Underserved Neighborhoods Research Articles

Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records

The 2009 American Recovery and Reinvestment Act spurred adoption of electronic health records (EHRs) in the United States, through such measures as financial incentives to providers through Medicare and Medicaid and regional extension centers, which provide ongoing technical assistance to practices. Yet the relationship between EHR adoption and quality of care remains poorly understood. We evaluated the early effects on quality of the Primary Care Information Project, which provides subsidized EHRs and technical assistance to primary care practices in underserved neighborhoods in New York City, using the regional extension center model. We found that just general participation in, or exposure to, the project was not enough to improve quality of care. It took sustained exposure on the part of these practices and technical assistance to them before they demonstrated improvement on measures of care most likely to be affected by the use of electronic health records, such as cancer screenings and care for patients with diabetes. Participating in the Primary Care Information Project for nine or more months was associated with significantly improved quality, but only for this limited group of quality measures and only for physicians receiving extensive technical assistance.

Healthy Bodegas: Increasing and Promoting Healthy Foods at Corner Stores in New York City

We assessed the effectiveness of an initiative to increase the stock and promotion of healthy foods in 55 corner stores in underserved neighborhoods. We evaluated the intervention through in-store observations and preintervention and postintervention surveys of all 55 store owners as well as surveys with customers at a subset of stores. We observed an average of 4 changes on a 15-point criteria scale. The most common were placing refrigerated water at eye level, stocking canned fruit with no sugar added, offering a healthy sandwich, and identifying healthier items. Forty-six (84%) store owners completed both surveys. Owners reported increased sales of healthier items, but identified barriers including consumer demand and lack of space and refrigeration. The percentage of customers surveyed who purchased items for which we promoted a healthier option (low-sodium canned goods, low-fat milk, whole-grain bread, healthier snacks and sandwiches) increased from 5% to 16%. Corner stores are important vehicles for access to healthy foods. The approach described here achieved improvements in participating corner stores and in some consumer purchases and may be a useful model for other locales.

Convenience Stores and the Marketing of Foods and Beverages Through Product Assortment

Product assortment (presence and variety) is a key in-store marketing strategy to influence consumer choice. Quantifying the product assortment of healthier and less-healthy foods and beverages in convenience stores can inform changes in the food environment. To document product assortment (i.e., presence and variety of specific foods and beverages) in convenience stores. Observational survey data were collected onsite in 2011 by trained promotora-researchers in 192 convenience stores. Frequencies of presence and distributions of variety were calculated in 2012. Paired differences were examined using the Wilcoxon matched-pairs signed-rank test. Convenience stores displayed a large product assortment of sugar-sweetened beverages (median 86.5 unique varieties); candy (76 varieties); salty snacks (77 varieties); fried chips (44 varieties); cookies and pastries (19 varieties); and frozen sweets (21 varieties). This compared with 17 varieties of non-sugar sweetened beverages and three varieties of baked chips. The Wilcoxon signed-rank test confirmed a (p<0.001) greater variety of sugar-sweetened than non-sugar-sweetened beverages, and of fried chips compared with baked chips. Basic food items provided by convenience stores included milk (84% of stores); fresh fruit (33%); fresh vegetables (35%); canned vegetables (78%); white bread (71%); and deli-style packaged meat (57%). Healthier versions of milk, canned fruit, canned tuna, bread, and deli-style packaged meat were displayed in 17%-71% of convenience stores. Convenience stores in this area provide a greater assortment of less-healthy compared with healthier foods and beverages. There are opportunities to influence consumer food choice through programs that alter the balance between healthier and less-healthy foods and beverages in existing convenience stores that serve rural and underserved neighborhoods and communities.

Clinging to Any Bit of Joy: Urban, Ethnically Diverse, Impoverished Women's Descriptions of Anxiety and Depression

Depression and anxiety are mental health issues that disproportionately affect women. This study sought to capture perceptions of anxiety and depression in 3 urban, ethnically diverse, underserved, and impoverished neighborhoods. Using community-based participatory research, in the context of long-term partnerships between a department of nursing and these neighborhoods, the researchers recruited 61 women aged 18 to 69 years. Data were collected via 6 homogeneous focus groups composed of Black, Hispanic, and White women, respectively. The women identified themes pertaining to the manifestations and effects of anxiety and depression as well as unique coping strategies.

Enhancing Accurate Identification of Food Insecurity Using Quality-Improvement Techniques

Infants who live in households experiencing food insecurity are at risk for negative health and developmental outcomes. Despite large numbers of households within our population experiencing food insecurity, identification of household food insecurity during standard clinical care is rare. The objective of this study was to use quality-improvement methods to increase identification of household food insecurity by the second-year pediatric residents working in the Pediatric Primary Care Center from 1.9% to 15.0% within 6 months. A secondary aim was to increase the proportion of second-year pediatric residents identifying food insecurity. A team was formed to identify key drivers thought to be critical to the process of identifying food insecurity during well-child care. This project addressed 5 key drivers and tested interventions based on these drivers over a 6-month period at a hospital-based primary care site that serves ∼15 000 children from underserved neighborhoods. Tests included implementing an evidence-based electronic screen for food insecurity, educational interventions to improve understanding of food insecurity, empowerment exercises targeting clinicians and families, and gaining buy-in and support from ancillary personnel. Implementation of these changes led to an increase in the identification rate of household food insecurity from 1.9% to 11.2% over the 6 months (P < .01). The proportion of residents identifying food insecurity increased from 37.5% to 91.9% (P < .01). Application of quality-improvement methods in a primary care clinic increased ability to effectively screen and positively identify households with food insecurity in this population.

Yoga for Heart Failure Patients: A Feasibility Pilot Study with a Multiethnic Population

Congestive heart failure (CHF) is highly prevalent and the most costly cardiovascular illness in the United States. Yoga is known to be effective in lowering stress, lessening depression, and increasing physical fitness and may be used as an adjuvant management program for CHF patients. To determine the feasibility of a yoga intervention program among a multiethnic CHF population living in underserved neighborhoods. Uncontrolled intervention trial. Kaiser Permanente Medical Centers, Richmond and Oakland, California. 14 CHF patients (7 female), mean age 64 (SD=6.4) years, and 62% African-American. Eight-week, 2x/week, 1-hr yoga classes that included meditation, breathing exercises, gentle yoga poses, and relaxation. The intervention feasibility was measured by recruitment rates, participant retention and adherence. Body weight and self-reported depression and quality of life were measured before and after the intervention. Among the 14 patients enrolled, 13 completed the intervention. Of those who completed the trial, 92% attended at least 50% of the classes. There was a significant reduction in weight (-3.5 lb, p=0.01) and improvement in the severity of depression (p<0.05), as well as a trend toward increased quality of life (p=08). No adverse events were observed. This pilot trial demonstrates that it is feasible for patients with CHF to incorporate yoga into their lifestyle. Yoga may help with routine disease management, prevention of fluid retention, and improvement of depression and quality of life. A larger trial is needed to confirm efficacy and to determine the long-term effects on other important outcomes, such as hospital re-admission rates or prognostic biomarkers.

Brief Report of a Low-Cost Street-Corner Methodology Used to Assess Inner-City Residents’ Awareness and Knowledge about Asthma

The goal of the Philadelphia Community Asthma Prevention Program (CAPP) Collaborative was to reduce the burden of asthma among children (0–18 years) living in underserved neighborhoods with high asthma prevalence by implementing a comprehensive set of community-based asthma interventions. An equally important objective of the collaborative, which included community agencies, the school district, the health department, faith-based organizations, and hospitals, was to increase the community’s awareness of asthma and its capacity to address the problem. CAPP’s components included home environmental remediation and educational visits (784 participants), a series of classes at community sites for children with asthma (303 participants) and caregivers (644 participants), on-site office training for primary care providers and nursing staff (196 individuals), professional asthma education for school nurses and teachers (752 participants), and asthma classes for public school students (901 participants). The collaborative also conducted a communication campaign throughout the life of the project, including notices in neighborhood newspapers, public service announcements on radio stations, postings on community agency list serves, and distribution of flyers to churches, libraries, schools, local clinics, community agencies, beauty salons, and Laundromats. The project focused on a population of approximately 330,000 located in parts of Upper and Lower North Philadelphia, and Germantown. These areas are characterized by blighted housing, overcrowding, drug trafficking, violence, and poverty.1 Initiation of interventions was staggered over a 5-year period (June 2003–June 2008) in 4 area quadrants identified by zip code. After its initiation, each intervention continued throughout the remainder of the project. The CAPP team sought to obtain information related to its focus on community empowerment and broad dissemination of asthma messages. Traditional survey methods may not to yield a representative sample in urban, low-income populations. Formal phone or in-person surveys to gather community data at regular intervals are costly and burdensome. Moreover these methods, as well as internet and mailed surveys, do not reach people who are illiterate, move frequently, or lack land-line phone service.2–5 Therefore CAPP adapted a street-intercept methodology reported by Miller and colleagues6 by using students to administer surveys on street corners in Philadelphia. This paper describes this approach and its results.

Queens Library HealthLink: Fighting Health Disparities through Community Engagement

Queens, New York is a diverse urban environment and home to many recent immigrants and low-income populations, which are known to have lower access to healthcare and are thus at higher risk for a wide range of negative health outcomes. Queens residents face serious cancer disparities, with late-stage cancer detection rates for breast, colorectal and prostate cancers far surpassing national averages. Developed to address such disparities, Queens Library HealthLink (HealthLink) is a four-way partnership that seeks to increase access to cancer screening, care and education in medically underserved neighborhoods in Queens. Through 20 of the 62 Queens Public Libraries, HealthLink organizes community members into Cancer Action Councils that develop and tailor interventions suited to community needs, assets and priorities, as well as perform evaluation of their work. This article describes the partnership, its program outcomes and case examples of successful initiatives in order to present HealthLink’s relevance to other urban public libraries as a model for reaching broad, underserved audiences with health information and services.

Engagement, Ecology, and Design Education: Outreach Work of the Tulane City Center

of Architecture, the Tulane City Center (TCC) supports teams of architecture faculty members and students, who work with local nonprofit groups to provide design and “visioning” help to underserved neighborhoods of the Greater New Orleans community. Since the center’s establishment less than two months after the devastating floods that followed Hurricane Katrina, Tulane School of Architecture students and faculty have collaborated on the design and construction of dozens of innovative and award-winning projects that support the city’s recovery. These projects include six ecologically sound single-family houses, several green markets and their related “urban agriculture” facilities, shade and watercollection pavilions that promote neighborhood communication and environmental education, and more than 50 other projects that range from neighborhood planning to the development of cooperative grocery stores in urban areas that lack access to healthful food. Tulane City Center projects are designed with extensive and diverse community input that is gathered through formal community meetings and informal neighborhood events, which often involve food and music (we are in New Orleans, after all). The design proposals are then published in “visioning booklets” that enable prospective supporters and constituents to read about the goals and ambitions. Finally, many of the projects are constructed by groups of students who gain hands-on experience in the execution of progressive design concepts and new construction technologies. This work gives students a unique educational experience—applying classroom lessons to real design problems and engaging a broad range of issues to connect the built and natural environments.

Race, class and spatial dimensions of mortgage lending practices and residential foreclosures

The American dream of homeownership for low‐income minority households has been sustained by reliance on a complex web of public programs and private institutions during the past several decades. This paper explores the racial, class and spatial dimensions of mortgage lending practices and residential foreclosures for underserved neighborhoods in Cuyahoga County, Ohio using multiple regression analysis with a spatial‐lag model. This paper shows different spatial dimensions of subprime and government‐backed loans. It reveals that subprime loans are the most influential factor explaining neighborhood foreclosure rates. This paper also demonstrates that neighborhoods with low‐income and minority households have a higher likelihood of experiencing higher rates of foreclosure. We recommend introducing targeted government programs in areas avoided by traditional lenders. These programs could reduce the foreclosure rate for homeowners that have the ability to sustain their homeownership.

From Partnership to Policy: The Evolution of Active Living by Design in Portland, Oregon

Portland's Active Living by Design focused on two communities facing different active living challenges: Lents is an urban, lower-income community with poor bicycle/pedestrian and park infrastructure, and Damascus is a semirural community expected to see extensive urban growth in the next 30 years. Pilot projects were implemented in a semirural community with considerable growth potential, and a lower-income, ethnically diverse urban neighborhood. The partners' primary active-living goals included: prepare and sustain a network of public health, planning, community, and policymaking partners; affect urban planning and policy decisions to influence built-environment changes in Portland neighborhoods; and support active-living program and promotion partners. Partners have focused on building capacity for cross-disciplinary collaboration and leading strategic efforts toward policy, environmental, and social change. Partners have been engaged in policy advocacy and strategic campaign initiatives, as well as community program efforts that bring active living opportunities to underserved neighborhoods. The ALbD community-action model served as a valuable tool for organizing intervention activities and bringing diverse partners together under a shared vision. Public health professionals engaged in land-use and transportation collaborations must strike a balance between becoming experts in technical aspects of new disciplines and addressing a wide range of active living determinants. Embracing a healthy community agenda can create fruitful new partnerships and increase the impact on systemic change. Many of the partnerships' collaborative efforts to encourage healthy communities through policy, environmental, and social change have been largely successful and can serve as a model for other communities.

The Effects of Redesigning the IDEATel Architecture on Glucose Uploads

The objective of this evaluation was to determine the effect of redesigning the Informatics for Diabetes Education and Telemedicine (IDEATel) telemedicine architecture on the average upload delay and on the average number of glucose uploads to a central database. These two measures positively influence our ability to deliver timely and accurate patient care to the study population. The redesign was also undertaken to improve the patients' experience in using the system and thereby increase the frequency and timeliness of their self-monitoring behavior. Using the total number of glucose uploads, we compared the delay in glucose upload times according to the type of home telemedicine unit the study participants used and the region where the participants lived. The participants were Medicare beneficiaries with diabetes living in medically underserved neighborhoods in New York City and rural Upstate New York. The populations in these two regions differed considerably in terms of ethnicity, language spoken (Spanish, English), and education level. Participants who had Generation 2 (Gen 2) (mean = 10.75, SD +/- 7.96) home telemedicine units had significantly shorter upload delay times (p < 0.001) as measured in days than those participants with Generation 1 (Gen 1) (mean = 22.44, SD +/- 11.18) and those who were upgraded from Gen 1 (mean = 20.67, SD +/- 8.85) to Gen 2 (mean = 14.93, SD +/- 9.37). Additionally, the delay was significantly shorter for participants living upstate (mean = 24.14 days, SD +/- 11.95 days) than downstate (mean = 15.30 days, SD +/- 7.87 days), t (975) = 13.98, p < 0.01. The system redesign made a significant impact in reducing glucose upload delays of IDEATel participants. However, upload delays were significantly impacted by the region where the participants resided.

The Impact of Secondary Mortgage Market and GSE Purchases on Home Prices

Since 1992, the federal government has established regulations encouraging the government-sponsored enterprises (GSEs) Fannie Mae and Freddie Mac to purchase home mortgages originated in neighborhoods traditionally underserved by financial institutions, with the aim of stimulating housing-market activity within such neighborhoods. This research tests this proposition empirically through an econometric analysis of variations in secondary mortgage market activity and single-family home prices across underserved census tracts in Cleveland, Ohio, from 1993 to 1999. We find no large or statistically significant relationship between variations in secondary-market purchasing rates of home-purchase mortgages in underserved neighborhoods and home prices one or two years hence, controlling for a rich variety of dwelling and neighborhood characteristics. These conclusions follow both for GSE and other sectors of the secondary market. We find some evidence that the secondary market was more responsive to changes in home prices than vice versa. We offer a possible explanation and draw policy implications.

Feasibility of Management of High-Grade Cervical Lesions in a Single Visit: A Randomized Controlled Trial

In this randomized, controlled trial, women from underserved neighborhoods who underwent cervical screening were either managed in the usual fashion and notified of their results with a recommendation for follow up at a later visit or treated in the same visit. Women in the “usual-care” group were dismissed after pelvic examination and Pap smear, and test results were mailed to them. If the smears were abnormal, they were contacted by phone and referred for additional evaluation either within the authors’ clinical system or to their primary care physician with a written copy of their test results. Follow-up information for usual-care patients with abnormal test results was obtained from the patient and from a review of medical records. Participants were told to return for a follow-up examination in 12 months. Women randomized to the “single-visit” group remained after the examination until the results of the cervical smear were known. If the findings were atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous epithelial lesion (LGSIL), the women were referred for additional evaluation as in the usual group. Patients whose smears were positive for high-grade squamous intraepithelial lesion (HGSIL), atypical glandular cells (AGUS), or carcinoma underwent immediate treatment with cervical loop electrosurgical procedure (LEEP). Neither colposcopy nor endocervical excision was performed; however, endometrial biopsies were taken in patients with AGUS. All LEEP patients were asked to return in 2 weeks and at 3 and 12 months for follow up. A total of 3521 women recruited from community health centers in primarily Latino neighborhoods participated in the study. One thousand seven hundred sixteen were randomly assigned to the single-visit group, and 1805 were assigned to the usual group. There was no difference in the rate of abnormal cervical smears (approximately 4% each) or in the rate of high-grade lesions (1%) between the two groups. Fourteen of 16 (88%) women with high-grade lesions in the single-visit group received definitive treatment compared with 10 of 19 (53%) women with a similar diagnosis in the usual-care group (P = .04). One of the two single-visit patients left before her results were known, and one refused treatment. Thirteen of 19 usual-care patients were evaluated with colposcopy within 6 months of the cervical screening, but only 10 were treated as recommended. Treatment and evaluation of low-grade abnormalities were similar for both groups of patients. Two patients, one in the single-visit group and one in the usual-care group, were found to have invasive cancer in the LEEP specimen. Thirty-six percent of patients in each treatment group returned for the follow-up Pap smear at 12 months. Among women with high-grade lesions, more patients in the single-visit group attended the 1-year examination (10 of 16, 63%) than did women in the usual-care group (4 of 19, 21%) (P = .02). The time each woman spent in the clinic was recorded. The mean time from registration to discharge was 2.8 hours for single-visit patients and 1.25 hours for usual-care patients. Responses on a patient questionnaire indicated that 76% of single-visit patients felt that the duration of the first visit was acceptable compared with 89% of those in the usual-care group (P < .001). Ninety-five percent of single-visit women would choose to have a single-visit screening again, and 67% of usual-care patients indicated they would have preferred to wait for results at the same visit.

Do the GSEs matter to low-income housing markets? An assessment of the effects of the GSE loan purchase goals on California housing outcomes

This study evaluates the effects of the GSE mortgage purchase goals on homeownership and housing conditions among communities that are the focus of the 1992 GSE Act and the HUD affordable housing goals. To identify GSE effects, the test framework exploits differences in the definition of lower-income and underserved neighborhoods under the 1992 GSE Act, which specifies loan purchase goals for the GSEs, and the 1977 Community Reinvestment Act, which governs loan origination activity among the federally-insured depository institutions. Research finding suggest little efficacy of the GSE home loan purchase goals in elevating the homeownership and housing conditions of targeted and underserved neighborhoods, in turn suggesting the importance of ongoing federal policy focus in achievement of affordable housing objectives.

The importance of place of residence in predicting late-stage diagnosis of breast or cervical cancer

We tested whether inner-city women were at significantly increased risk of late-stage cancer diagnosis because they resided in extremely poor and socially isolated neighborhoods or in neighborhoods meeting the federal definition of a medically underserved area (MUA). Cancer registry data on women in three American cities were matched to Census data. Using logistic regression we found that residence in economically and socially distressed or medically underserved neighborhoods tended to increase the likelihood of late-stage cancer diagnoses. Further, we found that not all areas that are economically and socially distressed receive the federal MUA designation. Consequently, we argue that economically and socially distressed neighborhoods should be automatically designated as MUA.

Distributional issues in the analysis of preventable hospitalizations.

To describe patterns in ambulatory care sensitive (ACS) admissions at the zip code level based on zip code demographic and other characteristics. These patterns include trends over time, persistence within zip codes over time, and variation between and within socioeconomic strata. New York State hospital discharge data 1990-1998, U.S. census data 1990, and New York State birth records 1990. Age- and sex-adjusted rates and volumes of ACS admissions are calculated at the zip code level. Descriptive statistics are analyzed cross-sectionally and over time. Kernel density functions are estimated across income strata. Ordinary and quantile regression techniques are used to determine the impact of socioeconomic variables on average and extreme values of the distribution of ACS admission rates. Ambulatory care sensitive admissions rates declined during the study period but in conjunction with a greater decline in overall admission rates. Thus, as a percentage of total admissions, they actually rose by 4 percent. Ambulatory care sensitive admissions are geographically concentrated and rates are highly persistent within zip codes over time. Even on a log scale ACS admissions are typically greater and exhibit more variability among low-income zip codes. Other variables positively associated with ACS admissions are total population, births to unwed mothers (a proxy for family structure), black population, Hispanic population, and the number of non-ACS admissions. Births to immigrant mothers (a proxy for immigrant population) are negatively associated with ACS admissions. The concentration and persistence of ACS admissions point to a chronic, geographically limited deficiency of primary ambulatory care in the most underserved neighborhoods. Much of the difference in preventable hospitalization levels between high- and low-income areas is driven by very high volumes in the low-income areas unrelated to population density. New York data suggest that most costs from preventable hospitalizations could be saved by focusing on targeted neighborhoods. Socioeconomic and area utilization variables play a role in both average and extreme values of the rate of preventable hospitalizations at the zip code level. Since variables that affect the average volume of preventable hospitalizations can change the distribution of that volume, analysis based on averages alone may be inadequate. The findings on area demographics and non-ACS admissions point to the need to better understand social and cultural issues as well as local admitting practice patterns to encourage appropriate and efficient use of the health care delivery system.

Chicago Community-Based Asthma Intervention Trial: Feasibility of Delivering Peer Education in an Inner-City Population

The most effective means of educating children with asthma and their families has not been clearly demonstrated in previous studies. Peer education is uniquely suited to the complex problems encountered in underserved populations. The purpose of this study was to show the feasibility of delivering a peer education program for children with asthma and the effect of the program on indoor allergen levels in an inner-city population in Chicago. Overall, the program was well received. Baseline allergen levels were consistent with some previous studies in showing low levels of mite allergens and high levels of cockroach allergens, with 79.6% of samples having levels > 8 U/g. A total of 28.2% of samples had cat allergen levels > 2 microg/g, although only 9.7% of homes had cats, confirming previous reports that cat allergen is ubiquitous. Mold levels were seasonal, with the highest levels in the summer. Results from this study suggest that intervention programs should focus more on elimination of cockroaches than was previously appreciated, while minimizing the use of pesticides, and on identification of the sources of cat allergen. Structural and psychosocial issues in homes need to be addressed in future studies. This study has demonstrated the feasibility of delivering peer education in a inner-city population and highlighted the need for comprehensive intervention strategies addressing complex issues facing underserved neighborhoods.

Medicaid Managed Care and Urban Poor People: Implications for Social Work

Many state Medicaid programs are implementing managed care, and more can be expected to do so in the future. Medicaid managed care will have an important impact on Medicaid recipients and uninsured people who live in cities. It will also pose significant new challenges for hospitals, community health centers, and clinics serving these populations and for social workers practicing in these settings. Social workers need to understand the reasons for Medicaid managed care's development and phenomenal growth and its likely impact or clients, service delivery, and access to care in medically underserved urban neighborhoods. This article identifies roles for social workers in supporting clients in the transition to Medicaid managed care and advocating for policies that will improve access to care for disadvantaged urban populations.

Business plan proposals for inner-city neighborhoods: A Strategic Management assignment for MBA students at Loyola University Chicago

Beginning in 1992, MBA students enrolled in a capstone Strategic Management course at Loyola University Chicago have, as their major course assignment, researched and prepared an original business plan proposal to provide a needed good or service, as well as employment opportunities, to residents in one of Chicago's underserved innercity neighborhoods. This paper describes the genesis of the project, how it works, and what the outcomes have been to date. The pedagogical model is arguably appropriate for MBA programs in or near any area that is economically underdeveloped, be it urban or rural.