Healthy Environments and Access to Good Health Care

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Good and stable health helps people of all ages surmount life’s challenges, excel in school and on the job, ensure their families’ well-being, and fully participate in their communities. Environmental quality reduces people’s risk of health complications that may undermine school or work performance. Access to and utilization of health services can help parents ensure that their children receive basic care through critical formative years and enable adults to obtain the tests needed to screen for early detection of diseases, enhancing the likelihood of effective treatment.

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PREDICTORS

ACCESS TO HEALTH SERVICES


Access to health services can help ensure children receive basic care through critical formative years, obtain needed prescriptions, and that adults can obtain early screenings for diseases to enhance the likelihood of effective treatment. A lack of regular medical care can compromise one’s short- and long-term health and have negative effects on later life outcomes. Access to health services leads to improved physical health, which promotes power and autonomy.

Metric: Ratio of population per primary care physician.


This ratio represents the number of residents per physician in a community. For example, if a community has a population of 50,000 and has 20 primary care physicians, the ratio would be: 2,500:1. If a community has no primary care physicians, the ratio would be zero.

Validity: This metric is defined and established by the US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce.

Availability: Data for this metric are nationally available through the US Department of Health and Human Services’ Area Health Resource File.

Frequency: Data are collected annually.

Geography: These data are available at the county and city level. Data are also available at the neighborhood level in metropolitan areas.

Consistency: This ratio can be measured in the same way across geographies and over time, but the definition of a primary care physician changed in 2013, so values before and after 2013 should not be compared.

Structural equity and subgroups: Because this metric aggregates to a geography, the data cannot be broken down by demographic characteristics, but the data can be used in combination with the American Community Survey to identify the racial or ethnic composition of subareas, such as neighborhoods (census tracts). In cases when this ratio is available at subareas of a community, it is possible to identify pockets with a lower availability of primary care for that subarea population. The subarea can be characterized by the demographic characteristics of its residents, which allow us to compare relative availability, for example, between neighborhoods whose residents largely have income below the federal poverty level or are mostly people of color.

Structural relevance: This metric measures the extent to which community residents have access to primary care physicians based on the presence of physicians in the community. As such, it is a structural feature of the community.

Limitations: Because of financial and insurance constraints, the presence of physicians in an area does not mean that all local residents can access their services or that the care they access is good quality. Conversely, physicians are not the only type of primary care provider available to patients. Nurse practitioners, physician assistants, or other practitioners can also provide primary care services.

 

NEONATAL HEALTH


Strong evidence demonstrates that neonatal health has lasting effects throughout the life course. Poor childhood health has short-term effects on educational attainment and long-term negative effects on adult physical health and mental health, which in turn can affect employment opportunities and wages.

Metric: Share of low-weight births.


A child born weighing less than 5 pounds 8 ounces (about 2,500 grams) is considered to have a low birth weight. Children with low birth weight are at elevated risk for health conditions and infant mortality. This metric looks at the share of low birth weight babies out of all births.

Validity: This metric is the standard currently used by the Centers for Disease Control and Prevention (CDC) as part of its national assessment on health among infants.

Availability: Data on the share of children born with low birth weights are nationally available through the CDC’s National Center for Health Statistics, Division of Vital Statistics.

Frequency: New data for the metric are available annually.

Geography: County-level estimates are available through public-use microdata files provided by the National Center for Health Statistics as well as through other data collection efforts, such as the Kids Count Data Center or the CDC WONDER system.

Consistency: Medical advances have improved the outcomes for low birth weight babies, so this metric may change in the future. However, it has been consistently used for decades as a metric for neonatal health.

Subgroups: The share of children born with low birth weights can be disaggregated by race or ethnicity and mother’s age.

Limitations: Data are not readily available at lower levels of geography, such as neighborhoods, where disparities by race and socioeconomic status within a city are most notable. Large numbers of women with risky pregnancies moving in or out of a jurisdiction could influence this metric. Counties with populations under 100,000 persons based on the decennial census are pooled into “Unidentified Counties” in the CDC WONDER data.

 

ENVIRONMENTAL QUALITY


Living in communities with poor environmental quality—including hazardous wastes and other toxins, ambient and indoor air pollutants, poor water quality, and high levels of ambient noise—can place people at higher risk of health complications that impose costs and may undermine school or work performance. Exposure to hazardous environmental conditions can have negative implications for the health of residents, especially those who are more susceptible to health problems, such as children and elderly people.

Metric: Air quality index.


The air quality index is an index that summarizes potential exposure to harmful toxins at a neighborhood level. The index is a linear combination of standardized Environmental Protection Agency (EPA) estimates of carcinogenic, respiratory, and neurological hazards in the air measured at the census-tract level. Values are inverted and then percentile ranked nationally and range from 0 to 100. The higher the index value, the less exposure to toxins harmful to human health. These data are only available for approximately one-third of the largest counties. To ensure all counties across the country have a value for the air quality index, we also use data from the National Air Toxics Assessment, which are available for all communities, but its most recent data are from 2014. One-third of counties will have an air quality index defined using annualized Environmental Protection Agency data from its Air Quality Index; the remainder will have an air quality index based on older data from the National Air Toxics Assessment.

Validity: EPA scientists and researchers link levels of air pollutants to health effects that can manifest within a few hours or days after breathing polluted air. For each of the pollutants, the EPA has established national air quality standards to protect public health.

Availability: Air quality systems data are produced by the EPA and are publicly available.

Frequency: Air quality information from the National Air Toxics Assessment data were updated every three years since 1996, but the most recent update was in 2014.

Geography: This metric is available at the neighborhood (census tract) level. Values can be averaged at higher levels of geography. For example, one can calculate a population-weighted average value among all census tracts in a county to determine a county-level value.

Consistency: Levels of air pollutants can be consistently measured over time and space.

Subgroups: This metric can be disaggregated by subarea when used in combination with the ACS to identify the racial or ethnic composition of neighborhoods (census tracts) with different levels of air quality. We distinguish census tracts that are majority nonwhite, that have no majority race or ethnicity, and that are majority non-Hispanic white. We define a majority as at least 60 percent of residents.

Limitations: Data are not updated with enough frequency. Other data sources can offer information annually or daily, so one-third of counties will have an air quality index defined using annualized Environmental Protection Agency data from its Air Quality Index; the remainder will have an air quality index based on older data from the National Air Toxics Assessment.

 

SAFETY FROM TRAUMA


Children with greater safety from trauma, particularly multiple traumas, are at lower risk for developing emotional and behavioral problems, such as depression, anxiety, dissociation, post-traumatic stress disorder, low self-esteem, hopelessness, withdrawn behaviors, and impaired peer relationships. Safety from trauma in adults can reduces the likelihood of diminished cognitive ability as well as worsening physical and mental health. More broadly, “community trauma” affects social groups or neighborhoods long subjected to interpersonal violence, structural violence, and historical harms. Community and systems trauma, like individual trauma, affects cognitive decisionmaking that can lead to reduced civic engagement and weakened social networks and social cohesion; it can also adversely influence how individuals view themselves, their capabilities, and their social status.

Metric: Number of deaths due to injury per 100,000 people.


This metric represents the number of deaths of community residents, both from intentional injuries such as homicide or suicide and unintentional injuries such as motor vehicle deaths, per 100,000 people in the jurisdiction.

Validity: These data are collected by the National Center for Health Statistics and the Centers for Disease Control and Prevention. Injury can be traumatic, and people living in communities with a high incidence of injury can experience both the direct trauma from injury and vicarious trauma from injuries sustained by others, which can lead to psychological distress, increased rates of aggression, and diminished physical health. High rates of injuries that lead to death in a community, such as opioid overdose, suicide, traffic fatalities, and homicide, can lead to community-level trauma.

Availability: Data for this metric are nationally available through the National Center for Health Statistics Mortality Files and Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research.

Frequency: Data are collected annually.

Geography: Data are available at the county level.

Consistency: The metric can be measured in the same way across geographies and over time.

Structural equity and subgroups: The metric can be disaggregated by race and ethnicity, age, gender, and education level. Because this metric can be disaggregated by race and ethnicity, it can be used to see the how much exposure to trauma varies between racial and ethnic groups within a community.

Structural level: This metric is concerned with individual deaths, but deaths caused by injury can be reflective of both individual-level factors and structural factors such as neighborhood design, crime rates, and access to mental health services.

Limitations: The metric captures only one aspect of exposure to trauma. Injury more generally would capture a larger aspect, but data on that are not nationally available.

 

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