Historical Redlining, Social Determinants of Health, and Stroke Prevalence in Communities in New York City

Abstract

ImportanceHistorical redlining was a discriminatory housing policy that placed financial services beyond the reach of residents in inner-city communities. The extent of the impact of this discriminatory policy on contemporary health outcomes remains to be elucidated.ObjectiveTo evaluate the associations among historical redlining, social determinants of health (SDOH), and contemporary community-level stroke prevalence in New York City.Design, Setting, and ParticipantsAn ecological, retrospective, cross-sectional study was conducted using New York City data from January 1, 2014, to December 31, 2018. Data from the population-based sample were aggregated on the census tract level. Quantile regression analysis and a quantile regression forests machine learning model were used to determine the significance and overall weight of redlining in relation to other SDOH on stroke prevalence. Data were analyzed from November 5, 2021, to January 31, 2022.ExposuresSocial determinants of health included race and ethnicity, median household income, poverty, low educational attainment, language barrier, uninsurance rate, social cohesion, and residence in an area with a shortage of health care professionals. Other covariates included median age and prevalence of diabetes, hypertension, smoking, and hyperlipidemia. Weighted scores for historical redlining (ie, the discriminatory housing policy in effect from 1934 to 1968) were computed using the mean proportion of original redlined territories overlapped on 2010 census tract boundaries in New York City.Main Outcomes and MeasuresStroke prevalence was collected from the Centers for Disease Control and Prevention 500 Cities Project for adults 18 years and older from 2014 to 2018.ResultsA total of 2117 census tracts were included in the analysis. After adjusting for SDOH and other relevant covariates, the historical redlining score was independently associated with a higher community-level stroke prevalence (odds ratio [OR], 1.02 [95% CI, 1.02-1.05]; P < .001). Social determinants of health that were positively associated with stroke prevalence included educational attainment (OR, 1.01 [95% CI, 1.01-1.01]; P < .001), poverty (OR, 1.01 [95% CI, 1.01-1.01]; P < .001), language barrier (OR, 1.00 [95% CI, 1.00-1.00]; P < .001), and health care professionals shortage (OR, 1.02 [95% CI, 1.00-1.04]; P = .03).Conclusions and RelevanceThis cross-sectional study found that historical redlining was associated with modern-day stroke prevalence in New York City independently of contemporary SDOH and community prevalence of some relevant cardiovascular risk factors.

Historic redlining and health outcomes: A systematic review

“…Of the 36 included articles, 31 (86%) found a significant association between worse redlining scores (i.e., HOLC grade C or D) and adverse health outcomes. More specifically, living in a redlined neighborhood, compared to neighborhoods with better redlining scores (i.e., HOLC grade A or B), was associated with more severe asthma (Friedman et al., 2022; Nardone, Casey et al., 2020; Schuyler & Wenzel, 2022), increased preterm birth rates (Hollenbach et al., 2021; Krieger, Van Wye et al., 2020; Nardone, Casey et al., 2020), increased late‐stage cancer diagnoses (Krieger, Wright et al., 2020), poorer breast cancer outcomes (Bikomeye et al., 2023), increased prevalence of cardiovascular disease or events (Al‐Kindi et al., 2023; Deo et al., 2023; Jadow et al., 2023; Motairek et al., 2022; White et al., 2021; Wing et al., 2022), increased COVID‐19 infection and death rates (Li & Yuan, 2022), poorer diabetes outcomes (Linde et al., 2022; White et al., 2021), increased gunshot wounds rates (Benns et al., 2020; Jacoby et al., 2018; Mehranbod et al., 2022; Spitzer et al., 2023), increased heat‐related illness rates (Li et al., 2021), increased infant mortality (Huang & Sehgal, 2022; Lynch et al., 2021), increased kidney failure rates (Nguyen et al., 2023), more childhood obesity (Kowalski et al., 2023), increased pedestrian fatalities (Taylor et al., 2023), increase in fatal encounters with police (Mitchell & Chihaya, 2022), worse postoperative outcomes (Diaz et al., 2021), increased maternal mortality (Gao et al., 2022), overall worse self‐rated physical health (Lynch et al., 2021; McClure et al., 2019), poorer mental health (Lynch et al., 2021), and increased prevalence of visual impairment and blindness (Hicks et al., 2023).…”

“…There is an emerging body of literature focused on identifying the impact of redlining on current-day health. For instance, findings from recent studies suggest that redlining is associated with increased rates of strokes (Jadow et al, 2023) and a higher risk of death from breast cancer (Wright et al, 2022). Recent reviews reported on the associations between historic redlining and adverse health outcomes, but they covered articles published through March 2022 (Cross et al, 2023;Lee et al, 2022;Swope et al, 2022).…”

Risk of Stroke Among HIV Patients: A Systematic Review and Meta-analysis of Global Studies and Associated Comorbidities

“…46,47 However, it was reported that upstream of established social determinants of health, historical housing discrimination resulting from structural racism could contribute to the community's stroke risk. 48 Several studies have reported a higher stroke risk in women in the general population, 15,49 whereas others have shown that male people living with HIV are more susceptible to stroke occurrence than female people. 6,36 The observed discrepancies among studies can be attributed to age group effects or associations with stroke risk.…”

Advances in the Understanding of Social Determinants of Health in Stroke

“…Social status determinants of health (Figure ) were shown to have an impact on stroke prevalence and care. Low education, low income, and living in a health care professional shortage area were associated with increased community-level stroke prevalence in a cross-sectional study of residents in New York City 17 and were critical drivers of the excess likelihood of uncontrolled blood pressure among Black versus White participants in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). 13 Unemployed and low-income patients with stroke had lower likelihood of receiving reperfusion therapies, even when only considering patients with timely hospital arrival.…”

“…16 Similarly, historical redlining was associated with modern-day stroke prevalence in New York City independently of contemporary individual measures of socioeconomic status. 17 Data from the Black Women's Health Study suggested that Black women who experienced interpersonal racism had higher stroke incidence than those without prior experiences of racism, 18 thus establishing a direct link between interpersonal racism and stroke incidence later in life.…”