8.2 Neighborhood and Built Environment

Food Access

Nutritious foods are an essential component of a healthy diet. Vegetables, fruits, whole grains, low-fat dairy, protein, and oils are all nutritious foods when consumed in healthy portion sizes. Healthy eating habits, defined as eating a variety of nutrient-dense foods and beverages across all food groups within calorie limits, can lower the risk of chronic disease. Foods and beverages with added sugars, saturated fat, and sodium, along with alcoholic beverages, are associated with unhealthy diets. Research has consistently demonstrated that healthy eating habits are associated with decreased cardiovascular disease, obesity, type 2 diabetes, and breast and colorectal cancer and improved bone health (ODPHP, 2020q). Therefore, access to healthy and affordable food is vital for health.

Often a result of economic insecurity and poverty, food insecurity is a condition in which individuals or families have limited access to adequate amounts of high-quality food (ODPHP, 2020r). Factors influencing food security include income, employment status, race, ethnicity, and disability. Food insecurity increases when income is limited or unavailable due to unemployment. In 2020, BIPOC households were more than twice as likely as the national average to struggle with food insecurity. Individuals living with disabilities are also more likely to experience food insecurity due to limited employment opportunities and health care expenses (ODPHP, 2020r). In 2020, almost 14 million U.S. households were food insecure at some point in the year, and almost 30 percent of low-income households were food insecure compared to the national average of almost 11 percent (ODPHP, 2020r). Factors influencing this disparity are thought to be related to neighborhood conditions, transportation access, and physical access to food (ODPHP, 2020r).

Healthy food choices are inaccessible in many neighborhoods because full-service grocery stores are not readily available, particularly in certain rural areas and low-income neighborhoods (ODPHP, 2020r; U.S. Department of Agriculture [USDA], 2017). These areas where residents have limited or no options for affordable and healthy foods are often termed food deserts (ODPHP, 2020r; RHIhub, 2020b; USDA, 2017). Limited access to healthy and affordable food sources, income level, transportation access, and distance are barriers to healthy food access for many Americans. Almost 13 percent of the U.S. population lives in low-income food deserts (USDA, 2017). Food deserts are common in locations with small populations and high rates of vacant or abandoned homes; in areas where residents have lower incomes, lower levels of education, and higher rates of unemployment; and disproportionately within BIPOC communities (The Annie E. Casey Foundation, 2021). Lack of transportation also contributes to food insecurity. Lack of or limited public transportation is a barrier to accessing affordable healthy food. Further contributing to health disparities among vulnerable populations, individuals experiencing disabilities, those with chronic diseases, BIPOC communities, and those living in rural areas are more likely to lack transportation to full-service supermarkets (ODPHP, 2020r).

In addition to accessibility issues, food affordability is a major obstacle, as healthier diets are more expensive than diets rich in processed and refined foods (The Annie E. Casey Foundation, 2021). Because nutrient-poor foods tend to be cheaper and more convenient to access than nutrient-dense foods, low-income individuals and families tend to rely on them. Convenience stores often have higher food prices with lower quality and less variety of foods than full-service supermarkets (ODPHP, 2020q). Residents of neighborhoods with fewer full-service supermarkets with fresh produce are at higher risk of obesity and diabetes, whereas rates of these conditions are lower among those who live in areas with increased access to grocery stores (ODPHP, 2020q). Studies have demonstrated a link between individuals experiencing food insecurity and higher rates of obesity and chronic diseases such as hypertension and heart disease. In children experiencing food insecurity, studies have demonstrated increased risks of obesity and developmental issues and even a negative impact on mental health (ODPHP, 2020r).

The Role of the Nurse in Addressing Food Access Disparities

Community health nurses play a major role in advocating for individuals experiencing food insecurity. School nurses nationwide have paved the way for free breakfast and lunch for students from low-income families via the National School Lunch Program (NSLP) (ODPHP, 2020r). School nurses, in conjunction with school administrators, are also at the forefront of promoting healthier food options for school-provided breakfast and lunch. Nurses both promote access to food and ensure that the food provided is nutritionally appropriate. This is one example of how community health nurses impact the health of the communities in which they serve.

Community health nurses often work with local food pantries to help families in need access food. Nurses can also help individuals obtain food benefits through programs such as Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP) (ODPHP, 2020r). These government-sponsored programs provide food assistance to lower-income individuals and families. SNAP gives a monthly dollar amount, determined by income level, which must be used to purchase food. WIC is meant for pregnant, breastfeeding, or postpartum parents and for children under age five and provides nutrition education, breastfeeding support, and nutrient-dense foods (Benefits.gov, 2021). Community health nurses can advocate for increasing access to nutrient-dense foods in low-income neighborhoods to address food disparities and their subsequent negative impacts on health. At the policy level, public health nurses can be involved in policies to limit the number of fast-food restaurants in a community or to incentivize full-service supermarkets to expand into underserved neighborhoods.

Crime and Violence

Violence is a public health issue that adversely affects the target, any witnesses, the communities in which they live, and the perpetrator. It may include child abuse, firearm violence, intimate partner violence, sexual violence, or elder abuse. Violence has cumulative biological effects on the brain, neuroendocrine system, and immune response, resulting in increased incidence of depression, anxiety, posttraumatic stress disorder (PTSD), and suicide and increased risk of cardiovascular disease and premature death (Rivara et al., 2019). Repeated exposure to crime and violence is linked to an increase in negative health outcomes such as asthma, hypertension, cancer, stroke, and mental disorders (ODPHP, 2020e).

Childhood exposure to violence at home, at school, online, or in the neighborhood is considered an adverse childhood experience (ACE). ACEs are traumatic events such as experiencing or witnessing violence or abuse at home or in the community, having a family member attempt suicide, or any event that undermines a child’s sense of safety, security, and bonding (CDC, 2022c). ACEs are linked to lifelong negative health outcomes such as chronic disease, mental illness, and substance use problems. Additionally, research has found that ACEs can negatively impact education levels, future job opportunities, and overall earning power. Evidence also links exposure to violence in childhood to an increased risk of experiencing intimate partner violence or being violent in adulthood (USDHHS Office on Women’s Health, 2021). Exposure to violence as an adult is also associated with poor health outcomes, such as mental health disorders, depression, anxiety, suicidal ideation, and physical injuries from violence (ODPHP, 2020e). See Caring for Vulnerable Populations and Communities for more information on ACEs.

Individuals who are economically insecure are more likely to live in impoverished neighborhoods that lack resources and have higher rates of crime and violence (ODPHP, 2020e). Additionally, the national homicide rate is higher for BIPOC adolescents and young adults than their White counterparts (ODPHP, 2020e). Individuals who feel unsafe in their neighborhoods are more likely to avoid community gatherings and outdoor spaces, placing them at higher risk of poor physical and mental health (ODPHP, 2020e). If a community experiences violent crime, families will likely avoid utilizing public parks and partaking in outdoor physical activity out of safety concerns. This negatively affects the family, causing increased isolation and mental health stress and decreased physical activity, socialization, and play for children.

The Role of the Nurse in Addressing Violence

Strategies for public health nurses to address crime and violence include educational programs on building resilience and developing healthy interpersonal relationships. The community health nurse can collaborate to offer school-based programs that build emotional self-awareness and regulation, problem-solving, and teamwork skills to prevent violent behavior. Such educational and training programs can occur in a community center or even an outpatient community health clinic. Building resilience and emotional self-awareness and regulation skills, even from a young age, creates a culture of accountability and can reduce violence. Community and public health nurses can also offer parenting classes to help educate families on how to model resilient behaviors and give strategies for dealing with difficult parental situations. Finally, community health nurses can work with community members to provide high-quality child care, mentoring programs for young individuals, and safe, affordable after-school programs to keep children engaged with playing and learning in a supervised environment.

The Built Environment

A community’s built environment includes transportation access and roadways, the availability of green space, locations for community gatherings, and the buildings or other physical structures within the neighborhood (ODPHP, 2020d). Almost 20 percent of economically insecure households in the United States lack access to private transportation (Langston, 2018). Low-income individuals without a vehicle are doubly burdened if they reside in neighborhoods without adequate and affordable public transportation, such as bus routes or subways. These individuals may struggle to access schools, work, health care, and other necessary resources. Economically insecure individuals, particularly those who identify as Black, Native American, and mixed/other race, are more likely than those who identify as White, Latina/Latino, or Asian or Pacific Islander to report dropping out of the labor force due to transportation issues (Langston, 2018).

The availability of outdoor green space and access to sidewalks and bike lanes have major health impacts on a community. A lack of green space for outdoor activities and community gatherings negatively affects residents’ physical and mental health and well-being. Children need green space to play outside. Play is a means for children to learn and grow as individuals. It is difficult to socialize with groups of other children if play is limited to indoors only. Walking is a free and easy exercise activity, but residents may be hesitant to participate in this beneficial physical activity without a sidewalk or wide road shoulder to permit safe walking. Bike paths are also a cost-effective way to increase walking, biking, roller-skating, and other leisure activities and can serve as a means of transportation, but if there is not a safe way to engage in these physical activities, they will not occur.

The Role of the Nurse in Addressing the Built Environment

Public health nurses are well positioned to work within the local community and government to advocate for shared public green spaces. Building community partnerships is a core policy development role for a public health nurse. From a windshield assessment of the community to raising awareness at the local level and collaborating with policymakers and community leaders, public health nurses can effect positive change within the community. Working with urban design planners and city planners, nurses can advocate for the construction of playground structures, tennis or pickleball courts, and basketball courts to afford more physical activity and community-building opportunities. School nurses can also be involved in this process by advocating for more physical education and outdoor recess time at school and by advocating for more gathering places for children and families to congregate, socialize, and play after school.

Quality of Housing

Housing quality refers to a home’s physical condition and the quality of the environment (neighborhood) in which it is located. Quality housing is characterized by clean air, home safety, enough space per individual, access to heating and cooling systems, and the absence of environmental risk factors. Crowded living conditions are associated with food insecurity, infectious diseases, and poorer mental health (ODPHP, 2020k). Low-income individuals are more likely to live in older homes and homes needing maintenance and repair.

Poor housing quality and poor living conditions contribute to negative health outcomes for a variety of reasons. The presence of lead, mold, asbestos, radon, poor air quality, and overcrowding are all associated with illness and disease. Children under age six are at increased risk for adverse health outcomes due to lead exposure because their bodies are rapidly growing and developing and because they tend to put their hands and other objects into their mouths. Children can be exposed to lead from touching, swallowing, or breathing in lead dust from lead paint, pipes, and water faucets. Lead exposure can result in slowed growth and development, damage to the brain and nervous system, learning and behavioral problems, and hearing and speech issues, all of which may result in lower IQs and underperformance in school (CDC, 2022f). Many of the outcomes associated with lead exposure are permanent; for example, lead poisoning may result in infertility, hypertension, heart disease, renal disease, and even premature death (NIOSH, 2021). Even low levels of lead in the blood have been linked to negative outcomes in a child’s attention span and academic achievement (CDC, 2022f).

Many modifiable environmental risk factors related to housing are associated with negative health outcomes. Water issues such as leaking are associated with mold growth, increasing the likelihood of childhood asthma and triggering asthma exacerbation. Mold is also associated with respiratory illnesses, coughing, and wheezing. Exposure to asbestos, a class of mineral fibers used in various industrial products like insulation, cement, textured paint, and shingles, may place individuals at increased risk of developing several health conditions. Asbestos in good condition is not considered harmful, but handling asbestos products may release the fibers into the air; if inhaled, they accumulate in the lungs and may cause lung cancer, asbestosis, pleural disease, and mesothelioma (Agency for Toxic Substances and Disease Registry, 2016; CDC, 2023). While most modern products do not contain asbestos, homes built before the 1970s may have asbestos, placing families living in older rental homes at higher risk of exposure to it (U.S. Consumer Product Safety Commission, n.d.). Exposure to vermin such as cockroaches and rodents causes an increased risk for developing asthma and allergies and places exposed individuals at increased risk of psychosocial distress (CDC, 2009).

The Role of the Nurse in Addressing Quality of Housing

Community health nurses can promote the overall health and well-being of an entire neighborhood and community by addressing the quality of housing. Widespread deterioration in neighborhoods can negatively impact the mental health of residents in that community. The social and economic conditions in a neighborhood affect health outcomes as much as the quality of housing, further disadvantaging low-income groups, creating even more health disparities. To fulfill their core assessment function, community and public health nurses should assess the lived experience of community members; appropriately screen for issues such as lead poisoning, mold-related illnesses, mental health illness, and communicable diseases; and then work to develop policies to address these issues. By championing new laws and regulations on housing quality and strengthening support for affordable housing, the nurse is well positioned to lead effective change. Past successes in public health efforts on quality housing include banning lead paint products and creating local building codes and state statutes governing rental properties.

Environmental Conditions

The most common environmental conditions that may negatively impact population health are air quality, water safety, and extreme weather. Indoor and outdoor air quality is a major contributor to health.

Air Quality

Globally, air pollution is estimated to be responsible for nine million deaths per year, equating to one in six deaths worldwide (Fuller et al., 2022). The USDHHS reports that air pollution is associated with 100 to 200 thousand annual deaths in the United States (ODPHP, 2020p). Air quality is affected by pollution from smoke, dust, carbon monoxide, ozone, and nitrogen oxides. Indoor air quality can be affected by environmental smoke, cooking oils and smoke, secondhand smoke, and exposure to mold or radon. Outdoor air pollution can be affected by environmental smoke, car exhaust fumes, and other outdoor air pollutants. Pollution occurs with motor vehicles and industrial plant emissions and fires (Figure 8.4). Poor air quality can cause or exacerbate respiratory illness, and air pollution has been linked to lung cancer and heart disease. Urban communities tend to have more sources contributing to pollution and therefore tend to have worse air quality than more rural areas (ODPHP, 2020p). BIPOC communities disproportionately encounter more air pollution than predominantly White communities due to a history of structural racism. BIPOC neighborhoods are more likely to be located near factories and other industrial facilities that emit more pollution due to discriminatory city planning (ODPHP, 2020p). See Structural Racism and Systemic Inequities for more information.

Exposure to loud noises and living in close proximity to hazardous waste sites are other environmental community factors that adversely impact health. Traffic and construction contribute to noise pollution, which is associated with hearing loss and has been found to elicit stress responses in the body. BIPOC communities and low-income communities are disproportionately impacted by noise pollution. Living near hazardous waste sites or industrial facilities is also associated with increased rates of cancer, respiratory disease, skin conditions, and adverse pregnancy outcomes compared to those not living near these sites (Taylor, 2022).

Figure 8.4 Poor air quality affects the residents living in this area. (credit: “Wildland Urban Interface at Sherburne National Wildlife Refuge” by Russ Langford/USFWS/Flickr, Public Domain)

The Role of the Nurse in Addressing Environmental Conditions

Community and public health nurses work within the core functions of assessment and policy development to monitor environmental conditions and their effects on health outcomes. They assess and monitor population health, investigating and addressing health hazards and their root causes. In areas with high levels of air pollution, these nurses monitor the community’s respiratory health, as poor air quality can cause or exacerbate respiratory health conditions. For any increased prevalence of air pollution-related respiratory issues, these nurses educate the public and mobilize community partnerships to address the issue. By cataloging the detrimental health effects of air pollution, public health nurses have evidence to support the implementation of new laws and policies to address its causes. For residents struggling with poor indoor air quality, educating individuals and families on the importance and use of indoor air filters is a great mitigating and possibly a primary prevention intervention.

Community health nurses assess poor health outcomes related to contaminated water and investigate or address these health outcomes. While the EPA sets standards for water quality within public municipal water systems, compliance is often left to local governments. Once a link between water quality and health outcomes is established, community and public health nurses communicate with and educate the local government and the public, and they mobilize efforts to address the root cause. Using legal and regulatory avenues, the public health nurse assures that the community can access one of the most basic human rights, safe water. See Pandemics and Infectious Disease Outbreaks for more information on waterborne disease.

Community and public health nurses should familiarize themselves with environmental health concerns and join environmental nursing groups such as the Alliance of Nurses for Healthy Environments (ANHE) to stay current on the latest climate change information. A national nursing organization focused on the intersection of health and the environment, ANHE offers many learning opportunities, with podcasts, webinars, newsletters, and other events. Its goal is to advance research, incorporate evidence-based practice on the environment, and influence policy (ANHE, n.d.). Massachusetts General Hospital Institute of Health Professions (MGH IHP) has opened a Center for Climate Change, Climate Justice, and Health, created and driven by nurse scholars passionate about tackling climate change issues. This center offers many opportunities for health professionals to learn about the issues and to “address mitigation, adaptation, and resilience through education, practice, research, and service related to the health effects of climate change” (MGH IHP, 2023, para. 1).

Nurses can use information from these resources to implement community interventions and to advocate for policy changes to address climate change. Some community interventions require community health nurses to collaborate with local government, city planners, and urban designers to investigate ways to mitigate the effects of climate change, such as promoting the planting of more trees and greeneries, on the street and on rooftops, to relieve heat and improve air quality. At the family level, the community health nurse can direct families struggling with heating or electricity costs to resources such as low-income home energy assistance programs.