High-poverty Census Tracts Research Articles

Influence of Neighborhood Conditions on Recurrent Hospital Readmissions in Patients with Heart Failure: A Cohort Study

PurposeThis study examined how certain aspects of residential neighborhood conditions (ie, observed built environment, census-based area-level poverty, and perceived disorder) affect readmission in urban patients with heart failure. MethodsA total of 400 patients with heart failure who were discharged alive from an urban-university teaching hospital were enrolled. Data were collected about readmissions during a 2-year follow-up. The impact of residential neighborhood conditions on readmissions was examined with adjustment for 7 blocks of covariates: 1) patient demographic characteristics; 2) comorbidities; 3) clinical characteristics; 4) depression; 5) perceived stress; 6) health behaviors; and 7) hospitalization characteristics. ResultsA total of 83.3% of participants were readmitted. Participants from high-poverty census tracts (≥20%) were at increased risk of readmission compared with those from census tracts with <10% poverty (hazard ratio [HR]: 1.53; 95% confidence interval: 1.03-2.27; P < .05) when adjusted for demographic characteristics. None of the built environmental or perceived neighborhood conditions were associated with the risk of readmission. The poverty-related risk of readmission was reduced to nonsignificance after including diabetes (HR: 1.33) and hypertension (HR: 1.35) in the models. ConclusionsThe effect of high poverty is partly explained by high rates of hypertension and diabetes in these areas. Improving diabetes and blood pressure control or structural aspects of impoverished areas may help reduce hospital readmissions.

Beverage Availability and Price: Variations by Neighborhood Poverty Level in New York City.

Objective:To describe the variability in the availability and price of sugary drinks, low-calorie drinks, and water/seltzer across high- and low-poverty census tracts in the five boroughs of New York City (NYC).Design:Cross-sectional study. Our primary analysis compared the overall sample of beverages. Secondary analyses included tests for differences in the availability of beverage categories by neighborhood poverty level.Setting:We collected data from 106 stores (31 supermarkets, 29 convenience stores, 29 pharmacies, 9 Targets, and 8 Dollar Trees) in NYC. Fifty-four stores were located in high-poverty census tracts and 52 were located in low-poverty census tracts.Results:The mean Price per 0.03-liter of sugary drinks across the sample was $0.08, which was significantly higher than the price of low-calorie drinks ($0.07, p=0.01) but not different from water/seltzer ($0.08, p=0.65). Sugary drinks and water/seltzer were available in 91% of retailers, and low-calorie drinks were available in 87% of retailers. There was no statistical difference in availability of sugary drinks compared with low-calorie drinks or water/seltzer overall or within high- or low-poverty census tracts. Analyzed by store type, the mean price per ounce of sugary drinks differed significantly from water/seltzer at convenience stores, pharmacies, and Target stores (bodegas: $0.08 vs. $0.09, p=0.03; pharmacies: $0.11 vs. $0.08, p=0.02; Target stores: $0.07 vs. $0.09, p=0.01).Conclusions:Sugary drinks were available in most food retail settings in NYC, with little variation by census tract poverty level. Interventions that raise the price of sugary drinks to make healthier alternatives, such as water, the more affordable option should be considered.

Geographic ecological momentary assessment methods to examine spatio-temporal exposures associated with marijuana use among young adults: A pilot study

BackgroundThis study demonstrates the use of geographic ecological momentary assessment (GEMA) methods among young adult marijuana users. MethodParticipants were 14 current marijuana users ages 21–27 living in Greater Seattle, Washington. They completed brief surveys four times per day for 14 consecutive days, including measures of marijuana use and desire to use. They also carried a GPS data logger that tracked their spatial movements over time. ResultsParticipants completed 80.1% of possible EMA surveys. Using the GPS data, we calculated daily number of exposures to (i.e., within 100-m of) marijuana retail outlets (mean = 3.9 times per day; SD = 4.4) and time spent per day in high poverty census tracts (mean = 7.3 h per day in high poverty census tracts; SD = 5.1). ConclusionsGEMA may be a promising approach for studying the role spatio-temporal factors play in marijuana use and related factors.

Associations between disparities in tobacco retailer density and disparities in tobacco use

Research has separately established that there are disparities in tobacco use, that greater tobacco retailer density (TRD) is positively associated with tobacco use, and that TRD is greater in high poverty and high racial/ethnic minority neighborhoods. Connecting these topics, this study examined the association between disparities in TRD and disparities in the prevalence of tobacco use among adults and youth. We obtained Ohio data on tobacco use from two statewide adult surveys and two sub-state regional youth surveys (2017–2019). Licensed tobacco retailers in Ohio were geocoded within census tracts. Disparity in TRD within regions across the state was defined as the ratio of TRD in high vs. low poverty (and in high vs. low racial/ethnic minority) census tracts per region. Disparity in cigarette smoking (adults) and any tobacco use (youth) was defined as the ratio of use prevalence among socioeconomically disadvantaged vs. non-disadvantaged (and racial/ethnic minority vs. non-minority) individuals. We estimated Pearson correlation coefficients to assess the linear relationship between the TRD disparity ratios and tobacco use disparity ratios. Poverty-based and race/ethnicity-based TRD disparities were positively associated with smoking disparities among adults. Negative associations between TRD disparities and tobacco use disparities were found among youth. To our knowledge, this is the first analysis directly linking TRD disparities and tobacco use disparities. Different adult and youth findings may be due to trends by age and product preferences. For adults in particular, this analysis suggests a detrimental effect of the tobacco retail environment on disadvantaged populations.

Census tract socioeconomic indicators and COVID-19-associated hospitalization rates-COVID-NET surveillance areas in 14 states, March 1-April 30, 2020.

ObjectivesSome studies suggested more COVID-19-associated hospitalizations among racial and ethnic minorities. To inform public health practice, the COVID-19-associated Hospitalization Surveillance Network (COVID-NET) quantified associations between race/ethnicity, census tract socioeconomic indicators, and COVID-19-associated hospitalization rates.MethodsUsing data from COVID-NET population-based surveillance reported during March 1–April 30, 2020 along with socioeconomic and denominator data from the US Census Bureau, we calculated COVID-19-associated hospitalization rates by racial/ethnic and census tract-level socioeconomic strata.ResultsAmong 16,000 COVID-19-associated hospitalizations, 34.8% occurred among non-Hispanic White (White) persons, 36.3% among non-Hispanic Black (Black) persons, and 18.2% among Hispanic or Latino (Hispanic) persons. Age-adjusted COVID-19-associated hospitalization rate were 151.6 (95% Confidence Interval (CI): 147.1–156.1) in census tracts with >15.2%–83.2% of persons living below the federal poverty level (high-poverty census tracts) and 75.5 (95% CI: 72.9–78.1) in census tracts with 0%–4.9% of persons living below the federal poverty level (low-poverty census tracts). Among White, Black, and Hispanic persons living in high-poverty census tracts, age-adjusted hospitalization rates were 120.3 (95% CI: 112.3–128.2), 252.2 (95% CI: 241.4–263.0), and 341.1 (95% CI: 317.3–365.0), respectively, compared with 58.2 (95% CI: 55.4–61.1), 304.0 (95%: 282.4–325.6), and 540.3 (95% CI: 477.0–603.6), respectively, in low-poverty census tracts.ConclusionsOverall, COVID-19-associated hospitalization rates were highest in high-poverty census tracts, but rates among Black and Hispanic persons were high regardless of poverty level. Public health practitioners must ensure mitigation measures and vaccination campaigns address needs of racial/ethnic minority groups and people living in high-poverty census tracts.

Associations of objective and perceived greenness measures with cardiovascular risk factors in Philadelphia, PA: A spatial analysis

There is mounting scientific evidence that greenness is associated with improved cardiovascular health. However, few studies have distinguished between vegetation type, measured perceived green space access, or investigated heterogeneity of associations across categories of neighborhood sociodemographic and racial/ethnic composition. We conducted an ecologic spatial analysis of associations of three objective measures of greenness (percent vegetation cover, percent tree canopy cover, and greenness density), and one measure of perceived access to green spaces with census tract level percentages of the adult population who were obese, ever had a high blood pressure diagnosis, and ever had a diabetes diagnosis, in the city of Philadelphia, PA, year 2013. We explored effect modification by census-tract level percent living in poverty and percent non-Hispanic Black categories. We used data from the Southeastern Pennsylvania Household Health Survey (SEPAHH) linked with high-resolution landcover, remotely sensed, and American Community Survey data and estimated associations using spatial lag models. We observed modest protective associations between percent of the adult population reporting perceived access to green spaces and percent with the cardiovascular risk factors, particularly in moderate and high poverty census tracts. Percent tree canopy cover was also protective against the cardiovascular risk factors, particularly in census tracts with low percentages of the population living in poverty and with low percent non-Hispanic Black populations. These results suggest that perceived access to green spaces and objectively measured high tree canopy cover, may protect against cardiovascular disease, but associations may vary across neighborhood sociodemographic categories.

Abstract B46: Trends in stage at diagnosis for ovarian, fallopian tube, and serous primary peritoneal cancers, 2004–2015

Abstract Introduction: Timely diagnosis is key to reducing distant stage ovarian cancer. The purpose of this study was to examine trends in the proportion of women diagnosed with ovarian cancer by stage and predictors of distant stage diagnosis, comparing two time periods: 2004–2009 and 2010–2015. Methods: We analyzed newly diagnosed malignant ovarian, fallopian tube, and serous primary peritoneal cancers reported to population-based central cancer registries funded by CDC’s National Program of Cancer Registries (NPCR) or the NCI’s Surveillance, Epidemiology, and End Results Program (SEER). We conducted a descriptive analysis examining demographic and clinical characteristics by SEER summary stage at diagnosis (localized, regional, distant, unstaged). We compared women diagnosed between 2004–2009 and 2010–2015 by stage, histology, race/ethnicity, and stage. We built a logistic regression model to examine predictors of a distant stage diagnosis. Results: In 2004, 18% of women were diagnosed at regional stage, which increased to 23% in 2015. There was a slight increase in local stage tumors (14% to 15%). Unstaged tumors declined from 10% to 7% over the same time period, and distant stage tumors declined from 58% to 56%. Only American Indian/Alaska Native (AI/AN) women did not experience a statistically significant decline in distant stage tumors over the two time periods. A greater proportion of serous tumors were diagnosed in the 2010–2015 time period compared to the first (53.2% vs. 50.5%). Predictors of distant stage diagnosis included being diagnosed between 2004–2009, older age (those over age 65), residence in the southern and western U.S., black race, serous histology, and residence in high-poverty census tracts. Conclusion: In the 2010–2015 time period, a smaller proportion of ovarian cancers were distant or unstaged at diagnosis compared to 2004–2009, and most subpopulations of women experienced a decline in distant ovarian cancer. More efforts are needed to increase timely diagnosis and access to specialized care in the southern and western US, high-poverty areas, and among black women. Citation Format: Julie S. Townsend, Mary C. Puckett, Sherri L. Stewart. Trends in stage at diagnosis for ovarian, fallopian tube, and serous primary peritoneal cancers, 2004–2015 [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr B46.

The unintended effects of place based programs: Fertility and health effects of urban empowerment zones

Whether place-based welfare programs affect fertility and health outcomes is an understudied question. I estimate the health impacts of the Empowerment Zone (EZ) program—a federal program that gave sizeable grants and tax breaks to certain high-poverty census tracts in selected cities. Using difference-in-differences methods, I find that the EZ program decreased fertility rates by 11 percent and improved birth outcomes. Compositional changes in fertility likely cannot explain changes in infant health. Recent research on the later-life impacts of low birth weight suggest that the health impacts of this program may have substantial long-term benefits.

Race and gender disparities in physical function before and after total hip arthroplasty: a retrospective analysis

Purpose: Race and gender disparities in rates of total joint replacement surgery in the United States have been well-documented, and it appears that socioeconomic status plays a role in the generation of such disparities. However, little research exists regarding whether disparities persist amongst those who undergo arthroplasty surgery. The purpose of this study was to investigate physical function in a database of individuals who underwent total hip arthroplasty (THA) and identify potential disparities by race, gender, and socioeconomic status. Methods: We retrospectively analyzed electronic chart data of individuals who underwent THA with a single surgeon at a large urban hospital between January 2013 and March 2016. Individuals were included who underwent unilateral THA for a primary diagnosis of osteoarthritis. For those who received staged bilateral THAs during the study period, data from their first arthroplasty surgery only were included. Demographic data were retrieved, including age, sex, race, ethnicity, health insurance status, and census tract of residence. The proportion of households with incomes below the United States federal poverty level (FPL) in each individual's census tract of residence was used as a marker for socioeconomic status. Medical comorbidities were collected and summed using the Functional Comorbidity Index (FCI). Self-reported physical function was measured using the Harris Hip Score (HHS) pre-operatively and at six months post-operatively. Descriptive statistics were used to summarize sample demographics. T-tests were used to compare pre-operative and post-operative physical function between men and women, between white/Caucasian and black/African-American patients, and between patients living in low-poverty and high-poverty census tracts. Low-poverty census tracts were defined as those in which fewer than 20% of household incomes are below the federal poverty level (FPL), and high-poverty census tracts were defined as those in which greater than 20% of household incomes fall below FPL. Results: The sample of 271 individuals contained an even distribution of men (49.4%) and women (49.4%). On average, patients were slightly less than retirement age (mean age 63.2 years, SD 11.9) and had relatively low number of comorbidities (mean FCI 3.3, SD 1.8). A majority of patients (60.1%) had private health insurance, with smaller proportions using Medicare (22.1%), Medicaid (5.5%), or other types of insurance (12.2%). 86.7% of patients in the sample were white/Caucasian and non-Hispanic; 11.1% were black/African-American and non-Hispanic; fewer than one percent were Hispanic ethnicity and/or any other race. 83.0% (n = 225) of patients lived in low-poverty neighborhoods, while 10.7% (n = 29) lived in high-poverty neighborhoods (census tracts of residence for the remaining 17 patients were unable to be determined from electronic chart data). At baseline, men (mean HHS 46.3, SD 11.5) were functioning significantly better than women (mean 42.4, SD 13.7), P = .03. However, this difference was no longer significant at six-month follow-up (mean HHS for men 79.8, SD 16.7; mean HHS for women 77.5, SD 16.3), P = .41. At baseline, black patients (mean HHS 38.8, SD 13.3) were functioning significantly poorer than white patients (mean HHS 45.3, SD 12.4), P = .02. This difference persisted at six-month follow-up: mean HHS 79.7 (SD 15.8) for white patients and 68.0 (SD 1.92) for black patients, P = .03. There were no statistically significant differences between patients living in high-poverty neighborhoods and those in low-poverty neighborhoods at baseline (high-poverty mean HHS 39.1, SD 15.7; low-poverty mean HHS 45.2, SD 12.0) or at six-month follow-up (high-poverty mean HHS 69.4, SD 20.2; low-poverty mean HHS 79.8, SD 15.7). However, the relatively low proportion of patients residing in low-poverty census tracts resulted in low statistical power to detect such differences. Conclusions: In this sample of 271 individuals who underwent unilateral THA, women and black patients were functioning significantly poorer than men and white patients pre-operatively. At six months post-operatively, the significant difference in physical function between white and black patients persisted. Medical and rehabilitation providers and community organizations should be aware that undergoing THA surgery may not fully resolve existing disparities in physical function in this population.

Pervasive Income-Based Disparities In Inpatient Bed-Day Rates Across Conditions And Subspecialties.

Building a culture of health in hospitals means more than participating in community partnerships. It also requires an enhanced capacity to recognize and respond to disparities in utilization patterns across populations. We identified all pediatric hospitalizations at Cincinnati Children's Hospital Medical Center, in the period 2011-16. Each hospitalized child's address was geocoded, allowing us to calculate inpatient bed-day rates for each census tract in Hamilton County, Ohio, across all causes and for specific conditions and pediatric subspecialties. We then divided the census tracts into quintiles based on their underlying rates of child poverty and calculated bed-day rates per quintile. Poorer communities disproportionately bore the burden of pediatric hospital days. If children from all of the county's census tracts spent the same amount of time in the hospital each year as those from the most affluent tracts, approximately twenty-two child-years of hospitalization time would be prevented. Of particular note were "hot spots" in high-poverty census tracts neighboring the hospital, where bed-day rates were more than double the county average. Hospitals that address disparities would benefit from a more comprehensive understanding of the culture of health-a culture that is more cohesive inside the hospital and builds bridges into the community.

Proximity to Pediatric Cardiac Surgical Care among Adolescents with Congenital Heart Defects in 11 New York Counties.

Many individuals with congenital heart defects (CHDs) discontinue cardiac care in adolescence, putting them at risk of adverse health outcomes. Because geographic barriers may contribute to cessation of care, we sought to characterize geographic access to comprehensive cardiac care among adolescents with CHDs. Using a population-based, 11-county surveillance system of CHDs in New York, we characterized proximity to the nearest pediatric cardiac surgical care center among adolescents aged 11 to 19 years with CHDs. Residential addresses were extracted from surveillance records documenting 2008 to 2010 healthcare encounters. Addresses were geocoded using ArcGIS and the New York State Street and Address Maintenance Program, a statewide address point database. One-way drive and public transit time from residence to nearest center were calculated using R packages gmapsdistance and rgeos with the Google Maps Distance Matrix application programming interface. A marginal model was constructed to identify predictors associated with one-way travel time. We identified 2522 adolescents with 3058 corresponding residential addresses and 12 pediatric cardiac surgical care centers. The median drive time from residence to nearest center was 18.3 min, and drive time was 30 min or less for 2475 (80.9%) addresses. Predicted drive time was longest for rural western addresses in high poverty census tracts (68.7 min). Public transit was available for most residences in urban areas but for few in rural areas. We identified areas with geographic barriers to surgical care. Future research is needed to determine how these barriers influence continuity of care among adolescents with CHDs. Birth Defects Research 109:1494-1503, 2017.© 2017 Wiley Periodicals, Inc.

The effect of health insurance coverage and the doctor-patient relationship on health care utilization in high poverty neighborhoods.

African Americans have higher rates of mortality than whites who are the same age and sex. We hypothesize that in low socioeconomic status neighborhoods, having health insurance coverage and a regular health care provider increases the likelihood of receiving diagnostic tests for cardiovascular disease and diabetes. We use data from a random two-stage cluster sample of 230 adults living in high poverty census tracts to examine the effects of insurance coverage and having a regular doctor on the likelihood receiving diagnostic tests for high cholesterol, high blood sugar, and blood pressure. We find that health insurance coverage increases the odds of having a regular health care provider (p < 0.05) and of receiving the diagnostic tests (p < 0.05). Having a regular doctor mediates the effect of insurance coverage on the likelihood of receiving the tests, especially when the participant can report the physician's name.

Encouraging Residential Moves to Opportunity Neighborhoods: An Experiment Testing Incentives Offered to Housing Voucher Recipients

Substantial benefits can accrue from living in low-poverty neighborhoods, yet approximately 80% of the 2.2 million Housing Choice Voucher (HCV) recipients rent homes in moderate- or high-poverty census tracts. The Chicago Regional Housing Choice Initiative tested several ways to promote opportunity moves. It included the first experiment that tests whether two types of light-touch incentives induce opportunity moves for HCV recipients who had requested a moving voucher. Based on the 2,005 HCV recipients in the study, we found that neither the offer of a $500 grant nor the offer of a $500 grant coupled with free mobility counseling induced opportunity moves. The receipt of mobility counseling also did not boost opportunity moves. Regardless of the type of offer, 11%–12% of participants moved to opportunity neighborhoods. Despite requesting a moving voucher, half of the study participants remained in place, indicating significant barriers to moving. We offer potential reasons for the results and conclude with two recommended pilots to increase opportunity moves.

Neighborhood Socioeconomic Disadvantage; Neighborhood Racial Composition; and Hypertension Stage, Awareness, and Treatment Among Hypertensive Black Men in New York City: Does Nativity Matter?

Neighborhood-level poverty and racial composition may contribute to racial disparities in hypertension outcomes. Little is known about how the effects of neighborhood social environments may differ by nativity status among diverse urban Black adults. We aimed to characterize the influence of neighborhood-level socio-demographic factors on hypertension outcomes among US- and foreign-born Black men with uncontrolled blood pressure. We conducted a cross-sectional analysis of baseline data from two large community-based trials of hypertensive Black men aged 50 and over linked with census tract data from the 2012 American Community Survey 5-year estimates. We defined census tracts with high racial segregation as those where 60% or more self-identified as Black and high-poverty census tracts as those where 20% or more lived below the poverty line. Multivariable general estimating equation models were used to measure associations between neighborhood characteristics and stage of hypertension, hypertension awareness, and treatment to yield adjusted prevalence ratios (aPR). Models were run separately for US- and foreign-born Black men. Over 64% of the 1139 participants lived in a census tract with a high percentage of Black residents and over 71% lived in high-poverty census tracts. Foreign-born Black men living in neighborhoods with a high concentration of Black residents were less likely to be treated for their high blood pressure (aPR 0.44, 95% CI 0.22-0.88), but this result did not hold for US-born Black men. There were no significant associations between neighborhood poverty and hypertension outcomes. Neighborhood context may impact treatment for hypertension, one of the most important factors in hypertension control and decreasing hypertension-related mortality, particularly among foreign-born Black men.

The Effect of Urban Empowerment Zones on Fertility and Health: A Case Study of Chicago, New York City, and Philadelphia

I estimate the health impacts of the Empowerment Zone (EZ) program—a federal program that gave sizeable grants and tax breaks to certain high-poverty census tracts in selected cities. Using differences-in-differences and synthetic control methods I find that the urban empowerment zone program (EZ) decreased fertility rates by 10 percent, decreased the prevalence of low birth weight by 8 percent, and increased overall birth weight by 0.8 percent. This increase in infant health was not driven by changes in the composition of births but reflects increased health among mothers. The urban empowerment zone program provided $100 million in block grants for infrastructure improvements and business tax credits. I compare the Chicago, New York City, and Philadelphia EZs to a control group of areas which applied for, but were not granted the EZ program in the first round. Synthetic control methods and estimates using an alternative control group support these findings. Recent research on the later-life impacts of low birth weight suggest that the health impacts of this program, despite not being the focus of the program, may have substantial long-term benefits.

Pediatric dental clinic location and utilization in a high-resource setting.

Examine dental utilization by Medicaid-insured children living in a high-resource area. Characterize distance and travel-related variables to accessing care. Cross-sectional data were collected on dental clinics in Pittsburgh, Pennsylvania, caring for Medicaid-insured children ≥1 year. Shortest distances, drive times, and bus travel between dental clinics and high-poverty census tracts were determined through geographical information systems analysis. Primary care clinic (PCC) survey data were analyzed for children's dental use. Demographic characteristics and travel-related variables were compared between children who had and had not been to a dentist. Ten dental clinics accepted Medicaid-insured children ≥1 year. Mean distance between high-poverty census tracts and their nearest clinic was 1.2 miles [standard deviation (SD) 0.2 miles], with mean bus travel time 15.6 minutes (SD 12.3 minutes). Overall, 46 percent of PCC children reported a dental visit, and this was not significantly different between those who lived in a high-poverty census tract versus those who did not (41 percent and 35 percent, respectively, P = 0.58). Children traveled a mean distance of 4.75 miles (SD 2.37 miles) to their dental clinic. Mean distance to their nearest dental clinic was 2.81 miles (SD 2.12 miles). Dental clinics in a high-resource area are in close proximity to where young Medicaid-insured children live; and distances between children's homes and dental clinics are not significantly different between children who had and had not reported a dental visit, suggesting that barriers persist despite close proximity. Regardless, closer proximity may contribute to the higher utilization of services observed compared with national rates.

The impact of the tobacco retail outlet environment on adult cessation and differences by neighborhood poverty.

This study examined the impact of tobacco retail outlets on cessation outcomes over time among non-treatment-seeking smokers and assessed differences by neighborhood poverty and individual factors. Observational longitudinal cohort study using geospatial data. We used generalized estimating equations to examine cessation outcomes in relation to the proximity and density of tobacco retail outlets near the home. Eight large Designated Media Areas across the United States. A total of 2377 baseline smokers followed over three waves from 2008 to 2010. Outlet addresses were identified through North American Industry Classification System codes and proximity and density measures were constructed for each participant at each wave. Outcomes included past 30-day abstinence and pro-cessation attitudes. Smokers in high poverty census tracts living between 500 m and 1.9 km from an outlet were over two times more likely to be abstinent than those living fewer than 500 m from an outlet (P < 0.05). Density within 500 m of home was associated with reduced abstinence [odds ratio (OR) = 0.94; confidence interval (CI) = 0.90, 0.98) and lower pro-cessation attitudes (Coeff = -0.07, CI = -0.10, -0.03) only in high poverty areas. In low poverty areas, density within 500 m was associated with greater pro-cessation attitudes (OR = 0.06; CI = 0.01, 0.12). Gender, education and heaviness of smoking did not moderate the impact of outlet proximity and density on cessation outcomes. In the United States, density of tobacco outlets within 500 m of the home residence appears to be negatively associated with smoking abstinence and pro-cessation attitudes only in poor areas.

Low-income housing development and crime

This paper examines the effect of rental housing development subsidized by the federal government’s Low-Income Housing Tax Credit (LIHTC) program on local crime. Under the LIHTC program, certain high-poverty census tracts receive Qualified Census Tract (QCT) status, which affects the size of the tax credits developers receive for building low-income housing. Changes in federal rules determining QCT status generate quasi-experimental variation in the location of LIHTC projects. Exploiting this variation, we find that low-income housing development in the poorest neighborhoods brings with it significant reductions in violent crime that are measurable at the county level. There are no detectable effects on property crime.

Immigration, Spatial Mismatch and Entrepreneurship in Empowerment Zones and Enterprise Communities

Did immigrants contribute to revitalization in the Department of Housing and Urban Development’s (HUD) Empowerment Zone/Enterprise Community (EZ/EC) programs? These programs combined strategic planning grants for capacity building and economic opportunity with tax incentives for businesses who do work in high-poverty census tracts. Theories of immigrant entrepreneurship would argue that immigrants start businesses when they are excluded from formal labor markets or because they have a concentration of coethnic resources as potential customers, investors and employees. This study estimates changes in immigrant population, the spatial mismatch index (aka jobs housing balance), and entrepreneurship. The population of immigrants increased in designated EZ/ECs from 1990 to 2000. Furthermore, for every one percent change in the percentage foreign born, there was a 20% increase in the rate of immigrant entrepreneurs as a proportion of the labor force, holding other variables constant. However, the rate of native-born entrepreneurs in EZ/ECs also increased at about the same rate, suggesting that nativity, in and of itself, did not influence returns to entrepreneurship. In regards to the impact of the EZ/EC on the jobs housing balance for immigrants, there was a 6 to 15% improvement for immigrants, holding other variables constant. Taking population and job trends together suggests that the EZ/EC program improved the job housing balance through entrepreneurship. Future urban policy needs to acknowledge the role of immigration in local economies through culturally competent workforce development, language training, and mentoring new entrepreneurs.

Area‐Level Poverty Is Associated with Greater Risk of Ambulatory–Care–Sensitive Hospitalizations in Older Breast Cancer Survivors

To estimate the frequency of ambulatory care-sensitive hospitalizations (ACSHs) and to compare the risk of ACSH in breast cancer survivors living in high-poverty with that of those in low-poverty areas. Prospective, multilevel study. National, population-based 1991 to 1999 National Cancer Institute Surveillance, Epidemiology, and End Results Program data linked with Medicare claims data throughout the United States. Breast cancer survivors aged 66 and older. ACSH was classified according to diagnosis at hospitalization. The percentage of the population living below the U.S. federal poverty line was calculated at the census-tract level. Potential confounders included demographic characteristics, comorbidity, tumor and treatment factors, and availability of medical care. Of 47,643 women, 13.3% had at least one ACSH. Women who lived in high-poverty census tracts (>or=30% poverty rate) were 1.5 times (95% confidence interval (CI)=1.34-1.72) as likely to have at least one ACSH after diagnosis as women who lived in low-poverty census tracts (<10% poverty rate). After adjusting for most confounders, results remained unchanged. After adjustment for comorbidity, the hazard ratio (HR) was reduced to 1.34 (95% CI=1.18-1.52), but adjusting for all variables did not further reduce the risk of ACSH associated with poverty rate beyond adjustment for comorbidity (HR=1.37, 95% CI=1.19-1.58). Elderly breast cancer survivors who lived in high-poverty census tracts may be at increased risk of reduced posttreatment follow-up care, preventive care, or symptom management as a result of not having adequate, timely, and high-quality ambulatory primary care as suggested by ACSH.