neighborhoods and health: building evidence for local policy cross-site analysis kathy pettit and...

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


% 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


% 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


% 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


% 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


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


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

neighborhoods and health: building evidence for local policy cross-site analysis kathy pettit and...

Documents