Chapter 7

Handbook of Health Social Work, 2nd Edition

COMMUNITY AND HEALTH

• Individuals tend to live neat their similar economic circumstances.

• Individuals of a particular ethnicity or cultural background often prefer to live near people that are similar to their ethnicity and culture.

• These practices in the U.S. have resulted in limited housing opportunities for many groups

• These neighborhood differences do not reflect the wishes or best interests of all populations

COMPOSITION OF U.S. NEIGHBORHOODS

The characteristics of Neighborhood Disparity are: Economic circumstances Racial segregation Educational segregation Employment discrimination

NEIGHBORHOOD DISPARITY

• In 2000 the typical White American lived in a neighborhood that was– 80.2% White–6.7% African American–7.0% Hispanic–3.9% Asian.

• Typical African American –51.4% African American–33% White–11.4% Hispanic–3.3% Asian

• Typical Hispanic –45.5% Hispanic –36.5% White–10.8% African American–5.9% Asian

• Typical Asian–17.9% Asian–54% White–9.2% African American–17.4% Hispanic

RACIAL SEGREGATION

• The 2000 U.S. census reported that 3.5 million people live in neighborhoods with poverty concentrations of 40% or greater (Orr et al., 2003)

• In schools attended by the average African American Student 38.3% of students are poor

• Contrast to the average Hispanic student that attended a school where 44% of the students are poor

• Schools attended by the average White American student only 19.6% of the students are poor

ECONOMIC SEGREGATION

• There is evidence that public school segregation is increasing in the U.S.

• In 1980, 62.9% of African American students attended schools with minority enrollment over 50%

• In 1998 it had risen to 70.2%, while more than one third of African American students attended schools with minority enrollment of 90%-100%

• Between 1968 and 1998, the proportion of Hispanic students who attended schools with minority enrollments of 90%-100% increased from 23.1% to 36.6% (Orfield, 2001)

EDUCATIONAL SEGREGATION

Communities with high proportions of minority residents often have higher unemployment rates and lower average incomes.

Among Chicago’s 77 community areas, unemployment rates in the most economically depressed areas varied from 25.8% to 33.5% in 2000.

The proportion of African American residents varied from 85.5% to 97.8%, and median household income was $17,209

EMPLOYMENT DISCRIMINATION

• A 2007 U.S. survey of 23,393 adults shows that poor health continues to affect lower income individuals to a greater extent than those with higher incomes

• Those with household incomes below the federal poverty line, 29.5% reported having hypertension and 4.2% reported having a stroke

• Only 21.9% reported having hypertension and 1.9% reported having a stroke of those with incomes greater than or equal to 200% of the poverty threshold

• Rates of diabetes and kidney disease were 12.2% and 2.6% among the poor and 6.6% and 1.1% among the not poor

HEALTH DIFFERENCES BY INCOME

• Obesity among those with incomes of less than $35,000 was also more prevalent (28.9%) compared with those who had incomes of $100,00 or more (19.8) (Pleis & Lucas)

• In 2007, 26.8% of those with annual incomes less than $35,000 smoked, while 12.4% of those with annual incomes of $100,000 or did so

• Incomes of $100,000 or more, 92.2% had a usual place of care, while 77.4% of those with incomes less than $35,000 reported a usual place of care

HEALTH DIFFERENCES BY INCOME CONTINUED

• According to the National Health Interview Survey, the prevalence of obesity was– 35.1% among African

Americans– 27.5% among Hispanics– 25.4% among White

Americans • Prevalence of hypertension

and stroke– 22.2% and 2.2% among White

Americans– 31.7% and 3.7% among

African Americans– 20.6% and 2.5% among

Hispanic Americans

• Rates of diabetes and kidney disease – 6.8% and 1.4% among White

Americans – 12.3% and 2.5% among

African Americans– 11.1% and 1.8% among

Hispanic Americans• Reported a usual place of

care– 84.5% for White Americans– 85.5% for African Americans– 74.4% for Hispanic Americans

DISEASE PREVALENCE & ACCESS TO CARE BY ETHNICITY

• In 2006 the life expectancy at birth was 73.2 years for African American infants and 78.2 years for white infants.

• Death of infants younger than 1 year, the rat per 100,000 was lower among White infants (576.0) compared to African American (1,303.1) and Hispanic infants (590.6) in 2006

• For cause-specific mortality, the age-adjusted Black: White ratio was 1.3 for diseases of the heart, 1.2 for malignant neoplasms, 1.5 for cerebrovascular disease, 2.1 diabetes mellitus, and 2.7 for hypertensive disease

LIFE EXPECTANCY AND MORTALITY BY ETHNICITY

• The 2007 National Health Interview Survey reported those with household incomes less than $35,000 reported higher rates of psychological distress compared to those with incomes of $100,000 or greater in the following areas:–Feeling sad all of most of the time (5.7% vs. 0.7%)–Feeling hopeless all or most of the time (4.3% vs. 0.5%)–Feeling worthless all or most of the time (3.8% vs. 0.4%)–Everything is an effort all or most of the time (9.0% vs. 1.7%)

PSYCHOLOGICAL DISTRESS BY INCOME

Feeling sad all or most of the time was higher among African American people (3.7%) compared to White people (2.6%)

Reporting everything is an effort all or most of the time was also more common among African American respondents (6.8%) compared to White respondents (4.4%)

PSYCHOLOGICAL DISTRESS BY ETHNICITY

Those with higher education tend to have lower mortality rates compared with those who have less education

In 2006 the age-adjusted mortality rate (per 100,000) among those with fewer than 12 years of education was 528.8 compared to those with 13 or more years of education, the rate was 200.0 (Heron et al., 2009)

INCOME/ETHNICITY AND HEALTHY BY EDUCATION

• Low income and low educational attainment are risk factors of homelessness

• This is associated with poor health, higher rates of HIV, tuberculosis, hypertension, diabetes, substance abuse, and trauma

• Homeless people are more likely to experience complications from chronic diseases

• These health conditions are risk factors due to increased exposure to adverse environmental conditions, reduced access to regular medical care, prioritizing food and shelter above medical concerns, and exposure to violence.

• Minorities have higher rates of homelessness compared to White Americans

• A recent survey of homeless shelters in 16 cities found that 47% of residents were African American

HOMELESSNESS

Health outcomes have been associated with neighborhood features including Healthcare resourcesPresence of green space for exerciseAvailability of healthy foodsQuality of housingNorms and valuesCrime

HEALTH EFFECTS BY NEIGHBORHOOD FEATURES

• Contextual features include neighborhood norms and values, number of parks, quality of schools, and amount of crime in a given neighborhood

• Compositional features include individual ethnicity, income, education, and health behaviors

• A way to distinguish between the two features is to perform a multilevel analysis, a statistical approach that categorizes data by level, and assess the relative effect of each level on the outcome

CONTEXTUAL AND COMPOSITIONAL FEATURES

An individual’s social circumstances and physical environment are ways that communities influence health.

Social circumstances include neighborhood educational level, employment, income disparities, poverty, crime, and social cohesion.

A community in which social relationships are easy to make and maintain is likely to be a healthier environment than a community in which residents are afraid to venture from their homes because of concerns about crime.

Physical environment refers to sanitation; quality of housing, food, and water; and exposure to environmental toxins and pathogens.

Public health and safety programs often monitor these environmental characteristics.

Living conditions and environmental quality also reflect national priorities and the relative amount of resources dedicated to public health programs.

MECHANISMS BY WHICH COMMUNITIES INFLUENCE HEALTH

• The medical model of health care focuses on treatment of disease after it is diagnosed

• First-world countries have increasingly embraces the medical model

• This has led to tremendous advances in surgery and medicine • The model deemphasizes disease prevention and treatment

of disease after it is established has become extremely expensive.

• Cuba is often cited as an example of the health success that can be attained through public health practices.

MEDICAL MODEL OF HEALTH CARE

• Shortfalls in medical care account for approximately 10% of early mortality, and adverse social circumstances and environmental exposures account for 15% and 5% of premature mortality in first-world countries.

• In third-world countries, access to and quality of medical care as well as social circumstances and environmental exposures likely play much greater roles in early mortality.

DETERMINANTS OF HEALTH

• Some experts in the U.S. are beginning to advocate for changes in education, housing, and employment policies as ways to improve national health.

• Studies have shown that adults are more likely to exercise in their neighborhood if they perceive it to be safe or if they have access to parks, trails, and other areas conducive to physical activity.

• Healthy foods such as fruits and vegetables are less available and more expensive in poor neighborhoods compared with wealthy neighborhoods.

• Obesity has been linked to increased portion sizes and consumption of high-fat foods, such as those served at fast-food restaurants.

ADVOCATING FOR HEALTH

• Patterns of social relationships and sexual practices are tied to the economy and culture of the community.

• Residents of higher-income communities tend to meet their partners at school or work and form longer-term relationships more frequently

• Residents of low-income communities are more likely to be in polygamous or short-term, transactional relationships.

RELATIONSHIPS AND SEXUAL PRACTICES

• Newer tests and procedures may be available in urban areas long before they become standard practice in rural communities.

• A recent study of U.S. patients with cardiac arrest found survival differed markedly by location of arrest.

• The survival rate was 9% in rural areas, 14% in suburban areas, and 23% in urban sites.

• These differences were attributed to several factors related to the communities, including medical response time, transport time, resuscitative skill, and type of medical intervention.

ACCESS TO MEDICAL CARE BY COMMUNITY

Community effects can impact individual health at any or all stages of the life course, including gestation, childhood, adolescence, adulthood, and end of life.

Interest in community effects on health has spurred interest in health geography and area analysis of epidemiological data.

COMMUNITY EFFECTS AND THE LIFE COURSE

Many investigators have examined the relationship between the social experience of pregnant women and the health of their newborns.

A study of 176 U.S. cities found that mortality among African American infants was positively associated with the city’s index of segregation.

It was suggested that higher African American infant mortality rates in highly segregated cities reflect older housing stock, higher levels of stress and environmental toxins, and reduced levels of city and medical care services in minority communities.

In Santiago, Chile, women living in high-violence neighborhoods in 1985 and 1986 were five times more likely to experience pregnancy complications compared with women living in less violent neighborhoods.

In a series of studies, Barker (1998) found evidence that low birth weight is a risk factor of coronary artery disease, stroke, diabetes, and hypertension later in life.

GESTATION

Effects on health can be direct, involving physiologic pathways, or indirect, involving long-term health behaviors.

Using National Health and Nutrition Examination Survey data from 1988-1994, Bernard and Mcgeehin found blood lead levels (BLL) were greater than or equal to 5mcg/dL in 42.5% of children living in housing built before 1946 but only 14.1% of children living in housing built after 1973.

Cognitive changes associated with lead toxicity include a decrement in IQ, distractibility, poor organizational skills, and hyperactivity.

Maltreatment including neglect, physical abuse, and sexual abuse appear to be related to community social organization.

The highest risk of maltreatment occurred among children who lived in neighborhoods characterized by poverty, high numbers of children per adult resident, population turnover, and concentration of female-headed households.

CHILDHOOD

• Depending on the study, neighborhood socioeconomic status comprises one or more of the following community characteristics:– Percentage of college-educated residents– Percentage of residents living below poverty– Percentage of managerial/professional residents– High school dropout rate– Levels of female family headship– Female employment

• In the National Survey of Adolescent Males, a high rate of neighborhood unemployment was associated with impregnating someone and fathering a child.

• Five conceptual models or pathways of influence of the relationship between neighborhood characteristics and adolescent behaviors are:– Institutional resources – Collective socialization – Contagion or epidemic effects– Competition– Relative deprivation

ADOLESCENCE

• The dimensions of the neighborhood environment that have been linked to illness and mortality among adults include:– Crime rates– Ratio of homeowners to renters– Percentage of residents receiving public assistance– Index of segregation – Percentage of unemployment – Percentage of households headed by women– Income– Education– Collective efficacy – Housing value

• For both White Americans and African Americans, heart disease rates were higher in the poorest census tracts

• Neighborhoods with high proportions of female-headed households may be associated with increased financial, physical, and emotional stress

ADULTHOOD

End-of-life issues “are resolved in ways that depend on where the patient happens to live, not on the patient’s preferences or the power of care to extend life”.

In some communities the chance of being hospitalized at the time of death was 20%; in other communities, this proportion was 50%.

During the last 6 months of life, the chance of spending a week or more in an intensive care unit also varied by community, ranging from less than 4% to over 20% of patients.

END OF LIFE

• Some social workers address problems at the individual level, others work for change at the community level, and others do both.

• Moving to a new neighborhood can lead to disruption of social networks and loss of support systems.

• Minorities or individuals with lower incomes may also feel stressed in high-income neighborhoods, especially if there is little ethnic or economic diversity.

• The implication for social workers and other service providers is that relocation is not without cost, and every effort should be made to help individuals access services and develop support networks in their new communities.

• Social workers can play a key role in advocating economic reform and directing community improvement. Social workers observe firsthand the effects of unemployment, low wages, and lack of health insurance.

• Social workers often lead the way in bringing attention to resource-poor communities.

IMPLICATIONS OF SOCIAL WORK PRACTICE