Abstract

1. Introduction

Neighborhood crime can confer deleterious health effects that lead to or exacerbate chronic conditions, such as obesity and hypertension (Fish et al., 2010; Tamayo et al., 2016). People living in communities with high levels of crime experience frequent and prolonged activation of stress response pathways (Burdette and Hill, 2008; McEwen, 1998). These pathways are postulated to impact health directly through metabolic and autonomic dysregulation (Burdette and Hill, 2008; McEwen, 1998), or indirectly through adverse health behaviors (e.g., stress eating) (Billimek and Sorkin, 2012; Foster and Giles-Corti, 2008; Russell et al., 2016). However, less is known about the relationship between neighborhood crime and access to health-enabling resources, despite growing consensus in clinical practice that these resources are integral to addressing chronic disease (Coleman et al., 2009; Stellefson et al., 2013).

Andersen's enduring Behavioral Model defines access in two ways (Andersen, 1995): potential access indicates the availability of resources in a neighborhood, and realized access indicates the actual use of those resources (Andersen, 1995). In a recent study, we found that people often bypassed nearby resources for more distant resources, and bypassing was associated with higher BMI; poor safety was identified as an important reason for bypassing (Tung et al., 2016). Zenk and colleagues, in prior qualitative work, also identified crime-related safety as a barrier to accessing healthy and nutritious foods (Zenk et al., 2011). However, few quantitative studies have explicitly examined the relationship between neighborhood crime and access to health-enabling resources, such as grocery stores, pharmacies, and fitness centers. None to our knowledge have used a directly-observed census of the built environment to measure access.

We used cross-sectional data from an address-based probability sample, collected on Chicago's South Side, to examine relationships between neighborhood crime and access to health-enabling resources. Based on previously published work (Tung et al., 2016; Zenk et al., 2011), we hypothesized that neighborhood crime is inversely associated with both potential and realized access to health-enabling resources.

2. Methods

3. Results

Table 1 summarizes sociodemographic characteristics of the sample population. Overall, 431 eligible residents were invited to participate and 267 (62%) completed the survey. The majority of residents were female (63%) and identified as non-Hispanic black (69%; Table 1).

Many participants had at least one small grocer (84%) within 1 mile from home; fewer had at least one large grocer (57%), pharmacy (45%) or fitness resource (57%) within 1 mile. Poor neighborhood safety was associated with low potential access to large grocery stores (AOR = 1.73, 95% CI = 1.04–2.87), pharmacies (AOR = 2.24, 95% CI = 1.33–3.77), and fitness resources (AOR = 1.93, 95% CI = 1.15–3.24), but not small grocery stores (Table 2).

Among residents who had resources within 1 mile from home, many bypassed grocers (50%) and pharmacies (58%) to use resources farther away; very few used any fitness resources (11%). A prior experience of theft or property crime was associated with higher adjusted odds of bypassing nearby pharmacies (AOR = 3.78, 95% CI = 1.11–12.87; Table 2); an association with bypassing grocery stores (AOR = 1.14, 95% CI = 0.67–1.96) was not significant in final adjusted models (Table 2).

A prior experience of theft or property crime was also associated with 74% higher adjusted odds of obesity (95% CI = 1.02–2.95) and 50% higher adjusted odds of hypertension (95% CI = 0.86–2.60); however, hypertension analyses were not significant in final adjusted models.

4. Discussion

In this high-poverty, urban community with a predominantly racial and ethnic minority population, we found a consistent relationship between neighborhood crime and poor access to health-enabling resources. People reporting poor neighborhood safety were less likely to have large grocers, pharmacies, and fitness resources within 1 mile from home. Even among those who did have resources within 1 mile from home, a prior experience of neighborhood crime was associated with bypassing pharmacies.

These findings provide evidence to suggest that neighborhood crime may impede access to health-enabling resources in two important ways. First, neighborhood crime may reduce the total number of available resources (i.e., potential access), perhaps because health-enabling businesses avoid locating to high-crime neighborhoods. Second, neighborhood crime may impede utilization of available resources (i.e., realized access). In previous qualitative work, an older woman reported bypassing a nearby grocery store due to loitering gang members—her safety concern presented a physical barrier to accessing fresh produce (Tung et al., 2016). This prior work also identified a relationship between bypassing and higher BMI (Tung et al., 2016). Our new quantitative findings build on this prior work to support evidence of a potential pathway between crime, accessing resources and health.

Notably, we found that experiences of neighborhood crime were consistently associated with poor access to pharmacies. In addition to having fewer pharmacies, participants were also more likely to bypass nearby pharmacies if they had been a victim of theft or property crime. No quantitative studies to our knowledge have specifically identified exposure to crime as a risk factor for bypassing nearby pharmacies. Importantly, a previous study from our group identified bypassing as a risk factor for medication underuse (Qato et al., 2017), thus corroborating concerns that neighborhood crime may pose a barrier to medication adherence in vulnerable populations (Billimek and Sorkin, 2012). Taken together, we speculate that health prevention efforts, which have heavily emphasized the quantity of resources in a given community, will also need to address the social barriers that impede access to and utilization of resources that support and sustain a healthy life.

There are several limitations to this study. This is a cross-sectional analysis, limiting causal inference. The survey queried participants about prior experiences of theft or property crime, but did not include other types of crime (e.g., homicide). However, theft or property crime may be the more relevant exposure type when analyzing resources (e.g., pharmacies) where products are directly purchased, if residents are primarily concerned about personal theft. We were underpowered to examine realized access to fitness resources due to low utilization (11%). Additionally, we did not limit respondents to reporting use of large grocers only, potentially biasing our food access result toward the null.

Limitations are balanced by several important strengths. First, we recruited a probability sample, representative of the entire Chicago South Side population. Second, many prior studies have used secondary or proprietary databases of the built environment. Ours used a directly-observed census (Lindau et al., 2016) which has been found to have significantly higher sensitivity for resources in high-poverty settings (Makelarski et al., 2013). Finally, our study examines a high-poverty, urban region quite similar to other urban metropolitan areas with high levels of concentrated poverty and residential segregation by race.

5. Conclusion

Neighborhood crime may be associated with barriers to accessing health-enabling resources in urban communities with high rates of crime. Strategies to mobilize community resources in healthcare settings should address the impact of safety on both potential and realized access among vulnerable populations.

Acknowledgements

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