HCA415: Community & Public Health-10 Essential Services of Public Health

Community Health and Changing Demographic Trends Learning Objectives After reading this chapter, you should be able to: •Define the term demography and explain how it is applied to community \ health.

•State a rationale for the effects of human ecology upon community health.

•Describe how place affects the health of a community.

•Describe international and domestic population trends.

•Analyze the impact of population growth on community health.

•Compare and contrast communities that differ in health disparities.

•Discuss policy developments that are the result of demographic trends.

•Discuss assessment tools used for improving community health. Chapter 2 Mauroof Khaleel/Getty Images fri80977_02_c02.indd 45 8/30/13 12:46 PM Section 2.1 Introduction 2.1 Introduction Chapter 2 describes how community health is linked with demographic trends, human ecology, and geographic location (place). (Refer to the Spotlight: The Importance of Place and Human Well-Being for an overview of the importance of place in human well-being.) The chapter begins with an explanation of terms (e.g., human ecology and de\ mography) used to describe the social and physical attributes of communities and their \ impacts upon both public health and community health. Demography and human ecology are fields that aid in understanding community health by describing the structure of human populations and the environmental qualities of their locations. We will consider how the foregoing attributes tend to influence our health-related behaviors and regulate our ability to obtain resources that contribute to good health (Tarkowski, 2009). Included with the social attri - butes of communities are customs and social norms that affect people’s decisions regard - ing age at marriage and family size. For example, in India, the second m\ ost populous nation on Earth, the custom is for persons who live in villages to marry\ at an early age and have many children.

The scientific discipline that examines population structures and changes is demography, which is defined as, “the statistical study of human populations especially with reference to size and density, distribution, and vital statistics [information about births and deaths from birth certificates and death certificates]” (Merriam-Webster, 2013d). With respect to demographic trends, the world population is increasing exponentially and will reach 10 billion inhabitants by mid-century (United States Census Bureau and USAID, 2004). Pop - ulation growth has adverse consequences for the environment; examples of these include deforestation, depletion of fisheries, and changes in the climate (About.com\ , 2013). These consequences, in turn, can be harmful to people’s health.

Former political leader Adlai Stevenson compared the Earth with a spaceship: “On its sur - face there is a thin film of life which is a closed support-system driven by ener\ gy from the sun. It is the fitness of the eco- system that provides for its con- tinuity, but this fitness depends very much on the quality of the environment within which this system functions” (qtd. in Sar - gent, 1972). Presently, vital resources needed for sustaining the human population are being depleted rapidly and used in unsustainable ways (Tarkowski, 2009). This chapter will explain how population growth affects community health by contribut - ing to economic inequality, health disparities, and adverse health outcomes. Previously, we defined health disparities as health differences (particularly adverse health outcomes) that are linked closely with social, economic, and/or environmental disadvantage. Refer to Table 2.1 for a list of important terms used in this chapter.

Table 2.1: Key terms used to describe human ecology, methodologies, population trends, and disparities Ecology Health field concept Human ecology Social area analysis Ecosystem health Geographical information systems (GIS) Demography Carrying capacity Environmental risk transition Health disparities iStockphoto/Thinkstock With the world population expected to soon hit 10 billion, community and public health authorities will have even greater difficulty providing for the needs of their people. fri80977_02_c02.indd 46 8/30/13 12:46 PM CHAPTER 2 Section 2.2 Human Ecology and Community Health economic, and/or environmental disadvantage. Refer to Table 2.1 for a list of important terms used in this chapter.

Table 2.1: Key terms used to describe human ecology, methodologies, population trends, and disparities EcologyHealth field concept Human ecology Social area analysis Ecosystem health Geographical information systems (GIS) Demography Carrying capacity Environmental risk transition Health disparities iStockphoto/Thinkstock With the world population expected to soon hit 10 billion, community and public health authorities will have even greater difficulty providing for the needs of their people. Spotlight: The Importance of Place and Human Well-Being Place is a key element in our identity. Who we are is reflected in the places we occupy and the spaces we control. These places range from nation to region, state, metropolitan area, community, neighborhood, block, and residential dwelling. Each location has profound social meaning for us, and in a literal sense, defines not only who we are, but also how we live and die.

Despite the evolution of cyberspace technologies capable of transforming “theres” into “heres,” resi- dence continues to have dramatic consequences for individual health and well-being. The prevalence and incidence of risks for a variety of physical and mental health conditions within metropolitan areas range widely by residential area. Most notably, life and death experiences in the inner city are more simi - lar to those of people in the Third World than to the experience of suburbanites just a few miles away.

Perhaps the most notorious examples of this situation are the neighborhoods of Harlem in New York City and Roxbury in Boston. Mortality rates in these places for Black men under 65 are more than double the rates of U.S. Whites and 50 percent higher than the rate for all U.S. Blacks.

For certain segments of the population, being in the wrong place is not a matter of timing or accident, but rather a function of the social structure . The places we live, work, and play in are fundamental resources like time or money. The access we have to these resources dramatically affects our well-being.

All human beings live in a spatial world where everything and everybody has its place. Everyday lives are spatially structured. At the heart of this structure is a simple fact—there is distance between ourselves and the other actors and objects in our environment. To satisfy basic needs and interests we must find ways of getting objects or actors we have an interest in to either come to us, or find ways of getting to them. Hence, where people live is of great importance.

Source: Adapted from Fitzpatrick, K. M., & LaGory, M. E. (2000). Unhealthy places: The ecology of risk in the urban landscape .

London, England: Routledge. 2.2 Human Ecology and Community Health The field of human ecology enables us to analyze and identify aspects of the community that may be associated with particular health outcomes. In order to formulate a clear pic - ture of community health and public health, one needs to view the connectio\ ns between human populations and the environment; this topic falls within the scope of human ecol - ogy. The term ecology refers to “a branch of science concerned with the interrelationships fri80977_02_c02.indd 47 8/30/13 12:46 PM CHAPTER 2 Section 2.2 Human Ecology and Community Health between organisms and their environment” (Merriam-Webster, 2013a), while human ecology denotes “a branch of sociology dealing especially with the sp\ atial and temporal interrelationships between humans and their economic, social, and political or\ ganiza- tion.” It is “concerned with preservation of environmental quality (as of air or water) through proper application of conservation of civil engineering practices” (Me\ rriam- Webster, 2013b).

The noted European public health expert Stanislaw Tarkowski underscored the close link - ages between human ecology and people’s health. Tarkowski wrote that [t]he social and physical surroundings in which people live affect their health. Individuals and populations are embedded within social, political and economic systems that shape behaviors and offer or constrain access to resources necessary to maintain health. Recognition that health is a prod - uct of the antecedent biological evolution interacting with current social and environmental conditions facilitates identification of social and envi - ronmental determinants that might be amenable to community interven - tions that can lead to improved health outcomes. (Tarkowski, 2009, p. 447) The components of human ecology include physical, biological, and social\ dimensions.

These are key features of the health of communities in the developed and developing world. In the United States, communities vary dramatically with respect to human ecol - ogy. Some affluent suburban communities have excellent health status that is similar\ to that of the most advanced countries of the world. In comparison, some poorer communi - ties (often in inner cities) have health characteristics that resemble those found in eco - nomically developing countries. Demographic factors, such as pressures from expanding populations in developing countries, affect human ecology. These impacts upon human ecology and, in turn, upon community health, involve increased competition for food and housing, depletion of limited natural resources, and ever greater urban crowding.

Achievements of public health science and medicine have led to drastic reductions in infant mortality in many of the world’s developing nations with corresponding augmenta- tion in the number of children who would not have survived in the past. Paradoxically, this achievement has been accom - panied by reduced food avail - ability and increases in famine; a consequence of the limited food supply has been malnu - trition associated with mortal - ity among children (Kartman, 1967). The growing population has affected human ecology in these developing nations by Exactostock/SuperStock In the Harlem neighborhood of New York City, mortality rates among residents are much higher than in surrounding areas.

Location is a resource like any other and plays a major role in our ability to manage good health. fri80977_02_c02.indd 48 8/30/13 12:46 PM CHAPTER 2 Section 2.2 Human Ecology and Community Health worsening adverse health and environmental conditions, even though infant mortality has declined.

The Environment The environment is defined as, “the complex of physical, chemical, and biotic factor\ s (as climate, soil, and living things) that act upon an organism or an ecological community and ultimately determine its form and survival” (Merriam-Webster, 2013c). Two examples of the effects of environmental exposures are those from carcinogenic chemicals and molds.

Exposure to environmental toxins such as bisphenol A (an ingredient in some plastics), pesticides, and dioxins may cause adverse health outcomes. Hazards such as radiation, lead, mold, and radon may also cause such outcomes (National Institute \ of Environmen - tal Health Science [NIEHS], 2013). For example, researchers documented an association between environmental mold exposures following Hurricane Katrina in 2005 and an increased prevalence of upper and lower respiratory symptoms among children and ado - lescents (Rath et al., 2011).

The environment also can be categorized according to physical, biological, and social dimensions. The physical environment consists of air, water, soil, noise pollution, geogra - phy, and physical features of a neighborhood (e.g., public safety and housing). The biological environment includes patho- gens or reservoirs for infectious diseases. You will recall from Chapter 1 that the social envi - ronment encompasses the total - ity of a community’s social structure, socioeconomic levels, cultural characteristics, and degree of urbanization. The social environment can provide positive contributions to com- munity health (e.g., recreational opportunities, educational pro- grams, and availability of social support) and negative features (e.g., social stressors, uninten - tional injuries, and interpersonal violence).

Ecosystem Health The term ecosystem refers to interconnections among social, biological, lifestyle, envi - ronmental, and related factors. Included in the concept of the ecosystem are the position of human beings within it and the dependence of humanity upon it for sur\ vival (Coutts, 2010). In characterizing patterns of health, the ecosystem view conceptualizes how the iStockphoto/Thinkstock The way in which people interact with their environment helps to determine their community’s health status. Wealthier suburbs, for instance, tend to provide greater health benefits for their people (such as this farmer’s market), whereas poorer communities have less access to these benefits. fri80977_02_c02.indd 49 8/30/13 12:46 PM CHAPTER 2 Section 2.2 Human Ecology and Community Health interrelationships among several factors—social, biological, lifestyle, and environmen- tal—are reflected in health.Ecosystem Health sees the human species as one among many in an envi - ronment that is changing as a result of human activity: land-use patterns, climate change, population growth, resource depletion, pollution, urban - ization, loss of biodiversity, and other local and global processes all disrupt the natural self-regulation of the biosphere. These changes harm people, domestic animals, wildlife, the oceans, and the forests (Levins & Lopez, 1999, p. 265).

A challenge for both community health and public health is preservation of the ecosystem (Sargent, 1972).

In illustration, changes in the ecosystem can affect the health of animals and, in turn, have consequences for human health. Zoonotic diseases (diseases that affect animals) can trans - fer to humans when animal and human populations are brought into contact, perhaps as a result of ecosystem disruptions from changing land-use patterns and agricultural prac- tices. Examples of diseases that have zoonotic origins and can be spread to humans are bird flu and swine-origin influenza. Another example of ecosystem disruption is global warming. This phenomenon is hypothesized to have caused northward movement of insect vectors such as mosquitoes that can transmit the West Nile virus and encephalitis viruses from animals to humans. Diseases such as influenza and West Nile demonstrate how the health of domestic animals and wildlife is crucial to community health and how such conditions may stem from ecosystem disruption. The Health Field Concept The health field concept refers to four general factors that act upon human health. The four broad components are human biology, lifestyle, environment, and the health care system (Green & Ottoson, 1994). This framework was developed to analyze the influence of lifestyle and environmental factors on the leading causes of death and disability. The health field concept, which evolved during the 1970s, represented a change of focus with respect to methods for improving health. Prior to the adoption of the health field concept, there had been an earlier emphasis upon control of infectious diseases and use of the health care system as the primary means for improving health.

In 1974, the influential Lalonde Report applied the health field concept to an analysis of how biology, lifestyle, environment, and the health care system affected health in Canada (Pinder & Rootman, 1998). The concepts presented in the Lalonde Report were revolution - ary in their time but are now endorsed by many community health professionals. Let us consider how the four factors included in the health field concept affect human health.

The first factor is human biology. One of the concerns of human biology is an individual’s genetic makeup. In fact, Healthy People 2020 includes the goal of using genomic tools in clini - cal and public health practices. According to Healthy People 2020, “Women with certain high- risk family health history patterns for breast and ovarian cancer could benefit from receiving genetic counseling to learn about genetic testing for BRCA1/2. [BRCA1 and BRCA2 are fri80977_02_c02.indd 50 8/30/13 12:46 PM CHAPTER 2 Section 2.2 Human Ecology and Community Health genes that can mutate and increase a woman’s risk of breast and ovarian cancer.] For women with BRCA1/2 mutations, sur- gery could potentially reduce the risk of breast and ovarian cancer by 85 percent or more” (Healthy - People.gov, 2012). In addition, changes in lifestyle (for example, exercising more and reducing saturated fat consumption) might help to reduce the activa - tion of the BRCA genes. Over time, recognition of the great importance of genetic influences in human diseases has increased.

The term lifestyle refers to influ - ences upon health from indi - viduals’ decisions, actions, and behaviors. Examples of adverse lifestyle influences include risk- taking behaviors (e.g., engaging in unprotected sexual intercourse, driving without a seat belt, riding a bicycle without a helmet, eating high-fat and sodium\ -laden foods, and avoiding exercise). In addition, lifestyle can refer to the act of engaging in protective health behaviors: consuming a nutritious diet, joining a gym, participating in \ stress-reducing activities, and obtaining adequate amounts of sleep.

The environment, discussed earlier in the chapter, is a central aspect of human health world - wide. A significant burden of disease is a consequence of environmental exposures. The exposures might be to disease-causing microbes, pesticides applied to fruits and vegetables, toxic chemicals, heavy metals, or radiation. Other environmental exposures are to air and water pollution. Consequences of rising levels of air pollution include \ increases in lung dis - eases such as childhood asthma. Finally, environmental exposures are implicated in cancer and other chronic diseases; these exposures are thought to interact with genetic factors.

The health care system refers to an organized structure of health professionals (e.g., phy - sicians, nurses, physician assistants, and dentists) who provide health care services to a population in a variety of settings. For example, individuals and famili\ es obtain health care services from urgicenters (urgent care centers), medical and dental offices, outpa - tient clinics, hospital emergency rooms and inpatient facilities, skilled rehabilitation cen - ters, and nursing homes. Community health settings include public health\ agencies, local health departments, community health centers, and community-based organizations.

Public health departments as components of the health care system provide many types of direct health services to individuals in order to prevent and control diseases that endanger public health. The health care system can be on the front line with respect to identifying new presentations of clinical disease that may signal an epidemic. For example\ , a patient who seeks care from a physician for a cough and fever may be an indicator of a new vari - ety of influenza that is starting to break out in a community. Science Photo Library/SuperStock Biology, or the genetic factors that make up an individual’s physical being, is just one of the components considered in the health field concept. However, with current genetic testing, researchers are now able to help determine individual risk factors for disease. fri80977_02_c02.indd 51 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health 2.3 Place and Community Health Place, which denotes the geographic location of where we live, bears an extremely impor- tant influence upon community health. For example, place is associated w\ ith racial and ethnic residential segregation that in turn affects inequalities in health care (White, Haas, & Williams, 2012). It is also related to striking variations in life expectancy and health outcomes, as demonstrated in research conducted in both the United Kingdom and the United States.

Place determines environment quality and whether the resources available to some com - munities are adequate. An unhealthy built environment causes pollution and discourages physical activity. Examples of deficiencies in resources include inadequate or unhealthy foods such as those from liquor stores, fast food outlets, and markets that sell high-priced, stale produce. In some communities, movement in the spatial world is restricted because of violence and other unsafe conditions. As a result, children and families cannot play outside.

Theoreticians have developed several hypotheses to account for place variatio\ ns in com - munity health. The reasons for place variations in health include compositional, contextual, and collective explanations (Mcintire, Ellaway, & Cummins, 2002). The term compositional denotes the characteristics of the inhabitants of a given geographical a\ rea. Contextual expla - nations refer to opportunity structures associated with the physical and social character - istics of a community. Collective explanations pertain to the traditions, norms, and values found in a particular community.

Research conducted among the Cambodian American community in Long Beach, Cali - fornia, provides an example of compositional, contextual, and collective explanati\ ons for place variation regarding smoking. With respect to the composition of the community, residents were male and female refugees from Cambodia and U.S.-born persons of Cam - bodian heritage who represented various ages, levels of education, and socioeconomic levels. Cambodian American men were found to have a higher smoking prevalence (24.4%) than that of the general California population (14.3%). Age, gender, education, marital status, and health status were related significantly to current smoking among Cambodian Americans in the city of Long Beach (a compositional explanation) (Fr\ iis et al., 2011).

In most American communities, advertising and media contribute to the promotion of smoking among racial and ethnic minorities (Friis et al., 2006). A disproportionate num- ber of billboards advertise tobacco in racial and ethnic minority communities (USDHHS,\ 1998), with the highest average number of tobacco displays in Asian American stores.

This contextually based explanation for smoking applies equally well to \ the Cambo - dian American community of Long Beach. Similarly, alcohol advertisements also dem - onstrate this pattern in many of the communities in which racial and eth\ nic minorities reside.

The sociocultural and traditional factors that influence Cambodians to s\ moke (a collective explanation) include smoking during social gatherings, birthday parties\ , special occasions, temple ceremonies, funeral ceremonies, offerings to ancestors, and as part of religious fri80977_02_c02.indd 52 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health practices. Research with the Cambodian community demon- strated the role of compositional, contextual, and collective influ- ences with respect to the high prevalence of smoking. Conse - quently, public health profes - sionals need to take these influences into account when developing community-based health promotion programs such as smoking cessation inter - ventions. An implication of this research is that “one size fits all” programs may not be effective in communities that have unique demographic compositions and cultural values. For example, the Cambodian community affords high levels of respect to Bud - dhist monks who can have an important influence on the health-related behaviors of the population. The monks can aid in building ties and communication channels with community residents.

Examples of the effects of place on community health come from Glasgow, Scotland, and the United States. For example, the Glasgow effect is a term used to describe the poor health status of the residents of Glasgow, Scotland. Glaswegians exhibit higher levels of morbidity and mortality for both adult men and women when compared with compa - rable and economically similar cities in the United Kingdom (Walsh, Bendel, Jones, & Hanlon, 2010). According to research conducted by Sir Michael Marmot and colleagues, a boy who lived in a deprived area of Glasgow had a life expectancy of only 54 years; in comparison, the figure for a boy who lived in an affluent area only 12 kilometers away was 82 years (Reid, 2011).

An implication of the Glasgow effect for public health is that place is an important aspect of a community’s health. Characteristics of place—for example, eco\ nomic, social, cultural, and political dimensions—influence the health of a community’s residents by impact- ing the social and physical environment. In turn, these environmental factors influence residents’ levels of stress, interpersonal relationships, and health-related behaviors. The Glasgow effect is noteworthy for public health because of the associated adverse h\ ealth outcomes and reductions in life expectancy reported for the city in comparison with nearby cities that had lower levels of economic deprivation. Consequently, successful community health programs need to address economic deprivation and adverse social conditions. For more information about the Glasgow effect, refer to Case Study: Blame “Glasgow effect” for city’s chronic ill health—not deprivation. Bloomberg via Getty Images Companies can use their knowledge of the effects of place on ethnic segregation to drive advertising campaigns. For instance, there is a much higher incidence of tobacco advertising that targets racial minorities—particularly Asian Americans—across the United States. fri80977_02_c02.indd 53 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health Case Study: Blame “Glasgow Effect” for City’s Chronic Ill Health—not Deprivation Helen Puttick Reams [large quantities] of figures have been published showing the scale of Glasgow’s ills but still the question remains: why are the citizens so unhealthy?

The most obvious answer is there are higher levels of deprivation, given poverty around the world is associated with illness, poor diet, and addictions. The results of a new study, however, mean this can no longer be seen as the sole cause.

The study shows the deprivation profile of the city is virtually the same as that of Liverpool and Manchester—yet between 2003 and 2007 in Glasgow there were 60% more deaths among men aged 15 to 44, and 4,502 extra deaths in total.

The deaths did not just occur in the poorest communities. Every social class was affected.

Professor Phil Hanlon, expert in public health at Glasgow University, compares the city to a patient in denial about the complexity of their illness.

He said: “There are a lot of policymakers and city fathers who are in denial about this. We are really concerned about the people of Glasgow.

Let’s look honestly at the problem.” Inherited genetic defects in the local population could be behind what is dubbed the “Glasgow effect,” or biological changes caused by Scotland’s grey climate, but Prof Hanlon is persuaded by neither theory. He said: “The weather is cloudier in Scotland, but there are two important points. Some of the countries with the highest life expectancy in the world are several hundred miles north of here with worse weather than we have. Also, the cloud was here 30 or 40 years ago when the ‘Glasgow effect’ was not.” He discounts defective DNA on the same basis.

Another possibility is while surveys suggest diet and drinking habits are no more indulgent among Glas - wegians than the people of Liverpool or Manchester, the results are misleading. There were more than double the number of deaths from alcohol in Glasgow.

Among men there were nearly treble [triple] the number of fatal drug overdoses. But this does not explain why 50% of the city’s excess deaths are caused by cancer and heart disease, nor does it explain why Glasgow people turn to alcohol or heroin.

David Walsh, lead author of the study, said: “The ‘Glasgow effect’ is about people missing out on their grandchildren growing up and the grief of losing relatives. When you see the number of alcohol-related deaths, you have to remember people do not drink themselves to death for no reason. There must be other things causing stress in their lives.” Stress and the sense of control people have are thought to cause biological changes which age cells prematurely.

Professor Hanlon said: “The best shot is there is a series of factors to do with the social, cultural, politi - cal history of the city which manifests itself in chronic stress, relationship issues, attitudinal issues and (continued) Ingram Publishing/Thinkstock New research points to a more complex explanation in the search for the factors behind Glasgow’s high rate of morbidity. fri80977_02_c02.indd 54 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health Richmond, California, a small city located in Contra Costa County (San \ Francisco Bay Area) provides another demonstration of place effects. Residents in this city experience a much greater number of health disparities than do the inhabitants of other comm\ unities in Contra Costa County (McLean, Wilson, & Kent, 2011). These health inequities include high general rates for disease and death plus increased death rates from diabetes, heart disease, cancer, and stroke. Rates for hospitalizations for mental health and substance abuse issues and for children’s asthma-related conditions are elevated as well (Commu- nity Health and Wellness, n.d.). Moreover, in comparison with other racial and ethnic groups, low-income non-Whites, particularly Richmond’s Blacks, are at the greatest risk for poor health outcomes.

A review of socioeconomic and environmental conditions in the city identified potential contributing factors (called “healthy living determinants”) asso\ ciated with the reported high number of adverse social and health outcomes. One group of determinants was related to the built environment: excessive distance from poorly maintained recreational facilities and unavailability of full-service grocery stores and health food markets. Many venues for social congregation (e.g., parks, playgrounds, schools, and commercial areas) experienced a high incidence of violent crimes. Richmond oversees a seap\ ort, major oil refinery, and railroad terminal. Consequently, air, water, soil, and noise pollution impact residents and workers adversely. A second group was transportation associated: forced dependence upon the automobile as the primary method of transportation d\ ue to the wide dispersal of retail shops, restaurants, and community services and inadequate pub- lic transportation during the evening and weekends. The third set was health-service related: minimal availability of emergency medical services despite a sufficient number of other health services. The fourth was a function of socioeconomic condit\ ions: numerous residents in low socioeconomic and poverty status, overcrowded and unaffordable hous - ing for many low-income households, and inadequate training and skills f\ or employment in a competitive job market.

In response to the social, economic, physical, and environmental factors that contribute to Richmond’s health inequities and poor health outcomes, the city has prioritized com - munity health and preventative health actions in its community vision statement for 2030.

City leaders have addressed this priority by incorporating a health and wellness element into the City of Richmond General Plan (Element 11). The element is known as the Com- munity Health and Wellness Element (HWE), which establishes a framework for devel - oping policies and implementing actions that will improve the health of all Richmond behavioural issues. These biological, relational, environmental and cultural things are combining in a particularly toxic way for Glasgow.” Children appear to be protected from the “Glasgow effect”—although the seeds could take time to sprout. Professor Hanlon, raised in the west of Scotland himself, said: “Give kids a loving upbringing and you might protect them.” Source: Herald Scotland. (2010). Blame “Glasgow effect” for city’s chronic ill health—not deprivation. Retrieved from http://www.heraldscotland.com/news/health/blame-glasgow-effect-for-city-s-chronic-ill-health-not-deprivation-1.1015066 Case Study (continued) fri80977_02_c02.indd 55 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health residents. The HWE demonstrates the city of Richmond’s commitment to reducing critical health risks in the community and improving the quality of life among all residents.

These factors and their relationship with community health and wellness are shown in Figure 2.1. Based on the assessment of healthy living determinants, a set of \ goals related to improvement of community health was established (Community Health and Wellness, n.d.). This process shows the importance of public and community health in terms of assessment, policy development, and assurance to provide improvements in the infra- structure for overall healthy people. Refer to Table 2.2 for a list of the 10 goals that are particularly applicable to community health.

Figure 2.1: Ten factors that influence community health and wellness Community Health and Wellness 9. Environmental Quality 3. Access to Medical Services 1. Access to Recreation and Open Space 6. Access to Economic Opportunity 10. Green and Sustainable Development and Practices 2. Access to Healthy Foods 8. Safe Neighborhoods and Public Spaces 4. Access to PublicTransit and Active Transportation 7. Completeness of Neighborhoods 5. Access to Quality Affordable Housing Source: Adapted from McLean J., Wilson, L., & Kent, M. Health in all policie\ s, health data in all decisions. Data, indicators, tracking Strategies for Implementation of the City of Richmond’s Health and Wellness Element: An assessment and recommendations, December 2011. Available at: http://www.ci.richmond.ca.us/DocumentView.aspx?DID=8663 The Richmond Health and Wellness Element set goals to address the 10 key factors influencing Commu- nity Health and Wellness. fri80977_02_c02.indd 56 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health Table 2.2: Goals of Community Health and Wellness for 2030, City of Richmond Goal 1Improve access to parks, recreation, and open space.

Goal 2 Expand access to healthy food and nutrition choices.

Goal 3 Improve access to medical services.

Goal 4 Increase the safety and convenience of public transit and active transportation options.

Goal 5 Improve the range of quality and affordable housing.

Goal 6 Expand economic opportunity.

Goal 7 Promote complete neighborhoods. (Situate community amenities within walking distance.) Goal 8 Improve safety in neighborhoods and public spaces.

Goal 9 Improve environmental quality.

Goal 10 Continue to commit to green and sustainable development and practices by implementing green building requirements and encouraging walking, bicycling and use of public transportation.

Source: Adapted and reprinted from Community Health and Wellness (n.d.). City of Richmond General Plan Element 11. Retrieved fr\ om http://www.ci.richmond.ca.us/DocumentView.aspx?DID=8579 A final example of place effects in this chapter is the Eight Americas Study (Murray, Kulkarni, & Ezzati, 2005). The research segmented the population of the United States into eight groups found to have distinctive patterns of mortality. The study’s findings were consistent with those of numerous U.S. investigations of health inequities: Many population groups expe - rience health disparities, particularly Blacks. Mur - ray et al. (2005) reported that the two groups with the lowest life expectancies at birth were poor Blacks who resided in the rural South (the group America 7) and Blacks who lived in high-risk urban areas (the group America 8). (Note that in 2008, the life expectancy of Blacks was about 4 years shorter than that of Whites.) In contrast, the population group with the highest life expectancy in the United States in 2001 was Asians (the group America 1 in the research). The Eight Americas Study suggested that subgroups of the U.S. popu - lation have characteristic epidemiologic patterns of morbidity and mortality.

One of the implications of the Eight Americas Study is that health disparities cannot be viewed simplistically. Large socioeconomic variations occur in health outcomes within specific racial and ethnic groups in the United States. In addi - tion, subgroups that exist within the country have distinctive epidemiologic patterns of health risks.

The research suggests that characteristics of the John Fedele/Blend Images/SuperStock The Eight Americas Study shows poor Black Americans living in either the rural South or high-risk urban areas to have the lowest life expectancies of the groups created during the study. fri80977_02_c02.indd 57 8/30/13 12:46 PM CHAPTER 2 Section 2.3 Place and Community Health community and individual coupled with access to the health care system interact in caus- ing health outcomes. Given the uniqueness of each racial and ethnic subg\ roup and the communities in which they live, public health solutions will need to be customized t\ o each of the Eight Americas in order to address health disparities. An approach might be for research to focus on how to most effectively deliver health interventions in each of the different types of communities in America.

For more information refer to Case Study: The Eight Americas Study.

Case Study: The Eight Americas Study The Eight Americas Study divides the U.S. population into eight distinct groups with different epidemio - logic patterns and mortality experience. (The findings reported in this exhibit are based on male and female life expectancy at birth for 2001 in the Eight Americas.) The Eight Americas are: • America 1—Asians •America 2—below-median-income Whites (living in rural areas) in the “Northland” (Minnesota, North Dakota, South Dakota, Iowa, Montana, and Nebraska) •America 3—middle America (the large fraction of the U.S. population largely composed of white Americans) •America 4—poor Whites living in Appalachia and the Mississippi Valley •America 5—Native Americans living on reservations in the West •America 6—Blacks living in middle America •America 7—poor Blacks living in the rural South •America 8—Blacks living in high-risk urban environments.

In 2001, life expectancy for high-risk, urban black males in America 8 was 21 years lower than life expec- tancy for females in America 1. For males, the gap between America 1 and America 8, 16.1 years, was as large as the gap between Iceland with the highest male life expectancy in the world and Bangladesh.

Even in Americas 5, 6, 7, and 8, U.S. child mortality was in the middle of the range defined by the Organi - zation of Economic Cooperation and Development (OECD) countries. For young and middle-aged males and females, however, mortality experience in the disadvantaged Americas was up to two times worse than the worst OECD country.

The enormous excess of young and middle-aged mortality is largely due to chronic disease death. Based on the World Health Organization Comparative Risk Assessment project, we expect the major risks in the United States to be tobacco, alcohol, obesity, blood pressure, and cholesterol. Risk factor analysis using Behavioral Risk Factor Surveillance System data for the Eight Americas suggests that the pattern for tobacco, alcohol, and obesity is distinct for each America. (The Behavioral Risk Factor Surveillance System [BRFSS] is an ongoing telephone survey of behavioral factors for disease. The Centers for Disease Control and Prevention [CDC] operates the survey, which collects data nationwide from states in the United States.) Currently available data in the public domain do not provide an adequate basis to assess levels of blood pressure and cholesterol in the Eight Americas. To tackle disparities in the United States, public health will need to increase its focus on chronic diseases in young and middle-aged Americans.

In particular, if blood pressure and cholesterol are confirmed as major contributors to current mortal - ity patterns, innovative strategies such as the Polypill™ (a medication in the form of a pill that contains doses of several different drugs that in this example could control blood pressure and reduce blood cholesterol) and unique individual and population approaches need to be explored.

Source: Adapted from Murray, C. J. L., Kulkarni. S., & Ezzati, M. (2005). Eight Americas: New perspectives on US health disparities.

American Journal of Preventive Medicine, 29(5 Supplement 1), 4. fri80977_02_c02.indd 58 8/30/13 12:46 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health 2.4 Human Population Trends and Community Health This section describes how population trends affect community health. The rationale for examining the association between changing population trends and community health flows from the concept of human ecology and its impact upon health. The projected future exponential growth of the population is likely to be of great importance for community health. As the human population expands, preservation of environmental quality becomes increasingly difficult. We noted in the introduction that population growth has both posi- tive and negative significance for the health of the community. On the plus side, a grow - ing population increases opportunities for human interaction, cultural enhancements, social support, and sharing expertise. Less desirable consequences of po\ pulation growth include depletion of scarce resources, increased pollution levels, and urban crowding, with greater potential for transmission of communicable diseases.

In order to analyze population trends, researchers can make use of vital statistics and census data. In most jurisdictions of the United States, county and stat\ e governments col - lect vital statistics data, which are submitted to the National Center for Health Statistics.

Another type of information used in demographic analyses are census data, which aid in tracking the overall size of the U.S. population, describing its demogra\ phic composition, and revealing geographical variations in the distribution of the population. Census data provide a foundation for projections of future population trends such as changes in the age composition of the population over time.

The U.S. Bureau of the Census, one of the bureaus of the Department of Commerce, is the federal agency assigned the function of counting the U.S. population and collecting data on its characteristics. The U.S. Census is a systematic process of counting every resident in the United States. Article I, Section 2 of the U.S. Constitution requires that a census be conducted every 10 years (United States Census Bureau, n.d.); thus it is known as the decennial census (United States Census Bureau, 2002).

The U.S. Census Bureau (2012a) provides high-quality data about the nation’s residents and economy. By participating fully in the census, the community benefits, as data fr\ om the census help to shed light on needed resources. The information collected by the Cen - sus Bureau is used for the following purposes: • apportion congressional seats to the states as required by the U.S. Constitution • ascertain needed community services • situate new schools • distribute federal funds to state, local, and tribal governments to pay for the fol- lowing functions:

• community improvements • public health • emergency services • job training in schools and centers • provide information for age-related purposes such as verification of social secu- rity benefits. fri80977_02_c02.indd 59 8/30/13 12:46 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health A Snapshot of the World and U.S. Populations Some interesting facts about the world’s population include the total number in the popu- lation, projected growth in humanity, projected changes in the age and sex distribution of populations in the developing world, and increasing urbanization. These demographic aspects of the population will cause changes in the occurrence of infectious and chronic diseases, availability of health care resources, and many other key aspects of community health.

Current Population of the World In 2011, the world population totaled 7 billion, a figure that was reached after explosive growth during the 20th century, following relatively slow growth during the previous century. The world’s population grew very slowly between 1800 and 1927, a time inter - val when the population required 123 years to add 1 billion people. Beginning with the mid-20th century, population growth began to escalate and required only 12 years to add 1 billion people between 1999 and 2011. In about three decades, the world’s population could reach 10 billion.

The U.S. Population The population of the United States reached nearly 309 million persons in 2010 and increased by almost 10% over 2000 (United States Census Bureau, 2012b). The fastest- growing ethnic and racial group between 2000 and 2010 in terms of numerical growth was Hispanics, who made up 16% of the population in 2010 (United States Census Bureau, 2010). Whites and Blacks were 64% and 13% of the total population, respectively. Of all groups, the Asian population grew the fastest percentage-wise, increasing by 43% com - pared with an increase of about 5% for the total U.S. population. Large proportions of minority populations in 2010 were concentrated geographically in the South and West.

California, one of the states that had a “majority minority” popul\ ation, had the largest minority population in the United States. Since 2000, the Census Bureau has collected information on persons who classify themselves as multiracial. The multi\ racial popula - tion (around 3% in 2010) grew by 32%, faster than any group that represented a single racial category (United States Census Bureau, 2013). Figure 2.2 shows the population of United States and Puerto Rico. fri80977_02_c02.indd 60 8/30/13 12:46 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health Figure 2.2: The population of United States and Puerto Rico Population for United States and Puerto Rico: July 1, 2011 25,000,000 or more 2,000,000 to 4,999,99915,000,000 to 24,999,999 5,000,000 to 14,999,999 Less than 2,000,000 HI TX CA NV OR WA ID MT WY UT AK AZ NM OK KS CO NE SD ND WI MN IL IA MOAR LA MS AL GA FL PR SC NC TN KY MI IN OH PANY WV VA MA NH RI DE NJ CT MD ME VT Source: Adapted from the 2011 U.S. Census, available at http://www.census.gov/popest/data/maps/2011/pop_size2011.pdf What public and community health issues arise from more densely populated areas? From less popu - lated communities? How will the increasing trend toward urbanization and minority populations affect community health programs?

Future Trends: Urbanization and an Aging Population As a consequence of population growth, the world will become increasingly urbanized in the future. At present, approximately one in two people reside in an urban area; in about 35 years, that number is estimated to increase to two out of three. This percentage will increase by up to 60% in some countries (United Nations Population Fund [UN\ FPA], 2011). Urban population growth, especially among children aged 0 to 19 years, is greatest in less developed regions (United Nations International Children’s Emergency Fund [UNICEF], 2012). One of the consequences of increasing urbanization is the worldwide phenomenon of megacities, an example being Mexico City. People around Mexico City are draining the aquifer that lies directly under it and, consequently, the city is slowly sinking.

Formation of megacities and continuing world population growth bring about a set of fri80977_02_c02.indd 61 8/30/13 12:46 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health risks associated with the environmental risk transition, defined as the changes in environmen - tal risks (e.g., increased exposure to air pollution) that happen as a consequence of economic devel - opment in the less developed regions of the world (Friis & Sellers, 2009, p. 7).

In 2011, about half of the global population was composed of younger persons. Moreover, indi- viduals younger than 25 years of age made up about 43% of the world’s population. However, this age distribution will change in the future as the world’s population is projected to be made up of larger numbers of older persons during the next half-century in most countries (United Nations, 2001). During 2011, worldwide, there were about 893 million people aged 60 and over.

Demographers predict that by the middle of the 21st century, this number will grow to 2.4 bil- lion, challenging the resources of communities by greatly increasing the need for residential, medi - cal, and other services for the elderly.

The population pyramid (age and sex distribu - tions of the population) in Figure 2.3 demon - strates how the world’s population grew older between 1950 and 2010. In 1950, the proportion of younger individuals exceeded the proportion of older persons, causing a triangular population distribution. About 60 years later, the proportion of older people increased relative to the proportion of younger people. Projections for 2050 and 2100 indicate this trend will continue, forming a more rectangular population distribution by the end of the present century. Developing countries tend to have a triangular population distribution, such as that shown for developed countries in 1950. Presently, developed countries have a more rectangular population distribution, similar to the projected population distribution for 2100. A consequence of an aging population is that there may be too few young people to care for and fund benefits for the elderly through taxes. Cultura Limited/SuperStock As the population continues to grow to 2.4 billion worldwide, population pyramids are showing that the proportion of older people are increasing relative to younger individuals. The task for public health will be to ensure the elderly are cared for despite the fact that there are fewer young people to care for them and to help pay for this care. fri80977_02_c02.indd 62 8/30/13 12:47 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health Figure 2.3: Population pyramids World 1950 10 0 90 80 70 60 50 40 30 2010 0 10 5 6 4 2 0 2 4 6 World 2010 10 0 90 80 70 60 50 40 30 2010 0 10 5 6 4 2 0 2 4 6 World 2050 10 0 90 80 70 60 50 40 30 2010 0 10 5 6 4 2 0 2 4 6 World 2100 10 0 90 80 70 60 50 40 30 2010 0 10 5 6 4 2 0 2 4 6 Males Females Males Females Males Females Males Females Source: Adapted from the United Nations, Department of Economic and Social A\ ffairs. Available at http://www.un.org/en/development/ desa/population/theme/trends/index.shtml While sex distributions have remained fairly equal, the majority of the world’s population is aging. In 1950, most of the population was under the age of 10, but as that generation ages there has not been another “boom” to replace it. fri80977_02_c02.indd 63 8/30/13 12:47 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health Population Dynamics Among the reasons for the explosive growth of the world population are declining mor- tality rates, social customs that encourage large families, and high fertility and birth rates in some countries. The term population dynamics is a construct that helps to explain the evolving characteristics of populations over time—their growth and contraction and their demographic composition. Table 2.3 provides a list of terms related to population dynam - ics. Influences upon population dynamics include fertility and birth rat\ es, mortality, and migration. These variables affect community health by contributing to the age and sex distributions of a population (number of older versus younger residents; number of males versus females), the degree of urbanization of a geographic area, and the demand for and utilization of resources.

The next section will cover how population dynamics affect the health of the community.

Table 2.3: Terms used in describing population dynamics Term Definition Total fertility rate The average number of live births per woman to the end of her childbearing years.

Crude birth rate The number of live births during a specified period of time (e.g., during a year) per the resident population. The size of the population is assessed at the midpoint of the same year.

Crude death rate The number of deaths reported in a population during a defined period of time (e.g., during a year). The size of the population is assessed at the midpoint of the same year.

Migration The movement of people from one country or geographic area to another place.

Source: Data from Friis & Sellers (2009, p. 110).

Fertility Rates The term fertility, defined as the ability to produce of live children, can be measured by fertility rates, which are one of the factors that influence the size of a population. When a country’s total fertility rate (defined in Table 2.3) falls below 2.1 children per woman of childbearing age (called the replacement fertility rate), the population will tend to decline in size. Macedonia and Finland have fertility rates that are below the replacement rate and lower than elsewhere in the world. These countries have populations that are declin - ing in size because women give birth to fewer children than in countries with growing populations and because families delay childbearing (United Nations Pop\ ulation Fund [UNFPA], 2011). Some countries with declining numbers of children are searching for ways to encourage families to have more children. In contrast, other countries (for exam- ple, some of those in Africa and Southeast Asia), are experiencing explosive population growth, due to high fertility rates. Ethiopia and India, countries with bu\ rgeoning popu - lations, have attempted to limit fertility rates by actions such as incr\ easing educational opportunities for women and ending child marriages.

In some regions, such as Central America, the total fertility rate has declined substantially and is approaching the replacement rate. The countries in these regions are undergoing the fri80977_02_c02.indd 64 9/16/13 4:03 PM CHAPTER 2 Section 2.4 Human Population Trends and Community Health demographic transition (Friis & Sellers, 2009), or the shift from high birth and death rates found in agrarian societies (e.g., communities that rely heavily on agricultural produc- tion as their source of income) to much lower birth and deaths rates found in developed countries (e.g., a community whose economic foundation comes from manufacturing and technology). Crude birth rates and crude death rates are related to increases and decreases in the size of a population. The rate of natural increase (RNI) is the difference between a popula - tion’s crude birth rate and crude death rate. When birth rates exceed death rates, the RNI is a positive value, meaning that a population is tending to increase. Internationally, birth rates (in addition to fertility rates) have shown a declining trend. Nevertheless, despite declining birth rates, the global population has continued to surge because of the large number of women of childbearing age who are giving birth to fewer children. Accord- ing to the UNFPA, “In the poorest countries, extreme poverty, food insecurity, inequality, high death rates and high birth rates are linked in a vicious cycle. Reducing poverty by investing in health and education, especially for women and girls, can break this cycle” (UNFPA, 2011, p. 3). This statement provides a clear articulation of the adverse impacts of high birth rates and high death rates upon community health.

As birth rates are decelerating in most areas of the world, chronic diseases are replac - ing infectious diseases as the leading causes of mortality. The epidemiologic transition is defined as a shift in the pattern of morbidity and mortality from causes related primarily to infectious and communicable diseases (i.e., influenza, tuberculosis, and measles) to causes associated with chronic, degenerative diseases (i.e., asthma, diabetes, and hypertension)\ .

Migration is the movement from one geographic area or place to another. In-migration is associated with population increases and out-migration with depopulation of geographic areas. Migration of the population from the countryside to cities causes cities to grow and adjacent areas to become more urbanized. However, globally, migration is a less impor - tant factor in urbanization than the high birth rates found in many urba\ n areas (UNICEF, 2012).

Are There Limitations to Population Growth?

The ecosystem of “spaceship Earth” is endangered because of growing pressures from the burgeoning human population. In the future, human population growth may be cur - tailed due to inadequate basic resources for human survival: food, reasonable air quality, and safe water. Already, some areas of the world lack sufficient water supplies and also experience periodic famines. The term carrying capacity denotes the maximum popula - tion an area can support without causing the environment to deteriorate to the extent that human inhabitants are jeopardized. The carrying capacity includes available food and water supplies for support of the human population; also, it includes en\ ergy resources for the production of goods and services. When the carrying capacity is exceeded, \ most likely the human race will not have adequate resources for survival. At present, in many of the world’s arid regions (including the western parts of the United States), water sup - plies are under stress, and in some Middle Eastern countries they are insufficient to meet the needs of the population. Another adverse impact of the human footprint is global warming, which threatens to cause climate change and dangerous rises in sea level along fri80977_02_c02.indd 65 9/16/13 4:04 PM CHAPTER 2 Section 2.5 The Community and Health Disparities coastal areas of the world. One of the notable figures who brought attention to the effects of overpopulation on resources for human consumption is Dr. Paul R. Ehrlich, who is Bing Professor of Population Studies in the Department of Biological Sciences a\ t Stanford University. In his groundbreaking and controversial book, The Population Bomb, published in 1968, Dr. Ehrlich alleged that famine associated with overpopulation would cause\ large increases in the worldwide death rate. Although some of his predictions have not come to pass, his book has been noteworthy for bringing attention to the potenti\ al adverse conse - quences of overpopulation. Refer to Spotlight: A Prologue to The Population Bomb by Dr.

Paul R. Ehrlich.

Spotlight: A Prologue to The Population Bomb by Dr. Paul R. Ehrlich The battle to feed all of humanity is over. In the 1970s the world will undergo famines—hundreds of mil - lions of people are going to starve to death in spite of any crash programs embarked upon now. At this late date nothing can prevent a substantial increase in the world death rate, although many lives could be saved through dramatic programs to “stretch” the carrying capacity of the earth by increasing food production. But these programs will only provide a stay of execution unless they are accompanied by determined and successful efforts at population control. Population control is the conscious regulation of the numbers of human beings to meet the needs, not just of individual families, but of society as a whole.

Nothing could be more misleading to our children than our present affluent society. They will inherit a totally different world, a world in which the standards, politics, and economics of the 1960’s [sic] are dead. As the most powerful nation in the world today, and its largest consumer, the United States cannot stand isolated. We are today involved in the events leading to famine; tomorrow we may be destroyed by its consequences.

Our position requires that we take immediate action at home and promote effective action worldwide.

We must have population control at home, hopefully through a system of incentives and penalties, but by compulsion if voluntary methods fail. We must use our political power to push other countries into programs which combine agricultural development and population control. And while this is being done we must take action to reverse the deterioration of our environment before population pressure perma - nently ruins our planet. The birth rate must be brought into balance with the death rate or mankind will breed itself into oblivion. We can no longer afford merely to treat the symptoms of the cancer of popula - tion growth; the cancer itself must be cut out. Population control is the only answer.

Source: Ehrlich, P. R. (1968). Prologue. The population bomb. New York, NY: Ballantine Books. 2.5 The Community and Health Disparities Health disparities are rooted in historical policies and practices and are supported by social structures that shape barriers to opportunity. Despite impressive economic growth in the United States since the latter third of the 20th century, communities of color and poor people have experienced shorter life expectancies and higher morbid\ ity rates than other population groups (Hofrichter, 2006). Communities of color are communities that are made up of non-White residents who are predominantly from groups such as Blacks, Latinos, Asian and Pacific Islanders, and Native Americans. The manifestations of health disparities are causes and consequences of the overall health of the community. As stated in Chapter 1, elimination of health disparities is a goal that is related to the field of public health’s commitment to social justice, which is a fundamental aspect \ of public health. This fri80977_02_c02.indd 66 8/30/13 12:47 PM CHAPTER 2 Section 2.5 The Community and Health Disparities section will provide examples of health disparities related to the maintenance of adequate food intake. In addition, this discussion will highlight exemplary commu\ nity programs that have addressed a broad range of social and health inequities.

Food Availability The availability of healthy foods is vital to sustaining community health. Locations in the United States that are most often afflicted by health disparities are low- income minority communities, which also tend to have reduced access to healthy foods (Larson, Story, & Nelson, 2009).

Foods available in many low-income com- munities tend to be inexpensive, energy dense, and low in nutritional value: high- sugar sodas, low-nutrient chips, and high- calorie fast food items. We discussed this situation earlier in the chapter in the example of Richmond, California.

Unavailability of healthy food options is likely to have a significant impact on the health of residents in low-income com- munities. The residents of these disadvan - taged neighborhoods are predominantly members of minority population groups.

They are more likely than persons who are not from minority populations to suf- fer from heart disease, hypertension, and type 2 diabetes (Shak, Mikkelsen, &\ Chehimi, 2010). To improve health outcomes of those residing in low-income communities, foods should be high in nutritional content, affordable, and available at all places where people eat, drink, and buy groceries: schools, workplaces, restaurants, and supermarkets.

One example of an effort to improve access to healthy foods is Pennsylvania’s Fresh Food Financing Initiative (PFFFI, 2009). In 2004, the Pennsylvania legislature allocated a $10 million annual appropriation for a grant and loan program that would encourage the development of supermarkets and grocery stores in underserved areas. As of March 2009, the PFFFI committed $63.3 million in grants and loans to 68 stores across the state of Penn - sylvania. These investments in the community resulted in the provision of healthy and affordable foods in low-income neighborhoods and the generation of 3,734 jobs in food markets.

Environmental Justice One of the causes of health disparities is exposure of community residents to environmen- tal pollutants from nearby factories, refineries, highways, toxic waste sites, landfills, and Millennium Images/SuperStock Poorer, minority-based communities tend to have limited access to healthful food options at reasonable prices. fri80977_02_c02.indd 67 9/18/13 2:06 PM CHAPTER 2 Section 2.5 The Community and Health Disparities dumps. Often the health disparities observed in such communities are compounded by negative social conditions. Environmental justice is a social movement on behalf of com- munities affected disproportionately by disparities caused by exposure to environmental risks (Prochaska et al., 2012; Hilmers, Hilmers, & Dave, 2012).

In 1987, a report titled Toxic Waste and Race in America showed how non-White people and disadvantaged communities often are disproportionately burdened by environmental hazards (Wilson et al., 2012). Researchers assessed geographic disparities in the location of Toxic Release Inventory (TRI) facilities in Charleston, South Carolina. The GIS map shown in Figure 2.4 illustrates the widespread distribution of TRI facilities and their connection to the percentage of non-Whites in Charleston Metropolitan Statistical Area Census Tracts.

We will discuss census tracts later in this chapter, and we’ll explore environmental justice further in Chapter 7.

Figure 2.4: Toxic Release Inventory (TRI) facilities in Charleston, South Carolina Charleston MSA Census Tracts 1.10%–26.06% 26.06%–52.57% 52.7%–79.09% 79.09%–99.0% % Non-White TRI Sites < 0.5 SD 0.5 0.5 SD 0.5 1.5 SD 1. 5 2.3 SD Atlantic Ocean Charleston Charleston Berkeley Dorchester Lake Marion Lake Moultrie Source: Reprinted from Wilson, S. M., Fraser-Rahim, H., & Williams, E. (2012). Assessment of the distribution of t\ oxic release inventory facilities in metropolitan Charleston: An environmental justice case stu\ dy. American Journal of Public Health, 102(10), 1974–1980.

How can environmental justice and community health professionals reduce exposure of large popula - tions of non-Whites to environmental risks—such as those presented by the Toxic Release Inventory facilities that surround minority populations in South Carolina? fri80977_02_c02.indd 68 9/18/13 2:05 PM CHAPTER 2 Section 2.5 The Community and Health Disparities Programs and Policies to Reduce Health Disparities Health disparities are a global issue. The highly developed economies of Europe and the United States have introduced programs to counter the causes and effects of health dis- parities. For example, the United Kingdom developed the New Deal for Communities (NDC) in the late 1990s (Brennan Ramirez, Baker, & Metzler, 2008). The NDC is a large- scale community initiative directed at reducing health and other inequities by strengthen- ing local socioeconomic development in 39 of the United Kingdom’s mos\ t impoverished communities. Partnerships were formed among voluntary and community organizations, local governments, businesses, and the national government of the United\ Kingdom.

The NDC partnership addresses the principal areas of lack of employment opportunities, negative health outcomes, high crime levels, and low education levels. T\ he NDC’s efforts to tackle the social and health inequities include improving the physical environment and local services; upgrading facilities for various arts, sports, and leisure programs; chal - lenging the problem of racial discrimination; and building community capacity to initi\ - ate social action. Preliminary results suggest a remarkable improvement in crime rates, progress in educational attainment and school retention, and satisfactory improvements in self-rated health.

With the increasing diversity of the U.S. population, many communities are likely to experience growing numbers of health disparities. As is true of the United Kingdom, the United States has introduced a number of meritorious programs for addressing health disparities. Table 2.4 identifies five noteworthy programs and policy initiatives that target health disparities in the United States.

Table 2.4: Examples of programs/policies to reduce health disparities in the United States Program Title LocationApproximate Date Begun The Delta Health Center Mound Bayou, Mississippi1965 Various policy initiatives by the Joint Select Committee on Health Disparities (a legislative body) Washington State 2006 Health Care Language Assistance Act California2009 Massachusetts’s Chapter 58 of the Acts of 2006 Massachusetts2006 Campaign to Eliminate Racial and Ethnic Disparities in Health California 2001 Effective health policy creation is essential for improving community health, reducing health disparities, and achieving health equity. In 1965, The Delta Health Center was estab - lished in the community of Mound Bayou, Mississippi. Within a year, 10 local community associations were created and the North Bolivar County Health Council formed. In addi - tion to the provision of medical, dental, and nursing care services, other services, such as environmental, nutritional, transportation, educational, and financial, were offered. The purpose of these services was to change social determinants of health by\ assisting the community to organize, participate in, engage in, and act on their health-related needs (Brennan Ramirez et al., 2008). fri80977_02_c02.indd 69 8/30/13 12:47 PM CHAPTER 2 Section 2.5 The Community and Health Disparities Another example of an innovative policy initiative for reducing health disparities comes from the state of Washington (Smedley et al., 2008). In 2006, based on the recommenda- tions of the Joint Select Committee on Health Disparities, the legislatu\ re approved four bills that addressed the health needs of communities of color. These bills included the fol- lowing provisions: • addition of a health official from a federally recognized tribe to the State Board of Health (SB 6196) • biennial surveys on the diversity of licensed health professionals (SB 6193) • development of a multicultural health awareness and education program (SB 6194) • the establishment of a Governor ’s Interagency Coordinating Council on Health Disparities (SB 6197), which is required to create an action plan for eliminating health disparities in Washington.

California’s Health Care Language Assistance Act (SB 853) (California Pan-Ethnic Health Network, 2013) is yet another example of a policy to reduce health disparities. The act is based on the premise that culture shapes beliefs, behaviors, and expectations regarding health and health care practices; therefore, health care professionals should deliver ser - vices in a culturally competent manner. SB 853 went into full effect on January 1, 2009, and requires health plans to provide linguistically appropriate services. Further, the act requires the California Department of Managed Health Care to establish standards for interpreter services; translation of materials; and the collection of race, eth\ nicity, and lan - guage data.

Still another example of a policy to reduce health disparities reflects the view that every - one, including the most vulnerable populations, should have equal access\ to health care.

Massachusetts’s Chapter 58 of the Acts of 2006 aims to ensure that all state residents have health insurance options that provide “minimal creditable coverage.” The law also con - tains several provisions that address health disparities in health care: the subsidization of health premiums for residents whose incomes fall below 300% of the federal poverty level and the promotion of the diversity and cultural and linguistic competence of healt\ h care professionals (Smedley et al., 2008).

A final example of a policy initiated to counter health disparities is th\ e California Cam - paign to Eliminate Racial and Ethnic Disparities in Health (Prevention Institute, 2003). Established in April 2001 to address health disparities that residents of California were experiencing, this statewide campaign was created through the collaboration between the American Public Health Association and the California Health and Human Services Agency. Representatives from public health, health care, public policy, and related profes- sions serve as the leaders of this coalition.

The campaign identified three approaches to addressing disparities through prevention, intervention, and action. This multifaceted approach reflected the need to address a wide range of social and economic factors that impact the health of Californi\ a’s increasingly diverse communities. The first approach was to understand the causes (called roots and pathways) of health disparities, the second to determine needed actions, and th\ e third to implement activities to reduce disparities. fri80977_02_c02.indd 70 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health The first strategic approach (understanding the roots and pathways to disparities) required an investigation into the key causes of undesirable health conditions in\ order to model pathways of how such outcomes develop and worsen. By identifying these p\ athways, crucial preventive actions could be determined. The California Campaign identified\ nine Priority Medical Issues that are significant causes of morbidity and mortality among non- White people. These issues are linked to objectives of Healthy People 2010.

Based on the campaign’s pathway findings, two goals emerged regarding needed actions. The first was to prevent the development of illness and injury by fostering healthy behaviors, healthy community environments, and institutional support of good health outcomes. The second goal was to reduce the severity of illness and injury by providing high-quality medical care to all. The campaign suggested that strengthen- ing community environments and improving access and quality of health care were necessary and mutually supportive aspects of the strategy to reduce health disparities.

High-quality, accessible health care contributes to improving community environments.

In addition, positive behaviors and environments improve the success of treatment and disease management.

In 2010, approximately 60% of Californians were non-White; according to demographic projections the percentage will increase to about 75% by 2050 (Policy Link, 2012). As racial and ethnic subpopulations form ever-increasing percentages of California’s total popula - tion, the issue of health and other disparities is likely to become more and more significant for the state. Policy initiatives such as the California Campaign will b\ ecome increasingly relevant to the United States as a whole. The California Campaign is an e\ xcellent model for the entire country, which is becoming increasingly diverse as we approach the middle of the century. 2.6 Assessment Tools Used in Community Health Chapter 1 identified the core functions of public health: assessment, policy development, and assurance (Institute of Medicine, 1988). The IOM notes that assess\ ment includes “all the activities involved in the concept of community diagnosis, such as s\ urveillance, iden - tifying needs, analyzing the causes of problems, collecting and interpreting data, case- finding, monitoring and forecasting trends, research, and evaluation of outcomes” (IOM, 1988, p. 44). Assessment, which aids in making good programmatic decisions, needs to occur before public health departments can undertake the stage of policy developmen\ t.

The IOM states that policy development “is the process by which society makes decisions about problems, chooses goals and the proper means to reach them, handles conflicting views about what should be done, and allocates resources” (IOM, 1988, p. 44). The assur - ance function of public health means that legislative mandates for publi\ c activities are carried out and that desired levels of public services are maintained. This function also involves regulation of services and maintaining accountability. The determination of how well the activities associated with the assurances have been implemented links back to assessment. The next sections will describe methods for describing commu\ nity health and will then cover planning models for assessing and improving community health. fri80977_02_c02.indd 71 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health Geographic Information Systems and Social Area Analysis The two methodologies for describing community health are social area analysis and geographic information systems (GIS). Social area analysis, a methodology developed by Eshref Shevky and associates, helps to identify subsets of the community tha\ t are at high risk for adverse health outcomes. GIS provides a graphical display of health condi - tions and high-risk populations within a community. Several examples of this will be examined later in the chapter.

The method of social area analysis refers to “a set of integrated procedures designed to study characteristics of groups or subpopulations of people who live in defined geo - graphic areas” (Struening, 1974, p. 507). The process involves the use of census and other types of population-based data for classifying small areas and communities into units that have a similar socioeconomic status (Scott-Samuel, 1977). A social area is an urbanized region containing people who have a degree of uniformity: for example, in ethnic/racial background, socioeconomic standards, and lifestyle (Answers.com, 2004).

Shevky and Marilyn Williams (1949) and Shevky and Wen- dell Bell (1955) applied the method of social area analysis for describing urban ecology.

Shevky and his associates cre- ated a system for characteriz - ing social differences in census tract populations. Their meth - odologies first used 1940 census tract data from Los Angeles and subsequently 1940 census tract data from the San Francisco Bay region. (Census tracts refer to small subdivisions of a county and usually have about 2,500 to 8,000 residents.) From census tract data and other measures, Shevky and associates framed the constructs of social rank, segregation, and urbanization (Van Arsdol, Camilleri, & Schmid, 1958). For example, the social rank index was composed of measures of occupation and education.

People who were ranked higher in social status held occupations that were more presti - gious (e.g., the learned professions) than other occupations and also had higher levels of education. The urbanization index consisted of levels of fertility, number of women in the labor force, and number of single-family dwelling units. The segregation index applied measures of spatial isolation to ethnic groups to define segregation.

One of the original uses of social area analysis was for research on variations in voting behavior as a function of the social characteristics of city–county a\ reas (Kaufman & Greer, Macduff Everton/Science Faction/SuperStock Social area analysis describes human ecology within set social areas, or regions, that are socioeconomically similar. The information collected using this method helps to pinpoint groups of people in need of assistance. fri80977_02_c02.indd 72 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health 1960). Other applications have included identification of services need\ ed by pregnant women (such as high-risk women who live in disadvantaged social conditi\ ons) and plan- ning services for the elderly (Struening, 1974). Possible current applications of social area analysis might be identification of urban food deserts, as well as the locations of oppor - tunities for physical activity. Food deserts are urban geographic areas with few or no gro- cery stores that sell affordable fresh fruits, vegetables, and other nutritious foods.

A geographic information system (GIS) is defined as an arrangement that \ “integrates hardware, software, and data for capturing, managing, analyzing, and displaying all forms of geographically referenced information” (ESRI, n.d.). A GIS can produce a local map that shows the features of community health in a particular neighborhood. For exam - ple, a map could display community segments that are high-risk zones for specific health problems.

Consider the case of teenage pregnancy; GIS-derived infor - mation could be employed to tar - get areas of the community that have high rates of teenage preg - nancy. Interventions addressed to these targeted areas might introduce new social and health care services for reducing teen- age pregnancy and improving pregnancy outcomes. Another application of GIS might be to highlight sections of the commu- nity that have unsafe housing and other environmental haz - ards. For example, houses con- structed before lead was banned from paints could be identified on a map developed from a GIS.

(Refer to Figure 2.5.) iStockphoto/Thinkstock GIS analysis describes human ecology using information tied to specific geographical areas. The information collected using this method helps to pinpoint areas in need of assistance. fri80977_02_c02.indd 73 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health Figure 2.5: Lead poisoning case rate by county, California, 2006 Legend (%) <0.1 0.1–30.8 30.9–49.5 49.6–65.3 65.4–100 Source: Center for Disease Control and Prevention, California Data, Statisti\ cs and Surveillance. Available at www.cdc.gov/nceh/lead/data/ state/cadata.htm Based on information collected in California counties, it is possible to see where high levels of blood lead poisoning cases have been reported, allowing public health officials and policymakers to focus their efforts on those areas.

An extension of the GIS approach incorporates data mining techniques with spatial rela- tionships. Data mining is an innovative analytic procedure that adds to public health knowledge by uncovering new information that is contained in large, existing data sets.

An example is the use of data mining of large health, geographic, and sociodemographic databases to identify areas of a city that are most affected by poverty and its associated adverse health outcomes. fri80977_02_c02.indd 74 9/18/13 2:27 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health The term data mining refers to the distillation of new, previously undiscovered informa- tion from data sets (Spielman & Thill, 2008). When applied to geographic areas, data min - ing can produce a more sophisticated and advanced understanding of human ecology. An example of the use of data mining is the creation of self-organizing maps (SOMs), which result from combining a GIS with data mining. A SOM aids in understanding complex data sets that contain a large number of descriptors of a geographic area. Often, these complex data sets contain many variables and are difficult to interpret. SOMs group simi - lar types of data by using color coding in order to show their spatial relationships, which are easier to understand than the raw data. An application of a SOM was the classification of a large dataset containing 79 attributes used to describe census tracts in Ne\ w York, a highly diverse city. Experts used the SOM to show the spatial relationships among the social characteristics (e.g., economic levels) of census tracts in the city. The map indicated portions of New York where the most affluent people resided and the census tracts where more than half of the population lived in poverty (Spielman & Thill, 2008)\ .

Planning Models Used in Community Health Related to the themes of the core functions of public health, particularly assessment, are planning models that facilitate assessment by describing the health of a\ community and that provide a framework for improving health. Three examples of planning models are the Multilevel Approach to Community Health (MATCH) model developed in the 1980s; the Planned Approach to Community Health (PATCH) model, also created during the 1980s; and the Mobilizing for Action Through Planning and Partnerships (MAPP) model from the late 1990s.

Multilevel Approach to Community Health (MATCH) The MATCH planning model aids in planning for interventions designed to improve community health. Simons-Morton, McLeroy, & Wendel (2012, p. 335) state that “[a]n intervention is a set of actions taken to accomplish program goals and objectives.” An example of a community intervention might be a targeted health education program to reduce teenage pregnancy rates.

The MATCH model sets forth practical steps that can be used in program planning.

Simons-Morton et al. (2012, p. 336) write that “MATCH is a socio-ecologic planning framework that can guide the creation and implementation of effective health education and health promotion programs when based on sound assessment and conducted within the context of good planning.” MATCH intervention planning is based on five phases:

goals selection, intervention planning, program development, implementation planning, and evaluation. Each of the first three phases includes four steps. For example, one of the four steps of the goals selection phase is “identifying the targets of intervention at the community level,” and among the steps of the program development phase is “creat - ing program units or components that include paying attention to the target population” (Sharma & Romas, 2012, p. 51). The implementation phase has two steps,\ one of which is adopting an intervention and showing that the intervention is effective. The fifth and final phase is evaluation, which involves three levels of evaluation. One of these levels is called outcome evaluation—making an evaluation of an intervention with respect to attainment of fri80977_02_c02.indd 75 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health improved health outcomes, achievement of cost reductions, and generation of new impli- cations for health policies.

Planned Approach to Community Health (PATCH) The Centers for Disease Control and Prevention (CDC) created the PATCH model dur - ing the mid-1980s by working collaboratively with community groups as well as with state and local health departments. The CDC describes the model as “a process that many communities use to plan, conduct, and evaluate health promotion and disease preven - tion programs. . . .The goal of PATCH is to increase the capacity of communities to plan, implement, and evaluate comprehensive, community-based health promotion programs targeted toward priority health problems” (USDHHS, n.d.) A key aspect of PATCH is the involvement of a broad cross-section of the community (a community coalition) in the process of addressing a community health problem. As is true of MATCH, the PATCH model incorporates five phases: 1. Mobilizing the community—the community to be targeted is defined and par- ticipants from the community are selected. In this phase a community steering committee is activated in order to guide activities. 2. Collecting and organizing data—working groups from the community gather and process data on health and other local characteristics. 3. Choosing health priorities—members of the community establish priorit\ ies for programs and interventions that they would like to implement. 4. Developing a comprehensive intervention plan—the community group formu - lates a detailed and comprehensive intervention plan with a timetable and set of tasks. 5. Evaluating PATCH—evaluation is an ongoing process that includes monitoring progress and determining the success of interventions.

The model has been applied successfully to diverse populations and commu\ nities for health issues that range from cardiovascular disease to HIV to unintentional injuries. Mobilizing for Action Through Planning and Partnerships (MAPP) The National Association of County and City Health Officers (NACCHO) and the CDC collaborated in developing MAPP (see Figure 2.6 and Table 2.5), which is a tool that “helps communities improve health and quality of life through community-wide strategic plan - ning. Using MAPP, communities seek to achieve optimal health by identifying and form - ing effective partnerships for strategic action” (National Association of County and City Health Officers [NACCHO], 2013). fri80977_02_c02.indd 76 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health Figure 2.6: The Mobilizing for Action Through Planning and Partnerships (MAPP) model Visioning Four MAPP Assessments Identify Strategic Issues Formulate Goals and Strategies Organize for Success Evaluate Partnership Development Plan Implement Action Com m unity Them es & Strengths Assessm ent Forces of Change Assessm ent Status A ssessm ent C om m unity H ealth Local Public Health System Assessm ent Source: Adapted from http://www.naccho.org/topics/infrastructure/mapp/upload/MAPP_Handbook_fnl.pdf The Four Assessments of the MAPP model, and the processes for forming strategic action. fri80977_02_c02.indd 77 8/30/13 12:47 PM CHAPTER 2 Section 2.6 Assessment Tools Used in Community Health Table 2.5: Description of the phases of MAPP PhaseActivity Organize for success/ partnership development Public and private agencies designated as leaders within the community begin by organizing themselves and preparing to implement MAPP.

Visioning A shared vision and common values provide a framework for pursuing long- range community goals. During this phase, the community answers questions such as “What would we like our community to look like in 10 years?” Conduct four MAPP assessments • The Community Themes in Strengths Assessment provides a deep understanding of the issues residents feel are important.

•The Local Public Health System Assessment is a comprehensive assessment that includes all of the organizations and entities that contributed to the public’s health.

•The Community Health Status Assessment identifies priority community health and quality-of-life issues.

•The Forces of Change Assessment focuses on the identification of forces such as legislation, technology, and the other impending changes that affect the context in which the community and its public health system operates.

Identify strategic issues During this phase, participants identify linkages between the MAPP assessments to determine the most critical issues that must be addressed for the community to achieve its vision.

Formulate goals and strategies Goals and objectives address strategic issues.

Action cycle During this phase, participants plan for action, implement, and evaluate. Source: Data from National Association of County and City Health Officers. (\ n.d.). Mobilizing for action through planning and partnerships: Achieving healthier communities through MAPP. A user’s handbook. Retrieved from http://www.naccho.org/topics/ infrastructure/mapp/upload/MAPP_Handbook_fnl.pdf The MAPP model has been effective for addressing a range of community health issues such as improvement in overall health, increasing the quality of public health depart - ments, and addressing the health needs of specific subgroups in the community. One example of the latter is Multnomah County’s (located in Oregon) use of MAPP to pro - mote the health and well-being of residents with disabilities (The Community Tool Box, 2013). To develop a plan for action for improved services for persons with disabilities, the county progressed through the phases of MAPP. The Multnomah County Health Depart - ment formed a partnership with numerous community organizations and through this partnership created a vision and mission for improving services for persons with disabili - ties, specified challenges to implementing this vision, and identified p\ ossible strategies to surmount these challenges. In addition, the process was informed by assessments that included a survey of persons with disabilities who were clients of primary care clinics operated by the health department. This example demonstrates the utility of the MAPP planning tool for improvement of community health. fri80977_02_c02.indd 78 8/30/13 12:47 PM CHAPTER 2 Summary Summary Demography and human ecology are fields that aid in understanding community health by describing the structure of human populations and the environmental qualities of their locations. In order to formulate a clear picture of community and public health, one needs to view the connections between human populations and the environment. The environ- ment may be categorized according to physical, biological, and social dimensions. The ecosystem involves interconnections among social, biological, lifestyle, and environmen- tal factors. Human beings are dependent upon a healthy ecosystem for their survival.

However, some human activities such as destruction of the natural environment threaten to harm the ecosystem by causing pollution, climate change, and loss of \ biodiversity. In this chapter, we highlighted environmental and lifestyle factors as major influences in human health, according to the health field concept.

Place, which denotes the geographic location of where we live, is an important determi - nant of the health of the community. Examples of place effects described in this chapter were the “Glasgow effect,” Eight Americas, and health outcomes in Richmond, California.

Migration, fertility rates, birth rates, and death rates are demographic trends that impact health in the United States and elsewhere in the world. Population growth affects human ecology and can contribute to degradation of the environment through urbanization and depletion of scarce resources. A challenge for community health stakeholders is to cre - ate a sustainable environment in the face of continuing population expansion. Aging of the population also will create challenges, related primarily to meeting the needs of the elderly.

As a result of social and income inequalities, some of this country’s popul\ ation subgroups (for example, minority populations and non-White people) experience health disparities.

The elimination of racial and ethnic health disparities in communities t\ hat exhibit poor health outcomes reflects public health’s commitment to social justice. The elimination\ of such disparities will necessitate collaboration among public health professionals, commu - nity services groups, government officials, schools, businesses, and health care organiza - tions. This multilevel approach is needed to improve the social and economic conditions of a community, and to ensure that community members have access to high-quality and culturally competent health care.

To conclude the chapter, assessment is identified as one of the three essential functions of public health. Two examples of assessment tools are social area analysis and geographic information systems. Other tools used in community health assessment and\ program planning are the MATCH, PATCH, and MAPP planning models. fri80977_02_c02.indd 79 8/30/13 12:47 PM CHAPTER 2 Key Terms Study Questions and Exercises 1. Define the term human ecology and discuss its relationship with community health. 2. Provide a definition of the health field concept. How did the health field concept differ from earlier explanatory frameworks for human health? What role did the health field concept play in the development of health care policy? 3. What is meant by environmental justice? Give examples of two types of environ- mental injustices and suggest programs and policies for their alleviation. 4. In a few sentences, and using your own words, describe the significance of place for community health. What are three examples of the effects of place on health? 5. How might a geographic information system contribute to the improvement of community health? 6. State how each of the following examples demonstrates place effects:

a. Glasgow, Scotland b. Richmond, California c. The Eight Americas Study 7. Analyze the impact of changing population trends upon human ecology and community health. 8. Define the term population dynamics, providing examples of its relationship with community health. 9. Describe how the Earth’s carrying capacity could limit population growth. Refer to Dr. Ehrlich’s statement in Spotlight: A Prologue to The Population Bomb by Dr.

Paul R. Ehrlich. 10. State three factors associated with health disparities and health inequities and \ suggest policy initiatives to address them. 11. Describe at least two assessment tools for assessing the health of the c\ ommunity. Key Terms biological environment Pathogens or reservoirs for infectious diseases within an environment. carrying capacity The maximum popula- tion an area can support without caus- ing the environment to deteriorate to the extent that human life is jeopardized. census tracts A small subdivisions of a county, typically between 2,500 and 8,000 people. collective explanations The traditions, norms, and values found in a particular community. compositional explanations The char - acteristics of inhabitants of a given geo- graphical area. contextual explanations Opportunity structures associated with the physical and social characteristics of a community. crude birth rates The number of live births during a specified period of time per resident population. crude death rates The number of deaths reported in a population during a defined period of time. fri80977_02_c02.indd 80 8/30/13 12:47 PM CHAPTER 2 Key Terms data mining The distillation of new, previ- ously undiscovered information from data sets, typically used to advance the under - standing of human ecology. demographic transition Changes in birth and death rates within a population. demography The statistical study of human populations, which generally include size, density, distribution, births and deaths. ecology A branch of science that focuses on the relationship between the environ- ment and living organisms. ecosystem The interconnections among social, biological, lifestyle, environmental, and related factors including the position of human life within it. environment Those factors (physical, chemical, and biotic) that act upon living organisms or communities. environmental justice A social movement on behalf of communities affected dis- proportionately by disparities caused by exposure to environmental risks. environmental risk transition Changes in the risk of exposure to air pollution as a result of economic development. fertility The ability to produce live children. food deserts Urban areas with few or no grocery stores that sell affordable fresh fruits, vegetables, and other nutritious food items. geographic information system (GIS) A system that utilizes computer technology to map and analyze the features of a com- munity, including health status and risk for specific health problems. Glasgow effect A term used to describe the poor health status of residents of Glasgow, Scotland, which have higher lev- els of adult morbidity and mortality than any other city in the United Kingdom. health field concept Four general fac- tors that act upon human health: biology, lifestyle, environment, and the health care system. health care system An organized struc- ture of elements that meet the health needs of a population. This system includes health care professionals as well as insur - ance providers, government assistance, and other health services. human ecology A branch of ecology that focuses on the relationship between humans and their environment (often used in terms of economics, social, political environment as well as the physical and biological environments). lifestyle A combination of decisions, actions, and behavioral elements that influ - ence individual health. migration The movement of people from one country or geographic area to another. physical environment Consists of air, water, soil, noise pollution, geography, and physical features of a neighborhood or community. population dynamics A construct that helps to explain the evolving character - istics of populations over time, including their growth and contraction and their demographic composition. rate of natural increase (RNI) The differ - ence between a population’s crude birth rate and crude death rate. fri80977_02_c02.indd 81 9/16/13 4:08 PM CHAPTER 2 Key Terms segregation index Measures of spa- tial isolation to ethnic groups to define segregation. social area analysis A systematic study of the characteristics of a population or group within the a defined geographic region. social rank index A measure of occupa- tions and education levels of a group of people. urbanization index An index, which con- sists of levels of fertility, number of women in the labor force, and number of single- family dwelling units. fri80977_02_c02.indd 82 9/16/13 4:08 PM CHAPTER 2