Can neighborhoods hurt our health?

Doctoral student Caitlin Eicher wants to understand how people’s perceptions of their local surroundings shape what they eat, how much they exercise, and other health behaviors.

[ Spring/Summer 2011 ]

A single mother living in public housing may want to feed her children healthy food, but if the nearest affordable grocery store is a crowded bus ride or expensive taxi trip away, that goal may feel unattainable. At the end of a long day, she may turn instead to the corner store, with its easy-to-prepare packaged goods and candy by the register, or to one of the many fast-food restaurants on the block. And if she doesn’t feel safe on her street, is it any wonder that her children don’t get much outdoor physical activity?

“Studying neighborhoods brings public health to a level that everyone can relate to,” says Caitlin Eicher, a doctoral student in Harvard School of Public Health’s Department of Society, Human Development, and Health (SHDH). “Everyone can offer an opinion based on their own experiences about how neighborhoods affect health. But by studying this academically, I am developing the tools to objectively answer questions that have always been in the back of my head.”

Some Neighborhoods Appear to Promote Obesity

Eicher is exploring one of the most urgent issues in public health today. Over the past 30 years, waistlines have expanded dramatically across the United States and around the world. In Massachusetts, nearly 60 percent of adults and one in three children are overweight or obese. And the burdens of all that excess girth—chronic diseases such as type 2 diabetes and heart disease, and the high medical expenses and lost productivity that come with them—are not shared equally across the population.

Massachusetts Department of Public Health statistics reveal disparities in obesity rates that track differences in income, level of education, and race. Some blame individual choices for these disparities, but SHDH researchers believe that people’s environments often set them up for failure. “Individual interventions to prevent obesity have not worked well,” says Ichiro Kawachi, professor of social epidemiology and SHDH department chair. “At the same time, we see enormous differences in obesity rates between neighborhoods. In Boston alone, there’s a twofold difference between residents in low-income and higher-income neighborhoods. Even when we control for factors such as income, race, and education levels, there appears to be something about certain neighborhoods that promotes obesity.”

Building a Complete Picture

Prevention vs. Prescription

Before entering HSPH as a master’s student five years ago, Caitlin Eicher’s path seemed to point towards clinical medicine. She earned a degree in psychology from Brown University and was considering medical school while working as a research assistant on end-stage clinical trials at Memorial Sloan-Kettering Cancer Center. But the job’s emphasis on pharmacology rather than prevention frustrated her. “The patients I worked with didn’t have a lot of options. Prevention was not spoken of much at this stage of the game,” she says. “It disturbed me how little I would be able to make a difference.”

She was able to return to HSPH for doctoral study thanks to the Julie E. Henry Scholarship for Maternal and Child Health. She was close to choosing another school for financial reasons when the scholarship came in. “It made all the difference in the world,” she says. “Staying here allowed me to hit the ground running.” Building on her master’s studies, she was able to take her doctoral exam early and will ultimately be able to graduate early.

“Caitlin exemplifies the sort of public health student that we like to turn out,” says Kawachi. “Given her independence and the creative way that she approaches problems, I see her as a potential leader in understanding neighborhood-level influences on obesity.”

Eicher is focused on teasing out these factors. For her dissertation, she is exploring whether living close to a supermarket leads to more fruit and vegetable consumption, and how perceptions about the safety and cohesion of a neighborhood can affect residents’ likelihood of using services such as public parks, which can help promote physical activity. She is analyzing data from a cancer-risk survey of 828 people who lived in 20 public and private low-income housing sites in Cambridge, Somerville, and Chelsea, Massachusetts, between 2007 and 2009—a study she was involved in as a master’s student working with SHDH Professor Glorian Sorensen at Dana-Farber’s Center for Community-Based Research. She is also pulling in census data that details the social and economic characteristics of the neighborhoods and mapping distances to an array of food retail outlets and other neighborhood features to build a complete picture of residents’ health environments.

According to the U.S. Department of Agriculture, 11.5 million people in the United States live in low-income areas more than one mile from a supermarket.

Pricing, Placement Matter

Geography matters, but clearly it is just one of a complex array of factors at work. Some of the housing sites Eicher is studying are actually near supermarkets. However, when the market is an upscale food retailer, high prices and unfamiliar products can keep many who live in the neighborhood away.

Research has shown that factors such as shelf placement influence people’s food choices. With cheap and tempting items lining supermarket and convenience store shelves at eye level, even lowering the cost of produce cannot guarantee that people buy more of it.

Encouraging healthy eating habits is complicated, says Kawachi, Eicher’s adviser. “It’s not just a matter of either changing preferences or improving access.” Efforts to establish public-private partnerships to bring more grocery stores into underserved neighborhoods and incentivize corner stores to provide healthier food are underway in Philadelphia, New York, and in Massachusetts, which launched a new campaign in February led by the state’s public health department.

Eicher is part of a growing group of researchers drawn to understand what drives people’s health behavior and to tackle the larger forces that lead to obesity in some neighborhoods, from food policies and school lunch programs to poverty and mental health issues.

Amy Roeder is assistant editor of the Review.