individuals live today, but also on where they lived in the past. Previous research, however, usually measured neighborhood context only once and did not account for length of residence, thereby understating the detrimental effects of long-term neighborhood disadvantage. This study investigates the effects of duration of exposure to disadvantaged neighborhoods on high school graduation. It follows 4,154 children in the PSID, measuring neighborhood context once per year from age 1 to 17. The analysis overcomes the problem of dynamic neighborhood selection by adapting novel methods of causal inference for time-varying treatments. In contrast to previous analyses, these methods do not "control away" the effect of neighborhood context operating indirectly through time-varying characteristics of the family, and thus they capture the full impact of a lifetime of neighborhood disadvantage. We find that sustained exposure to disadvantaged neighborhoods has a severe impact on high school graduation that is considerably larger than effects reported in prior research. Growing up in the most (compared to the least) disadvantaged quintile of neighborhoods is estimated to reduce the probability of graduation from 96% to 76% for black children, and from 95% to 87% for nonblack children.     

Mapping Elder Mistreatment Cases: Interactions Between Mistreatment,Dementia, Service Utilization,Access to Services,and Disadvantage

Typical explanations of elder mistreatment have focused on individual-level models. The current study adds to the literature by considering the neighborhood context in which reports of elder mistreatment are made to protective services. Using geographic information system software, the distribution of 751 adult protective services (APS) reports from three cities in southeastern Virginia is analyzed. Results suggest that Alzheimer's cases are distributed differentially across cities and that in one city, reports primarily come from disadvantaged areas. The results also suggest that clients from disadvantaged areas are more likely to refuse services. Implications for policy, theory, and future research are provided.     

Neighborhood structural disadvantage,collective efficacy,and self-rated physical health in an urban setting

Our analyses examine the role neighborhood structural characteristics--including concentrated disadvantage, residential instability, and immigrant concentration--as well as collective efficacy in promoting physical health among neighborhood residents. Using data from the 1990 census, the 1994 Project on Human Development in Chicago Neighborhoods Community Survey, and the 1991-2000 Metropolitan Chicago Information Center-Metro Survey, we model the effects of individual and neighborhood level factors on self-rated physical health employing hierarchical ordered logit models. First, we find that neighborhood socioeconomic disadvantage is not significantly related to self-rated physical health when individual level demographic and health background are controlled. Second, individuals residing in neighborhoods with higher levels of collective efficacy report better overall health. Finally, socioeconomic disadvantage and collective efficacy condition the positive effects of individual level education on physical health.     

Racial Residential Segregation,Perceived Neighborhood Conditions,and Self-Rated Health: The Case of Houston,Texas

Previous research has linked racial residential segregation to a number of poor health outcomes. Yet, the mechanisms that could account for this association remain poorly understood and have seldom been empirically tested in the literature. In an analysis of the Houston area, we test one potential mechanism—perceived neighborhood conditions, as measured by two indices for neighborhood disorder and environmental quality. Using individual-level health data from a survey of Houston residents and neighborhood-level sociodemographic data from the U.S. Census, we estimate a series of multilevel models. We find that black and Latino segregation are linked to the perceived neighborhood disorder index, but no such relationship for the environmental quality index. Moreover, we find that both indices are related to poor self-rated health in that residents who evaluate their neighborhood conditions negatively are more likely to evaluate their health as poor. We also find a direct effect of black and Latino segregation on poor self-rated health, and that perceived neighborhood disorder partially mediates this relationship. We do not find a mediation effect for environmental quality. The results suggest that in order to improve the health of these communities, both residential segregation and neighborhood conditions need to be addressed.     

Toward a New Conceptualization of Suburbs: A Theoretical and Empirical Exploration

Abstract

The objective of this research is to see whether characteristics of the neighborhood in which a person lives influence the likelihood of having a gun in the household. I use my 1995 “Community, Crime and Health” multilevel data set, a survey of a probability sample of 2,482 Illinois adults with linked census information on the respondent's census tract, zip code, city and county from the STF3 of the 1990 Census. Logistic regression shows that gun ownership is low in neighborhoods where a high percentage of adults are college-educated. Adjustment for individual-level race, ethnicity, sex, age, education, income, and household structure indicates that the presence of well-educated neighbors affects the likelihood of gun ownership, over and above individual characteristics. This relationship appears to be due to the normative climate, not to perceived threat, since neighborhood disorder does not significantly affect the likelihood of having a gun in the house. Previous victimization, however, is positively associated with having a gun in the household. In addition, people who are college-educated themselves are less likely to have a gun in the household.     

Unemployment Duration and Disability: Evidence from Portugal

This paper studies the relationship between having a disability and unemployment duration by focusing on individuals registered at Portuguese job centers. Despite its relevance, because disabled people are likely to occupy disadvantaged positions in the labor market, it has received little attention in the literature. As different disabilities affect unemployment duration differently, we distinguish different types of disabilities and shed light on disability-specific support policies. We apply a discrete time hazard model with unobserved heterogeneity to microdata from the Instituto do Emprego e Formação Profissional, which are free from self-reporting problems in disability identification. We find lower reemployment probabilities for many groups of disabled people: individuals with impairment in general functions, disfiguring, speech and visual disorders, muscle-skeletal and other organ impairments experience the more disadvantaged positions. Decomposition analysis indicates that part of the disadvantage is due to differences in returns rather than to differences in characteristics. These findings suggest that the disadvantage of disabled people in the labor market is not only explained by a different distribution of characteristics but especially by the interaction of their characteristics with the work environment. Policy implications are discussed.     

Resource effects on access to long-term care for frail older people

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Do work commutes moderate the association between perceived neighborhood disorder and psychological distress?

ABSTRACT

Although numerous studies show that living in a neighborhood that is characterized by disorder (crime and dilapidation) can be psychologically distressing, very few studies have considered the element of exposure time or duration of exposure to adverse neighborhood environments. In this paper, we explore the intersection of commuting, mental health, and the subjective experience of neighborhood disadvantage and impoverished community life. Using data from the Welfare, Children, and Families project (2001), a probability sample of 1057 low-income women with children living in Boston, Chicago, and San Antonio, we test whether the association between neighborhood disorder and psychological distress is moderated or attenuated by commuting time and distance. Our results show that although neighborhood disorder is associated with higher levels of anxiety, depression, and somatization, disorder tends to be less distressing for residents who are able to spend time away from these environments through longer commuting times and distances. In other words, working away from one’s neighborhood of residence may help to mitigate the adverse psychological consequences of neighborhood disorder. Our findings support previous research on the stress process and neighborhood disorder. Our work builds on the commuting literature by re-conceptualizing commuting time and distance as protective resources for disadvantaged populations.     

The urban neighborhood and cognitive functioning in late middle age

This study examines the association of cognitive functioning with urban neighborhood socioeconomic disadvantage and racial/ethnic segregation for a U.S. national sample of persons in late middle age, a time in the life course when cognitive deficits begin to emerge. The key hypothesis is that effects of neighborhood on cognitive functioning are not uniform but are most pronounced among subgroups of the population defined by socioeconomic status and race/ethnicity. Data are from the third wave of the Health and Retirement Survey for the birth cohort of 1931 to 1941, which was 55 to 65 years of age in 1996 (analytic N = 4,525), and the 1990 U.S. Census. Neighborhood socioeconomic disadvantage has an especially large negative impact on cognitive functioning among persons who are themselves poor, an instance of compound disadvantage. These findings have policy implications supporting "upstream" interventions to enhance cognitive functioning, especially among those most adversely affected by neighborhood socioeconomic disadvantage.     

LESS ACCESS,WORSE QUALITY

High-quality child care is a boon for children and buffers some of the long-term negative effects of growing up in straitened circumstances. Yet, just one in seven Canadian children has access to regulated care. Within this, poor children have worse access and are over-represented in lower-quality care arrangements. Canada's policy architecture, as reviews of Winnipeg, Quebec, and Vancouver demonstrate, generates inequities of access and quality that reproduce neighborhood socioeconomic gradients of class and racialization. Poor children are systematically disadvantaged by a national approach that relies on privatized partnerships with the voluntary sector to implement public child care policy. Equalizing poor children's access to quality child care remains a pressing Canadian challenge, and will require policy and delivery redesign.     

NEIGHBORHOOD DISADVANTAGE, SOCIAL CAPITAL, STREET CONTEXT, AND YOUTH VIOLENCE

This article integrates arguments from three perspectives on the relationship between communities and crime—constrained residential choices, social capital, and street context perspectives—to specify a conceptual model of community disadvantage and the violence of individual adolescents. Specifically, we propose that status characteristics (e.g., race, poverty, female headship) restrict the residential choices of families. Residence in extremely disadvantaged communities, in turn, increases the chances of violent behavior by youths by influencing the development and maintenance of community and family social capital, and by influencing the chances that youths are exposed to a criminogenic street context. We assess our conceptual model using community contextual and individual-level data from the National Longitudinal Study of Adolescent Health. Our findings suggest that individual or family status characteristics influence violence largely because of the communities in which disadvantaged persons and families reside. Although we find that community social capital does not predict individual violence, both family social capital and measures of an alternative street milieu are strong predictors of individual violence. Moreover, our street context variables appear to be more important than the social capital variables in explaining how community disadvantage affects violence.     

Disadvantage and Discrimination Compounded: the experience of Pakistani and Bangladeshi parents of disabled children in the UK

This paper discusses a qualitative and quantitative study of the circumstances of 20 Pakistani and Bangladeshi families with one or more severely disabled children living in Birmingham, England. Parents and other adult carers were interviewed using a combination of structured questionnaires and a semi-structured interview schedule focusing on the families' material circumstances, their use of formal services, informal care arrangements, and aspects of the parents' social and psychological well-being. The study suggests that previous national surveys of disabled families may have under-estimated the extent of material disadvantage, while it confirms that health and social care professionals should not assume that Pakistani and Bangladeshi parents have recourse to high levels of extended family support. The combination of disadvantaged circumstances and difficulties in securing access to appropriate services, which are found for the majority of families with a disabled child, was particularly acute for these ethnic minority families, suggesting the additional dimension of institutional racism.     

The cost of caregiving: wage loss among caregivers of elderly and disabled adults and children with special needs

Sixty-one percent of the adults caring for elderly and disabled family members and 53% of parents of children with special needs are employed. Yet studies examining the experience of employed caregivers of children with special needs and elderly or disabled adult family members have not examined the impact on earnings or the workplace policies that might help reduce the conflicts between work and caregiving. This study begins to fill this gap using data from a nationally representative US survey of American adults. We find that employees who live with a child with a health problem are 48% more likely to have lost wages. Each adult with health issues that an employee is responsible for raises the chances of wage loss by 29%. At the same time, access to paid leave for family health needs reduces the likelihood of wage loss by 30%, and having a supportive supervisor reduces the odds of experiencing wage loss by 37%. Implications for employers and US policy-makers are discussed.     

Disparities in Access to Health Care Among Middle-Aged and Older Adults with Disabilities

Disability is increasing among middle-aged adults and, reversing earlier trends, increasing among older adults as well. Disability is experienced disproportionately by Black and lower socioeconomic status (SES) individuals. We used Medical Expenditure Panel Survey data to examine health care disparities in access to health care for middle-aged (31 to 64 years of age) and older (65+ years of age) adults with disabilities by race and ethnicity, education, and income (n = 13,174). Using logistic regression, we examined three measures of potential (e.g., usual source of care), and three measures of realized (e.g., counseling related to smoking) access. Middle-aged and older minority individuals with disabilities had lower relative risks of having usual sources of care and higher relative risks of having suboptimal usual sources of care (e.g., a place rather than a person) than White adults with disabilities. There were SES effects observed for middle-aged adults with disabilities across most measures that were, for certain measures, more pronounced than SES effects among older adults with disabilities. These findings are important, since health resources (e.g., a usual source of care) may mediate relations among disability, morbidity, and mortality. Policy actions that may mitigate the disparities we observed include financial incentives to support access to an optimal usual source of care and mechanisms to foster behavioral interventions related to smoking and exercise. Ensuring that these actions address the specific concerns of individuals with disabilities, such as physical accessibility and provider cultural competency, is essential.