How Important Are Our Neighborhoods and Built Environments in Shaping Our Health?
Published on Jan 17, 2024. Updated on Jan 18, 2024.
With nearly 66% of Americans owning a home, many of us take where we live for granted, choosing our homes based on what's available in a given area and what we can afford to rent, buy, or build. Yet, when considering the broader aspects of community health and well-being, the significance of where we live and the environment we live in becomes clear. It's not just about the physical places we inhabit; it's about how our environment influences and shapes our daily lives and long-term health.
Let's take a deep dive into how our neighborhoods and built environments affect our overall health and well-being.
The Link Between Neighborhood, Built Environment, and Health
To understand the vital link between our environment and health, let's begin with a quick review of Social Determinants of Health (SDOH). The SDOH encompasses non-medical factors in our lives that can affect our health. They include economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social inclusion. Each SDOH plays an important role in health outcomes and contributes to identifying and addressing the systematic and unjust differences, or disparities, among different social groups, contributing to inequities and shedding light on how SDOH influences the health and well-being of individuals and communities.
Neighborhoods and built environments include the design, infrastructure, and planning of the physical spaces where we live, work, and engage in daily activities, and they play a pivotal role in shaping health outcomes; it's all about how these places are set up, designed, and planned. Quality housing, green spaces, and essential services play a crucial role in promoting fair health opportunities and positively impacting diverse populations.
For example, consider this scenario. You step outside your front door, greeted by the sights and sounds of your surroundings. You hear the joyful noise of children playing, neighbors chatting, and maybe even the distant hum of traffic or chirping birds. You might not realize that this seemingly ordinary scene has a powerful influence on your health. Your neighborhood and built environment aren't just collections of people; they shape your health.
The problems lie in the disparities. Some of us have access to vibrant, well-maintained spaces, while others live in inadequately developed areas lacking essential resources such as nutritious food, clean water, clean air, and adequate housing, resulting in an underserved environment where only some people get their basic needs met.
When we do the work to understand and address SDOH, we can help reduce health disparities and promote equity by identifying and acknowledging the factors that create systemic differences in health outcomes. Ultimately, the goal is to create a more just and inclusive society that enables us all to have equal opportunities for a healthy life.
The Importance of Access to Healthy Food
All human beings require access to essentials like food, water, and shelter to survive, much less thrive! Yet residents in lower-income communities, communities of color, and rural areas face mounting challenges in regularly accessing nutritious food options, often going hungry or relying on fast food or other less healthy choices for daily meals.
Limited access to nutritious food, known as food insecurity, is strongly linked to high levels of chronic illness and poorer overall health. The United States Department of Agriculture (USDA) reports that close to 30 million Americans live in places lacking affordable and nutritious food options, referred to as food deserts, underscoring the overall need to address living conditions that negatively affect a community's access to essential needs.
How does housing quality affect our health?
Recognizing and addressing disparities in housing quality is essential for creating healthier and more equitable communities. For example, the quality of our housing strongly influences our physical and emotional health. Substandard living conditions, including poor insulation, inadequate ventilation, heating, and air conditioning, along with the presence of mold, contribute to respiratory issues and pre-existing conditions such as asthma and allergies. Unstable housing conditions, such as a lack of safety and security, along with higher levels of anxiety and an increased feeling of vulnerability, can lead to chronic stress and a host of physical health issues, including increased risk of cardiovascular diseases, hypertension, diabetes, and mental health disorders. Additionally, the persistent stress of poverty can compromise immune function, leading to a higher susceptibility to infections and overall poorer health outcomes over time.
In addition to challenges with unstable housing, more than 150 million people worldwide are categorized as homeless or unhoused. Living outdoors has severe health risks, ranging from malnutrition and exposure-related illnesses to inadequate hygiene, which increases susceptibility to infections. As one can imagine, being unhoused also significantly impacts mental health, contributing to high rates of depression and anxiety. Substance use adds another layer of complexity, underlining the reality that it's not a simple housing issue but a critical public health concern.
The Importance of Clean Water
Access to clean water is essential for every human being. Yet according to a new United Nations World Water Development Report, nearly two billion people worldwide, or 28.5% of the world's population, live without safe drinking water 3.6 billion people, or 46% of the world's population, lack adequate sanitation services. These astonishing numbers demonstrate the disproportionate effect of inequity on marginalized communities as well as the urgent need to address disparities.
Communities without reliable access to safe drinking water face increased risks of waterborne illnesses, directly threatening public health. Addressing this challenge is not just a basic necessity; it's a vital step toward creating healthier and more equitable societies. Prioritizing initiatives to bridge this gap is essential, ensuring every community has the foundation for improved well-being and reduced health disparities.
How Safety, Crime, and Violence Are Related to Where We Live
When living in poverty, people often face severe limitations to quality education and adequate employment opportunities. Those limitations can create an overwhelming sense of desperation, frustration, and injustice, leading to a rise in criminal activity, underscoring how important our neighborhoods and built environments are in addressing disparities and achieving equity. In addition, simply facing the ongoing stress of poverty, paired with a lack of infrastructure basics, can lead to feelings of anger, resentment, and, in extreme cases, potential violence.
Implementing some simple infrastructure changes can increase safety. For example, enhancing street lighting not only contributes to a community's overall sense of security but also encourages outdoor activity, fostering an increase in overall well-being. Other examples include the upkeep and repair of sidewalks and addressing street maintenance, which inspires more traffic and benefits not only residents but businesses as well.
What other environmental conditions affect our health?
In addition to basic environmental conditions, broader socioeconomic and political factors such as zoning laws, urban development policies, and historical practices also shape our access to resources. For example, eminent domain and urban renewal projects, often presented as progress, disrupt established neighborhoods, affecting housing stability and community cohesion. Additionally, zoning regulations and the application of historical or ongoing land use laws impact our access to essential resources.
For instance, industrial pollution contributes to substandard housing conditions in a number of low-income urban and rural areas (e.g., Flint, Michigan and East Los Angeles, California, United States; Linfen, China; Mumbai, India). Building in flood zones and the effects of climate change exacerbate the risks of pollution by increasing community exposure to toxins, contaminating water sources, compromising infrastructure resilience, exacerbating housing challenges, and worsening health disparities.
Other impacts include inequitably planned highway and infrastructure development, which divides communities and limits access to resources, along with gentrification, which is intended to bring economic revitalization but also displaces residents and disrupts existing social support systems, further increasing health disparities. Recognizing and addressing the importance of a wide variety of environmental impacts on our health is essential for promoting equitable living conditions and fostering community well-being.
How do social support systems help communities?
Social support systems - including family, friends, and community organizations like schools, community centers, religious groups, government programs, and even online connections - play a pivotal role in empowering a community's ability to thrive. These systems provide emotional support and guidance that help us cultivate a sense of belonging and empathy, navigate challenges, and maintain our mental health.
Additionally, practical, hands-on support is often provided within social systems to help with immediate needs like food and housing, contributing to community stability. These networks also serve as sources of valuable information and guidance, supporting residents to make informed decisions about their health and overall well-being.
Social networks provide a sense of community and foster connections that empower marginalized people facing social, economic, and political exclusion or disadvantage due to factors like race, ethnicity, and socioeconomic status. These networks enable social engagement, collaboration, and mutual aid, nurturing a sense of purpose and identity.
Social support systems often advocate for the marginalized communities they serve, amplifying their voices and actively pursuing systemic change. They also serve as crucial buffers against systemic discrimination. By fostering connections and promoting inclusivity, these systems play a vital role in helping communities thrive despite the challenges they consistently face.
Redlining: A History of Inequitable Neighborhoods in the US
Now, let's explore the multifaceted impact of neighborhoods and the built environment on health by examining the historical consequences of redlining and its enduring effects on US neighborhoods.
In 1933, during the economic turmoil of the Great Depression, the US government established the Home Owners' Loan Corporation (HOLC) to prevent housing foreclosures by refinancing mortgages at risk of default. By 1935, the Federal Home Loan Bank Board recognized the need for a standardized approach and tasked HOLC with developing "residential security maps" across 239 cities. These maps were used as a risk assessment tool for real estate investments, significantly influencing home ownership and business development funding.
The HOLC maps used blocks of color to indicate the level of calculated risk associated with offering loans in specific neighborhoods. Yellow areas, which often included a mix of working-class residents, were characterized as having "obsolescence and infiltration of a lower-grade population." Red areas, which were predominantly minority neighborhoods, were deemed "hazardous," featuring "detrimental influences to a pronounced degree, undesirable population, or an infiltration of it." (US Department of Health and Human Services, 2021). This poorly informed practice resulted in banks and other mortgage lenders rejecting loans for creditworthy borrowers based strictly on their race or where they lived. While the goal of creating these color-coded maps was intended to guide the standardization of investment decisions, it instead led to the discriminatory practice known as redlining.
A widespread and deeply-rooted discriminatory practice, redlining has had lasting consequences in the US, resulting in ongoing underinvestment in minority communities and perpetuating decades of neglect. These underdeveloped neighborhoods, which often align with the red areas originally noted on HOLC's maps, offer limited options to communities disproportionately affected by environmentally related health issues.
The Impact of Redlining Practices
The consequences of redlining are evident in affected communities and include, but aren't limited to, less access to healthy food and grocery stores (food deserts), unstable living conditions driven by continuously inflated rent prices, poor or non-existent public transportation options, and disproportionate exposure to pollution, paired with higher incidences of health issues through the use of discriminatory zoning and land use practices. The result is a ripple effect: less access to essential resources, increased noise pollution, and far less recreational green space.
Despite being outlawed by the 1968 Fair Housing Act, the legacy of redlining is still affecting communities to this day through persistent wealth and housing disparities, economic and educational challenges, health disparities, segregation, and limited access to credit. Addressing these historical injustices requires concentrated investments from businesses, employers, community development entities, and investment firms in these disadvantaged neighborhoods, along with the power of the people to advocate for change. This collaborative effort serves as a potential game-changer, offering a much-needed boost to communities that have endured ongoing discrimination and neglect.
The Importance of Data in Identifying and Addressing Disparities
Data plays a crucial role in promoting health equity by guiding decision-makers, supporting targeted interventions, as well as promoting accountability, ultimately contributing to a more equitable society. Most importantly, data helps us recognize that disparities exist. By understanding the specific challenges faced by different communities, policymakers, in collaboration with residents, can make informed decisions.
Collecting data also allows for monitoring the progress of any initiatives, which helps communities and policymakers adjust their strategies to ensure that their work reduces disparities and improves overall health outcomes. For example, the 10 Essential Public Health Services (EPHS) report offers a well-developed framework to monitor population health status and other factors influencing health and community needs. Assembling this report involves the use of diverse sources of data, examining issues like income, education, and employment to develop a roadmap to understand the root causes of health disparities and inequities in communities and investigate diagnoses and other health problems that affect specific populations.
How to Address Disparities
Addressing historical disparities using SDOH-focused interventions reduces health inequities, enhances well-being, and creates a more just and inclusive environment. It also ensures that everyone, regardless of socioeconomic background, has equal opportunities for a healthy life, fostering a stronger and more resilient society. Addressing disparities also contributes to economic productivity and social cohesion (i.e., the level of connectedness and unity within a group), which are essential for a community's holistic development and prosperity.
To address historical disparities, communities need to develop SDOH-focused interventions, such as:
Advocating for policies that promote fairness in housing and finance.
Using a community-driven approach to empower neighborhoods.
Partnering with grassroots organizations familiar with the needs of their neighborhood (e.g., childcare, transportation vouchers, health education programs).
A number of policy measures and regulations are in place to address disparities, including affordable housing programs, policies limiting or preventing gentrification in minority neighborhoods, and efforts to increase the number of affordable housing units. Additionally, initiatives such as the CDC's Racial and Ethnic Approaches to Community Health (REACH) focus on reducing high rates of chronic disease for specific racial and ethnic groups in urban, rural, and indigenous communities.
New policies addressing climate resilience, environmental justice, and equitable economic development can also help ensure fair opportunities and mitigate environmental hazards in low-income/low-opportunity neighborhoods. Regional transportation equity policies and digital inclusion programs help to increase mobility, connectivity, and access to resources in these communities.
Other ways to address inequities and disparities include community-driven initiatives like the Purpose Built Communities model, with the successful revitalization of Atlanta, Georgia's East Lake neighborhood as an example. The community provides mixed-income housing, supports pre-K to college education, and invests in community wellness resources in partnership with residents. Community development efforts include housing, education, city planning, and public health, with project leaders prioritizing the neighborhood's unique needs, centering on the goals and values of residents.
Some examples of community goals include:
Learning more about finances and fair lending practices.
Promoting investment opportunities for minority-owned businesses.
Improving housing conditions and community safety.
Ensuring access to quality health care.
Improving community safety and security.
Not only does investment improve neighborhood conditions, but well-designed environments help to encourage physical activity, which is crucial for preventing chronic conditions like obesity and cardiovascular diseases. Proximity to parks, sidewalks, and healthy food options also influences lifestyle choices and improves long-term health, as demonstrated by residents in Blue Zones.
Helpful SDOH-Related Tools for Health Professionals
Addressing the needs of underserved areas is a critical responsibility for clinicians and caretakers. It's not just about providing medical services; it's about understanding and addressing the SDOHs that impact patient outcomes. The following tools can help track, identify, and address the social needs of patients and improve outcomes.
1. HealthBegins Upstream Risk Screening Tool: A 28-question survey that focuses on screening questions related to six of the SDOH.
2. PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences): Includes screening questions along with resources, best practices, and lessons learned to guide the implementation, data collection, and responses to social determinant needs.
3. Structural Vulnerability Assessment Tools: A list of software options that track and evaluate systemic factors and SDOH to promote equity and overall well-being in public health and community development.
The impact of neighborhood and built environment factors on health is not one-size-fits-all. It involves considering the diverse needs of humanity, ranging from people with disabilities to LGBTQIA+ individuals, children, immigrants, refugees, and beyond. Imagine a neighborhood where everyone feels safe, welcome, and supported regardless of background or identity. It's a vision rooted in social justice and equity and an essential part of the conversation on health and well-being.
Ultimately, it's more than just numbers; it's about valuing community and leveraging our influence for positive change. Understanding and addressing the impact of our neighborhoods and built environment on our health isn't just a job for policymakers; it's a collective call to action. Let's work together to build environments that embrace diversity and healthy living through collective action and support local initiatives. Take the time to encourage local and national policymakers, as well as community leaders, to make decisions that foster equity and well-being for everyone.