GeoJournal (2009) 74:107–113 DOI 10.1007/s10708-009-9263-z

Locating diversity: race, nativity and place in health disparities research Sara McLafferty Æ Ranjana Chakrabarti

Published online: 7 February 2009 Ó Springer Science+Business Media B.V. 2009

Abstract Nancy Krieger has been one of the leading voices in documenting how social ‘axes of difference’, including race, ethnicity and class make people vulnerable to poor health and limit their access to effective health care. We discuss the importance of ‘locating’ diversity in health inequalities research. This includes critically dissecting racial and ethnic axes into more nuanced social categories that incorporate differences based on immigration and other factors. It also involves considering how diverse population groups vary in their perception and use of space for healthrelated activities and exposures. Examples relating to immigrant populations’ health and access to health care are discussed. Keywords Immigrant health
Place
Health inequalities A strong and consistent theme in Nancy Krieger’s research is the deep interconnections between social divisions and health inequalities in the United States. Krieger has been one of the leading voices in documenting how social ‘axes of difference’, including race, ethnicity and class make people vulnerable to poor health and limit their access to effective health care. These axes of difference are not fixed, however: S. McLafferty (&)
R. Chakrabarti Department of Geography, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA e-mail: [email protected]

they are continually shaped and re-shaped through place-based social interactions and broader societal changes. In this paper, we discuss the importance of ‘locating’ diversity in health inequalities research—of first critically dissecting racial and ethnic axes into more nuanced social categories and in turn probing the intersections between social and spatial inequalities to consider how diverse population groups vary in their perception and use of space for health-related activities and exposures. After briefly reviewing Krieger’s important contributions, we describe current and future directions for geographic research on health inequalities that include: broadening our understandings of diversity to consider differences based on immigration and place, and better understanding how everyday experiences, activities and place environments affect health and well-being for diverse populations. Methodological issues related to measuring health disparities and analyzing the associations between place context and health are also discussed. During the past two decades, Krieger and colleagues have investigated the patterning of health inequalities by race, ethnicity and class in the U.S. Their research provides convincing and compelling evidence of the wide inequalities that exist in health outcomes and access to health care, and it shows pronounced racial and ethnic disparities for health outcomes ranging from breast cancer (Krieger et al. 1997; Krieger 2002) to BMI (Bates et al. 2008) to premature mortality (Chen et al. 2006). Beyond demonstrating health disparities, Krieger’s research

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strongly advocates critical understandings of ‘race’ in public health, viewing race as a social, rather than biological construct (Krieger 2005). Impacts of racism and unequal race relations on racial disparities in health are documented in studies of health and healthrelated behaviors (Chae et al. 2008; Krieger 2003). Krieger’s research is also significant in drawing attention to class disparities in health and to the intersections between class, race and ethnicity. Because health data in the U.S. typically do not include individual-level indicators of class such as income or education, Krieger has pioneered the use of area-based socioeconomic measures (ABSMs) as surrogates for individual socioeconomic status. As early as 1990, Krieger demonstrated how the geocoding of health data to census tracts made it possible to link tract-level socioeconomic variables from the Census to health outcome data (Krieger 1990). These linked data reveal the complex interactions between class and race/ethnicity. For example, a recent study of changes over time in breast cancer incidence rates by census tract shows that the socioeconomic gradient in breast cancer is small and stable for nonHispanic whites and blacks but widening over time for Hispanic and Asian populations (Krieger et al. 2006). Geocoded health data also provide a platform for investigating questions like: do differences in socioeconomic status account for racial and ethnic health disparities (Subramanian et al. 2005)? Although there are important geographic issues in defining and modeling ABSMs, our commentary emphasizes broader questions related to the nature and definition of racial and ethnic diversity in health disparities research in the United States. Clearly population diversity based on race, ethnicity and class is a central theme running through Krieger’s research, and it is a theme that has critical importance in understanding health disparities. Much of the literature on health disparities relies on traditional racial and ethnic categories such as ‘Black’, ‘Asian’ and ‘Hispanic’. We argue that in the U.S. these categories are losing meaning and becoming increasingly complex, due to wider social, demographic and geographic transitions. Our comments emphasize in particular the role of immigration in re-shaping these social axes of difference. This is a point raised in one of Krieger’s recent articles in which the authors call for: ‘‘considering the joint impact of socioeconomic position, race/ethnicity and immigration status on population

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health.’’ Drawing on our own research on reproductive health and selected research literature, we elaborate on this point and discuss implications for the definition and construction of contextual measures in health disparities research.

Diversity in diversity In the vast majority of research on health disparities in the U.S., population diversity is defined according to traditional racial and ethnic categories. This reflects not only data availability:—these categories are used in the Census and in most public health data sets—but also long-held beliefs and conceptions of social differentiation in this country. However, these categories are being eroded by socio-demographic processes such as immigration and intermarriage and by changing conceptions of race and ethnicity. Documented immigration to the U.S. has reached its highest levels since the 1920s, and the undocumented population remains large. Immigrants come from diverse countries and cultures; they migrate for diverse reasons; they differ in resources and opportunities; and they have varying geographical patterns of settlement and activity. Acknowledging the scope and diversity of immigrant populations, the health disparities literature has begun to investigate finergrained ethnic categories based on country of origin and nativity (e.g. Acevedo-Garcia et al. 2005; Fuentes-Afflick and Hessol 1997; Singh and Siahpush 2002; Zsembik and Fennell 2005). These (and many other) studies document wide disparities in health outcomes such as infant mortality, low birthweight and premature mortality by country of origin, especially within the Hispanic and Asian populations. Less well understood are the implications of immigration/nativity for racial health disparities. Socially-constructed racial categories haphazardly group people from diverse places and backgrounds, people who have diverse experiences that shape their health and well-being (Bhopal and Donaldson 1998; Wright et al. 2003). In many communities and places, racial groups are strongly divided according to nativity. In New York City, for example, half of the ‘black’ mothers who gave birth in 2000 were born outside the US (NYCDOH 2000). Their places of birth covered six continents and over 100 countries. ‘White’ mothers were similarly diverse in terms of

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the foreign-born percentage and range/number of countries represented. Within these racially-defined groups, health outcomes vary greatly based on nativity and country of origin (Fang et al. 1999; Howard et al. 2006). In New York City in 2000, the low birth weight percentage for singleton infants born to foreign-born black mothers (7.9%) was substantially less than that for U.S.-born black women (10.5%). Grouped by country of origin, the LBW percentage for infants born to black immigrant mothers ranged from 11.3% (Barbados, n = 298) to 4.4% (Dominican Republic, n = 2824). Such ‘diversity within diversity’ raises key questions about the meaning of racial disparities. The experience of immigration has complex associations with health outcomes. Research shows that although immigrants are often healthier than their counterparts in the country of origin (the ‘healthy immigrant’ concept), they face a host of important health concerns tied to their experiences in the home and host countries. Thus, immigrant health has a transnational dimension that extends across multiple geographic scales. Length of residence is critically important. At a population level, for recent immigrants, health outcomes tend to correspond to those observed in the home country among similar populations; however as length of residency increases health outcomes shift towards those observed in the US (e.g. Lara et al. 2005). These trends are likely vary depending on the environmental characteristics and population composition of the areas in which immigrants reside, indicating that place and location underpin immigrant health disparities as they do for the U.S.-born population as well (Park et al. 2008). Unfortunately many public health data bases lack information on length of residence and residential histories.

Locating health disparities Expanding our understandings of health disparities in the context of increased population diversity requires a detailed consideration of how place and context relate to health outcomes. Diversity based on nativity and immigration confounds the associations between place and health thus complicating what we know and don’t know about health disparities. Settlement patterns differ among immigrant groups and between the

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immigrant and U.S.-born populations. As a consequence, the implications of immigration for observed health disparities vary from place to place depending on the mix of immigrants in the local population. Impacts are especially significant in the large immigrant gateway cities which house a disproportionate share of immigrants, but they are also increasingly important in some suburban and rural communities whose immigrant populations are growing rapidly. ‘Ethnoburbs’ are emerging around major cities (Li 1998), and there is heightened migration to communities in the South, Midwest and Plains states, far from large gateway cities. In this context, understanding health disparities requires modeling strategies like those used in Krieger’s research, that explicitly consider differences in population composition related to immigration. The uneven geographies of immigrant settlement also highlight the need for routine collection of nativity information in public health data sets. Differences in where people live are also important at a more local scale. They affect access to resources and services, healthy and unhealthy environments, and opportunities for social interaction and social capital. Among immigrant groups and other vulnerable populations, varying residential geographies lead to varying levels of spatial access to health and social services, and employment, recreational and educational services (McLafferty and Grady 2005; Truelove 2000; Wolch et al. 2005). Cultural appropriateness of services is also important, and the intersections between geographical and cultural barriers for specific immigrant populations are just beginning to attract research attention (Wang 2007). These studies rely on innovative GIS-based methods which utilize distance or travel-time measures of spatial accessibility, however, they do not take into account differences in geographical mobility linked to car ownership and access. This is an especially important consideration for immigrant and racial/ ethnic minority populations whose access to transportation is constrained (Pucher and Renne 2003). Racial and ethnic segregation in local residential areas also influences health outcomes for racially- and ethnically-defined populations. Researchers hypothesize that for black persons, living in racially segregated neighborhoods adversely affects health through inequalities in local access to high-quality services and opportunities and through psychosocial stresses tied to racial discrimination. Several recent studies

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offer strong empirical support for this hypothesized inverse association between segregation and health (Acevedo-Garcia et al. 2003; Grady 2006); other studies reveal more mixed results (Masi et al. 2007). Although most studies use census tracts for measuring segregation, a recent innovation involves using spatial segregation measures (Grady 2006). Nativity is also key to understanding the association between segregation and health. If the effects of segregation occur through repeated exposure to racially segregated environments resulting from a long history of racial discrimination, then the association should vary between immigrants and U.S.-born. Recent findings based on a study of infant low birthweight in New York City support this. The authors uncovered a strong positive association between segregation and infant low birthweight for US-born black mothers, but no association for their foreign-born counterparts (Grady and McLafferty 2007). For immigrants, the opposite relationship between segregation and health has been postulated: as ethnic density increases, health outcomes are expected to improve due to the availability of culturally-appropriate resources and services and opportunities for social interaction. Some studies, especially for mental health outcomes such as depression and suicide, provide empirical support for this ethnic density hypothesis (Smaje 1995; Neeleman and Wessely 1999); however, these studies limited by the geographical definition of local neighborhood areas. Ethnic and racial residential areas typically have complex geographies that cut across the boundaries of the census areal units used in most studies. A better approach is to construct such ethnic concentration areas from fine-scale area units such as census blocks or to use point data if available. Our ongoing research using such spatially-detailed measures in New York City points to a nonlinear association between ethnic density and health outcomes that varies among immigrant groups. Such nonlinear associations have been noted in other recent research studies of the ethnic density hypothesis (Fagg et al. 2006). Health disparities research can also benefit by considering how racial minorities, immigrants and other vulnerable populations use and perceive space in maintaining health and well-being. The complex time-space geographies of everyday life have not been widely documented for vulnerable groups (but see Kwan 2002), and investigations that document variations in activity patterns using methods such as

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space-time aquariums are sorely needed (Kwan 2004; Cummins 2007). Research by Matthews and colleagues indicates that low-income people have highly complex and geographically dispersed activity spaces (Matthews et al. 2006). On the one hand such activity patterns may result in time-space constraints that limit health care use among vulnerable populations. On the other hand the wide spatial extent of daily travel may create opportunities for using services outside the local neighborhood. The impacts of space–time activity patterns on health care utilization and health-related behaviors, and their role in influencing the poor health outcomes of disadvantaged populations, have not been adequately investigated. Within a particular locale, immigrants and other vulnerable populations use a variety of strategies to support health and well-being (Dyck 1995). For immigrants, these strategies often involve interactions over a range of geographic scales from the local to the global. Ranjana Chakrabarti’s field research on how Bengali immigrant women in New York City gain access to prenatal care highlights the importance of both transnational and local connections and reveals how the use of local spaces is influenced by class and culture (Chakrabarti 2008). Her work reveals that women from different ethnic backgrounds use and form meaning about space differently. In general, pregnant Bangladeshi women made greater use of neighborhood spaces and spaces in ethnic neighborhoods in comparison to pregnant Indian Bengali women. Class, gender, religion and culture influenced how these women from diverse backgrounds, perceived and used space during an important life-cycle phase. Gender roles confined a majority of low-income women from Bangladesh to their neighborhood spaces. Amidst household chores, childcare responsibilities and part-time jobs to supplement family income these women tried to make maximum use of locally available resources. In contrast, the higher socio-economic status of Indian Bengali women and their relatively comfortable everyday schedules or professional jobs enabled them to make greater use of spaces in other parts of the city. Owning a car also made it easier for Indian Bengali women to include spaces beyond their immediate or nearby neighborhoods in their attempts to relax and unwind during pregnancy. For both groups of Bengali women, social interactions at the global scale were important for health and well-being. Regular contact via phone and

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email with friends and family in their home countries provided strong social and emotional support for most women which helped in overcoming the barriers they experienced as immigrants.

Conclusions Breaking down the traditional axes of difference in health disparities research involves considering a host of factors that create diversity within diversity and that complicate racial and ethnic definitions. Like Krieger, we feel that immigration is an important and relatively neglected dimension that demands research attention. A key issue in such investigations is to ‘locate’ diversity—to understand the geographical settings in which people’s daily activities unfold; to monitor how these settings and behaviors change over time in response to changes in socioeconomic resources and constraints and health policies; and to understand in turn how people shape their local environments in their pursuit of better health. Such an agenda demands several types of research strategies. GIS and spatial analysis methods can be used in creative ways to more accurately depict the geographic spaces that are important for health beyond the boundaries of geopolitical units such as census tracts. This is not to question the relevance of tracts. Indeed, we agree with Krieger that tracts are probably the best areal units for which socioeconomic data are routinely collected in the U.S. However, there is great potential for using more spatially explicit measures that encompass nearby areas. Moreover, with the advent of systems like Google Earth and the increasing availability of detailed local geospatial data bases about property characteristics, transportation, services, places of employment and environmental hazards, we can do better in creating contextual variables that are meaningful for health. Given the diversity how people perceive and experience local spaces, investigating the interactions between such contextual variables and individual and/or group characteristics such as nativity, race and class is also critically important. It is also apparent that more attention needs to be paid to the temporal dimension along with the spatial dimension. For immigrants, time is not only relevant with respect to length of residence, but also there may be cohort effects associated with age at immigration. Understanding how people’s residential histories

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impact health disparities is a challenging and important direction for future research investigation and one that can draw upon the rich array of methods for space–time and period-cohort analysis that have been developed in geography and other disciplines. The transnational dimensions of immigrant health call into question traditional analytic approaches that privilege the local neighborhood scale. At a basic level, immigrant health reflects both where a person lives and where s/he comes from. In addition, while the local environment is clearly important for day-today material well-being, transnational social interactions have increased greatly, as illustrated in Chakrabarti’s research. Immigrants who are able to maintain strong ties with the home country may be less affected by local environmental conditions and better able to deal with the challenges such environments present. This supports again the importance of considering interactions between individual characteristics and contextual measures and it highlights the need for multiscalar research investigations. Finally, given the geographical and temporal complexities in understanding health outcomes for diverse populations, different analytic strategies may be needed. We advocate increased use of mixed methodologies that integrate quantitative and qualitative approaches. Such methods have great potential both to reveal diversity within racial and ethnic groups and to help in understanding the sorts of barriers and opportunities people face in improving their health and gaining access to appropriate and effective care. They also reveal the role of human agency in shaping the health and health care landscapes. Although such mixed methodologies cannot be used at the population scale which informs national public health policy, the methods have great potential to inform health policies in local communities, the settings where policy implementation occurs. As population diversity in the U.S. increases, ‘locating’ the wide health disparities that Krieger and colleagues have so effectively researched to investigate the interactions among diverse people in diverse places is a critical topic for future research attention.

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