NEIGHBORHOOD BLIGHT AND FOOD SWAMPS: INVESTIGATING THE ROLE OF CRIME AND ABANDONED HOMES IN AN URBAN FOOD SYSTEM

Background: Suboptimal diet is ranked among the top causes of morbidity and mortality in the United States. While many factors influence diet, research on access to food stores has received substantial attention in the public health literature. Still lacking are empirical evidence and a deep understanding of the mechanisms driving the disproportionate availability of unhealthier food outlets relative to healthier food outlets, or food swamps, in low-income areas. Prior studies and theory point to the need to disentangle the role of distinct domains within the neighborhood context that interact with food stores. Specifically, factors of disorder that are deemed threatening to the built and social environments and how they compromise the food environment have yet to be explored. Objective: To evaluate the relationships between upstream neighborhood factors of disorder (crime rates, foreclosure and vacancy rates) and food swamps (quantified as the food swamp score, which is the density of BMI-unhealthy and BMI-intermediate food outlets out of the density of all food outlets, multiplied by 100), in Baltimore City, MD. Methods: Using a combination of food business data from Dun and Bradstreet and InfoUSA and neighborhood data from the Baltimore Neighborhood Indicators Alliance, longitudinal associations were examined between neighborhood crime rates and the food swamp score over a 13-year period and between foreclosure and vacancy rates and the food swamp score over a 12-year period in Baltimore’s 55 Community Statistical Areas, using fixed-effects linear regression models. Interaction terms were included to assess heterogeneity in the crime-food swamp score association by neighborhood socioeconomic status and by total population. For the foreclosure rate-food swamp score and vacancy rate-food swamp score relationships, interaction terms were included to assess heterogeneity by neighborhood socioeconomic status and population change. To contextualize quantitative analyses, this dissertation also included the design and implementation of a community-based system dynamics workshop that leveraged the perspectives of diverse stakeholders to develop a causal loop diagram depicting the system of neighborhood factors that influence access to healthy foods in Baltimore. Results: Over the study period, the average food swamp score increased from 93.5 to 95.3 percentage points. The interactions between neighborhood socioeconomic status and crime and between total population size and crime were not statistically significant, therefore, were excluded from the final model. Comparing neighborhoods to themselves over time, each one-unit increase in neighborhood crime rate was associated with a statistically significant increase in the food swamp score by an estimated 0.13 percentage points (95% CI, -0.00017 to 0.25), after accounting for concurrent change in neighborhood racial diversity, median sales price of households, and total population size. Overall, the association between foreclosure and vacancy rates and the food swamp score differed by neighborhood socioeconomic status and by neighborhood population change. Most notably, comparing low-socioeconomic status neighborhoods to themselves over time, a one-unit increase in foreclosure and vacancy rates was associated with a statistically significant increase in the food swamp score by 0.74 percentage points (95% CI, 0.19 to 1.29; p-value: 0.008) and 0.15 percentage points (95% CI, 0.014, 0.30; p- value: 0.03), respectively, after accounting for concurrent change in neighborhood racial diversity and total population size. Among high-socioeconomic status neighborhoods, increases in foreclosure and vacancy rates were associated with a less unhealthy food environment; however, this association was not statistically significant. Five key themes related to healthy food access emerged from the community-based system dynamics workshop, including factors associated with an unhealthy eating culture, healthy eating culture, individual and community wealth, social stability and support, and local and federal policies. In particular, crime played a role in several feedback loops within the neighborhood food system: contributing to healthy food being “risky food,” supporting unhealthy food stores, and severing social ties important for learning about healthy food. Conclusions: Understanding more distal drivers in the neighborhood context, such as crime and distressed homes, provide a more complete narrative of drivers shaping the neighborhood food environment. Findings from this dissertation underscore the need to consider the co-occurrence of the consumer, food outlet, and neighborhood environment, which will better equip public health practitioners and stakeholders in their efforts to revitalize neighborhoods and mediate equitable food access

NEIGHBORHOOD BLIGHT AND FOOD SWAMPS: INVESTIGATING THE ROLE OF CRIME AND ABANDONED HOMES IN AN URBAN FOOD SYSTEM

Background: Suboptimal diet is ranked among the top causes of morbidity and mortality in the United States. While many factors influence diet, research on access to food stores has received substantial attention in the public health literature. Still lacking are empirical evidence and a deep understanding of the mechanisms driving the disproportionate availability of unhealthier food outlets relative to healthier food outlets, or food swamps, in low-income areas. Prior studies and theory point to the need to disentangle the role of distinct domains within the neighborhood context that interact with food stores. Specifically, factors of disorder that are deemed threatening to the built and social environments and how they compromise the food environment have yet to be explored. Objective: To evaluate the relationships between upstream neighborhood factors of disorder (crime rates, foreclosure and vacancy rates) and food swamps (quantified as the food swamp score, which is the density of BMI-unhealthy and BMI-intermediate food outlets out of the density of all food outlets, multiplied by 100), in Baltimore City, MD. Methods: Using a combination of food business data from Dun and Bradstreet and InfoUSA and neighborhood data from the Baltimore Neighborhood Indicators Alliance, longitudinal associations were examined between neighborhood crime rates and the food swamp score over a 13-year period and between foreclosure and vacancy rates and the food swamp score over a 12-year period in Baltimore’s 55 Community Statistical Areas, using fixed-effects linear regression models. Interaction terms were included to assess heterogeneity in the crime-food swamp score association by neighborhood socioeconomic status and by total population. For the foreclosure rate-food swamp score and vacancy rate-food swamp score relationships, interaction terms were included to assess heterogeneity by neighborhood socioeconomic status and population change. To contextualize quantitative analyses, this dissertation also included the design and implementation of a community-based system dynamics workshop that leveraged the perspectives of diverse stakeholders to develop a causal loop diagram depicting the system of neighborhood factors that influence access to healthy foods in Baltimore. Results: Over the study period, the average food swamp score increased from 93.5 to 95.3 percentage points. The interactions between neighborhood socioeconomic status and crime and between total population size and crime were not statistically significant, therefore, were excluded from the final model. Comparing neighborhoods to themselves over time, each one-unit increase in neighborhood crime rate was associated with a statistically significant increase in the food swamp score by an estimated 0.13 percentage points (95% CI, -0.00017 to 0.25), after accounting for concurrent change in neighborhood racial diversity, median sales price of households, and total population size. Overall, the association between foreclosure and vacancy rates and the food swamp score differed by neighborhood socioeconomic status and by neighborhood population change. Most notably, comparing low-socioeconomic status neighborhoods to themselves over time, a one-unit increase in foreclosure and vacancy rates was associated with a statistically significant increase in the food swamp score by 0.74 percentage points (95% CI, 0.19 to 1.29; p-value: 0.008) and 0.15 percentage points (95% CI, 0.014, 0.30; p- value: 0.03), respectively, after accounting for concurrent change in neighborhood racial diversity and total population size. Among high-socioeconomic status neighborhoods, increases in foreclosure and vacancy rates were associated with a less unhealthy food environment; however, this association was not statistically significant. Five key themes related to healthy food access emerged from the community-based system dynamics workshop, including factors associated with an unhealthy eating culture, healthy eating culture, individual and community wealth, social stability and support, and local and federal policies. In particular, crime played a role in several feedback loops within the neighborhood food system: contributing to healthy food being “risky food,” supporting unhealthy food stores, and severing social ties important for learning about healthy food. Conclusions: Understanding more distal drivers in the neighborhood context, such as crime and distressed homes, provide a more complete narrative of drivers shaping the neighborhood food environment. Findings from this dissertation underscore the need to consider the co-occurrence of the consumer, food outlet, and neighborhood environment, which will better equip public health practitioners and stakeholders in their efforts to revitalize neighborhoods and mediate equitable food access

Rejoining the Planning and Public Health Fields

The growth of health disparities in the United States, particularly those associated with diet-related diseases, has motivated a reconvergence of the public health and planning disciplines to address this shared challenge. However, the dynamics and mechanisms through which public health and planning agencies can systematically address food-related issues have yet to be fully understood. This study analyzes how partnership between public health professionals and planners in local, regional, and metropolitan (LRM) governments can streng­then community food systems through a more integrated and holistic approach to health. Using a national survey of planning practitioners, we identify which formal local government plans are more likely to address food-related issues, as a way to offer insights on where engagement with public health agencies could be leveraged. Our analysis is further complemented by conducting semistruc­tured interviews with LRM governments in two communities that are known for their innovative plans and policies, to explore how this cross-disciplinary relationship unfolds on the ground. Findings reveal that comprehensive plans are most likely to address the food system, while stand-alone food systems plans are the least common formal plan to be adopted by LRM governments. Stake­holder interviews highlight how the planning–public health partnership can leverage local assets and strengthen the food system in urban versus rural jurisdictions, by formalizing cross-collabora­tion, identifying shared objectives, and building capacity

Relationships between Vacant Homes and Food Swamps: A Longitudinal Study of an Urban Food Environment

Research indicates that living in neighborhoods with high concentrations of boarded-up vacant homes is associated with premature mortality due to cancer and diabetes, but the mechanism for this relationship is unclear. Boarded-up housing may indirectly impact residents’ health by affecting their food environment. We evaluated the association between changes in vacancy rates and changes in the density of unhealthy food outlets as a proportion of all food outlets, termed the food swamp index, in Baltimore, MD (USA) from 2001 to 2012, using neighborhood fixed-effects linear regression models. Over the study period, the average food swamp index increased from 93.5 to 95.3 percentage points across all neighborhoods. Among non-African American neighborhoods, increases in the vacancy rate were associated with statistically significant decreases in the food swamp index (b = −0.38; 90% CI, −0.64 to −0.12; p-value: 0.015), after accounting for changes in neighborhood SES, racial diversity, and population size. A positive association was found among low-SES neighborhoods (b = 0.15; 90% CI, 0.037 to 0.27; p-value: 0.031). Vacant homes may influence the composition of food outlets in urban neighborhoods. Future research should further elucidate the mechanisms by which more distal, contextual factors, such as boarded-up vacant homes, may affect food choices and diet-related health outcomes

A community-based system dynamics approach suggests solutions for improving healthy food access in a low-income urban environment.

Little is known about the mechanisms through which neighborhood-level factors (e.g., social support, economic opportunity) relate to suboptimal availability of healthy foods in low-income urban communities. We engaged a diverse group of chain and local food outlet owners, residents, neighborhood organizations, and city agencies based in Baltimore, MD. Eighteen participants completed a series of exercises based on a set of pre-defined scripts through an interactive, iterative group model building process over a two-day community-based workshop. This process culminated in the development of causal loop diagrams, based on participants' perspectives, illustrating the dynamic factors in an urban neighborhood food system. Synthesis of diagrams yielded 21 factors and their embedded feedback loops. Crime played a prominent role in several feedback loops within the neighborhood food system: contributing to healthy food being "risky food," supporting unhealthy food stores, and severing social ties important for learning about healthy food. Findings shed light on a new framework for thinking about barriers related to healthy food access and pointed to potential new avenues for intervention, such as reducing neighborhood crime

Healthy versus Unhealthy Suppliers in Food Desert Neighborhoods: A Network Analysis of Corner Stores’ Food Supplier Networks

Background: Products in corner stores may be affected by the network of suppliers from which storeowners procure food and beverages. To date, this supplier network has not been well characterized. Methods: Using network analysis, we examined the connections between corner stores (n = 24) in food deserts of Baltimore City (MD, USA) and their food/beverage suppliers (n = 42), to determine how different store and supplier characteristics correlated. Results: Food and beverage suppliers fell into two categories: Those providing primarily healthy foods/beverages (n = 15) in the healthy supplier network (HSN) and those providing primarily unhealthy food/beverages (n = 41) in the unhealthy supplier network (UHSN). Corner store connections to suppliers in the UHSN were nearly two times greater (t = 5.23, p < 0.001), and key suppliers in the UHSN core were more diverse, compared to the HSN. The UHSN was significantly more cohesive and densely connected, with corner stores sharing a greater number of the same unhealthy suppliers, compared to HSN, which was less cohesive and sparsely connected (t = 5.82; p < 0.001). Compared to African Americans, Asian and Hispanic corner storeowners had on average −1.53 (p < 0.001) fewer connections to suppliers in the HSN (p < 0.001). Conclusions: Our findings indicate clear differences between corner stores’ HSN and UHSN. Addressing ethnic/cultural differences of storeowners may also be important to consider

Planning and food sovereignty in conflict cities

Problem, research strategy, and findings: Protracted political conflicts disrupt people's lives, including their ability to feed themselves. Urban planning, operating within the ambit of the state, impacts food systems in conflict cities. We examine the confluence of planning and political misgovernance on food sovereignty in conflict cities. We do so by documenting the experiences of urban growers who cultivate, eat, and distribute indigenous greens (haakh) in the city of Srinagar in the Himalayan belt of Jammu and Kashmir, the site of a protracted conflict. Experiences of growers were analyzed within the context of the city's complex urban planning landscape. Empirical methods included qualitative interviews of urban growers (n = 40) and review of land use plans and policies. We found that haakh production ensured access to affordable, nutritious, and culturally celebrated greens for haakh growing households. That said, intersecting burdens from undemocratic governance and militarism (from India), weak forms of local planning (within Srinagar), and climate change threaten urban growers' work, and imperils food sovereignty. Completing a study in a conflict region was extraordinarily challenging. The study's generalizability is limited by its short duration and small sample size—the inductive findings set the stage for future research. Takeaway for practice: Conflict cities are a reminder that urban planning is anything but technical. Planning curricula must prepare future planners for the politics of planning. Planners in conflict cities are in liminal positions—between the state and the public. To the best of their ability, planners in conflict cities such as Srinagar have to protect smallholder growers' control of their food system, especially over land and water. The monitoring, recording, and suspension of contested or undemocratic land conversions, land grabs, or land transfers without full consent of indigenous and local peoples ought to be a local and international policy priority