The Link Between Neighborhood Disadvantage and Health Outcomes

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Show Notes

Dr. Amy Kind is director of the Health Services and Care Research Program within the Department of Medicine at the University of Wisconsin School of Medicine and Public Health. The group strives to improve the health and quality of life of patients and caregivers throughout Wisconsin and beyond. Dr. Kind and her research group developed the Neighborhood Atlas, a website that houses the Area Deprivation Index, a metric which allows for rankings of neighborhoods by socioeconomic status disadvantage.

Read Dr. Amy Kind's article "Making Neighborhood-Disadvantage Metrics Accessible -- The Neighborhood Atlas," which appeared in The New England Journal of Medicine on June 28, 2018.

Transcript

Introduction: Welcome to Dementia Matters, a podcast presented by the Wisconsin Alzheimer's Disease Research Center. There are currently more than 5.3 million Americans living with Alzheimer's and over 40 million people living with this disease worldwide. Our podcast is here to educate you on the latest research, caregiver strategies and available resources for fighting back against this disease. I'm your host Nathaniel Chin. I'm a geriatric memory clinic physician at the University of Wisconsin and I'm the son of someone who lived and died with Alzheimer's disease. I'll be talking with experts from around the state as well as around the country and asking the questions that I believe are in the minds of many in our community. Thanks for joining us.

Nathaniel Chin: Today we're joined by Dr Amy Kind. Dr Kind has a long list of current appointments here at the University of Wisconsin. Some of these include being the director of the VA Dementia Care Clinic, the director of the Health Services and Care Research Program and an investigator here at our Wisconsin Alzheimer's Disease Research Center. Dr Kind and other researchers from the UW School of Medicine and Public Health recently released a new online resource called the Neighborhood Atlas. This is a free online tool that maps out neighborhood disadvantage in the United States and Puerto Rico. There's a lot to discuss. So with that we welcome Dr Amy Kind.

Amy Kind: Thanks for having me, Nate.

Nathaniel Chin: Now your Neighborhood Atlas puts the focus on social determinants of health. Can you explain social determinants of health for our audience and go into why this is something that needs more attention?

Amy Kind: Absolutely. So the social determinants of health are really the underpinning of so many of our health behaviors of our diseases, of the way we live, the choices we make and the environment we interact with. Some examples of social determinants of health are things like housing quality or what kind of income someone might have, what kind of food they can access. Each of these items is not traditionally thought of as a biophysiological health factor like hypertension or some of the other things that doctors might measure in a clinic. However, increasingly we are aware through many decades of research that these social determinants of health may be some of the most impactful factors on health outcomes in populations across the U.S. And across the world for that matter.

Nathaniel Chin: And that's really something because as clinicians, we know that often in the 15 minutes that we have with another person, we're focusing on the disease itself and not the social determinant.

Amy Kind: You're absolutely right, Nate. You know, it's fascinating how we can go through many, many years of medical training, but we may spend, if any, just a minority of our time on how to impact social wellbeing and on how to our patients who are living in some of the most disadvantaged areas. And when were encountered with these challenges as clinicians, sometimes we're not sure exactly what to do. These are not always the easiest things to talk about. You know, saying that, my housing doesn't have electricity 24 hours a day because I can't afford it. Or by the way, I only made it through fifth grade because I had trouble reading. These are factors that aren't always volunteered by our patients.

Nathaniel Chin: You're right that these are very personal, but hopefully at one of persons in a clinic they can have that kind of intimate conversation with their healthcare provider. We do ask about other personal questions, so it makes sense that we could incorporate them. But then this idea of having a mechanism for looking at these social determinants is so important, which leads us to this Neighborhood Atlas. So can you explain to us what is this atlas?

Amy Kind: The Neighborhood Atlas represents over two years of work and many more years before that in building some of the theory behind it. This atlas can be used by anyone. And, and it has a mapping technique that allows one to visualize neighborhood disadvantage and you can zoom in down to a city level to identify very discrete neighborhoods in any city, state or region across the United States and Puerto Rico. It allows for ranking these states both from a national perspective, which is very interesting, or just the state as compared to other neighborhoods within that state. So it's very, very exciting.

Nathaniel Chin: One of the things as a non-statistician, as a non-scientist, that I'm so impressed by is that one, it's free so that anyone truly can use it. It is accessible. So it's not just scientists. Any person right now could go online and use this tool. And then it's usable. So it's not something that requires a statistician or a computer science major to use. Frankly, if you can use a phone or a smartphone, you can use this application. And there's so much possibility other than just science, other than just research. And in our world of community outreach and community organizations, the idea that now these other agencies that are trying to help the public can use this as a tool to best reach people. It just seems like you're really touching on things that for so long we've sort of just acknowledged but never done anything about.

Amy Kind: Parts of our country have had, just for a single city for instance, might have had maps like this, or some states might have had maps like this, but suddenly we have something that can reach everywhere from rural Mississippi to Alaska, to Hawaii, to Massachusetts. There's lots of different opportunities here.

Nathaniel Chin: What information did you take into account when you determined which neighborhoods were better off than others, or their average score, just their area of deprivation?

Amy Kind: The metric that was used to develop the rankings that you see on the Neighborhood Atlas is a metric called the Area Deprivation Index, which was created by a branch of the government called HRSA back in the 1990s so it's almost three decades old now. And so we took the metric and we needed to update it so that it could be used in the modern day so that we could actually target exposures and think about resource targeting and environmental factors. So with the metric, we worked with a team of people here, including a PhD geographer by the name of William Buckingham, and we were able to refine the metric down to this neighborhood level or census block group level. And then we were able to update it to a new data source called the American Community Survey. Of course, any data like the American Community Survey or the U.S. Census will have inherit limitations. So a good example of that is subjects who are maybe in the country illegally may not be accounted for. So there are some challenges in the underlying data. However, it was the best data source we could have available to us at this time for this purpose, and the validation worked really, really well. The metric was performing as we had hoped and we decided it was time to release the metric along with the piece that was published in The New England Journal of Medicine.

Nathaniel Chin: So can you explain some of the impacts you expect this resource will have on communities on policy?

Amy Kind: This is an excellent question, Nate. Since the atlas was just released to the public two weeks ago, we are still waiting and watching to see what happens after the initial use. From a clinician outreach standpoint, I would love to see this used as a marker for additional discussions to have with patients to think about healthcare and incorporation of the social determinants of health as a fundamental approach to everything we do. We need to spend more time thinking about these social determinants. So how do we talk to patients about this? How do we, what do we do when we discover challenges? And then how do we interface with our community partners more effectively to come up with creative solutions towards societal problems? We can see graphs of patients' weights and their hypertension, and yet we know almost nothing about where they live. Wouldn't it be great to have those kinds of pictures? At the research level. I'd like to see this used in order to advance the field of health equity and health disparities research. The social context in which our patients and subjects live impacts their health in fundamental ways and yet it is an area that is, I would argue, understudied. I think there's a lot more that can be done both from the basic science standpoint of these basic fundamental bio mechanisms of how disparities lead to cancer, how do they lead to increased risk of Alzheimer's disease? How do they lead to hypertension? What exactly going on there? What is the basic bio mechanism? All the way up to the social approaches and public health approaches for new outreach, new models of care, new opportunities to make our patients and our societal lives better. And then from a policy standpoint, so often in health data, in particular Medicare data, insurance data, Medicaid data, they may have limited measures of social determinants of health. So this provides yet another new window to understand how health at a more broad population level may be linked to some of these social determinants, how hospital or health system performance may be linked to some of these social determinants, how we could more effectively target resources and other ways of thinking to incorporate social determinants in our policy decisions. So it should give our policymakers a brand new tool to consider new approaches toward improving the health of our neighborhoods, the health of our population, and hopefully the health of each of the individuals that we see in our clinics as well.

Nathaniel Chin: So I know this is relatively recent that this was released, so you have limited data, but I will ask you to speculate then on how you feel we can use this tool in the realm of Alzheimer's disease and dementia. Could you talk about some proposed socioeconomic factors that you feel like influence either of those at risk or those with Alzheimer's disease?

Amy Kind: When one thinks about the environment, particularly in young childhood, that you grow up in, there is tantalizing evidence that the environment impacts the way your brain grows. There are examples of terribly tragic cases of children who did not receive the basic fundamental social interactions and nurturing that one needs to grow up healthy. They may have had nutrition, they may have had a place to sleep, but ultimately their environment though was not as rich as it needed to be in terms of social interaction or in terms of some of the other environmental factors. And when you look at the pictures of their brain and an MRI, they're brain architecture is fundamentally different. And it really points to this fundamental connection between our society, our environment, and the way our brains develop. So when we started looking at some of the early findings, just some very preliminary work looking at exposure to neighborhood disadvantage and neuroimaging findings, Alzheimer's biomarker findings, and cognitive findings. What we see is that many of our patients or subjects, excuse me, that are exposed to neighborhood disadvantage me be having some of these biomarkers and changes that are associated with Alzheimer's disease earlier. Now we need to verify these in a larger sample, and that work is ongoing. But we know from large epidemiological studies that Alzheimer's disease is much more common in patients of certain racial and ethnic backgrounds and patients who are exposed to disadvantaged context, who are themselves poor. And one questions exactly why that happens. And so we're hopeful that this idea of contextual disadvantage, or these exposures that one might have to the environment ... if you live in a more disadvantaged neighborhood, you have less access to food, as we mentioned, it may be more difficult to exercise. You may be more apt to have lead in your water or goodness knows what else. Could some of these things lead to the changes that we're seeing? We don't know yet.

Nathaniel Chin: What do you hope will ultimately come from all of this?

Amy Kind: The research is still out on that. But with this line of research, what we're hopeful for is not only potentially discovering some of the associations that may exist between these social determinants of health and Alzheimer's disease, but coming up with new interventions both at a social standpoint, but also at a basic biophysiological standpoint. So what is the biology behind that? Why do our cells in our brains change because of the environment that we're in? The work in this area is just taking its first steps, but how exciting to have some of these new vantage points that one can potentially look through at these diseases from an entirely different angle to perhaps come up with new findings, new therapies, and perhaps new opportunities for treatments.

Nathaniel Chin: And then my last question for you is, what is the website address for this new Neighborhood Atlas tool?

Amy Kind: The website is at www.neighborhoodatlas.medicine.wisc.edu. So that's neighborhood atlas, all one word, at medicine dot wisc dot edu.

Nathaniel Chin: Well, thank you very much, Dr. Kind, for joining us on Dementia Matters.

Amy Kind: Thanks for having me, Nate.

Nathaniel Chin: Before we wrap up today's episode, I want to let everyone know about the 10-question survey we're doing to improve our podcasts. It takes about two minutes to complete and all the questions are very straight forward. You can find the link to this survey and this episodes description or on our website. The survey takes about two minutes, and your feedback would be much appreciated. Thank you.\

Nathaniel Chin: Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical and research expertise from the University of Wisconsin School of Medicine and Public Health and the Geriatric Research, Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private, university, state, and national sources, including a grant from the National Institute of Health for Alzheimer's Disease Centers. This episode was produced and edited by Alex Wehrli and our executive producer is Rebecca Wasieleski. Our musical jingle is "Cases to Rest" by Blue Dot Sessions. Check out our website at adrc.wisc.edu. You can also follow us on Twitter and Facebook. If you have any questions or comments, please email us at dementiamatters@medicine.wisc.edu. Thanks for listening.