Structural racism in the built environment: Segregation and the overconcentration of alcohol outlets

Examining the role of social vulnerability, neighborhood characteristics, and geospatial patterns of firearm-related injuries and clinical outcomes in Milwaukee county

BACKGROUND

Previous work has shown socioenvironmental factors can influence firearm injury. Milwaukee County, Wisconsin is a diverse midwestern county with historic disinvestment in marginalized communities yielding stark segregation along racial and ethnic lines. It is also one of the many U.S. counties burdened by surging firearm injuries. The differences among communities within Milwaukee County provides a unique opportunity to explore the intersection of socioenvironmental factors that may affect clinical outcomes and geospatial patterns of firearm injury.

METHODS

The trauma registry from the regional adult level 1 trauma center was queried for patients who sustained a firearm-related injury from 2015 to 2022 (N = 2402). The Social Vulnerability Index (SVI) ranking was derived using patient residence addresses to evaluate its association with traumatic injury clinical outcomes (i.e., in-hospital mortality, length of hospital stay, ICU or ventilator treatment, or injury severity score) and risk screening results for alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and depression. We evaluated hotspots of firearm injury density over time for patient residences and injury locations and distances between locations. A spatially lagged regression model tested the association between firearm injury density and SVI domains, alcohol outlet types, and park coverage.

RESULTS

Most firearm injury patients were younger, male, racial or ethnic minorities from disadvantaged neighborhoods (SVI total; M = 0.86, SD = 0.15). SVI was not associated with any clinical outcomes. Of those screened, 12.9% screened positive for AUD and 44.5% screened at risk for PTSD, depression, or both. Hotspot analysis indicated consistent concentrations of firearm injury density. There were no differences in clinical outcomes between those injured inside or outside the home. Census tracts with lower socioeconomic status, greater off-premises and lower on-premises alcohol outlet density were associated with greater firearm injury density.

CONCLUSIONS

In Milwaukee County, firearm injury patients are injured in and often return to the same disadvantaged neighborhoods that may hamper recovery. Results replicate and expand previous work and implicate specific socioenvironmental factors for intervention and prevention of firearm injury.

Are There Regional Differences in Mental Health among Black Americans? An Exploration of Explanatory Mechanisms

Using data from the National Survey of American Life (NSAL) (2001-2003), we examine regional differences in past-year anxiety disorder and past-year major depressive episodes among a geographically diverse sample of Black Americans (N = 3,672). We find that Black Americans residing in the South experience a mental health advantage over Black Americans living in other parts of the country, experiencing lower rates of both anxiety disorder and past-year major depression. We also examine the extent to which stress exposure, religious involvement, and neighborhood contexts help explain any regional differences. We find that stress exposure helps to explain much of the differences observed across regions, while religious involvement and neighborhood contexts help explain observed regional differences to a lesser extent. These findings highlight the importance of considering regional contexts in understanding intra-racial differences in mental health.

The Association between State-Level Structural Racism and Alcohol and Tobacco Use Behaviors among a National Probability Sample of Black Americans

BACKGROUND

Structural racism is how society maintains and promotes racial hierarchy and discrimination through established and interconnected systems. Structural racism is theorized to promote alcohol and tobacco use, which are risk factors for adverse health and cancer-health outcomes. The current study assesses the association between measures of state-level structural racism and alcohol and tobacco use among a national sample of 1,946 Black Americans.

METHODS

An existing composite index of state-level structural racism including five dimensions (subscales; i.e., residential segregation and employment, economic, incarceration, and educational inequities) was merged with individual-level data from a national sample dataset. Hierarchical linear and logistic regression models, accounting for participant clustering at the state level, assessed associations between structural racism and frequency of alcohol use, frequency of binge drinking, smoking status, and smoking frequency. Two models were estimated for each behavioral outcome, one using the composite structural racism index and one modeling dimensions of structural racism in lieu of the composite measure, each controlling for individual-level covariates.

RESULTS

Results indicated positive associations between the incarceration dimension of the structural racism index and binge drinking frequency, smoking status, and smoking frequency. An inverse association was detected between the education dimension and smoking status.

CONCLUSIONS

Results suggest that state-level structural racism expressed in incarceration disparities, is positively associated with alcohol and tobacco use among Black Americans.

IMPACT

Addressing structural racism, particularly in incarceration practices, through multilevel policy and intervention may help to reduce population-wide alcohol and tobacco use behaviors and improve the health outcomes of Black populations.

Parenting, Peers, and Alcohol Use Initiation Among Black, White, and Black-White Adolescents: Evidence Using Discrete-Time Survival Analysis

Alcohol use among Biracial adolescents remains understudied. This study examined how parenting and peer factors relate to age of alcohol use onset among Black, White, and Biracial Black-White adolescents and emerging adults. We used Add Health data to produce a final analytic sample of 13,528 adolescents who self-identified as White, Black, or Biracial Black-White. Discrete-time survival analysis implemented within logistic regression indicated Black adolescents showed the lowest probability of alcohol use onset by age 18, followed by Biracial adolescents, and White adolescents. The probability of alcohol use onset increased for Monoracial Black and White adolescents at ages 16, 18, and 21. Descriptively our model suggest that Biracial adolescents exhibit a sharp decline in their probability of alcohol use onset at age 16 and a sharp increase at age 21. However, this trend did not differ significantly from the other racial groups. Consistent with social control and learning theories, low parental acceptance, high parental control, and peer substance use were associated with alcohol use onset. Alcohol use onset trajectories differed for Monoracial and Biracial adolescents with Biracial individuals reporting greater alcohol onset in adulthood. Prevention efforts should continue to target parental acceptance, parental control, and peer substance use.

Tobacco and Alcohol Retailer Availability and Neighborhood Racialized, Economic, and Racialized Economic Segregation in North Carolina

BACKGROUND

Despite evidence of racialized and socioeconomic inequities in tobacco and alcohol outlet availability, few studies have investigated spatial inequities in areas experiencing both concentrated residential racialized segregation and socioeconomic disadvantage. This study examined whether segregation-racialized, economic or both-was associated with alcohol and tobacco retailer counts in North Carolina (NC).

METHODS

The NC Alcoholic Beverage Control Commission provided lists of 2021 off-premise alcohol retailers. We created a list of 2018 probable tobacco retailers using ReferenceUSA. We calculated three census tract-level measures of the Index of Concentrations at the Extremes (ICE), indicating racialized segregation between non-Hispanic White and Black residents and economic segregation based on household income. We used negative binomial regression to test associations between quintiles of each ICE measure and tobacco and, separately, alcohol retailer counts.

RESULTS

Tracts with the greatest racialized disadvantage had 38% (IRR, 1.38; 95% CI, 1.15-1.66) and 65% (IRR, 1.65; 95% CI, 1.34-2.04) more tobacco and alcohol outlets, respectively, as tracts with the lowest. Tracts with the highest racialized economic disadvantage had a predicted count of 1.51 tobacco outlets per 1000 people while those in the lowest had nearly one fewer predicted outlet. Similar inequities existed in the predicted count of alcohol outlets.

DISCUSSION

Tobacco and alcohol outlet availability are higher in NC places experiencing concentrated racialized and economic segregation. A centralized agency overseeing tobacco and alcohol outlet permits and strategies to reduce the retail availability of these harmful products (e.g., capping the number of permits) are needed to intervene upon these inequities.

Role of neighborhood context in ovarian cancer survival disparities: current research and future directions

Ovarian cancer is the fifth leading cause of cancer-associated mortality among US women with survival disparities seen across race, ethnicity, and socioeconomic status, even after accounting for histology, stage, treatment, and other clinical factors. Neighborhood context can play an important role in ovarian cancer survival, and, to the extent to which minority racial and ethnic groups and populations of lower socioeconomic status are more likely to be segregated into neighborhoods with lower quality social, built, and physical environment, these contextual factors may be a critical component of ovarian cancer survival disparities. Understanding factors associated with ovarian cancer outcome disparities will allow clinicians to identify patients at risk for worse outcomes and point to measures, such as social support programs or transportation aid, that can help to ameliorate such disparities. However, research on the impact of neighborhood contextual factors in ovarian cancer survival and in disparities in ovarian cancer survival is limited. This commentary focuses on the following neighborhood contextual domains: structural and institutional context, social context, physical context represented by environmental exposures, built environment, rurality, and healthcare access. The research conducted to date is presented and clinical implications and recommendations for future interventions and studies to address disparities in ovarian cancer outcomes are proposed.

Advancing health equity through implementation science: Identifying and examining measures of the outer setting

BACKGROUND

Implementation science (IS) could accelerate progress toward achieving health equity goals. However, the lack of attention to the outer setting where interventions are implemented limits applicability and generalizability of findings to different populations, settings, and time periods. We developed a data resource to assess outer setting across seven centers funded by the National Cancer Institute's IS Centers in Cancer Control (ISC3) Network Program.

OBJECTIVE

To describe the development of the Outer Setting Data Resource and characterize the county-level outer context across Centers.

METHODS

Our Data Resource captures seven key environments, including: (1) food; (2) physical; (3) economic; (4) social; (5) health care; (6) cancer behavioral and screening; and (7) cancer-related policy. Data were obtained from public sources including the US Census and American Community Survey. We present medians and interquartile ranges based on the distribution of all counties in the US, all ISC3 centers, and within each Center for twelve selected measures. Distributions of each factor are compared with the national estimate using single sample sign tests.

RESULTS

ISC3 centers' catchment areas include 458 counties and over 126 million people across 28 states. The median percentage of population living within ½ mile of a park is higher in ISC3 counties (38.0%, interquartile range (IQR): 16.0%-59.0%) compared to nationally (18.0%, IQR: 7.0%-38.0%; p < 0.0001). The median percentage of households with no broadband access is significantly lower in ISC3 counties (28.4%, IQR: 21.4%-35.6%) compared the nation overall (32.8%, IQR: 25.8%-41.2%; p < 0.0001). The median unemployment rate was significantly higher in ISC3 counties (5.2%, IQR: 4.1%-6.4%) compared to nationally (4.9%, 3.6%-6.3%, p = 0.0006).

CONCLUSIONS

Our results indicate that the outer setting varies across Centers and often differs from the national level. These findings demonstrate the importance of assessing the contextual environment in which interventions are implemented and suggest potential implications for intervention generalizability and scalability.

Pathways Through Early Psychosis Care for U.S. Youths From Ethnically and Racially Minoritized Groups: A Systematic Review

OBJECTIVE

The authors of this systematic review examined service utilization and outcomes among youths from ethnoracially minoritized groups after the youths initiated treatment for a psychotic disorder-that is, the youths' "pathway through care." Also examined were potential moderating variables in pathways through care for these youths at the clinic, family, and cultural levels. The goal was to describe methodologies, summarize relevant findings, highlight knowledge gaps, and propose future research on pathways through care for young persons from ethnoracially minoritized groups who experience early psychosis.

METHODS

The PubMed, PsycInfo, and Web of Science literature databases were systematically searched for studies published between January 1, 2010, and June 1, 2021. Included articles were from the United States and focused on young people after they initiated treatment for early psychosis. Eighteen studies met inclusion criteria.

RESULTS

Sixteen of the 18 studies were published in the past 5 years, and 11 had an explicit focus on race and ethnicity as defined by the studies' authors. Studies varied in terminology, outcomes measures, methodologies, and depth of analysis. Being an individual from an ethnoracially minoritized group appeared to affect care utilization and outcomes. Insufficient research was found about potential moderating variables at the clinic, family, and cultural levels.

CONCLUSIONS

Studies of pathways through care for persons from minoritized groups warrant further funding and attention.

Neighborhood Racial Segregation Predict the Spatial Distribution of Supermarkets and Grocery Stores Better than Socioeconomic Factors in Cleveland, Ohio: a Bayesian Spatial Approach

INTRODUCTION

The food environment influences the availability and affordability of food options for consumers in a given neighborhood. However, disparities in access to healthy food options exist, affecting Black and low-income communities disproportionately. This study investigated whether racial segregation predicted the spatial distribution of supermarkets and grocery stores better than socioeconomic factors or vice versa in Cleveland, Ohio.

METHOD

The outcome measure was the count of supermarket and grocery stores in each census tract in Cleveland. They were combined with US census bureau data as covariates. We fitted four Bayesian spatial models. The first model was a baseline model with no covariates. The second model accounted for racial segregation alone. The third model looked at only socioeconomic factors, and the final model combined both racial and socioeconomic factors.

RESULTS

Overall model performance was better in the model that considered only racial segregation as a predictor of supermarkets and grocery stores (DIC = 476.29). There was 13% decrease in the number of stores for a census tract with a higher majority of Black people compared to areas with a lower number of Black people. Model 3 that considered only socioeconomic factors was less predictive of the retail outlets (DIC = 484.80).

CONCLUSIONS

These findings lead to the conclusion that structural racism evidenced in policies like residential segregation has a significant influence on the spatial distribution of food retail in the city of Cleveland.

Place, Race, and Case: Examining Racialized Economic Segregation and COVID-19 in Louisiana

Early COVID-19 pandemic data suggested racial/ethnic minority and low-income earning people bore the greatest burden of infection. Structural racism, the reinforcement of racial and ethnic discrimination via policy, provides a framework for understanding disparities in health outcomes like COVID-19 infection. Residential racial and economic segregation is one indicator of structural racism. Little attention has been paid to the relationship of infection to relative overall concentrations of risk (i.e., segregation of the most privileged from the most disadvantaged). We used ordinary least squares and geographically weighted regression models to evaluate the relationship between racial and economic segregation, measured by the Index of Concentration at the Extremes, and COVID-19 cases in Louisiana. We found a significant global association between racial segregation and cumulative COVID-19 case rate in Louisiana and variation across the state during the study period. The northwest and central regions exhibited a strong negative relationship indicating greater risk in areas with high concentrations of Black residents. On the other hand, the southeastern part of the state exhibited more neutral or positive relationships indicating greater risk in areas with high concentrations of White residents. Our findings that the relationship between racial segregation and COVID-19 cases varied within a state further support evidence that social and political determinants, not biological, drive racial disparities. Small area measures and measures of polarization provide localized information better suited to tailoring public health policy according to the dynamics of communities at the census tract level, which may lead to better health outcomes.

The Association Between Racial Attitudes, Alcohol Use and Mood Disorders Among Black Adolescents

Alcohol is the most widely used substance among adolescents. Although Black adolescents use alcohol at lower rates than White adolescents, Black adolescents tend to have worse outcomes. This includes higher rates of mood disorders and criminal justice involvement associated with alcohol use and misuse compared to any other racial group. Black adolescents are also more likely to experience racial discrimination and be exposed to traumatic events within their communities, which may increase their chances of using substances. Understanding the relationship between racial attitudes (towards one's own group and others) and substance use and mental health can provide unique and meaningful insight into prevention programming for Black adolescents. Yet, these concepts have been understudied. To fill this gap, we examined the association between racial attitudes and alcohol use and mood disorders in Black adolescents in Philadelphia, PA (N = 154). We used the revised Adolescent Survey of Black Life to measure pro-Black (positive attitudes toward being Black and factors related to Black people), anti-White (negative attitudes toward White people due to experiences of racism and discrimination) and racism awareness (recognition of racism) domains. Logistic regression analyses were conducted to test the associations. Results showed that: higher pro-Black attitudes were associated with a lower odds of mood disorder (odds ratio [OR] = 0.72, 95% CI = 0.55, 0.89); and higher racism awareness was associated with an increased odds of alcohol use (OR = 1.18, 95% confidence interval [CI] = 1.06, 1.29). Findings provide preliminary support for interventions and policies for Black adolescents that bolster positive racial identity and eliminate experiences of racism as alcohol use and mood disorder prevention strategies.

Establishing the Relative Accuracy of Using City Directories as Proxies to Define and Reconstruct Historical Alcohol Environments

OBJECTIVE

Research on alcohol environments has established that poorer and minoritized communities are frequently overburdened by off-premise outlets (e.g., liquor stores). These outlets have more associated harms, including increased alcohol consumption and crime rates. Little, if any, research has shown how these socio-spatial disparities in exposure have grown or shifted over time, and no studies have established a method for re-creating historical alcohol environments.

METHOD

Our results suggest that in our study city of Flint, MI, disparities in the alcohol environment have narrowed since 1950. Although liquor stores are still more likely to be located in poorer and more heavily African American neighborhoods, the pattern has become insignificant over time. Furthermore, the number of alcohol outlets per capita has declined. Thus, although the city remains more overburdened with alcohol outlets than its suburbs, the disparity has shrunk.

CONCLUSIONS

This work has implications for those working in alcohol prevention and policy, as well as in urban planning. Practitioners and researchers can use this method to model alcohol availability over time in their own communities, which helps better inform the discussion on disparities experienced in poor and minoritized neighborhoods.

Linking Historical Discriminatory Housing Patterns to the Contemporary Alcohol Environment

Research on alcohol outlet density consistently shows greater disparities in exposure in disinvested communities. Likewise, structural racism via discriminatory housing practices has created many of the issues that beset contemporary disinvested neighborhoods. Little work, however, has examined the relationship between housing practices and alcohol outlet disparities. The central premise of our work is that these discriminatory and inequitable practices create distinctions in the alcohol environment, and that such disparities have implications for work on alcohol policy. Here we link alcohol outlet density with a spatial database examining redlining, blockbusting, and gentrification in Baltimore, Maryland, and Flint, Michigan (two cities with common experiences of urban disinvestment over the last 50 years). Standard measures are used to account for the impacts of neighborhood racial, socioeconomic, and housing composition in a multilevel model. Our findings highlight that gentrification and redlining are strongly associated with alcohol outlet density, while blockbusting is not. Gentrification and redlining also frequently co-occur in inner-urban areas, while the more suburban phenomenon of blockbusting rarely overlaps with either. These findings further contextualize nascent work on structural racism in housing that illustrates important disparities along the lines of these distinct practices. Future work should consider how legacy impacts of discriminatory housing patterns impact our communities today.

The association of residential racial segregation with health among U.S. children: A nationwide longitudinal study

Residential racial segregation in the U.S. has been hypothesized as a fundamental cause driving health disparities across racial groups. Potential mechanisms include economic and social marginalization, subsequent constrained opportunities, and high stress. Yet evidence on residential segregation's association with health among Black and White children—particularly longitudinally—is sparse. This study aims to address this gap. We used data from the Panel Study of Income Dynamics (PSID), a national longitudinal study of U.S. households, analyzing information on 1,251 Black and 1,427 White children who participated in the Child Development Supplement (CDS) at least twice (survey waves 1997, 2002, 2007, 2014). We fit individual fixed-effects models to estimate the within-person association of neighborhood-level residential segregation, measured with local Getis-Ord G* statistics, with three outcomes (general health, weight status, and behavioral problems). We examined heterogeneous effects by age and sex. We also examined associations between health and childhood segregation trajectories, i.e., the pattern of children's residential segregation exposures from birth through when their health outcomes were measured, providing additional insight on dynamic experiences of segregation. In fixed effects models, among Black children, higher segregation was associated with worse self-rated health, especially for Black children who were older (aged 11–17 years). In trajectory models, among White children, moving out of highly segregated neighborhoods was associated with a lower probability of poor self-rated health, while moving into those neighborhoods or back and forth between neighborhood types were both associated with increased behavioral problems. Our findings highlight the importance of early-life residential segregation in shaping persistent racial health disparities, as well as the costs of segregation for all children living in highly segregated neighborhoods.

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We used a national longitudinal data set with rich health and residential history data observed throughout childhood.

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We employed fixed effects models and trajectory models.

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Living in segregated neighborhoods was associated with poorer self-rated health among Black and White children.

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Moving into segregated neighborhoods was associated with more behavioral problems among White children.

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Interventions are needed to reduce segregation and improve health-promoting resources for children in segregated communities.

Mapping the Way to Good Health: The Interdisciplinary Challenges of Geographers in Medical Research

Geography has an important role to play in shaping the direction of medical research. In particular, its tools and theory provide essential understanding to the impacts of place on health behaviors and outcomes. Understanding some of its evolution-particularly into the subfield of medical geography-is therefore useful both for geographers and medical researchers. In this paper, we present some of the debates that geographers have grappled with, the growth of GIS (particularly in the context of medical research), some important methodological considerations that geographers help center, and some recommendations for future work at this nexus. Throughout, we speak from the perspective of geographers who have worked nearly exclusively in the health sciences since obtaining our PhDs.

The long shadow of residential racial segregation: Associations between childhood residential segregation trajectories and young adult health among Black US Americans

Residential racial segregation is a key manifestation of anti-Black structural racism, thought to be a fundamental cause of poor health; evidence has shown that it yields neighborhood disinvestment, institutional discrimination, and targeting of unhealthy products like tobacco and alcohol. Yet research on the long-term impacts of childhood exposure to residential racial segregation is limited. Here, we analyzed data on 1823 Black participants in the Panel Study of Income Dynamics, estimating associations between childhood segregation trajectories and young adult health. Black young adults who consistently lived in high-segregation neighborhoods throughout childhood experienced unhealthier smoking and drinking behaviors and higher odds of obesity compared to other trajectory groups, including children who moved into or out of high-segregation neighborhoods. Results were robust to controls for neighborhood and family poverty. Findings underscore that for Black children who grow up in segregated neighborhoods, the roots of structurally-determined health inequities are established early in life.

A Bibliometric Analysis on Research Regarding Residential Segregation and Health Based on CiteSpace

Considerable scholarly attention has been directed to the adverse health effects caused by residential segregation. We aimed to visualize the state-of-the-art residential segregation and health research to provide a reference for follow-up studies. Employing the CiteSpace software, we uncovered popular themes, research hotspots, and frontiers based on an analysis of 1211 English-language publications, including articles and reviews retrieved from the Web of Science Core Collection database from 1998 to 2022. The results revealed: (1) The Social Science & Medicine journal has published the most studies. Roland J. Thorpe, Thomas A. LaVeist, Darrell J. Gaskin, David R. Williams, and others are the leading scholars in residential segregation and health research. The University of Michigan, Columbia University, Harvard University, the Johns Hopkins School of Public Health, and the University of North Carolina play the most important role in current research. The U.S. is the main publishing country with significant academic influence. (2) Structural racism, COVID-19, mortality, multilevel modelling, and environmental justice are the top five topic clusters. (3) The research frontier of residential segregation and health has significantly shifted from focusing on community, poverty, infant mortality, and social class to residential environmental exposure, structural racism, and health care. We recommend strengthening comparative research on the health-related effects of residential segregation on minority groups in different socio-economic and cultural contexts.

Disparities in Activity and Traffic Fatalities by Race/Ethnicity

INTRODUCTION

Traffic fatalities remain a major public health challenge despite progress made during recent decades. This study develops exposure-based estimates of fatalities per mile traveled for pedestrians, cyclists, and light-duty vehicle occupants and describes disparities by race/ethnicity, including a subanalysis of fatality rates during darkness and in urban areas.

METHODS

Estimates of person-miles traveled by mode and race/ethnicity group were derived from the 2017 National Household Travel Survey using replicate weights. Three-year average (2016‒2018) traffic fatalities were measured by mode and race/ethnicity group with the U.S. Fatality Analysis Reporting System. Fatality rates per mile traveled and CIs were calculated for each subgroup as well as separately for trips occurring during darkness and in urban areas. Analysis was conducted in 2021‒2022.

RESULTS

Exposure to traffic fatality differs by race/ethnicity group and by mode, indicating that adjustment for differential exposure is needed when estimating disparities. The authors find that fatality rates per 100 million miles traveled are systematically higher for Black and Hispanic Americans for all modes and notably higher for vulnerable modes (e.g., Black Americans died at more than 4 times the rate for White Americans while cycling, 33.71 [95% CI: 21.84, 73.83] compared with 7.53 [95% CI: 6.64, 8.69], and more than 2 times the rate while walking, 40.92 [95% CI: 36.58, 46.44] compared with 18.77 [95% CI: 17.30, 20.51]). Previous estimates that do not adjust for differential exposure may underestimate disparities by race/ethnicity. Observed disparities remained when considering only urban areas and appear to be exacerbated during darkness.

CONCLUSIONS

Traffic fatalities are a substantial and preventable public health challenge in America. Black and Hispanic Americans have higher traffic fatality rates per mile traveled than White Americans across the transportation system, requiring urgent attention.

Examining how the geographic availability of alcohol within residential neighborhoods, activity spaces, and destination nodes is related to alcohol use by parents of young children

BACKGROUND

Alcohol outlet density and drinking behaviors have been assessed based on where people live, but exposure may differ based on where people spend time. We assessed the relationship between alcohol outlet density (using three measures of geographic availability), frequency of use, and continued volume of alcohol among parents. Parents are a unique population of drinkers where the risk for harm to others can be higher as they are caring for minor children.

METHODS

We conducted a cross-sectional telephone and web-based survey of 1599 parents in 2015 across 30 cities in California. Participants provided information on drinking, residential addresses, and locations of daily activities. We created three measures of alcohol availability using residential neighborhoods, convex hull polygons, and destination nodes. Data were analyzed using zero-inflated negative binomial models.

RESULTS

Density of bars in residential neighborhoods were related to more frequent drinking (b = 0.0139, 95% CI = 0.0016, 0.0261) and higher continued volume (b = 0.0295, 95% CI = 0.0067, 0.0522). Density of bars (b = 0.0070, 95% CI = 0.0019, 0.0121) and restaurants (b = 0.0018, 95% CI = 0.0003, 0.0033) in destination nodes were related to drinking a higher continued volume of alcohol. Higher off-premise outlet density was related to a lower continued volume (b = -0.0026, 95% CI = -0.0049, -0.0002).

CONCLUSIONS

Outlet densities in residential neighborhood and destination nodes are related to frequency of drinking and continued volume of alcohol. Future work should seek to determine why and how residential neighborhoods and nodes are related to alcohol use behaviors and if they differ for parents compared to other adults.

Racialized economic segregation and health outcomes: A systematic review of studies that use the Index of Concentration at the Extremes for race, income, and their interaction

Extensive research shows that residential segregation has severe health consequences for racial and ethnic minorities. Most research to date has operationalized segregation in terms of either poverty or race/ethnicity rather than a synergy of these factors. A novel version of the Index of Concentration at the Extremes (ICERace-Income) specifically assesses racialized economic segregation in terms of spatial concentrations of racial and economic privilege (e.g., wealthy white people) versus disadvantage (e.g., poor Black people) within a given area. This multidimensional measure advances a more comprehensive understanding of residential segregation and its consequences for racial and ethnic minorities. The aim of this paper is to critically review the evidence on the association between ICERace-Income and health outcomes. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a rigorous search of academic databases for papers linking ICERace-Income with health. Twenty articles were included in the review. Studies focused on the association of ICERace-Income with adverse birth outcomes, cancer, premature and all-cause mortality, and communicable diseases. Most of the evidence indicates a strong association between ICERace-Income and each health outcome, underscoring income as a key mechanism by which segregation produces health inequality along racial and ethnic lines. Two of the reviewed studies examined racial disparities in comorbidities and health care access as potential explanatory factors underlying this relationship. We discuss our findings in the context of the extant literature on segregation and health and propose new directions for future research and applications of the ICERace-Income measure.

Place Is Power: Investing in Communities as a Systemic Leverage Point to Reduce Breast Cancer Disparities by Race

Racial disparities in breast cancer present a vexing and complex challenge for public health. A diverse array of factors contributes to disparities in breast cancer incidence and outcomes, and, thus far, efforts to improve racial equity have yielded mixed results. Systems theory offers a model that is well-suited to addressing complex issues. In particular, the concept of a systemic leverage point offers a clue that may assist researchers, policymakers, and interventionists in formulating innovative and comprehensive approaches to eliminating racial disparities in breast cancer. Naming systemic racism as a fundamental cause of disparities, we use systems theory to identify residential segregation as a key leverage point and a driver of racial inequities across the social, economic, and environmental determinants of health. We call on researchers, policymakers, and interventionists to use a systems-informed, community-based participatory approach, aimed at harnessing the power of place, to engage directly with community stakeholders in coordinating efforts to prevent breast cancer, and work toward eliminating disparities in communities of color.

Racial disparities in triple negative breast cancer: toward a causal architecture approach

BACKGROUND

Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has suggested that neighborhood effects may contribute to this disparity beyond individual risk factors.

METHODS

The sample included a cohort of 3316 breast cancer cases diagnosed between 2012 and 2020 in New Castle County, Delaware, a geographic region of the US with elevated rates of TNBC. Multilevel methods and geospatial mapping evaluated whether the race, income, and race/income versions of the neighborhood Index of Concentration at the Extremes (ICE) metric could efficiently identify census tracts (CT) with higher odds of TNBC relative to other forms of invasive breast cancer. Odds ratios (OR) and 95% confidence intervals (CI) were reported; p-values < 0.05 were significant. Additional analyses examined area-level differences in exposure to metabolic risk factors, including unhealthy alcohol use and obesity.

RESULTS

The ICE-Race, -Income-, and Race/Income metrics were each associated with greater census tract odds of TNBC on a bivariate basis. However, only ICE-Race was significantly associated with higher odds of TNBC after adjustment for patient-level age and race (most disadvantaged CT: OR = 2.09; 95% CI 1.40-3.13), providing support for neighborhood effects. Higher counts of alcohol and fast-food retailers, and correspondingly higher rates of unhealthy alcohol use and obesity, were observed in CTs that were classified into the most disadvantaged ICE-Race quintile and had the highest odds of TNBC.

CONCLUSION

The use of ICE can facilitate the monitoring of cancer inequities and advance the study of racial disparities in breast cancer.