Inequality

Hospitalization for Ambulatory-care sensitive conditions (ACSC) in Ile de France: A view from across the Atlantic

Hospitalization for Ambulatory-care sensitive conditions (ACSC) in Ile de France: A view from across the Atlantic
Revue française des affaires sociales 2013/3 (n° 3)

Rodwin, V., Gusmano, M. and Weisz, D.
12/03/2013

This article presents an indicator used in the United States and other OECD nations (hospitalizations for ambulatory-care sensitive conditions – ACSC) to assess access to primary care services and their capacity to handle a set of medical conditions before they require acute hospital treatment. Based on a study of Ile de France, which relies on residence-based hospital discharge data on patient diagnoses and treatments, the indicator identifies areas where hospitalizations for ACSC appear particularly high. Such hospital stays are considered potentially avoidable. Based on data from the Programme de m.dicalisation des syst.mes d’information (PMSI), disparities are measured. We rely on logistic regression analysis to identify a range of individual factors and neighborhood-level factors that explain these disparities. Access to primary care appears to be worse among residents in areas with average household income in the lowest quartile and among those hospitalized in public hospitals. This raises an important question for the future of health policy. Should areas with higher hospital discharge rates of ACSC be understood as having populations with poor health-seeking behaviors or health care systems not well enough organized to target higher-risk populations?

Mobility and the Metropolis

Mobility and the Metropolis
Washington, D.C.: The Economic Mobility Project, An Initiative of The Pew Charitable Trusts

Graham, B., and P. Sharkey
12/03/2013

In a 2011 public opinion poll, The Pew Charitable Trusts asked Americans how important they thought a number of factors were in determining whether people in the United States get ahead or fall behind economically. More than 80 percent of respondents identified factors such as hard work, ambition, and access to education as key drivers of upward mobility, while less than half viewed growing up in a good neighborhood as an important factor. On the contrary, respondents strongly agreed that a young person with drive, ambition, and creativity growing up in a poor neighborhood is more likely to get ahead economically than someone growing up in a more affluent neighborhood who lacks those attributes.

Contrary to these perceptions, however, evidence is building that location actually matters a great deal and that Americans’ economic mobility prospects vary by state, locality, and even neighborhood.

For example, a 2009 Pew study indicated that a person who experienced high neighborhood poverty throughout childhood had a much higher risk of moving down the economic ladder as an adult. Other recent research examining mobility among metropolitan areas, including nearby towns and rural areas, showed that economic mobility varied widely across these localities. And, in a 2012, first-of-its-kind analysis of Americans’ economic mobility at the state level, Pew found that a number of states, primarily in the Mideast and New England regions, had higher mobility than the national average, and other states, primarily in the South, had lower mobility. 

This report adds to the growing body of research as it examines economic mobility across 96 U.S. metropolitan areas and the role of place in Americans’ prospects of moving up or down the economic ladder. It also offers insight on why and how location matters. Although a host of factors, such as state and local policies and labor market conditions, could influence mobility, this analysis considers one: neighborhood economic segregation, or the degree to which the poor and the wealthy live apart from each other. To begin to answer this question, Pew commissioned original research that, using three longitudinal data sets, measures differences in economic mobility across American metro areas over the last generation and identifies above-average-, average-, and below-average-mobility areas. The analysis then looks at whether metro areas’ rates of economic segregation are related to their rates of economic mobility.

Disparities in access to health care in three French regions

Disparities in access to health care in three French regions
Health Policy, DOI 10.1016/j.healthpol.

Michael K. Gusmano, Daniel Weisz, Victor G. Rodwin, Jonas Lang, Meng Quian, Aurelie Bocquier, Veronique Moysan, Pierre Verger
08/05/2013

Objectives: This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d’Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

Methods: To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age- adjusted hospital discharge rates for revascularization – bypass surgery and angioplasty – among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization. Results: In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

Conclusions: Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.

Why Do Higher Income Households Move Into Low Income Neighborhoods: Pioneering or Thrift?

Why Do Higher Income Households Move Into Low Income Neighborhoods: Pioneering or Thrift?
Urban Studies, September 2013; vol. 50, 12: pp. 2478-2495.

Ellen, Ingrid, Katherine O’Regan and Keren Horn
05/01/2013

This paper offers several hypotheses about which US higher-income households choose to move into low-income neighbourhoods and why. It first explores whether the probability that a household moves into a relatively low-income neighbourhood (an RLIN move) varies with predicted household and metropolitan area characteristics. Secondly, it estimates a residential choice model to examine the housing and neighbourhood preferences of the households making such moves. Thirdly, it explores responses to survey questions about residential choices. Evidence is found that, in the US, households who place less value on neighbourhood services and those who face greater constraints on their choices are more likely to make an RLIN move. No evidence is found that households making RLIN moves are choosing neighbourhoods that are more accessible to employment. Rather, it is found that households making RLIN moves appear to place less weight on neighbourhood amenities than other households and more weight on housing costs.

Stuck in Place: Urban Neighborhoods and the End of Progress toward Racial Equality

Stuck in Place: Urban Neighborhoods and the End of Progress toward Racial Equality
University of Chicago Press

Sharkey, P.
04/01/2013

In the 1960s, many believed that the civil rights movement’s successes would foster a new era of racial equality in America. Four decades later, the degree of racial inequality has barely changed. To understand what went wrong, Patrick Sharkey argues that we have to understand what has happened to African American communities over the last several decades. In Stuck in Place, Sharkey describes how political decisions and social policies have led to severe disinvestment from black neighborhoods, persistent segregation, declining economic opportunities, and a growing link between African American communities and the criminal justice system.

As a result, neighborhood inequality that existed in the 1970s has been passed down to the current generation of African Americans. Some of the most persistent forms of racial inequality, such as gaps in income and test scores, can only be explained by considering the neighborhoods in which black and white families have lived over multiple generations. This multigenerational nature of neighborhood inequality also means that a new kind of urban policy is necessary for our nation’s cities. Sharkey argues for urban policies that have the potential to create transformative and sustained changes in urban communities and the families that live within them, and he outlines a durable urban policy agenda to move in that direction.

 

Winner of the Mirra Komarovsky Book Award, Eastern Sociological Society.

Winner of The American Publishers Award for Professional and Scholarly Excellence (PROSE Award) in Sociology and Social Work. ​

Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region

Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region
International Journal for Equity in Health, 2012 Dec 18;11:80. doi: 10.1186/1475-9276-11-80

Macinko, J., P. Mullachery, F.A. Proietti, and M.F. Lima-Costa
12/18/2012

Introduction Perceived discrimination is related to poor health and has been offered as one explanation for the persistence of health inequalities in some societies. In this study, we explore the prevalence and correlates of perceived discrimination in a large, multiracial Brazilian metropolitan area.

Methods The study uses secondary analysis of a regionally representative household survey conducted in 2010 (n=12,213). Bivariate analyses and multiple logistic regression assess the magnitude and statistical significance of covariates associated with reports of any discrimination and with discrimination in specific settings, including when seeking healthcare services, in the work environment, in the family, in social occasions among friends or in public places, or in other situations.

Results Nearly 9% of the sample reported some type of discrimination. In multivariable models, reports of any discrimination were higher among people who identify as black versus white (OR 1.91), higher (OR 1.21) among women than men, higher (OR 1.33) among people in their 30’s and lower (OR 0.63) among older individuals. People with many health problems (OR 4.97) were more likely to report discrimination than those with few health problems. Subjective social status (OR 1.23) and low social trust (OR 1.27) were additional associated factors. Perceived discrimination experienced while seeking healthcare differed from all other types of discrimination, in that it was not associated with skin color, social status or trust, but was associated with sex, poverty, and poor health.

Conclusions There appear to be multiple factors associated with perceived discrimination in this population that may affect health. Policies and programs aimed at reducing discrimination in Brazil will likely need to address this wider set of interrelated risk factors across different populations.

Beyond Black: Diversity among Black Immigrant Students in New York City Public Schools

Beyond Black: Diversity among Black Immigrant Students in New York City Public Schools
Randy Capps and Michael Fix, editors, Young Children of Black Immigrants in America: Changing Flows, Changing Faces. Washington, DC: Migration Policy Institute: 299-331

Doucet, F., Schwartz, A. E., & Debraggio, E.
12/14/2012

The child population in the United States is rapidly changing and diversifying — in large part because of immigration. Today, nearly one in four US children under the age of 18 is the child of an immigrant. While research has focused on the largest of these groups (Latinos and Asians), far less academic attention has been paid to the changing Black child population, with the children of Black immigrants representing an increasing share of the US Black child population.

To better understand a unique segment of the child population, chapters in this interdisciplinary volume examine the health, well-being, school readiness, and academic achievement of children in Black immigrant families (most with parents from Africa and the Caribbean).

The volume explores the migration and settlement experiences of Black immigrants to the United States, focusing on contextual factors such as family circumstances, parenting behaviors, social supports, and school climate that influence outcomes during early childhood and the elementary and middle-school years.  Many of its findings hold important policy implications for education, health care, child care, early childhood development, immigrant integration, and refugee assistance.

Changes in ten years of social inequalities in health among elderly Brazilians (1998-2008)

Changes in ten years of social inequalities in health among elderly Brazilians (1998-2008)
Revista de Saude Publica, Vol. 46, supp. 1. 10.1590/S0034-89102012005000059

Lima-Costa, M.F.; L.A. Facchini; D.L. Matos, and J. Macinko
12/11/2012

OBJECTIVE: To assess the changes in income-related inequalities in health conditions and in the use of health services among elderly Brazilians.

METHODS: Representative samples of the Brazilian population aged 60 years and more were analyzed between 1998 and 2008 (n = 27,872 and 41,198, respectively), derived from the Pesquisa Nacional por Amostra de Domicílios (National Household Sample Survey). The following variables were considered in this study: per capita monthly household income, self-rated health, physical functioning, medical consultations and hospitalizations in the previous 12 months and exclusive use of the Sistema Único de Saúde (Unified Health System). Data analysis was based on estimates of prevalence and prevalence ratios obtained with robust Poisson regression.

RESULTS: In 1998 and 2008, the prevalence of poor self-rated health, mobility limitations and inability to perform activities of daily living (ADLs), adjusted for age and sex, showed strong gradients associated with per capita household income quintiles, with the lowest values being found among those in the lowest income quintile. The prevalence ratios adjusted for age and sex between the lowest quintile (poorest individuals) and highest quintile (richest individuals) of income remained stable for poor self-rated health (PR = 3.12 [95%CI 2.79;3.51] in 1998 and 2.98 [95%CI 2.69;3.29] in 2008), mobility limitations (PR = 1.54 [95%CI 1.44;1.65 and 1.69 [95%CI 1.60;1.78], respectively) and inability to perform ADLs (PR = 1.79 [95%CI 1.52;2.11] and 2.02 [95%CI 1.78;2.29], respectively). There was a reduction in income-related disparities when three or more medical consultations had been made and with the exclusive use of the Unified Health System. Inequalities were not observed for hospitalizations. 

CONCLUSIONS: Despite reductions in income-related inequalities among indicators of use of health services, the magnitude of disparities in health conditions has not decreased. Longitudinal studies are necessary to better understand the persistence of such inequalities among elderly Brazilians.

Do Federally Assisted Households Have Access to High Performing Public Schools?

Do Federally Assisted Households Have Access to High Performing Public Schools?
Poverty & Race Research Action Council

Ellen, Ingrid Gould and Horn, Keren Mertens.
11/01/2012

A family’s housing unit provides more than simply shelter. It also provides a set of neighborhood amenities and a package of local public services, including, most critically, a local school. Yet housing and education policymakers rarely coordinate their efforts, and there has been little examination of the schools that voucher holders or other assisted households actually reach. In this project we describe the elementary schools nearest to households receiving four different forms of housing assistance in the country as a whole, in each of the 50 states, and in the 100 largest metropolitan areas.We compare the characteristics of these schools to those accessible to other comparable households. We pay particular attention to whether voucher holders are able to reach neighborhoods with higher performing schools than other low-income households in the same geographic area.

 

In brief, we find that assisted households as a whole are more likely to live near low-performing schools than other households. Surprisingly, Housing Choice Voucher holders do not generally live near higher performing schools than households receiving other forms of housing assistance, even though the voucher program was created, in part, to help low-income households reach a broader range of neighborhoods and schools. While voucher holders typically live near schools that are higher performing than those nearest to public housing tenants, they also typically live near schools that are slightly lower performing than those nearest to households living in Low Income Housing Tax Credit (LIHTC) and Projectbased Section 8 developments and lower performing than those nearest to other poor households.

Residential Mobility and the Reproduction of Unequal Neighborhoods

Residential Mobility and the Reproduction of Unequal Neighborhoods
Cityscape: A Journal of Policy Development and Research, 2012. Volume 14, Number 3

Sharkey, P.
09/01/2012

Housing assistance policy has shifted away from project-based assistance toward tenantbased assistance. This shift in approach reflects a common assumption that, if families have the option to find homes on their own in the private market, they will seek out better quality homes in racially diverse neighborhoods with lower levels of poverty. This article presents evidence to qualify this assumption by highlighting the limits of residential mobility in reducing, in any substantive way, the degree of racial and ethnic inequality in urban America. Two empirical observations form the basis of the argument. The first observation is that residential mobility typically serves to reproduce urban inequality instead of disrupting it. The second is that urban inequality is resilient: even when individuals or families make moves that disrupt patterns of racial and ethnic inequality, the changes such moves induce are undermined by system-level processes that serve to reproduce inequality in the urban landscape. As a result, changes in families’ neighborhood environments arising from residential mobility are often temporary and are diluted by subsequent changes occurring around families. The article concludes with a discussion of implications for housing assistance policy.

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