Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas.

Federally qualified health centers (FQHCs) improve access to care for important health services (e.g., preventive care), particularly among marginalized and underserved communities. However, whether spatial availability of FQHCs influences care-seeking behavior for medically underserved residents is unclear. The objective of this study was to examine the relationships of present-day zip-code level availability of FQHCs, historic redlining, and health services utilization (i.e., at FQHCs and any health clinic/facility) in six large states. We further examined these associations by states, FQHC availability (i.e., 1, 2-4 and ≥5 FQHC sites per zip code) and geographic areas (i.e., urbanized vs. rural, redlined vs. non-redlined sections of urban areas). Using Poisson and multivariate regression models, we found that in medically underserved areas, having at least one FQHC site was associated with greater likelihood of patients seeking health services at FQHCs [rate ratio (RR) = 3.27, 95%CI: 2.27-4.70] than areas with no FQHCs available, varying across states (RRs = 1.12 to 6.33). Relationships were stronger in zip codes with ≥5 FQHC sites, small towns, metropolitan areas, and redlined sections of urban areas (HOLC D-grade vs. C-grade: RR = 1.24, 95%CI: 1.21-1.27). However, these relationships did not remain true for routine care visits at any health clinic or facility (ß = -0.122; p = 0.008) or with worsening HOLC grades (ß = -0.082; p = 0.750), potentially due to the contextual factors associated with FQHC locations. Findings suggest that efforts to expand FQHCs may be most impactful for medically underserved residents living in small towns, metropolitan areas and redlined sections of urban areas. Because FQHCs can provide high quality, culturally competent, cost-effective access to important primary care, behavioral health, and enabling services that uniquely benefit low-income and marginalized patient populations, particularly those who have been historically denied access to health care, improving availability of FQHCs may be an important mechanism for improving health care access and reducing subsequent inequities for these underserved groups.

Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis.

BACKGROUND: Redlining was a racialized zoning practice in the U.S. that blocked fair access to home loans during the 1930s, and recent research is illuminating health problems in the current residents of these historically redlined areas. However, this work has not yet been holistically summarized. Here, we present the first systematic review and meta-analysis comparing health outcomes in redlined versus non-redlined neighborhoods in U.S. cities. METHODS: We extracted relevant articles in PubMed, Web of Science, Cochrane and Science Direct databases published from January 2010 to September 2021. RESULTS: The search revealed 12 studies on preterm births (n = 3), gunshot-related injuries (n = 2), cancer (n = 1), asthma (n = 1), self-rated health (n = 1), multiple health outcomes (n = 2), heat-related outcomes (n = 1) and COVID-19 incidence and mortality (n = 1). A meta-analysis of three studies found the odds of having preterm birth was significantly higher (OR = 1.41, 95% CI: 1.05, 1.88; p = 0.02) among women living in redlined areas compared to those in non-redlined areas. Review of other outcomes revealed that gunshot-related injuries, asthma, heat-related outcomes, and multiple chronic conditions were worse in redlined areas, while associations with cancer varied by cancer type. In terms of cause-specific mortality, one study revealed no link between residential redlining and infant mortality rate, while one study on COVID-19 outcomes was inconclusive. CONCLUSIONS: Overall, this review presents evidence that living in historically redlined areas is associated with increased risk of multiple serious adverse health outcomes. Further research on mechanisms, remediation, and neighborhood-level interventions is needed to strengthen the understanding of the impacts of redlining on health.

Food system dynamics structuring nutrition equity in racialized urban neighborhoods.

BACKGROUND: The food system is a social determinant of health and a leverage point for reducing diet-related racial inequities. Yet, food system interventions have not resulted in sustained improvement in dietary outcomes for underrepresented minorities living in neighborhoods with a history of disinvestment. Research is needed to illuminate the dynamics structuring food systems in racialized neighborhoods to inform intervention development. OBJECTIVES: To conduct participatory research examining the complexity and inequity of food systems in historically redlined neighborhoods to identify feedback mechanisms to leverage in efforts to transform system outcomes for racial equity. METHODS: We conducted a mixed-methods study in Cleveland, Ohio, USA from 2018 to 2021 using participatory system dynamic modeling with 30 academic and community partners, in-depth qualitative interviews with 22 key stakeholders, and public convenings with 250 local food policy council affiliates. Data were synthesized into causal loop diagrams depicting feedback mechanisms reinforcing or balancing neighborhood-level food system dynamics. RESULTS: We identified 10 feedback mechanisms structuring nutrition equity, which was identified as a meta-goal for food systems in racialized neighborhoods. Feedback mechanisms were organized in 3 domains: 1) meeting basic food needs with dignity (i.e., side hustle, government benefits, emergency food assistance, stigma, and stereotypes); 2) local food supply and demand dynamics (i.e., healthy food retail, job security, food culture, and norms); and 3) community empowerment and food sovereignty (i.e., community power, urban agriculture, risk of gentrification). Five exogenous factors moderate feedback dynamics: neighborhood crisis, neighborhood investments, household costs, government benefit funding, and voter participation. CONCLUSIONS: We identified nutrition equity as an overarching goal for local food systems, which reflects a state of having freedom, agency, and dignity in food traditions resulting in people and communities healthy in body, mind, and spirit. It is a transformative goal designed to spur system-level interventions that further racial equity through improved local food system dynamics.

Fixes that Fail: A system archetype for examining racialized structures within the food system.

Access to fresh and healthy food within a neighborhood has been identified as a social mechanism contributing to community health. Grounded in the understanding that challenges related to equity within a food system are both structural and systemic, our research demonstrates how systems thinking can further understandings of food system complexity. Within systems thinking, we provide an illustration of how system archetypes offer an analytic tool for examining complex community issues. We map semi-structured interview data from community stakeholders (N = 22) to the "Fixes that Fail" system archetype to illuminate systemic challenges, such as incarceration and poverty, that structure food system inequity in urban communities. Within our research, the "Fixes that Fail" archetype provided a narrative interpretive tool for unveiling complexity within the food system and interdependencies with racialized systems such as criminal justice and labor markets. This system archetype provided an accessible approach for generating narratives about systemic complexity, the production of inequity through racialized forces, and opportunities for transformation.

Association of childhood stress with late-life dementia and Alzheimer's disease: the KIHD study.

Background: There remains a dearth of life-course studies analyzing childhood environment and late-life chronic illness. In particular, few have addressed possible early-life predictors of dementia. This study examines relationships between childhood stress and later-age dementia, specifically Alzheimer's disease (AD). Methods: We used data from 2682 men in the population-based Kuopio Ischemic Heart Disease Risk Factor Study who participated in extensive baseline health examinations and interviews between 1984 and 1989, when they were between 42 and 61 years of age. Childhood events were documented in these structured interviews. We created a composite childhood stress variable that included living in custody or an orphanage, experience of crisis in childhood, having problems with teachers and emigrating because of war. Data on incident cases of dementia, including AD, were obtained through 2014 via national health register linkages. Risk of developing dementia was estimated using Cox regression adjusting for age, education, income and prior/existing diseases at baseline. Results: Childhood stress was associated with increased risk of dementia (HR = 1.86, 95% CI: 1.12-3.10). Associations remained statistically significant after adjustment for age, education, income and other covariates (HR = 1.93, 95% CI: 1.14-3.25). Associations were marginally significant with AD, with HRs of similar magnitude. Conclusions: Childhood stress plays an important role in late-life dementia risk among men. Support systems should be developed for children suffering from stressful conditions. Further research examining childhood social and environmental effects on later morbidity, in diverse populations, is necessary to develop a holistic understanding of life-course disease burden.