Neighborhood Characteristics
Indicator Profile
Neighborhood characteristics affect cardiovascular disease (CVD) outcomes. Depending on where an individual lives, their health may be adversely affected by features of the socioeconomic (e.g., income), service (e.g., access to public transit), physical (e.g., presence of parks), and social (e.g., safety) environment of neighborhoods. Indicators of neighborhood characteristics are social determinants of health and are highly correlated.
For example, neighborhoods with high levels of poverty have a higher concentration of fast-food outlets and liquor stores, poor access to safe places to play and exercise, lack of employment opportunities, and limited availability of quality housing.1
Indicators
This document provides guidance for measuring 15 indicators related to neighborhood characteristics that are associated with certain CVD risk and protective factors, leading to differential risks for developing CVD. The 15 neighborhood characteristics indicators are measured at different levels of analysis, including the census block group, census tract, city, county, metropolitan area, and state levels.
Air and Water Quality
Why is this indicator relevant?
Air pollution is a heterogenous and complex mix of compounds in the air at levels that pose a health risk.2,3 The most commonly monitored air pollutants are particulate matter (PM), ozone, and nitrogen dioxide (NO2). In the United States, air pollution disproportionately affects lower–socioeconomic status communities and people of color, since these communities are more likely to be located next to highways and high-volume roadways due to land use and planning policies and practices that differentially disadvantages communities based on race or class.4,5 Living in areas with high traffic volume increases exposure to harmful air pollutants due to vehicle emissions. Hispanic/Latino communities are more likely to have higher mortality due to exposure to air pollution.6
Exposure to fine particulate matter also contributes to higher cardiovascular disease risk.7,8,9,10 The American Heart Association states that the likely pathways include an activation of oxidative stress/inflammation and autonomic imbalance and the transfer of particulate matter into systemic circulation, which, in turn, leads to subclinical cardiovascular disease (e.g., atherosclerosis progression) and thrombotic and non-thrombotic acute cardiovascular events (e.g., stroke).11,12
Safe drinking water is essential for hydration, cooking, and sanitation and is a source of minerals that are essential for human health and development. Community water fluoridation, a practice that involves adjusting the amount of mineral fluoride in public water supply to a level recommended for preventing tooth decay, is recognized by CDC as one of the 10 major public health achievements of the 20th century.13 Fluoride impedes the demineralization and enhances remineralization of enamel, which confers protection against oral diseases, a risk factor for CVD.14 Poor oral health and periodontal diseases are hypothesized to increase CVD risk through bacteremia (bacteria enters bloodstream and travels to the heart), immune activation, and inflammation.15,16
This indicator can be assessed by the following measures. Click on each measure to learn more:
Civic Participation
Why is this indicator relevant?
Civic participation, synonymous with civic engagement, refers to working to make a difference in the civic life of one’s community with the help of one’s knowledge, skills, values, and motivation.18 Civic participation includes a wide range of activities, such as participating in social groups, volunteering, and voting.19 In addition to contributing to improvements in the community through volunteerism and activism, civic participation plays an important role in advancing health and well-being, including cardiovascular health, by reducing social isolation, strengthening social networks, and increasing social cohesion and connectedness.20
Engagement in civic groups can make people more aware of opportunities to be physically active in their community thereby facilitating physical activity.21 Such civic engagement also builds social capital, defined as “features of social organization such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit.”22 Similarly, through improved social and psychological health, volunteering can also yield physical health benefits, including reduced risk factors for chronic disease.23,24 Research has found that volunteering was associated with lower odds of lipid dysregulation, lower odds of central adiposity, lower blood pressure, and lower risk of hypertension.25,26 Studies on aggregated measures of civic participation report that community-level civic participation and social capital (e.g., census block level) are associated with reduced recurrence of acute coronary syndrome.27
Civic participation improves social support and social cohesion and connectedness, which influences CVD outcomes through both physiological and psychological stress response as well as health behaviors. In contrast, poor social cohesion and connectedness is associated with poor mental health outcomes, activated hypothalamic–pituitary–adrenal (HPA) axis, and increased inflammatory marker levels, heart rate, blood pressure, and cortisol.28 Likewise, lack of social support is linked to unhealthy coping responses to stress, such as smoking, excessive alcohol consumption, and low physical activity levels.29
Civic participation, synonymous with civic engagement, refers to working to make a difference in the civic life of one’s community with the help of one’s knowledge, skills, values, and motivation. This indicator can be assessed by the following measures. Click on the measure to learn more:
Community Food Environment
Why is this indicator relevant?
Community food environment, or physical access to food at the neighborhood level, is often recognized as a potential point of intervention for public health.30 Access to healthy food is commonly determined by a community’s average income level and proportion of the population living close to a supermarket, supercenter, or large grocery store. Other factors affecting food access include affordability and quality of food.31,32 People with lower incomes, people of color, and people who live in rural communities are more likely to live in neighborhoods with poor food access, which contributes to health inequities. Such communities disproportionately experience poor access to healthy and affordable foods due to historical neighborhood disinvestments resulting from structural racism and classism, including discriminatory practices such as redlining and segregation.
Lack of access to healthy foods is associated with risk of developing CVD.33,34,35,36 Poor food access is linked to lower consumption of healthier foods, such as fruits and vegetables, and higher consumption of unhealthy foods high in refined sugar and saturated fats, as well as higher BMI and obesity.37,38,39,40 The influence of food access on dietary intake and dietary quality is associated with biologic and psychological mechanisms of cardiovascular health, such as inflammation, stress response, and immune response.41
Community food environment, or physical access to food at the neighborhood level, is often recognized as a potential point of intervention for public health. Access to healthy food is commonly determined by a community’s average income level and proportion of the population living close to a supermarket, supercenter, or large grocery store. This indicator can be assessed by the following measures. Click on the measure to learn more:
Community Safety
Why is this indicator relevant?
Actual and perceived violence in neighborhoods is a barrier to healthy behaviors, such as walking and bicycling, using parks and recreational spaces, and accessing healthy food retailers. Structural determinants, including racism and sexism, result in differential patterns in exposure to violence.44,45
The risk of experiencing violence varies significantly by race/ethnicity. In 2020, among those 15–24 years of age, homicide was the leading cause of death for Black/African American persons, the second leading cause of death for Hispanic/Latino persons, the third leading cause of death for American Indians/Alaskan Native persons and White persons, and the fourth leading cause of death among Asian and Pacific Islander persons.46
Some studies have found that perceived crime, violence, and disorder are associated with incident coronary heart disease and stroke.47,48 These findings may be explained by the relationship between perceived neighborhood crime, personal safety, anxiety, and physical activity.49,50 Neighborhood violence may result in a chronic heightened state of physiological vigilance, greater levels of stress, and decrease in physical activity. These factors mediate the relationship between neighborhood violence and cardiovascular disease.51
Actual and perceived violence in neighborhoods is a barrier to healthy behaviors, such as walking and bicycling, using parks and recreational spaces, and accessing healthy food retailers. This indicator can be assessed by the following measures. Click on each measure to learn more:
Green Space
Why is this indicator relevant?
Research shows that access to green space, defined by all vegetated land, such as lawns, forest, and gardens, is associated with well-being and promotes physical activity and mental health in a community or neighborhood.55 Access to green space is also linked to lower CVD risk; higher levels of neighborhood greenness are associated with a lower incidence of type 2 diabetes, acute myocardial infarction, ischemic heart disease, and heart failure.56 Researchers recommend a minimum of 9 m2 of green space per individual and an urban green space (UGS) value of 50 m2 per capita.57 However, many neighborhoods do not meet this minimum level of green space, and there are disparities in green space distribution in the United States.58 Specifically, Black/African American persons are more likely to live in areas characterized by less green space than White persons are, in part because of lower income and less access to affordable housing.59
Research shows that access to green space, defined as all vegetated land (e.g., lawns, forest, gardens), is associated with well-being and promotes physical activity and mental health in a community or neighborhood. This indicator can be assessed by the following measure. Click on the measure to learn more:
Housing
Why is this indicator relevant?
Housing is defined as physical dwellings that intended to be used for living, sleeping, cooking, and eating60,61 and is a key pathway through which health inequities arise and persist over time.62 Housing issues span multiple dimensions, including affordability (cost burden), quality, and residential stability (stability of household occupancy), neighborhood safety, and opportunity.63 Social and structural forces such as gentrification and displacement, redlining and residential segregation, and economic recession have disproportionately constrained access to affordable, livable, and stable housing for low-income people and people of color.
Cost-burdened households, or households with high housing costs relative to income, are less likely to have a usual source of health care and are more likely to delay medical care.64 Poor physical housing quality such as structural deterioration; presence of mold, pests, and lead; insufficient heating/cooling; and poor indoor air quality are correlated with psychological distress, asthma, nervous system disruption, and respiratory infections.65,66,67,68 Likewise, residential instability, or high turnover in households, is associated with poorer self-rated health, health care access, and mental health outcomes.69
Housing affordability, quality, and stability can be linked to CVD risk and related mortality due to downstream consequences from psychological distress and competing stressors (i.e., spending on housing vs. medical care) associated with housing insecurity (i.e., high housing costs, poor housing quality, housing instability70) as well as secondhand smoke exposure (common in low-income and public housing) and cardiotoxic air pollutants from poor-quality homes. Among the elderly, insufficient cooling and extreme housing temperatures have been linked to cardiovascular events.71
Housing is defined as physical dwellings intended to be used for living, sleeping, cooking, and eating and is a key pathway through which health inequities arise and persist over time. Housing issues span multiple dimensions, including affordability (cost burden), quality, residential stability (stability of household occupancy), neighborhood safety, and opportunity. This indicator can be assessed by the following measures. Click on each measure to learn more:
Incarceration
Why is this indicator relevant?
Incarceration, or confinement in jail or prison, can have lasting impacts on mental well-being and is a severe stressor for people who are or have been incarcerated, their families, and their communities due to exposure to dehumanization, deprivation, degradation, and danger during incarceration.72,73 Neighborhoods with high incarceration rates experience disruptions in family structures, social bonds, and employment networks. Restrictive hiring practices and policies that continue to punish formerly incarcerated individuals can also constrain employment opportunities, limiting one’s ability to access health-supporting resources such as a livable wage, adequate housing, health care, and healthy food. The United States has the highest incarceration rate in the world. Racism within the criminal justice system affects policing and sentencing and leads to the disproportionate imprisonment of Black/African American and Latino persons.74 Compared with White men, Black/African American men are 6 times more likely to be incarcerated, and Hispanic/Latino men are 2.5 times more likely. For Black men in their 30s, about 1 in every 12 is in prison or jail on any given day.75
CVD is a leading cause of death among people who are currently incarcerated or people with a recent history of incarceration; they have a higher risk of dying or being hospitalized due to CVD in comparison to the general population.76 Furthermore, incarceration not only affects the incarcerated individuals, but also impacts their communities.77,78 Having a family member imprisoned influences CVD risk through three pathways: lowered socioeconomic status and family functioning, reduced social support, and higher levels of chronic stress.79
Incarceration, or confinement in jail or prison, can have lasting impacts on mental well-being and is a severe stressor for people who are or have been incarcerated, their families, and their communities. This indicator can be assessed by the following measures. Click on each measure to learn more:
Liquor Store Density
Why is this indicator relevant?
Studies show that heavy drinking, defined as more than 14 drinks per week for men or more than 7 drinks per week for women, leads to higher risk for CVD, compromises overall health, and affects the health and well-being of others around individuals who drink heavily.80,81 Restricting the density of liquor stores, or the number of places where alcohol can be sold or consumed either per area or per population, can curb excessive alcohol consumption and prevent alcohol-related morbidity and mortality.82 Higher liquor store density is associated with increased alcohol consumption, multiple chronic disease pathways, neighborhood-level social effects, and increased rates of motor vehicle crashes, pedestrian injuries, and violence.83,84,85,86 Liquor store density is higher in low-income communities and communities of color leading to disproportionate alcohol-related outcomes in these communities. People who live in neighborhoods with higher liquor store densities also experience lower life expectancies and higher rates of violence.87
Restricting the density of liquor stores, or the number of places where alcohol can be sold or consumed either per area or per population, can curb excessive alcohol consumption and prevent alcohol-related morbidity and mortality. This indicator can be assessed by the following measure. Click on the measure to learn more:
Physical Activity Environment
Why is this indicator relevant?
Physical activity refers to any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal level.88 Research has consistently shown that lack of physical activity is associated with a spectrum of chronic conditions, including CVD, diabetes, obesity, osteoporosis, and psychological disorders.89,90 Physical activity is effective at all stages of chronic disease management, from prevention, treatment, and through rehabilitation.91,92 Yet more than a quarter of Americans do not meet the recommended guideline of at least 150 minutes of moderate-intensity physical activity (e.g., brisk walking) a week or 75 minutes of vigorous-intensity physical activity (e.g., running) a week.93 It is well-established that key aspects of the built environment, such as the availability of pedestrian-friendly infrastructure (e.g., sidewalks, street lights), walking and biking paths, proximity to parks and open space, and social engagement for physical activity at these facilities, positively affect the frequency and intensity of participation in physical activity.94,95,96 Researchers, program planners, and policy makers recognize the built environment as a point of intervention to increase physical activity, and the American Heart Association (AHA) has identified environmental interventions as an economical community-wide approach to CVD prevention.97,98
Physical activity environment refers to aspects of the built environment, such as the availability of pedestrian-friendly infrastructure (e.g., sidewalks, streetlights), walking and biking paths, and proximity to parks and open space that positively affect the frequency and intensity of participation in physical activity. This indicator can be assessed by the following measures. Click on each measure to learn more:
Poverty
Why is this indicator relevant?
Poverty is often defined as the lack of resources necessary to meet basic human needs.100 However, poverty is not only a measure of economic status and material deprivation but is also an indicator of social power and capability to navigate and fully participate in society.101 Poverty has been linked to several adverse health outcomes such as CVD, diabetes, kidney disease, infectious disease, maternal and infant mortality, and many others. In terms of CVD outcomes, the effect of poverty is observed not only at the individual level but also at the community level. Several studies have reported that county-level poverty rate is a strong predictor of heart failure, coronary heart disease, and CVD mortality.102,103,104
Concentrated poverty is a measure that captures unfavorable neighborhood conditions and identifies neighborhoods with a significantly high proportion of residents living below the federal poverty level (annual income thresholds set by the federal government to determine financial eligibility criteria).105,106 Specifically, it is defined as an area with an official poverty rate above 40% and where at least 30% of residents are poor.107 Concentrated poverty is associated with negative outcomes for all residents, whether or not they themselves are poor. Neighborhoods with high levels of poverty are associated with high crime; poor access to school, health care, and social services; and lack of economic resources, all of which limit opportunities and mobility for residents in the entire region.108,109 In the U.S., it is estimated that four out of five people living in areas of concentrated poverty are either Black/African American or Hispanic/Latino.110 Although Black/African American persons represent only 12% of the U.S. population, nearly 40% of Black/African American persons live in areas of concentrated poverty.111 Likewise, 40% of Hispanic/Latino persons live in concentrated poverty despite representing only 16% of the U.S. population.
Poverty is often defined as the lack of resources necessary to meet basic human needs. This indicator can be assessed by the following measures. Click on each measure to learn more:
Public Assistance
Why is this indicator relevant?
Public assistance refers to assistance programs that provide either cash assistance or in-kind benefits to individuals and families from any governmental entity.114 The U.S. government currently provides economic support to those in greatest need through social assistance programs and social insurance programs. Social assistance programs, such as Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Medicaid are means-tested, which limit eligibility to individuals and families whose incomes and or assets meet a pre-determined threshold (means test).115 Social insurance programs provide benefits to individuals who have paid into the program or whose employers have paid into the program and include Social Security, Medicare, unemployment insurance, workers’ compensation, and disability insurance.116
Although public assistance is an important policy tool to intervene against socioeconomic disadvantage, receipt of public assistance is a proxy for social disadvantage, food insecurity, housing insecurity, low socioeconomic status, and poor health status, all of which are risk factors for CVD.117,118,119 For example, SNAP recipients are likely experiencing food insecurity, which negatively affects CVD risk due to food insecurity’s association with poorer diet quality, unhealthy coping strategies, and psychological distress.120,121
Public assistance refers to assistance programs that provide either cash assistance or in-kind benefits to individuals and families from any governmental entity. This indicator can be assessed by the following measures. Click on each measure to learn more:
Social Cohesion
Why is this indicator relevant?
Social cohesion refers to the extent of connectedness and the sense of solidarity among members of a community.122 Social cohesion, or a higher level of social support and strengthened social connectedness, positively influences health outcomes by reducing stress, improving mental health, encouraging healthier behaviors (i.e., taking medication, participating in physical activity, and eating healthy), increasing social engagement, and expanding access to resources.123,124
Living in areas with higher levels of social cohesion protects cardiovascular health through behavioral and psychosocial pathways such as promoting positive health behaviors, improving coping abilities, and enhancing mental health.125 Increased neighborhood-level social cohesion is associated with lower risk of myocardial infarction, stroke, and incident coronary heart disease, improved medication adherence, and increased odds of meeting physical activity guidelines.126,127,128 Residence in a neighborhood (defined by census-tracts) with high levels of social cohesion is associated with lower prevalence of hypertension and higher overall CVD health.129,130
Social cohesion refers to the extent of connectedness and the sense of solidarity among members of a community. This indicator can be assessed by the following measure. Click on the measure to learn more:
Social Environment
Why is this indicator relevant?
Neighborhood social environment refers to the physical, material, social, and socioeconomic conditions in a given community.133 Deprived or disadvantaged neighborhoods are usually characterized by high concentrations of poverty, high rates of unemployment, and limited material resources and services such as poorer access to quality housing, health care, healthy food, community resources, and recreational facilities.134 Crime and disorder are more likely to arise in disadvantaged neighborhoods, which may induce stress, weaken social cohesion, and have a detrimental effect on mental health and coping.135 Living in a stressful neighborhood environment contributes physiologic, neurologic, and psychological dysfunction that adversely impacts cardiovascular health.136,137 Specifically, studies have observed elevated blood pressure, higher incident hypertension, and increased cardiovascular disease mortality among residents in deprived neighborhoods.138,139
Neighborhood disadvantage is considered a key determinant of racial inequities in health. Black/African American persons are disproportionately exposed to neighborhood disadvantage due to structural discrimination such as residential segregation and redlining.140,141 One study found that among Black/African American adults, residence in a disadvantaged neighborhood was associated with greater cumulative biological risk, a measure of eight biomarkers across cardiovascular, metabolic, inflammatory, and neuroendocrine physiological systems.142 Another study found that among Black/African American women, one standard deviation increase in neighborhood disadvantage was associated with a 25% increased risk of CVD.143 A third study found that Black/African American women living in the top 10% of most socially vulnerable neighborhoods, as measured by the Social Vulnerability Index (SVI), were three times more likely to have hypertension when compared to those living in less vulnerable neighborhoods.144
Neighborhood social environment refers to the physical, material, social, and socioeconomic conditions in a given community. This indicator can be assessed by the following measure. Click on the measure to learn more:
Transit and Transportation
Why is this indicator relevant?
Transportation refers to street design and connectivity, pedestrian infrastructure, bicycle infrastructure, and public transit infrastructure and access.146 Transportation policy affects health through multiple pathways, including active transportation (e.g., walking, biking, rolling in a wheelchair), safety, clean air, and connectivity.147 Increased public transit and improved pedestrian and bicycle infrastructure create opportunities for people to exercise for recreation and commuting, reduce incidence of motor vehicle crashes, and improve air quality and accessibility of services, resources, and recreation, thereby creating a more connected community. Low-income neighborhoods and communities of color are often burdened by inadequate transportation and more likely to be located next to highways and major roadways. In addition, residents of these neighborhoods are less likely to own a car. These factors are due to structural racism and classism, including historical discriminatory practices (e.g., redlining) and current land use and planning policies, practices, and directives that differentially disadvantages communities based on race (i.e., environmental racism). Inequities in access to transportation often result in longer commutes, higher transportation costs, and increased exposure to air pollutants.148,149
Transportation affects the ability to access health-promoting resources, such as health care, jobs, parks, schools, and grocery stores, which can affect the risk of cardiovascular disease. Access to safe public transportation and safe environments also encourages walking and/or biking to destinations. Individuals who use public transit add up to 30 minutes of physical activity to their day.150,151 The Community Preventive Services Task Force and the American Heart Association recognize transportation policy as health policy and recommend improving transportation systems as an upstream approach to improve cardiovascular health.152,153 This recommendation is based on a systematic review which found sufficient evidence on the relationship between transportation, physical activity, and cardiovascular health.154,155
Transportation refers to street design and connectivity, pedestrian infrastructure, bicycle infrastructure, and public transit infrastructure and access. This indicator can be assessed by the following measures. Click on each measure to learn more:
Rurality
Why is this indicator relevant?
Rurality is a term used to describe areas with low population density or areas with a geographically diffuse population.156,157 Residence in a rural area presents many challenges, such as limited employment and education opportunities, long travel distances, lack of public transit, and poorer access to health care, healthy foods, and social services.158,159 Compared to urban residents, rural residents are older, less educated, and have lower incomes.160,161 All of these sociodemographic and environmental characteristics are linked to poorer health outcomes and are contributing factors to rural health disparities. According to CDC, rural residents are more likely than urban residents to have higher premature mortality rates from the five leading causes of death: heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke.162
Although rural areas are less diverse than the nation as a whole, rural areas have been diversifying over the past decade, and nearly 25% of rural residents are people of color.163 It is hypothesized that living in rural areas exacerbates exposure to unequal social conditions already experienced by people of color (e.g., fewer collective resources, higher poverty, lower health care supply) leading to racial/ethnic health disparities among rural residents.164 Premature death rates are significantly higher in rural counties with majority Black/African American or American Indian/Alaskan Native residents than in rural communities that are predominantly White.165 Compared with rural White residents, rural people of color are less likely to see a physician due to costs and more likely to have poorer self-reported health status and obesity.166
There is a significant gap in CVD outcomes along rural-urban lines: People living in rural areas have higher prevalence of heart disease and higher mortality rates for stroke and CVD.167 Determinants of the rural–urban gap include socioeconomic, behavioral, psychosocial, and access factors. Substance use, smoking, and physical inactivity are more prevalent in rural populations than in urban ones, leading to higher rates of obesity, high cholesterol, and high blood pressure among rural residents. Rural populations are more likely to suffer from depression, a CVD risk factor, and have limited access to mental health services to prevent and treat depression related disorders.168 People living in rural areas are less likely to have insurance and live farther away from health services, which can result in fewer preventive visits and delays in treatment.169 Rural areas also face critical shortages in health services, such as health care workers, hospitals, and emergency facilities. It is estimated that 20% of the U.S. population resides in a rural area, yet only 9% of physicians practice in rural areas.170 It has also been suggested that physicians and care facilities in rural areas may lack experience with certain CVD conditions and may not provide specialized care for treating CVD.171
Rurality refers to areas with low population density or areas with a geographically diffuse population. This indicator can be assessed by the following measures. Click on each measure to learn more:
Case Example
This case example was developed from the Health Equity Indicators (HEI) Pilot Study. Seven health care organizations participated in the HEI Pilot Study from January 2022 to April 2022 to pilot-test a subset of HEIs in order to assess the feasibility of gathering and analyzing data on these indicators within health care settings. The pilot case examples document participating sites’ experiences with data collection and lessons learned from piloting the HEIs.
Field Notes
These field notes showcase other examples of health equity measurement and evaluation at health care organizations, such as health departments. It is important to note that the examples in the field notes are not derived from the HEI Pilot Study and therefore may reflect slightly different uses or definitions of HEIs. In some cases, the HEIs presented in the field notes may not perfectly align with the measurement definition and guidance provided in the HEI Profiles.
- Health Department: Los Angeles County Department of Public Health
- Focus Area: Neighborhood Characteristics
- Measure: Park Access
This content presents an example of how one health department, the Los Angeles County Department of Public Health (LACDPH), used data on the health equity indicator physical activity environment. Key aspects of the built environment, such as proximity to parks and open space, positively impact the frequency and intensity of participation in physical activity.177,178,179
Research has consistently shown that lack of physical activity is associated with a spectrum of chronic conditions, including cardiovascular disease (CVD), obesity, diabetes, osteoporosis, and psychological disorders.180 LACDPH leveraged the park access measure as a factor for informing and implementing key health interventions.181 Park access is defined as the portion of a city’s or a local jurisdiction’s population living no more than a 10-minute walk to a park.182 For more information on the park access measure, please see the Physical Activity Environment indicator in the Neighborhood Characteristics Indicator Profile.183
Representatives from LACDPH participated in a subject matter expert panel to provide input for the development of CDC’s Health Equity Indicators for CVD toolkit. To support this work, LACDPH shared this example of how their Chronic Disease and Injury Prevention division accessed and analyzed data—including data sources, challenges, and facilitators—on park access. Their approach and lessons learned are summarized below.
Health Equity in Action: Los Angeles County Department of Public Health
LACDPH serves more than 10 million residents, of whom 48.4% are Hispanic/Latino, 28.3% are White, 14.4% are Asian American, and 8.5% are Black/African American. LACDPH is committed to developing and implementing policies and programs that support the department and the overall county government’s priority to advance health equity. For example, LACDPH’s Center for Health Equity assists other programs within the department in addressing health disparities. As part of this effort, LACDPH worked with the county’s Department of Parks and Recreation to implement the Parks After Dark (PAD) program, an initiative designed to serve as a place-based strategy for building resilient communities that re-envisions parks as community hubs. In addition to PAD, LACDPH is developing a Park Rx program under the oversight of the Join Us in Moving People to Play (JUMPP) Coalition.184 Park Rx is an initiative that educates and encourages medical providers to connect patients to parks; in doing so, these providers can help patients enjoy physical activity and mental health benefits from visiting parks. A number of years ago, LACDPH also received funding from the Robert Wood Johnson Foundation to promote park access by increasing physical activity opportunities through shared use agreements. These agreements are developed and executed when government entities, or sometimes private and/or nonprofit organizations, agree to work with schools to open campus facilities or provide open space for community use.
Indicator: Redlining
Measure: HOLC Risk Maps
Data Collection Method: Secondary data analysis
Data Source: Home Owners’ Loan Corporation (HOLC) maps
Data Availability: Census tract
Application/Use: Spatial analysis of redlining data overlaid with chronic disease prevalence data at the census tract level.
Data Collection and Analysis Methods. LACDPH used public data from the Los Angeles County Geographic Information System (GIS) Repository to overlay data layers by Service Planning Area (SPA) boundaries and by park locations. The department also used public data from the Public Health Alliance of Southern California’s Healthy Places Index (HPI) to visualize socioeconomic gaps across Los Angeles County. Collectively, these analyses generated socio-geographic information that LACDPH and its partners used to help identify locations where PAD and other public health programming could be implemented to help communities that lack access to health-promoting resources (Figure 1). The HPI is a composite score ranging from 1 to 99 that ranks the well-being of neighborhoods in terms of social conditions and health. The HPI consists of 23 indicators across eight domains: clean environment, economics, education, health care access, housing, neighborhood, social condition, and transportation. Higher HPI values indicate less healthy community conditions. LACDPH divided HPI scores into four quartiles and mapped these scores at the census-tract level.
Challenges and Limitations. The COVID-19 pandemic affected the timeline and level of LACDPH programming in the community; specifically, the health crisis delayed the continuation of shared use agreements, because most schools were closed, and delayed the launch of the Park Rx program. In addition, LACDPH noted that safety presents a constant barrier to park access and programming in a number of low-income areas.
Figure 1. Map of Park Locations and HPI by SPA in Los Angeles County
Image description: A colored map of the Healthy Places Index and park locations by service planning areas in Los Angeles County in 2022. The points represent park locations. Parks indicated by turquoise (n = 6), yellow (n = 10), and magenta (n = 13) points were Parks After Dark locations. Grey points indicate all other park locations. The boundaries indicate the eight service planning locations, and the color-coded shading represents the Healthy Places Index at the census-tract level. The Healthy Place Index color scale is divided into four quartiles that range from dark orange, representing the most disadvantaged census tracts, to light orange, light blue, and blue, which represents the least disadvantaged census tracts. Census tracts shaded in light gray did not have Healthy Place Index data available.
References
- Center on Social Health Disparities, Build Healthy Places Network, and Robert Wood Johnson Foundation. How Do Neighborhood Conditions Shape Health? Updated April 11, 2019. Accessed June 3, 2022. https://www.buildhealthyplaces.org/content/uploads/2015/09/How-Do-Neighborhood-Conditions-Shape-Health.pdf
- Brook RD, Rajagopalan S, Pope CA 3rd, Brook JR, Bhatnagar A, et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Circulation. 2010;121(21):2331–78. doi:10.1161/CIR.0b013e3181dbece1
- Brauer M, Casadei B, Harrington RA, Kovacs R, Sliwa K; WHF Air Pollution Expert Group. Taking a stand against air pollution—The impact on cardiovascular disease. Eur Heart J. 2021;42(15):1460–3. doi:10.1093/eurheartj/ehaa1025
- Nolan JES, Coker ES, Ward BR, Williamson YA, Harley KG. “Freedom to breathe”: Youth Participatory Action Research (YPAR) to investigate air pollution inequities in Richmond, CA. Int J Environ Res Public Health. 2021;18(2):E554.
- U.S. Department of Transportation. Health and Equity. Accessed June 14, 2022. https://www.transportation.gov/mission/health/health-equity
- Sacks JD, Stanek LW, Luben TJ, Johns DO, Buckley BJ, Brown JS, et al. Particulate matter-induced health effects: Who is susceptible? Environ Health Perspect. 2011;119(4):446–54.
- Brook RD, Rajagopalan S, Pope CA 3rd, Brook JR, Bhatnagar A, et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Circulation. 2010;121(21):2331–78. doi:10.1161/CIR.0b013e3181dbece1
- Brauer M, Casadei B, Harrington RA, Kovacs R, Sliwa K; WHF Air Pollution Expert Group. Taking a stand against air pollution—The impact on cardiovascular disease. Eur Heart J. 2021;42(15):1460–3. doi:10.1093/eurheartj/ehaa1025
- Fiordelisi A, Piscitelli P, Trimarco B, Coscioni E, Iaccarino G, Sorriento D. The mechanisms of air pollution and particulate matter in cardiovascular diseases. Heart Fail Rev. 2017;22(3):337–47.
- Hayes RB, Lim C, Zhang Y, Cromar K, Shao Y, Reynolds HR, et al. PM2.5 air pollution and cause-specific cardiovascular disease mortality. Int J Epidemiol. 2020;49(1):25–35.
- Brook RD, Rajagopalan S, Pope CA 3rd, Brook JR, Bhatnagar A, et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association. Circulation. 2010;121(21):2331–78. doi:10.1161/CIR.0b013e3181dbece1
- Brauer M, Casadei B, Harrington RA, Kovacs R, Sliwa K; WHF Air Pollution Expert Group. Taking a stand against air pollution—The impact on cardiovascular disease. Eur Heart J. 2021;42(15):1460–3. doi:10.1093/eurheartj/ehaa1025
- Centers for Disease Control and Prevention. Water Fluoridation Basics. Updated October 1, 2021. Accessed July 29, 2022. https://www.cdc.gov/fluoridation/basics/index.htm
- Iheozor-Ejiofor Z, Worthington HV, Walsh T, O’Malley L, Clarkson JE, Macey R, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2015;2015(6):CD010856. doi:10.1002/14651858.CD010856.pub2
- Gianos E, Jackson EA, Tejpal A, Aspry K, O’Keefe J, Aggarwal M, et al. Oral health and atherosclerotic cardiovascular disease: A review. Am J Prev Cardiol. 2021;7:100179. doi:10.1016/j.ajpc.2021.100179
- Yang S, Zhao LS, Cai C, Shi Q, Wen N, Xu J. Association between periodontitis and peripheral artery disease: A systematic review and meta-analysis. BMC Cardiovasc Disord. 2018;18(1):141. doi:10.1186/s12872-018-0879-0
- County Health Rankings & Roadmaps. Air Pollution—Particulate Matter. Accessed July 10, 2022. https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model/health-factors/physical-environment/air-water-quality/air-pollution-particulate-matter
- Youth.gov. Civic Engagement. Accessed June 29, 2022. https://youth.gov/youth-topics/civic-engagement-and-volunteering#_ftn
- Abbott S. Social capital and health: The role of participation. Soc Theory Health. 2010;8(1):51–65.
- Singh R, Javed Z, Yahya T, Valero-Elizondo J, Acquah I, Hyder AA, et al. Community and social context: An important social determinant of cardiovascular disease. Methodist Debakey Cardiovasc J. 2021;17(4):15–27. doi:10.14797/mdcvj.846
- Abbott S. Social capital and health: The role of participation. Soc Theory Health. 2010;8(1):51–65.
- U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Civic Participation. Healthy People 2030. Accessed July 18, 2022. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/civic-participation
- U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Civic Participation. Healthy People 2030. Accessed July 18, 2022. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/civic-participation
- Burr JA, Tavares J, Mutchler JE. Volunteering and hypertension risk in later life. J Aging Health. 2011;23(1):24–51. doi:10.1177/0898264310388272
- Singh R, Javed Z, Yahya T, Valero-Elizondo J, Acquah I, Hyder AA, et al. Community and social context: An important social determinant of cardiovascular disease. Methodist Debakey Cardiovasc J. 2021;17(4):15–27. doi:10.14797/mdcvj.846
- Burr JA, Tavares J, Mutchler JE. Volunteering and hypertension risk in later life. J Aging Health. 2011;23(1):24–51. doi:10.1177/0898264310388272
- Scheffler RM, Brown TT, Syme L, Kawachi I, Tolstykh I, Iribarren C. Community-level social capital and recurrence of acute coronary syndrome. Soc Sci Med. 2008;66(7):1603–13. doi:10.1016/j.socscimed.2007.12.007
- Singh R, Javed Z, Yahya T, Valero-Elizondo J, Acquah I, Hyder AA, et al. Community and social context: An important social determinant of cardiovascular disease. Methodist Debakey Cardiovasc J. 2021;17(4):15–27. doi:10.14797/mdcvj.846
- Singh R, Javed Z, Yahya T, Valero-Elizondo J, Acquah I, Hyder AA, et al. Community and social context: An important social determinant of cardiovascular disease. Methodist Debakey Cardiovasc J. 2021;17(4):15–27. doi:10.14797/mdcvj.846
- Kelli HM, Kim JH, Samman Tahhan A, Liu C, Ko Y-A, Hammadah M, et al. Living in food deserts and adverse cardiovascular outcomes in patients with cardiovascular disease. J Am Heart Assoc. 2019;8(4):e010694. doi:10.1161/JAHA.118.010694
- U.S. Department of Agriculture. Food Access. Updated May 24, 2021. Accessed June 3, 2022. https://www.ers.usda.gov/data-products/food-access-research-atlas/documentation/#definitions
- Berkowitz SA, Karter AJ, Corbie-Smith G, Seligman HK, Ackroyd SA, Barnard LS, et al. Food insecurity, food “deserts,” and glycemic control in patients with diabetes: A longitudinal analysis. Diabetes Care. 2018;41(6):1188–95. doi:10.2337/dc17-1981
- Kelli HM, Kim JH, Samman Tahhan A, Liu C, Ko Y-A, Hammadah M, et al. Living in food deserts and adverse cardiovascular outcomes in patients with cardiovascular disease. J Am Heart Assoc. 2019;8(4):e010694. doi:10.1161/JAHA.118.010694
- Gaglioti AH, Xu J, Rollins L, Baltrus P, O’Connell LK, Cooper DL, et al. Neighborhood environmental health and premature death from cardiovascular disease. Prev Chronic Dis. 2018;15:E17
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Powell-Wiley TM, Baumer Y, Baah FO, Baez AS, Farmer N, Mahlobo CT, et al. Social determinants of cardiovascular disease. Circ Res. 2022;130(5):782–99. doi:10.1161/CIRCRESAHA.121.319811
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Cooksey-Stowers K, Schwartz MB, Brownell KD. Food swamps predict obesity rates better than food deserts in the United States. Int J Environ Res Public Health. 2017;14(11):1366. doi:10.3390/ijerph14111366
- Spence JC, Cutumisu N, Edwards J, Raine KD, Smoyer-Tomic K. Relation between local food environments and obesity among adults. BMC Public Health. 2009;9:192. doi:10.1186/1471-2458-9-192
- Babey SH, Diamant A, Hastert TA, Goldstein H. Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes. UCLA Center for Health Policy Research; 2008. https://escholarship.org/uc/item/9zc7p54b
- Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The impact of neighborhoods on CV risk. Glob Heart. 2016;11(3):353–63. doi:10.1016/j.gheart.2016.08.002
- Babey, SH, Diamant, A, Hastert, TA, Goldstein, H. Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes. UCLA Center for Health Policy Research; 2008.
- Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The impact of neighborhoods on CV risk. Glob Heart. 2016;11(3):353–63. doi:10.1016/j.gheart.2016.08.002
- Jones CP. Systems of power, axes of inequity: Parallels, intersections, braiding the strands. Med Care. 2014;52(10 Suppl 3):S71–5.
- Sprung MR, Faulkner LMD, Evans MK, Zonderman AB, Waldstein SR. Neighborhood crime is differentially associated with cardiovascular risk factors as a function of race and sex. J Public Health Res. 2019;8(3):1643.
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. WISQARS—Web-based Injury Statistics Query and Reporting System. Accessed July 29, 2022. https://www.cdc.gov/injury/wisqars/index.html
- Barber S, Hickson DA, Wang X, Sims M, Nelson C, Diez-Roux AV. Neighborhood disadvantage, poor social conditions, and cardiovascular disease incidence among African American Adults in the Jackson Heart Study. Am J Public Health. 2016;106:2219–26. doi:10.2105/AJPH.2016.303471
- Kim ES, Park N, Peterson C. Perceived neighborhood social cohesion and stroke. Soc Sci Med. 2013;97:49–55. doi:10.1016/j.socscimed.2013.08.001
- Powell-Wiley TM, Baumer Y, Baah FO, Baez AS, Farmer N, Mahlobo CT, et al. Social determinants of cardiovascular disease. Circ Res. 2022;130(5):782–99. doi:10.1161/CIRCRESAHA.121.319811
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Sprung MR, Faulkner LMD, Evans MK, Zonderman AB, Waldstein SR. Neighborhood crime is differentially associated with cardiovascular risk factors as a function of race and sex. J Public Health Res. 2019;8(3):1643.
- Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The impact of neighborhoods on CV risk. Glob Heart. 2016;11(3):353–63. doi:10.1016/j.gheart.2016.08.002
- Elo IT, Mykyta L, Margolis R, Culhane JF. Perceptions of neighborhood disorder: The role of individual and neighborhood characteristics. Soc Sci Q. 2009;90(5):1298–320. doi:10.1111/j.1540-6237.2009.00657.x
- Ewart CK, Suchday S. Discovering how urban poverty and violence affect health: Development and validation of a Neighborhood Stress Index [published correction appears in Health Psychol. 2002;21(5):458]. Health Psychol. 2002;21(3):254–62. doi:10.1037//0278-6133.21.3.254
- Jennings V, Baptiste AK, Osborne Jelks N, Skeete R. Urban green space and the pursuit of health equity in parts of the United States. Int J Environ Res Public Health. 2017;14(11):1432. doi:10.3390/ijerph14111432
- Sims M, Kershaw KN, Breathett K, Jackson EA, Lewis LM, Mujahid MS, et al. Importance of housing and cardiovascular health and well-being: A scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2020;13(8):e000089. doi:10.1161/HCQ.0000000000000089
- Russo A, Cirella GT. Modern compact cities: How much greenery do we need? Int J Environ Res Public Health. 2018;15(10):2180. doi:10.3390/ijerph15102180
- Wen M, Zhang X, Harris CD, Holt JB, Croft JB. Spatial disparities in the distribution of parks and green spaces in the USA. Ann Behav Med. 2013;45(Suppl 1):S18–27.
- Wen M, Zhang X, Harris CD, Holt JB, Croft JB. Spatial disparities in the distribution of parks and green spaces in the USA. Ann Behav Med. 2013;45(Suppl 1):S18–27.
- Swope CB, Hernández D. Housing as a determinant of health equity: A conceptual model. Soc Sci Med. 2019;243:112571. doi:10.1016/j.socscimed.2019.112571
- Centers for Disease Control and Prevention. Definitions. Healthy Housing Reference Manual. Updated October 1, 2009. Accessed July 29, 2022. https://www.cdc.gov/nceh/publications/books/housing/definitions.htm
- D’Alessandro D, Appolloni L. Housing and health: An overview. Ann Ig. 2020;32(5 Supple 1):17–26. doi:10.7416/ai.2020.3391
- D’Alessandro D, Appolloni L. Housing and health: An overview. Ann Ig. 2020;32(5 Supple 1):17–26. doi:10.7416/ai.2020.3391
- Centers for Disease Control and Prevention. Definitions. Healthy Housing Reference Manual. Updated October 1, 2009. Accessed July 29, 2022. https://www.cdc.gov/nceh/publications/books/housing/definitions.htm
- Centers for Disease Control and Prevention. Definitions. Healthy Housing Reference Manual. Updated October 1, 2009. Accessed July 29, 2022. https://www.cdc.gov/nceh/publications/books/housing/definitions.htm
- D’Alessandro D, Appolloni L. Housing and health: An overview. Ann Ig. 2020;32(5 Supple 1):17–26. doi:10.7416/ai.2020.3391
- Sims M, Kershaw KN, Breathett K, Jackson EA, Lewis LM, Mujahid MS, et al. Importance of housing and cardiovascular health and well-being: A scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2020;13(8):e000089.
- Taylor LA. Housing and health: An overview of the literature. Health Affairs Health Policy Brief. 2018. doi:10.1377/hpb20180313.396577
- D’Alessandro D, Appolloni L. Housing and health: An overview. Ann Ig. 2020;32(5 Supple 1):17–26. doi:10.7416/ai.2020.3391
- Virgile M, Tuttle D, Katz J, Terry R, Graber J. Cognitive pretesting of 2019 American Housing Survey module on housing insecurity research and methodology directorate. U.S. Census Bureau Center for Behavioral Science Methods Research Report Series (Survey Methodology #2019-08). 2019. Accessed May 20, 2022. http://www.census.gov/content/dam/Census/library/working-papers/2019/adrm/rsm2019-08.pdf
- Centers for Disease Control and Prevention. Definitions. Healthy Housing Reference Manual. Updated October 1, 2009. Accessed July 29, 2022. https://www.cdc.gov/nceh/publications/books/housing/definitions.htm
- Haney C. Prison effects in the era of mass incarceration. Prison J. 2012;1–24.
- Lee H, Wildeman C, Wang EA, Matusko N, Jackson JS. A heavy burden: The cardiovascular health consequences of having a family member incarcerated. Am J Public Health. 2014;104(3):421–7
- Wang EA, Redmond N, Dennison Himmelfarb CR, Pettit B, Stern M, Chen J, et al. Cardiovascular disease in incarcerated populations. J Am Coll Cardiol. 2017;69(24):29–76. doi:10.1016/j.jacc.2017.04.040
- The Sentencing Project. Criminal Justice Facts. Accessed July 29, 2022. https://www.sentencingproject.org/criminal-justice-facts/
- Wang EA, Redmond N, Dennison Himmelfarb CR, Pettit B, Stern M, Chen J, et al. Cardiovascular disease in incarcerated populations. J Am Coll Cardiol. 2017;69(24):29–76. doi:10.1016/j.jacc.2017.04.040
- Lee H, Wildeman C, Wang EA, Matusko N, Jackson JS. A heavy burden: The cardiovascular health consequences of having a family member incarcerated. Am J Public Health. 2014;104(3):421–7.
- Topel ML, Kelli HM, Lewis TT, Dunbar SB, Vaccarino V, Taylor HA, Quyyumi AA. High neighborhood incarceration rate is associated with cardiometabolic disease in nonincarcerated Black individuals. Ann Epidemiol. 2018;28(7):489–92. doi:10.1016/j.annepidem.2018.01.011
- Topel ML, Kelli HM, Lewis TT, Dunbar SB, Vaccarino V, Taylor HA, Quyyumi AA. High neighborhood incarceration rate is associated with cardiometabolic disease in nonincarcerated Black individuals. Ann Epidemiol. 2018;28(7):489–92. doi:10.1016/j.annepidem.2018.01.011
- National Institute on Alcohol Abuse and Alcoholism. Drinking Levels Defined. Accessed July 29, 2022. https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking
- Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health. 2011;34(2):135–43.
- Campbell CA, Hahn RA, Elder R, Brewer R, Chattopadhyay S, Fielding J, et al. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. Am J Prev Med. 2009;37(6):556–69. doi:10.1016/j.amepre.2009.09.028
- Brenner AB, Borrell LN, Barrientos-Gutierrez T, Diez Roux AV. Longitudinal associations of neighborhood socioeconomic characteristics and alcohol availability on drinking: Results from the Multi-Ethnic Study of Atherosclerosis (MESA). Soc Sci Med. 2015;145:17–25. doi:10.1016/j.socscimed.2015.09.030
- Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014;11:E109.
- Cambron C, Kosterman R, Rhew IC, Catalano RF, Guttmannova K, Hawkins JD. An examination of alcohol use disorder symptoms and neighborhood disorganization from age 21 to 39. Am J Community Psychol. 2017;60(1–2):267–78.
- Snowden AJ, Hockin S, Pridemore WA. The neighborhood-level association between alcohol outlet density and female criminal victimization rates. J Interpers Violence. 2020;35(15-16):2639–62.
- Furr-Holden CDM, Nesoff ED, Nelson V, Milam AJ, Smart M, Lacey K, et al. Understanding the relationship between alcohol outlet density and life expectancy in Baltimore City: The role of community violence and community disadvantage. J Community Psychol. 2019;47(1):63–75.
- U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Updated 2018. Accessed June 3, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
- U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Updated 2018. Accessed June 3, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
- Centers for Disease Control and Prevention. Adult Physical Inactivity Prevalence Maps by Race/Ethnicity. Updated February 17, 2022. Accessed June 3, 2022. https://www.cdc.gov/physicalactivity/data/inactivity-prevalence-maps/index.html
- U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Updated 2018. Accessed June 3, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
- Centers for Disease Control and Prevention. Adult Physical Inactivity Prevalence Maps by Race/Ethnicity. Updated February 17, 2022. Accessed June 3, 2022. https://www.cdc.gov/physicalactivity/data/inactivity-prevalence-maps/index.html
- U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Updated 2018. Accessed June 3, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
- Sallis JF, Cerin E, Kerr J, Adams MA, Sugiyama T, Christiansen LB, et al. Built environment, physical activity, and obesity: Findings from the International Physical Activity and Environment Network (IPEN) Adult Study. Annu Rev Public Health. 2020;41:119–39.
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Kärmeniemi M, Lankila T, Ikäheimo T, Koivumaa-Honkanen H, Korpelainen R. The built environment as a determinant of physical activity: A systematic review of longitudinal studies and natural experiments. Ann Behav Med. 2018;52(3):239–51. doi:10.1093/abm/kax043
- Pearson TA, Palaniappan LP, Artinian NT, Carnethon MR, Criqui MH, Daniels SR, et al. American Heart Association guide for improving cardiovascular health at the community level, 2013 update: A scientific statement for public health practitioners, healthcare providers, and health policy makers. Circulation. 2013;127(16):1730–53. doi:10.1161/CIR.0b013e31828f8a94
- Zheng Z, Zhang P, Yuan F, Bo Y. Scientometric analysis of the relationship between a built environment and cardiovascular disease. Int J Environ Res Public Health. 2022;19(9):5625. doi:10.3390/ijerph19095625
- Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The impact of neighborhoods on CV risk. Glob Heart. 2016;11(3):353–363. doi:10.1016/j.gheart.2016.08.002
- Beech BM, Ford C, Thorpe RJ Jr, Bruce MA, Norris KC. Poverty, racism, and the public health crisis in America. Front Public Health. 2021;9:699049. doi:10.3389/fpubh.2021.699049
- Wagle U. Rethinking poverty: Definition and measurement. Int Soc Sci J. 2002;54:155–65. 10.1111/issj.12192
- Ahmad K, Chen EW, Nazir U, Cotts W, Andrade A, Trivedi AN, et al. Regional variation in the association of poverty and heart failure mortality in the 3135 counties of the United States. J Am Heart Assoc. 2019;8(18):e012422. doi:10.1161/JAHA.119.012422
- Rao S, Hughes A, Segar MW, Wilson B, Ayers C, Das S, et al. Longitudinal trajectories and factors associated with U.S. county-level cardiovascular mortality, 1980 to 2014. JAMA Netw Open. 2021;4(11):e2136022. doi:10.1001/jamanetworkopen.2021.36022
- Al-Turk B, Harris C, Nelson G, Smotherman C, Palacio C, House J. Poverty, a risk factor overlooked: A cross-sectional cohort study comparing poverty rate and cardiovascular disease outcomes in the state of Florida. J Investig Med. 2018;66(3):693–5.
- Federal poverty level (FPL). Healthcare.gov. Accessed June 21, 2022. https://www.healthcare.gov/glossary/federal-poverty-level-fpl/
- Meade EE. Overview of Community Characteristics in Areas With Concentrated Poverty. ASPE Research Brief. U.S. Department of Health and Human Services; 2014. https://aspe.hhs.gov/system/files/pdf/40651/rb_concentratedpoverty.pdf
- Meade EE. Overview of Community Characteristics in Areas With Concentrated Poverty. ASPE Research Brief. U.S. Department of Health and Human Services; 2014. https://aspe.hhs.gov/system/files/pdf/40651/rb_concentratedpoverty.pdf
- Meade EE. Overview of Community Characteristics in Areas With Concentrated Poverty. ASPE Research Brief. U.S. Department of Health and Human Services; 2014. https://aspe.hhs.gov/system/files/pdf/40651/rb_concentratedpoverty.pdf
- Kneebone E, Holmes N. U.S. Concentrated Poverty in the Wake of the Great Recession. Brookings Institute; 2016. https://www.brookings.edu/research/u-s-concentrated-poverty-in-the-wake-of-the-great-recession/
- Meade EE. Overview of Community Characteristics in Areas With Concentrated Poverty. ASPE Research Brief. U.S. Department of Health and Human Services; 2014. https://aspe.hhs.gov/system/files/pdf/40651/rb_concentratedpoverty.pdf
- Meade EE. Overview of Community Characteristics in Areas With Concentrated Poverty. ASPE Research Brief. U.S. Department of Health and Human Services; 2014. https://aspe.hhs.gov/system/files/pdf/40651/rb_concentratedpoverty.pdf
- The Annie E. Casey Foundation. Concentrated poverty. Accessed June 14, 2022. https://www.aecf.org/topics/concentrated-poverty#:~:text=Areas%20of%20concentrated%20poverty%20are%20defined%20as%20census,options%2C%20top-performing%20public%20schools%20and%20quality%20medical%20care
- Congressional Research Service. The 10-20-30 Provision: Defining persistent poverty counties. Updated April 14, 2022. Accessed June 3, 2022. https://sgp.fas.org/crs/misc/R45100.pdf
- Shahidi FV, Ramraj C, Sod-Erdene O, Hildebrand V, Siddiqi A. The impact of social assistance programs on population health: A systematic review of research in high-income countries. BMC Public Health. 2019;19(1):2.
- University Wisconsin-Madison Institute for Research on Poverty. Social Insurance Programs. Accessed July 29, 2022. https://www.irp.wisc.edu/research/economic-support/social-insurance-programs/
- University Wisconsin-Madison Institute for Research on Poverty. Means-Tested Programs. Accessed July 29, 2022. https://www.irp.wisc.edu/research/economic-support/means-tested-programs/
- Shahidi FV, Ramraj C, Sod-Erdene O, Hildebrand V, Siddiqi A. The impact of social assistance programs on population health: A systematic review of research in high-income countries. BMC Public Health. 2019;19(1):2.
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Powell-Wiley TM, Baumer Y, Baah FO, Baez AS, Farmer N, Mahlobo CT, et al. Social determinants of cardiovascular disease. Circ Res. 2022;130(5):782–99. doi:10.1161/CIRCRESAHA.121.319811
- Te Vazquez J, Feng SN, Orr CJ, Berkowitz SA. Food insecurity and cardiometabolic conditions: A review of recent research. Curr Nutr Rep. 2021;10(4):243–54. doi:10.1007/s13668-021-00364-2
- Seligman HK, Berkowitz SA. Aligning programs and policies to support food security and public health goals in the United States. Annu Rev Public Health. 2019;40:319–37. doi:10.1146/annurev-publhealth-040218-044132
- U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Social Cohesion. Healthy People 2030. Accessed July 18, 2022. https://health.gov/healthypeople/objectives-and-data/social-determinants-health/literature-summaries/social-cohesion
- U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Social Cohesion. Healthy People 2030. Accessed July 18, 2022. https://health.gov/healthypeople/objectives-and-data/social-determinants-health/literature-summaries/social-cohesion
- Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000;51(6):843–57. doi:10.1016/s0277-9536(00)00065-4
- Singh R, Javed Z, Yahya T, Valero-Elizondo J, Acquah I, Hyder AA, et al. Community and social context: An important social determinant of cardiovascular disease. Methodist Debakey Cardiovasc J. 2021;17(4):15–27. doi:10.14797/mdcvj.846
- Singh R, Javed Z, Yahya T, Valero-Elizondo J, Acquah I, Hyder AA, et al. Community and social context: An important social determinant of cardiovascular disease. Methodist Debakey Cardiovasc J. 2021;17(4):15–27. doi:10.14797/mdcvj.846
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Powell-Wiley TM, Baumer Y, Baah FO, Baez AS, Farmer N, Mahlobo CT, et al. Social determinants of cardiovascular disease. Circ Res. 2022;130(5):782–99. doi:10.1161/CIRCRESAHA.121.319811
- Mujahid MS, Diez Roux AV, Morenoff JD, Raghunathan TE, Cooper RS, Ni H, Shea S. Neighborhood characteristics and hypertension. Epidemiology. 2008;19(4):590–8. doi:10.1097/EDE.0b013e3181772cb2
- Unger E, Diez-Roux AV, Lloyd-Jones DM, Mujahid MS, Nettleton JA, Bertoni A, et al. Association of neighborhood characteristics with cardiovascular health in the Multi-Ethnic Study of Atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7(4):524–31. doi:10.1161/CIRCOUTCOMES.113.000698
- Diez Roux AV, Mujahid MS, Hirsch JA, Moore K, Moore LV. The impact of neighborhoods on CV risk. Glob Heart. 2016;11(3):353–63. doi:10.1016/j.gheart.2016.08.002
- Buckner JC. The development of an instrument to measure neighborhood cohesion. Am J Commun Psychol. 1988;16(6):771–91.
- Singh GK. Area deprivation and widening inequalities in US mortality, 1969–1998. Am J Public Health. 2003;93(7):1137–43. doi:10.2105/ajph.93.7.1137
- Claudel SE, Adu-Brimpong J, Banks A, Ayers C, Albert MA, Das SR, et al. Association between neighborhood-level socioeconomic deprivation and incident hypertension: A longitudinal analysis of data from the Dallas heart study. Am Heart J. 2018;204:109–18. doi:10.1016/j.ahj.2018.07.005
- Barber S, Hickson DA, Kawachi I, Subramanian SV, Earls F. Neighborhood disadvantage and cumulative biological risk among a socioeconomically diverse sample of African American adults: An examination in the Jackson Heart Study. J Racial Ethn Health Disparities. 2016;3(3):444–56. doi:10.1007/s40615-015-0157-0
- Coulon SM, Wilson DK, Alia KA, Van Horn ML. Multilevel associations of neighborhood poverty, crime, and satisfaction with blood pressure in African-American adults. Am J Hypertens. 2016;29(1):90–5. doi:10.1093/ajh/hpv060
- Barber S, Hickson DA, Wang X, Sims M, Nelson C, Diez-Roux AV. Neighborhood disadvantage, poor social conditions, and cardiovascular disease incidence among African American adults in the Jackson Heart Study. Am J Public Health. 2016;106(12):2219–26. doi:10.2105/AJPH.2016.303471
- Claudel SE, Adu-Brimpong J, Banks A, Ayers C, Albert MA, Das SR, et al. Association between neighborhood-level socioeconomic deprivation and incident hypertension: A longitudinal analysis of data from the Dallas heart study. Am Heart J. 2018;204:109–18. doi:10.1016/j.ahj.2018.07.005
- Ford MM, Highfield LD. Exploring the spatial association between social deprivation and cardiovascular disease mortality at the neighborhood level. PLoS One. 2016;11(1):1–17. doi:10.1371/journal.pone.0146085
- Barber S, Hickson DA, Kawachi I, Subramanian SV, Earls F. Neighborhood disadvantage and cumulative biological risk among a socioeconomically diverse sample of African American adults: An examination in the Jackson Heart Study. J Racial Ethn Health Disparities. 2016;3(3):444–56. doi:10.1007/s40615-015-0157-0
- Barber S, Hickson DA, Wang X, Sims M, Nelson C, Diez-Roux AV. Neighborhood disadvantage, poor social conditions, and cardiovascular disease incidence among African American adults in the Jackson Heart Study. Am J Public Health. 2016;106(12):2219–26. doi:10.2105/AJPH.2016.303471
- Barber S, Hickson DA, Kawachi I, Subramanian SV, Earls F. Neighborhood disadvantage and cumulative biological risk among a socioeconomically diverse sample of African American adults: An examination in the Jackson Heart Study. J Racial Ethn Health Disparities. 2016;3(3):444–56. doi:10.1007/s40615-015-0157-0
- Barber S, Hickson DA, Wang X, Sims M, Nelson C, Diez-Roux AV. Neighborhood disadvantage, poor social conditions, and cardiovascular disease incidence among African American adults in the Jackson Heart Study. Am J Public Health. 2016;106(12):2219–26. doi:10.2105/AJPH.2016.303471
- Basile Ibrahim B, Barcelona V, Condon EM, Crusto CA, Taylor JY. The association between neighborhood social vulnerability and cardiovascular health risk among Black/African American women in the InterGEN Study. Nurs Res. 2021;70(5S Suppl 1):S3–12. doi:10.1097/NNR.0000000000000523
- Basile Ibrahim B, Barcelona V, Condon EM, Crusto CA, Taylor JY. The association between neighborhood social vulnerability and cardiovascular health risk among Black/African American women in the InterGEN Study. Nurs Res. 2021;70(5S Suppl 1):S3–12. doi:10.1097/NNR.0000000000000523
- Omura JD, Carlson SA, Brown DR, Hopkins DP, Kraus WE, Staffileno BA, et al. Built environment approaches to increase physical activity: A science advisory from the American Heart Association. Circulation. 2020;142(11):e160–6. doi:10.1161/CIR.0000000000000884
- U.S. Department of Transportation. Literature and Resources. Accessed June 14, 2022. https://www.transportation.gov/mission/health/literature-and-resources
- Centers for Disease Control and Prevention. Transportation and Health. Accessed June 14, 2022. https://www.cdc.gov/healthyplaces/healthtopics/transportation/default.htm
- U.S. Department of Transportation. Health and Equity. Accessed June 14, 2022. https://www.transportation.gov/mission/health/health-equity
- Freeland AL, Banerjee SN, Dannenberg AL, Wendel AM. Walking associated with public transit: Moving toward increased physical activity in the United States. Am J Public Health. 2013;103(3):536–42.
- Khan LK, Sobush K, Keener D, Goodman K, Lowry A, Kakietek J, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Recomm Rep. 2009;58(RR-7):1–26.
- Centers for Disease Control and Prevention. Transportation and Health. Accessed June 14, 2022. https://www.cdc.gov/healthyplaces/healthtopics/transportation/default.htm
- U.S. Department of Transportation. Health and Equity. Accessed June 14, 2022. https://www.transportation.gov/mission/health/health-equity
- Omura JD, Carlson SA, Brown DR, Hopkins DP, Kraus WE, Staffileno BA, et al. Built environment approaches to increase physical activity: A science advisory from the American Heart Association. Circulation. 2020;142(11):e160–6. doi:10.1161/CIR.0000000000000884
- Community Preventive Services Task Force. Physical Activity: Built Environment Approaches Combining Transportation System Interventions With Land Use and Environmental Design. Update December 2016. Accessed June 13, 2022. https://www.thecommunityguide.org/findings/physical-activity-built-environment-approaches
- U.S. Health Resources & Services Administration. Defining Rural Population. Updated March 2022. Accessed June 14, 2022. https://www.hrsa.gov/rural-health/about-us/definition/index.html
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Centers for Disease Control and Prevention. Rural Health. Updated July 1, 2019. Accessed June 14, 2022. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/rural-health.htm
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Centers for Disease Control and Prevention. Rural Health. Updated July 1, 2019. Accessed June 14, 2022. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/rural-health.htm
- Centers for Disease Control and Prevention. Rural Health. Updated July 1, 2019. Accessed June 14, 2022. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/rural-health.htm
- Rowlands DW, Love H. Mapping Rural America’s Diversity and Demographic Change. Published September 28, 2021. Accessed August 2, 2022. https://www.brookings.edu/blog/the-avenue/2021/09/28/mapping-rural-americas-diversity-and-demographic-change/
- Caldwell JT, Ford CL, Wallace SP, Wang MC, Takahashi LM. Intersection of living in a rural versus urban area and race/ethnicity in explaining access to health care in the United States. Am J Public Health. 2016;106(8):1463–9. doi:10.2105/AJPH.2016.303212
- Henning-Smith CE, Hernandez AM, Hardeman RR, Ramirez MR, Kozhimannil KB. Rural counties with majority black or indigenous populations suffer the highest rates of premature death in the US. Health Aff (Millwood). 2019;38(12):2019–26. doi:10.1377/hlthaff.2019.00847
- James CV, Moonesinghe R, Wilson-Frederick SM, Hall JE, Penman-Aguilar A, Bouye K. Racial/ethnic health disparities among rural adults—United States, 2012–2015. MMWR Surveill Summ. 2017;66(23):1–9. doi:10.15585/mmwr.ss6623a1
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Gudbranson E, Glickman A, Emanuel EJ. Reassessing the data on whether a physician shortage exists. JAMA. 2017;317(19):1945–6. doi:10.1001/jama.2017.2609
- Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615–44. doi:10.1161/CIR.0000000000000753
- Beech BM, Ford C, Thorpe RJ Jr, Bruce MA, Norris KC. Poverty, racism, and the public health crisis in America. Front Public Health. 2021;9:699049. doi:10.3389/fpubh.2021.699049
- Ahmad K, Chen EW, Nazir U, Cotts W, Andrade A, Trivedi AN, et al. Regional variation in the association of poverty and heart failure mortality in the 3135 counties of the United States. J Am Heart Assoc. 2019;8(18):e012422. doi:10.1161/JAHA.119.012422
- Rao S, Hughes A, Segar MW, Wilson B, Ayers C, Das S, et al. Longitudinal trajectories and factors associated with US county-level cardiovascular mortality, 1980 to 2014. JAMA Netw Open. 2021;4(11):e2136022. doi:10.1001/jamanetworkopen.2021.36022
- Al-Turk B, Harris C, Nelson G, Smotherman C, Palacio C, House J. Poverty, a risk factor overlooked: A cross-sectional cohort study comparing poverty rate and cardiovascular disease outcomes in the state of Florida. J Investig Med. 2018;66(3):693–5.
- Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nat Med. 2022;28(3):583–90. doi:10.1038/s41591-022-01689-3
- Sallis JF, Cerin E, Kerr J, Adams MA, Sugiyama T, Christiansen LB, et al. Built environment, physical activity, and obesity: findings from the International Physical Activity and Environment Network (IPEN) Adult Study. Annu Rev Public Health. 2020;41:119–39.
- Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
- Kärmeniemi M, Lankila T, Ikäheimo T, Koivumaa-Honkanen H, Korpelainen R. The built environment as a determinant of physical activity: A systematic review of longitudinal studies and natural experiments. Ann Behav Med. 2018;52(3):239–51. doi:10.1093/abm/kax043
- U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Updated 2018. Accessed June 3, 2022. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
- Note: LACDPH use of the indicator is different from guidance provided in the HEI Indicator Profiles.
- ParkServe. The Trust for Public Land’s ParkServe® Website (TPL). Updated 2022. Accessed December 12, 2022. https://www.tpl.org/parkserve/about
- Note: LACDPH use of the indicator is different from guidance provided in the HEI Indicator Profiles.
- At the time of implementation, the coalition was renamed the Joint/Shared-Use Moving People to Play (JUMPP) Coalition.
- Agency for Toxic Substances and Disease Registry. CDC/ATSDR Social Vulnerability Index. Accessed December 12, 2022. https://www.atsdr.cdc.gov/placeandhealth/svi/index.html
- Agency for Toxic Substances and Disease Registry. At A Glance: CDC/ATSDR Social Vulnerability Index. Accessed December 12, 2022. https://www.atsdr.cdc.gov/placeandhealth/svi/at-a-glance_svi.html
- Coulon SM, Wilson DK, Alia KA, Van Horn ML. Multilevel associations of neighborhood poverty, crime, and satisfaction with blood pressure in African-American adults. Am J Hypertens. 2016;29(1):90–5. doi:10.1093/ajh/hpv060
- Barber S, Hickson DA, Wang X, Sims M, Nelson C, Diez-Roux AV. Neighborhood disadvantage, poor social conditions, and cardiovascular disease incidence among African American adults in the Jackson Heart Study. Am J Public Health. 2016;106(12):2219–26. doi:10.2105/AJPH.2016.303471
- Ibrahim BB, Barcelona V, Condon EM, Crusto CA, Taylor JY. The association between neighborhood social vulnerability and cardiovascular health risk among Black/African American women in the InterGEN Study. Nurs Res. 2021;70(5S Suppl 1):S3–12. doi:10.1097/NNR.0000000000000523
- Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nat Med. 2022;28(3):583–90. doi:10.1038/s41591-022-01689-3
