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NEIGHBORHOODS AND HEALTH:Building Evidence for Local Policy
Cross-Site Analysis
Kathy Pettit and Tom Kingsley
The Urban Institute
NNIP Collaborative effort - Urban Institute and local partners in twenty cities
Partners operate local information systems - Recurrently updated neighborhood data- Multiple topics-data sources
Success from 3 kinds of innovations1. Technological2. Institutional3. Using information for change
Competitive procurement this study- 9 proposals, 5 selected
Research questions Neighborhood conditions and health outcomes
Basic relationships health, demographic and contextual variables - Multiple cities, consistent definitions
- Variations across sites
How relationships change over time- Long time series almost all sites- Specifically – 1990s trends in high-poverty areas
Feasibility – tract level analysis
5 sites - major differencesMetro area population growth- Slow in Cleveland and Providence- Rapid in Denver, moderate Indianapolis, Oakland
Metropolitan Population Growth
11
-3
14
6
18
5
14
2
30
1615
5
-5
0
5
10
15
20
25
30
35
Largest 100 Metros Cleveland Denver Indianapolis Oakland Providence
Po
pu
lati
on
Gro
wth
%
1980-90
1990-00
Racial/ethnic contrasts - Cleveland, Indianapolis: high share black- Denver, Providence: rapid Hispanic growth- Oakland: minority-majority expanding
Percent of Population by Race (central city/county)
0
10
20
30
40
50
60
70
90 00 90 00 90 00 90 00 90 00
Cleveland Denver Indianopolis Oakland Providence
% o
f p
op
ula
tio
n b
y r
ac
e
% Hispanic
% Black
Concentrated Poverty
Devastating effects, inner-city neighborhoods- Loss of the middle-class, institutions and role models- Concentration “magnifies poverty and exacerbates its
effects.”
Concentration - seemingly inexorable trend- Major increases in 1970s and 1980s share of poor in high-poverty tracts
What happened in the 1990s?
Nationally – important reduction in
concentrated poverty- Share of poor: down in high categories up in middle categories
0
5
10
15
20
25
30
35
<10 10-20 20-30 30-40 40+Tract Poverty Rate
Perc
ent o
f Poo
r Pop
ulatio
n
1980
1990
2000
5 sites, overall poverty rate - change not dramatic, 1990s
Poverty Rate - Metro Area
12 12
10 10
9
10
12
11
8
9
10
12
0
2
4
6
8
10
12
14
16
18
Largest 100 Metros Cleveland Denver Indianapolis Oakland Providence
Po
ve
rty
Ra
te,
%
1990
2000
Concen. poverty: bigger changes- major drops, Cleveland, Denver - modest declines, Indianapolis, Oakland - increase in Providence
Percent of Poor - High Poverty Neighborhoods - Metro Area
46
25
19
1618
33
8
1315
29
0
5
10
15
20
25
30
35
40
45
50
Cleveland Denver Indianapolis Oakland Providence
% o
f p
oo
r in
hig
h-p
ov
ert
y t
rac
ts
1990
2000
% adults without HS degree
Improvements in high-povertyneighborhoods – all sites
Pct. of Population with no High School Degree - high poverty neighborhoods
51
42
46 46
49
3840
36
45 44
0
10
20
30
40
50
60
Cleveland Denver Indianapolis Oakland Providence
% p
op
.>2
5,
no
hig
h s
ch
oo
l d
eg
ree
1990
2000
% adults without HS degree
but major gaps remain rerest of city
Pct. of Population with no High School Degree - high vs. low poverty tracts, 2000
3840
36
4544
15
1817
23
30
0
5
10
15
20
25
30
35
40
45
50
Cleveland Denver Indianapolis Oakland Providence
% p
op
.>2
5,
no
hig
h s
ch
oo
l d
eg
ree
hi poverty neigh. 2000
other tracts 2000
% households rec. pub. assistance
Major declines, high-povertyneighborhoods – all sites
Pct. Households Receiving Public Assistance - high poverty neighborhoods
35
1918
38
26
17
6
8
18
15
0
5
10
15
20
25
30
35
40
Cleveland Denver Indianapolis Oakland Providence
% h
ou
sh
eo
lds
re
ce
ivin
g p
ub
lic
as
sis
tan
ce
1990
2000
% households rec. pub. assistance
again, major gaps remain
Pct. Households Receiving Public Assistance - high vs. low poverty neighborhoods
17
6
8
18
15
3 3 3
7
8
0
2
4
6
8
10
12
14
16
18
20
Cleveland Denver Indianapolis Oakland Providence
% h
ou
se
ho
lds
re
ce
ivin
g p
ub
lic
as
sis
tan
ce
hi poverty neigh. 2000
other tracts 2000
Rental vacancy rates
Tight housing markets exacerbate other problems
Rental Vacancy Rate - high poverty neighborhoods
13
16
12
7
12
13
4
15
5
7
0
2
4
6
8
10
12
14
16
18
Cleveland Denver Indianapolis Oakland Providence
Re
nta
l v
ac
an
cy
ra
te
1990
2000
Research approach Neighborhood conditions and health outcomes
Scan of Birth and Mortality Outcomes - Diversity of levels and trends within & between
cities
Examine relationships between health and neighborhood conditions - Bivariate and Multivariate analyses
Maternal and Infant Health Indicators
Pct. low-birth weight infants
Pct. of births to mothers with early prenatal care
Teen birth rates (age 15-19)
Age-adjusted mortality rate
Infant mortality rate
Gaps between poor/non-poor vary
Confirmed that gaps exist between high-poverty and non-poor tracts
BUT gaps vary by city and indicator
- Gaps most consistent for prenatal care
- Gaps generally lower in Oakland, Providence
(smaller geographies)
Pct. low birth weight births, 1998/2000Large gaps seen in black/white cities
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Cleveland Denver Indianapolis Oakland Providence
Non-poor tracts
High poverty tracts
Teen Birth Rates in Denver
Percent of Births to Teen Mothers Age 15-19 1998-20000 - 55 - 1010 - 1515 - 40Less than 10 Births 1998
Poverty Greater than 30 Percent 1990
Some progress in health outcomesacross all neighborhoods
Improvements in both high-poverty and non-poor neighborhoods
BUT generally not enough to close gaps Direction and speed of change varies by
city and indicator - Oakland generally saw most improvements- Teen birth, infant mortality rates dropped in all- Some troubling signs in Providence
Age-Adjusted Death RatesBegin together, but paths diverge
700
800
900
1000
1100
1200
1300
1400
1990/92 1991/93 1992/94 1993/95 1994/96 1995/97 1996/98 1997/99 1998/2000
Nu
mb
er
of
De
ath
s p
er
1,0
00
p
op
ula
tio
n
ClevelandDenverIndianapolisOaklandU.S. Total
High poverty census tracts
Oakland:Change in Early Prenatal Care Rates
Change in Percent of Mothers Receiving Prenatal Care in the First Trimester 1997-1999-5 - 55 - 1515 and GreaterLess than 10 Births 1998
Poverty Rate Greater then 30 Percent 1990City of Oakland
Change in Early Prenatal Care Rates 1997-1999
Source: Alameda County Public Health Department
Lessons from Introductory Scan
Improvements are possible
Racial/ethnic differences
- Change in teen births
- Low birth rates
Policy and programs can have impact
- Healthy Start
- Campaign for Healthy Babies
Pathways of Neighborhood Effects on Health (Ellen et al. 2001)
Physical Stressors
Social Stressors
Neighborhood-based Networks & Norms
Neighborhood Institutions & Resources
Static Research Hypotheses
Poorer birth & mortality outcomes will be associated with:
- higher levels of minority and immigrant population
- higher shares of low-income households
- higher levels of social risk factors
- poor housing quality
- higher crime rates
- more mobile and transient population
Dynamic Research Hypotheses
Some relationships will remain positive, but have decreased in strength over the 1990s
- high minority tracts and poor birth and mortality outcomes
- lower-income tracts and lower prenatal care rates
- lower-income tracts and higher low-birth weight rates
Socioeconomic Links Hold True
Poorer birth & mortality outcomes will be associated with:- higher levels of minority and immigrant population
» True except for foreign-born with low-birth weight & mortality rates
- higher shares of low-income households
» True for all measures (poverty, income, TANF, public assistance)
- higher levels of social risk factors
» True for all measures (No HS, female-headed HH with children, unemployed)
Physical, Social Stressors MatterSocial Network Proxies Mixed
Poorer birth & mortality outcomes will be associated with:- poor housing quality
» True for all measures (older housing, overcrowded, home values and mortgage amounts)
- higher crime rates» Not true for prenatal care, strongest with teen birth
rates- more mobile and transient population
» True for renter-occupancy & vacancy, mobility» Not true for change in population
Mixed results in link between non-white areas & poor health outcomes Some relationships will remain positive,
but have decreased in strength over the 1990’s:
- High minority tracts and poor birth and mortality outcomes
» True for low birth weight
» Not true for prenatal care and pct. Hispanic
» Not true for teen birth (much higher correlations) or mortality rates (about the same)
Again, mixed results in link between low-income areas & poor health outcomes
Some relationships will remain positive, but have decreased in strength over the
1990’s:
- lower-income tracts and lower prenatal care rates
» True but only slight drop in relationship
- lower-income tracts and higher low-birth weight rates
» True for all measures of income
Multivariate Regression
To test independent relationships of birth/mortality outcomes with neighborhood context variables
To test how much variation the neighborhood context variables explained
To test shifts over time for significance
Regression Model
Neighborhood Indicators
- Pct. African-American, Pct. Hispanic- Average Family Income- Pct. population not employed- Pct pop > age 5 who moved in past 5 years
Dummy Variables
- City, year, and interaction of city & year
Regression Summary
Regression strongest for prenatal care rates
- R-Squared: .45 (teen births) to .77 (prenatal care)
Neighborhood variables did explain some variation
- Pct. population not employed had highest coefficient
Conditions specific to time and place matter
- not just due to racial or income change
How well do neighborhood conditions explain differences in rates?
Reference City is Cleveland
Denver Indianapolis Oakland Providence
Percent of births to mothers receiving prenatal care in first trimester
Average difference in city rates, 1991 - 1999 -11.0 -6.5 -1.2 -16.2
Difference due to five tract characteristics in modelPercentage points -5.4 1.9 -7.3 -8.4
Difference due to unobserved characteristics in modelPercentage points -5.5 -8.4 6.1 -7.8
Testing for significance of change inunobserved characteristics
-15
-10
-5
0
5
10
1991 1992 1993 1994 1995 1996 1997 1998 1999
Dif
fere
nc
es
in
re
gre
ss
ion
-ad
jus
ted
me
an
s f
or
ea
rly
pre
na
tal
ca
re r
ate
s
Cleveland
Denver
Indianapolis
Oakland
Providence
Reference is Cleveland 1999 rate
Differences in Early Prenatal Care Rates
NEIGHBORHOODS AND HEALTH:Building Evidence for Local Policy
Cross-Site Analysis
Kathy Pettit and Tom Kingsley
The Urban Institute