Addressing Health Equity for Older Adults at the Neighborhood Level

Abstract:

Attending to neighborhood environments as important determinants of health equity among older adults emphasizes improving environments that prevent poor health and create health inequities in the first place. Investing in neighborhood solutions to improve older adults’ health and address health equity will require a shift in thinking and priorities. As our nation attempts to recover from the COVID-19 pandemic, it is imperative to make these shifts now, otherwise the risk is even greater devastation and deepened inequities in the aging population’s health.

Key Words:

health equity, health disparities, social determinants of health, neighborhood health, aging in place, age-friendly communities

To promote optimal health among older adults and address racial, socioeconomic, and other social determinants, it is imperative to recognize and address the neighborhood or community contexts that affect people’s health across the life course. This article summarizes the importance of neighborhoods to health and health equity and provides examples of policies or actions that aim to improve health inequities among older adults by focusing on their neighborhood contexts.

As a society, the United States continues to grapple with the lesson that health is fostered not only by access to healthcare and by individual health behaviors, but also by the physical, social, and economic conditions faced throughout life. These “social determinants of health” include a variety of factors such as education, income, social support, social isolation, stress, experiences of discrimination, job safety, and housing stability.

Research consistently shows that social determinants of health are strongly patterned by place. Characteristics of the neighborhoods and communities in which people live, work, and play affect health regardless of economic and social circumstances (Diez Roux and Mair, 2010). Research demonstrates that many aspects of neighborhood environments affect mortality, the onset of a range of mental and physical health conditions, as well as the progression of disease, disability, and well-being once one is sick (Cagney, Browning, and Wen, 2005; Freedman, Grafova, and Rogowski, 2011; Freedman et al., 2008). The health-challenging and health-supportive conditions of the places in which people live vary by whether we live in a high income versus high poverty neighborhood, a racially segregated versus integrated neighborhood, or a rural versus urban or suburban community.

Neighborhoods with greater socioeconomic disadvantage (e.g., higher poverty rates, higher unemployment rates, lower education levels) are most likely to have multiple aspects of physical, service, and social environments that are detrimental to health (Diez Roux and Mair, 2010). Socioeconomically disadvantaged neighborhoods are more likely to have physical environments with hazardous exposures (e.g., lead paint, pollution) and built environments that inhibit health-promoting behaviors (e.g., lack of parks; poor sidewalks).

They are more likely to have service environments that produce poor health (e.g., more fast-food restaurants, lack of stores with healthy food, more liquor stores) and often have inadequate access to quality healthcare, housing, and other health-promoting social services. They are also more likely to have social environments characterized by greater violence, lower social cohesion, and lower social capital—all of which are associated with poor health. The number of people living in socioeconomically disadvantaged neighborhoods is growing—between 1980 and 2018, the total population residing in high poverty neighborhoods doubled (Benzow and Fikri, 2020). With the economic fallout from the COVID-19 pandemic, the number of socioeconomically disadvantaged neighborhoods is expected to grow, as will the number of people living within them, suggesting serious implications for the health of older adults and the whole population as it advances toward old age.

Due to ongoing racial segregation and decades of disinvestment in communities of color, living in a socioeconomically disadvantaged neighborhood is not evenly distributed by race. Older adults of color, especially Black older adults, are significantly more likely to live in a socioeconomically disadvantaged neighborhood with conditions that are harmful to their health (Benzow and Fikri, 2020). Both historical and current policies rooted in systemic racism (e.g., redlining, exclusionary zoning codes, unfair lending practices) led to and maintain racial and economic segregation throughout the United States (Rothstein, 2017; Williams and Collins, 2001). These patterns of segregation and disinvestment at the neighborhood level contribute to ongoing racial inequities in health across the life course and at older ages (Cagney, Browning, and Wen, 2005; Robert and Lee, 2002; Robert and Ruel, 2006).

In the face of racism and structural inequities, some socioeconomically disadvantaged neighborhoods have nevertheless built a strong sense of community, have a higher investment in supportive services, consistent community participation in decision making, and built environments conducive to socializing and physical activity—all of which can contribute to better health. Research suggests that mutual support and strong social cohesion within some predominately Black and Hispanic neighborhoods may help protect residents from some (but not all) of the health consequences associated with living in a socioeconomically disadvantaged neighborhood (Aranda et al., 2011; Ruel and Robert, 2009; Weden et al., 2017). While recognizing that there are general trends that put people living in highly segregated and economically disadvantaged neighborhoods at risk for poor health, there also are unique strengths that neighborhoods and communities have built over time to support their residents.

In the United States, research consistently demonstrates that a range of neighborhood conditions affect various aspects of the health of older adults. For example, older adults living in neighborhoods with more accommodations for pedestrians report fewer mobility disabilities over time (Clarke, Ailshire, and Lantz, 2009). Living in neighborhoods with lower access to health-supportive services (e.g., physicians, pharmacies, supermarkets, and recreational facilities) and with commercial decline (e.g., liquor stores, pawn shops, and fast food) increases the risk for poor self-rated health among older adults (Spring, 2018). Older adults receiving home- and community-based services who live in areas with a higher number of social service organizations are less likely to have frequent hospitalizations (Kim and Xiang, 2020).

While neighborhoods affect the health of residents of all ages, older adults are particularly affected by the quality of their neighborhood environment (Robert and Li, 2001). Older people typically experience higher levels of exposure to neighborhood conditions, because they have often spent many years in the same community, and because changes in physical function and mobility often mean that most interactions occur in their immediate neighborhood. In addition, older adults who experience physical and cognitive decline are more vulnerable to the quality of the neighborhood environments if those environments provide too great a challenge (such as poor sidewalks and high crime) or too little support (too few high quality, available support services) (Robert and Li, 2001; Yen, Michael, and Perdue, 2010).

More research is needed to understand which interventions might best improve neighborhood conditions to address inequities in the physical, service, social, and economic opportunities that promote health across the life course and into old age. Nevertheless, there is enough information to move forward with a number of actions. Below are suggestions for approaches to reducing health inequities among older adults that consider the neighborhood context.  

Invest in Socioeconomically Disadvantaged Neighborhoods and Improve Access to Healthy Neighborhoods for Lower-Income Older Adults

Policy changes are needed to shift current patterns of neighborhood segregation and disinvestment, which are rooted in systemic racism, to ensure that all people have access to neighborhoods that promote health. Using a federal housing policy example, the Biden administration intends to reinstate the Obama administration’s fair housing rule, Affirmatively Furthering Fair Housing (AFFH), which the Trump administration terminated in 2020. AFFH requires cities and towns that receive HUD funding to examine patterns or practices that promote bias, or barriers to fair housing, and to devise a plan to address those barriers. Although not a panacea, enforcing AFFH is an important next step to encourage communities to assess and address contemporary patterns of neighborhood segregation and disinvestment.

Policies that are technically “race neutral” also can perpetuate ongoing patterns of racial segregation. For example, exclusionary zoning practices maintain racial and economic segregation (Human Impact Partners and Community Advocates Public Policy Institute, 2020). It is critical to change the economic distribution of neighborhoods to make healthy neighborhoods more accessible to low-income older adults, such as by encouraging inclusionary zoning policies that promote mixed-income neighborhoods and reduce barriers to affordable housing development. These changes can help challenge the systemic racism that upholds such vastly different neighborhood conditions for older adults of color and contributes to ongoing health inequities.

Restrictive zoning codes also can affect the ability of communities to build housing that promotes aging in the community. Municipal zoning codes can limit development of multifamily structures or disallow group care homes (such as assisted living facilities) in residential neighborhoods. Age-friendly zoning codes would provide affordable housing options, allow for a range of dwelling types (including cohousing), and promote mixed-use development. Such developments would encourage age integration and allow older adults to live near parks, grocery stores, hospitals, libraries, and other health-supporting services and amenities. 

Support Age-Friendly Initiatives that Explicitly Employ a Health Equity Approach

In response to population aging there have been global, national, and local efforts to make policies, places, and services more age friendly, such as initiatives called “Age-friendly communities,“ Age-Friendly Health Systems,” and “Age-Friendly Public Health Systems.” The World Health Organization’s Age-friendly Cities and Communities program, launched in 2006, has 1,114 cities in their Global Network. AARP is the U.S. agent for WHO’s age-friendly program and sponsors a Network of Age Friendly States and Communities comprising 511 communities to date. This initiative highlights eight domains that need to be considered to support a livable and age-friendly community: outdoor spaces and buildings; transportation; housing; social participation; respect and social inclusion; communication and information; community and health services; and civic participation and employment. A vast array of age-friendly initiatives has proliferated to promote change for older adults, focusing on one or more of these important domains.

Potential benefits of age-friendly initiatives include: Highlighting specific needs of older adults in a particular neighborhood (as needs can vary greatly across neighborhoods); emphasizing the positive contributions that older adults make to their communities; engaging older adults in providing input and advocating for change; and forging multisectoral collaborations that are necessary for working across policy and program domain silos (Scharlach and Lehning, 2016).

However, concerns have been raised about many of these initiatives that must be addressed to ensure these efforts do not perpetuate ongoing racial and economic inequities. Many age-friendly initiatives emanate from the state or city level and often engage residents of the most privileged neighborhoods rather than residents and neighborhoods needing the most support. Age-friendly initiatives also have been criticized for engaging only the most active older adults in the planning process, which can result in efforts that are not aligned with the needs of vulnerable older adults with health or mobility challenges (Buffel and Phillipson, 2018; Scharlach and Lehning, 2016).  

While many age-friendly initiatives are appropriately recognizing these dynamics, all age-friendly initiatives should explicitly employ a health equity approach that prioritizes changes aiming to reduce health inequities at the neighborhood level. This would include identifying initiatives that may have unintentionally perpetuated health inequities, implementing creative solutions to engage a more diverse range of older adults (e.g., providing financial compensation for volunteers, leveraging technology to reach homebound older adults), targeting efforts to socioeconomically disadvantaged neighborhoods, and ensuring lower-income older adults in advantaged neighborhoods also benefit from age-friendly initiatives. 

Join Movements to Improve Neighborhood Environments that Promote Health Equity for All Residents

Advocating for neighborhood changes that address older adults’ current needs should also be carried out in collaboration with other interest groups to promote changes to neighborhoods that can advance health equity across the life course. After all, there are many aspects of neighborhood environments, such as walkability, access to healthy food, clean water and air, and presence of libraries and other community-building institutions that support residents of all ages. Collaboration is more likely to bring about necessary change that can benefit everyone.

Neighborhood improvements that primarily target one group also can benefit another group. For example, investment in youth programming not only can improve youth outcomes, but also can reduce crime and improve neighborhood property values, thus enhancing the neighborhood environment for older adults. Older adults play a critical role in creating a sense of community within neighborhoods and can play an active role in advocating for neighborhood improvements that reduce health inequities for all residents. Moreover, by taking a life-course approach, improvements in neighborhood environments that reduce inequities among children and younger adults can enhance their well-being and reduce health inequities now and as they grow older (e.g., better schools, playgrounds, youth centers). Research shows that a person’s neighborhood environment at younger ages affects their health even into old age (Johnson, Schoeni, and Rogowski, 2012).

In response to the challenges presented by COVID-19, many states and cities have launched or enhanced their equity task forces, frameworks, and initiatives to advance health and prioritize health equity during the pandemic. Awareness of the disproportionate impacts of the pandemic on older adults may create an opportunity for older adults, aging advocates, and other age-friendly initiative participants to claim seats at the table with equity task forces. It is imperative that this work continue to expand to develop more effective approaches for addressing health equity across the life course, and it is critical that the needs of older adults from a range of diverse social and economic backgrounds be represented in these efforts.

Support, Require, and Incentivize the Healthcare System to Invest in Health-Related Social Needs

The healthcare system has begun to recognize that to promote optimal health, some spending should be allocated toward addressing people’s health-related social needs rather than only spending on medical care needs. Healthcare systems need to be supported, required, and incentivized to invest more in health-related social needs, and to do so not only by trying to help one patient at a time, but by investing in infrastructure and resources at the neighborhood or community level.

The Center for Community Investment (2020) has a toolkit called “Investing in Community Health: A Toolkit for Hospitals,” aimed at helping healthcare systems not only target grants to meet immediate health-related social needs (e.g., for food banks, housing vouchers, transit passes, and childcare subsidies), but more importantly to make investments—in buildings, grocery stores, affordable housing units, loans to small businesses, transit system improvements, and early education centers—that create long-term solutions that can improve community environments that affect health.

In addition, the IRS requires that all nonprofit hospital organizations spend some of their funds on “community benefit” to retain federal tax-exempt status. While historically healthcare systems have met this community benefit requirement by providing free or low-cost clinical care, the IRS has expanded allowable contributions to include spending on health-related social needs such as food insecurity, social isolation, and housing (Rosenbaum et al., 2016). This creates the possibility that healthcare systems can use their community benefit funds to better meet the health-related social needs of older people. The IRS should be encouraged to keep expanding and clarifying what is considered an allowable community benefit contribution, and healthcare systems should be encouraged and supported in making stronger neighborhood investments in health-related social needs through their considerable community benefit dollars.

Healthcare systems also should be required or financially incentivized to partner with community organizations to respond to high priority gaps in social care identified by the community. For example, some states require their Medicaid-funded managed care organizations to invest a portion of their surplus back into the communities they serve. More states could require this investment, and it should be implemented in collaboration with community stakeholders who can identify the community’s most pressing social care needs.

In terms of creating incentives, the National Academies of Sciences, Engineering, and Medicine (2019) produced an important report called “Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health.” Among its recommendations was providing a range of financial incentives to integrate healthcare and social care.

As one example, the Centers for Medicare and Medicaid Innovation Center (CMMI) is funding five-year (2017–2022) “Accountable Health Communities” pilot models in twenty-nine community-bridge organizations across the United States to test promising service delivery approaches linking Medicare and Medicaid beneficiaries in the same geographic area with services that will address their health-related social needs (i.e., housing, food insecurity, utilities, transportation, and help addressing interpersonal violence).

Results evaluating the outcomes of these pilots are forthcoming, but CMMI should be supported in continuing to help communities and states test payment strategies that incentivize collaborations across health and social service sectors to improve the health of individuals and communities. Similarly, CMMI’s initiatives with Accountable Care Organizations (ACOs) are encouraging ACOs to develop models that better link older adults to the social services they need to promote their health, such as by hiring community navigators and partnering with social service agencies. Such financial incentives that reward healthcare systems for good health outcomes rather than only for providing more medical services may shift the healthcare system toward investing in the social care that may maintain or improve health and facilitate recovery.

While supporting, requiring, and incentivizing the healthcare system to shift some of its investments to social care holds promise for reducing health inequities among older adults, there are limitations. First, many of these efforts focus on linking high-cost individual patients to resources that exist in their communities. This only works if there are enough appropriate high-quality options locally available. More efforts need to be made to identify gaps in neighborhood resources and build the political will to invest in developing and allocating new resources.

Having healthcare systems invest in neighborhoods also supports the health of older adults who share a geographic area, rather than linking older adults to services one person at a time. But, there often are competing healthcare systems in the same area and investments that one system makes in the community can financially benefit competitors, which in a competitive market can discourage such investment by healthcare systems. To address this challenge, efforts must continue to determine how to best reward healthcare systems for better health outcomes and community investments in health-related social care.

Invest in Prevention and Social Services Outside of the Healthcare System  

While it is important to support healthcare systems in addressing the health-related social needs of older adults, and to design better financial incentives for them to do so in the communities they serve, healthcare systems cannot be expected to be the primary solution to improving neighborhood environments. Currently, healthcare systems prioritize cure over prevention, individuals over populations, and focus on short-term return on investment rather than long-term investment in solutions. These foci may take away from larger community efforts to address health equity among populations. Moreover, while the healthcare sector is focused on physical health, there are other goals of communities that go beyond and even sometimes compete with the goal of optimal physical health, such as promoting the individual autonomy of older adults. As such, the healthcare system should not be the driver of all initiatives to support the optimal well-being of older adults in their neighborhoods.

Building the political will to directly invest in prevention and social services that can improve neighborhood environments and promote health equity among older adults is key. Increased funding could come through a number of venues such as increased federal allocations through the Older Americans Act, increased funding and prioritization of HUD for developing new housing/social service pilots and partnerships, and state and local initiatives that are place-based and funded by a combination of public and private dollars. Moreover, while it is important to support community self-determination by encouraging grassroots efforts for older adults and neighborhood groups to determine how to improve their own neighborhoods, it is irresponsible to do so without also allocating funding to support these efforts.

Conclusion

Attending to neighborhood environments as important determinants of health equity among older adults emphasizes improving environments that prevent poor health and create health inequities in the first place. Investing in neighborhood solutions to improve the health of older adults and address health equity will certainly require a shift in thinking and priorities. It will require committing to funding streams that focus on prevention rather than only on cure, and health equity rather than only individual health improvement. It will require increased funding in social investments and social services and better collaboration between social and medical care systems. It will require genuine engagement and participation from older adults and other neighborhood members from diverse backgrounds and experiences. As our nation attempts to recover from the COVID-19 pandemic, it is imperative to make these shifts now, otherwise the risk is even greater devastation and deepened inequities in the aging population’s health.

Stephanie Robert, MSW, PhD, is a professor, and Meghan Jenkins Morales, MSW, is a doctoral candidate, both at the Sandra Rosenbaum School of Social Work, University of Wisconsin-Madison. Robert may be contacted at sarobert@wisc.edu.

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