Vital places: Facilitators of behavioral and social health mechanisms in low-income neighborhoods

Abstract

Starkly unequal built and social environments among urban neighborhoods are part of the explanation for health disparities in the United States. This study is a qualitative investigation of the ways that residents of a low-income neighborhood in Madison, WI, use and interpret nearby neighborhood places. Specifically, I ask how and why certain places may facilitate beneficial behavioral and social mechanisms that impact health. I develop the organizing concept of “vital places”: nearby destinations that are important to and frequently-used by neighborhood residents, and that have theoretical relevance to health. I argue that conceiving of certain places as vital integrates our understanding of the essential components of places that are beneficial to health, while also allowing policy-makers to be creative about the ways they intervene to improve the life chances of residents in disadvantaged neighborhoods. I synthesize the findings into the characteristics of three types of vital places. First, I find that a convenient, comprehensive, and affordable food source can facilitate a healthy diet. An attractive, accessible, and safe recreational facility can support greater physical and social activity. Finally, shared, casual, focused social spaces provide opportunities to create and sustain supportive social ties. This study adds depth and complexity to the ways we conceptualize health-relevant community assets and provides insight into revitalization strategies for distressed low-income housing.

At the center of this study is a concern with how individuals living in low-income housing – among those with the highest risk for poor health and neighborhood structural disadvantage – interact with their environments. In order to strengthen low-income housing residents’ capacity to live better, healthier lives, researchers and policy-makers must understand the behavioral and social mechanisms through which a neighborhood’s structural environment influences individual health (Corburn, 2005). A substantial literature in public health identifies the ways that neighborhoods are associated with health behaviors, such as walking for exercise (Berke et al., 2007) and accessing healthy food (K. Morland et al., 2002). Social science investigations, on the other hand, focus more on understanding the ways in which health is linked to aspects of social processes in neighborhoods, like social support (Carpiano, 2007) and willingness to intervene on the behalf of the public good (Sampson, 2012). I ground the current study at the nexus of these traditions, taking an integrative approach to understanding the multiple ways people experience places in and near their low-income neighborhood.

I introduce the concept of “vital places”: nearby places in the neighborhood that are both important to and frequently-used by residents, and that are theoretically related to health through behavioral and/or social mechanisms. While extensive previous research has done a good job establishing that certain neighborhood places, like greenspaces (Maas et al., 2009) and healthy food establishments (K. B. Morland & Evenson, 2009), can be important for health, the qualitative nature of the current study allows us to delve into how and why places like these may matter for certain social and behavioral mechanisms that relate to health. The qualitative focus inherently means that this study cannot be conclusive of a causal link between neighborhood features and health. Rather, the main contribution of this study is its ability to unpack the complex and multi-faceted processes through which vital places may enable residents of a multiethnic, low-income neighborhood to enact health-related physical and social behaviors. I ground the analyses in the idea that places can facilitate both behavioral and social processes that are related to health, and generalize these findings to a set of abstract principles regarding the use of vital places as an organizing concept. I argue that focusing on the qualities of places that make them vital encourages a more creative, holistic understanding the multiple mechanisms through which neighborhood places are related to individual health.

Background

I draw on two main orientations in this study. Public health, urban design, and land use planning disciplines broadly conceive of neighborhoods as collections of physical resources and opportunities that are related to health behaviors, like healthy diet or physical activity; I refer to these as behavioral mechanisms through which neighborhoods are associated with health. Social scientific neighborhood research focuses on the ways that neighborhoods influence social relationships, which can enable or constrain social support or action on behalf of others in the community; I refer to these as social mechanisms through which neighborhoods are associated with health.

Behavioral Mechanisms

The built environment, broadly defined as “the human-made space in which people live, work and recreate on a day-to-day basis” (Roof & Oleru, 2008), plays an important role in supporting behavioral choices that can manifest in health outcomes. Generally speaking, built environments are organized in ways that are substantially less-supportive of good health in poor, urban neighborhoods (Lovasi et al., 2009). Many excellent recent studies have inquired into the built environment for physical activity by measuring neighborhood features such as residential density (Forsyth et al., 2007) and street connectivity (Saelens et al., 2003). My focus here, however, is on two specific place-based features of the built environment that are particularly relevant to the concept of vital places – the food environment and the presence of destinations within walking distance – because they represent features of self-contained places within the neighborhood that can enable or inhibit healthy behaviors.

Recently, research on obesity has broadened its focus to understanding the ways neighborhood environments may both encourage excessive food intake and discourage consumption of healthy food (Cummins & Macintyre, 2006; Larson et al., 2009). Obesity and obesity-related comorbidities are higher among individuals of low socioeconomic status (Paeratakul et al., 2002) and, because dietary patterns are influenced by neighborhood resources (K. Morland et al., 2002), researchers have proposed that neighborhood environments lacking access to healthy food and opportunities for physical activity are “obesogenic” (Lovasi et al., 2009; Reidpath et al., 2002). Proximity to supermarkets, which are considered beneficial because they tend to provide better availability and selection of high-quality foods at a lower cost than other types of stores, is associated with healthier BMI and lower prevalence of obesity (K. B. Morland & Evenson, 2009). Residents of disadvantaged neighborhoods, however, are less able to access supermarkets and disproportionately rely on nearby bodegas, convenience stores, and small grocery stores that can have inadequate selection of a diverse range of healthy foods (Cannuscio et al., 2013; Gibson, 2011). Research has not conclusively established, however, that locational access to healthy food sources affects healthy food choices (Mason et al., 2013; Pearce et al., 2008).

Individual engagement in physical activity results to some degree from personal choice, but is also a function of the built environment (Ferdinand et al., 2012). One aspect of the built environment, the presence and mix of attractive destinations in and around a neighborhood, has been found to be associated with increased physical activity (Berke et al., 2007), a behavioral mechanism linking neighborhood structure to health. Access to certain types of destinations like post offices, convenience stores, schools, transit stops, and shopping malls is associated with transport-related walking, not walking for recreation or exercise (McCormack et al., 2008). Powell and colleagues (2003) emphasize the importance of convenience in the choice to walk for exercise in one’s neighborhood; in their study, respondents with the ability to get to places less than ten minutes from their home were most likely to be physically active. On the other hand, some studies demonstrate that it is the quality and attractiveness of the recreational resources that promote greater physical activity, not the proximity of the destination (Kaczynski et al., 2008; Sugiyama et al., 2010). Studies targeting low-income neighborhoods find mixed results, with some reporting no association of physical activity resources (i.e., parks, trails, and community centers) with exercise (Heinrich et al., 2007) and others finding that residents of low-income neighborhoods derive greater benefit from nearby physical activity resources (i.e., gyms and parks) compared to residents of higher-income neighborhoods (Lee et al., 2007).

Social Mechanisms

Social scientists are interested in the ways neighborhood environments are associated with the quantity and quality of social relationships, and ultimately the resources produced from these relationships that can impact health among residents. Persistent segregation in cities across the country by race and socioeconomic status produces profoundly unequal neighborhood environments in the United States (Logan, 2011; Logan & Stults, 2011; Squires & Kubrin, 2005), where the urban poor contend not only with their own poverty, but also with the social effects of living in a neighborhood where most of their neighbors are also poor (W. J. Wilson, 1987). Residents of low-income neighborhoods face social isolation from mainstream social ties and institutions that can lead to social mobility (Briggs, 1998), and report having fewer and lower-quality social relationships that may be especially important for individuals faced with economic disadvantage (Smith, 2005; Wacquant & Wilson, 1989). Neighborhood disadvantage is also related to lower levels of social cohesion and social control, resulting in lower trust and poorer quality social relationships among residents (Jencks & Mayer, 1990; Small & Newman, 2001).

Gieryn (2000) suggests that social processes happen through the material forms that we design and build; he contends that neighborhood places arrange patterns of face-to-face interaction that provide bases for social relationships. Some recent work has begun to empirically-examine how neighborhood design can influence social relationships. For instance, Leyden (2003) finds that residents of pedestrian-oriented, mixed-use neighborhoods are more likely than those living in car-oriented neighborhoods to trust others and be socially engaged in their neighborhood.

Because of its demonstrated relationship with health, I conceptually focus here on the resource of social support to which social relationships afford access. Social support refers both to the emotionally-sustaining and instrumentally-beneficial qualities of social relationships (Umberson & Montez, 2010). Morenoff and Lynch (2004) argue that social support is especially important for the health low-income individuals who, in the absence of health-related resources like health insurance, educational skills, and family income, disproportionately rely on resources from their social relationships. Greater social support acts directly to improve physical and mental health (and indirectly as a buffer from the effects of stress) (S. Cohen, 2004; Uchino, 2006). Providing support to others gives meaning to people’s lives by allowing them to fulfill multiple social roles (Thoits, 1995) and can also engender a sense of responsibility to take care of their own health in order to fulfill their obligation to others and the community (Waite, 1995). Perhaps more intuitively, people also benefit as receivers of social support; for example, people may receive assistance from their neighbors with tangible needs, such as transportation for groceries, assistance at healthcare appointments, or help with health-related decision-making (Berkman et al., 2000; House et al., 1988).

The Current Study

In this study I explore how individuals in an ethnically-diverse low-income neighborhood interpret, use, and interact in neighborhood places. I then consider the potential relationships such places may have with health-related behavioral and social mechanisms. I use qualitative data to tell a detailed story of what residents say it means to live in this neighborhood by describing the ways in which three specific examples of vital places – an ethnic grocery store, a nearby park, and neighborhood courtyards – may facilitate beneficial behavioral and social processes that have empirically-demonstrated relationships with health (see Figure 1 for a conceptual model of the proposed relationships). The local knowledge I explore is critical for understanding how different features of neighborhoods can shape health, and can assist policy-makers in structuring place-based interventions (Corburn, 2005). In particular, I focus the analysis on the following research questions:

1. How do residents describe and use the places in the neighborhood they identify as important?

2. Why and how might these be vital places for residents’ health-related behavioral and social mechanisms?

Figure 1.

Conceptual Model: Vital Places and the Relationship of the Neighborhood Structural Environment with Individual Behavioral and Social Mechanisms with Health

Research Context and Methods

Setting

The Bayview neighborhood sits in the heart of what was once known as “The Bush”, a swampy area of Madison, WI, that resisted early development and was used by residents mainly as a refuse dump (Levitan, 2006). The swamp was eventually filled in the 1920s and became home to many ethnic groups, such as African Americans from the Southern U.S. and Italian immigrants. By the end of the 1950s, what was known as a flourishing ethnic community was simultaneously seen as a blighted ghetto to many outsiders and the neighborhood was razed in the spirit of urban renewal. The Bayview Townhomes were built in this area in 1971, consisting of 102 multifamily housing units intended to provide affordable housing. The Section 8 property is federally-subsidized by the U.S. Department of Housing and Urban Development (HUD), but owned and operated by the non-profit Bayview Foundation. A federally-subsidized, low-income housing neighborhood is an integral case for understanding the importance of neighborhood places because of its unique urban form; in an attempt to create areas that were “morally purer” than the slums they replaced, designers of affordable housing in the 1970s explicitly filtered out the “temptations of bars, the dangers of cars, and the entire realm of commercial activity” (Vale, 2002 p.9). The result, in many low-income and subsidized housing neighborhoods, was that the vitality and security of public streets and street life was lost, and over time many of these neighborhoods became isolated, degraded enclaves.

The Bayview neighborhood is not a totally isolated enclave, but it does lack a street life. The neighborhood itself consists of a series of two-story, attached apartments scattered in rings around grassy courtyards. Figure 2 provides a map of Bayview (located in the triangle near the center of the map) and some assets identified within approximately ten minutes of walking distance. My definition of “nearby” in the neighborhood is ten minutes or less of walking because of research showing that those who are able to walk to places within ten minutes are most likely to be active in their neighborhood (Powell et al., 2003). Bayview’s location close to downtown Madison means that residents have access to many bus lines; in fact, there are 6 lines serving the heavily-trafficked triangle of streets surrounding the neighborhood. Despite the neighborhoods access to public transportation, having destinations nearby is especially important for these residents who are often restricted in their ability to go far from home by financial, mobility, and health limitations. As Coley and colleagues (1997) put it, “Public housing residents tend to live their lives in and around their apartments; they have less choice in the locations in which they spend time and thus in the social experiences they encounter.” The residents of Bayview are, by and large, “foot people” (Jacobs, 2011 [1961], p.xxii), which is not necessarily an existential choice on their part, but more of a necessity, as many of the residents don’t drive because they lack formal education, are poor, speak little English, and are elderly.

Figure 2.

Bayview Neighborhood and Surrounding Area, Showing Asian Midway and Nearby Markets, Brittingham Park, and the Neighborhood Courtyards

Methods

Sample

I focused on the Bayview neighborhood because it exhibits certain features of structural disadvantage – poverty concentration and racial and ethnic minority concentration – that often align with social disorganization and worse individual outcomes in neighborhoods (Sampson, 2012). Poverty concentration relates to social isolation from positive role models and social networks (Jencks & Mayer, 1990; Quillian, 2003), mistrust (Ross et al., 2001), and unbalanced exchange relationships (Phan et al., 2009) among neighbors. Racial diversity also plays an important role in neighborhood social relationships in that it can hamper interpersonal communication (Putnam, 2007), limiting residents’ ability to resolve common problems and achieve community goals (Kornhauser, 1978). As such, neighborhood poverty and racial/ethnic concentration are negatively related to health and well-being (Lillie-Blanton & Laveist, 1996; Robert, 1999). Residents of Bayview are, by definition, poor; to qualify for the subsidized housing at Bayview, residents must demonstrate that they would otherwise be putting more than 30% of their income toward housing costs. The families who live at Bayview overwhelmingly belong to racial and ethnic minority groups; out of the 102 apartments at Bayview, 99 are occupied by non-white families.

I conducted 27 semi-structured interviews and 3 focus groups (comprised of 9 returning interviewees and 1 new participant) with the neighborhood residents at Bayview between July 2011 and May 2012, aiming to speak with residents of various ethnic backgrounds and ages. Participants were initially recruited through flyers posted in the Bayview Community Center (in English, Spanish, and Hmong) and directly through a Hmong cultural liaison living in the neighborhood. I also used snowball sampling techniques, asking each participant to suggest other residents I could speak with who had knowledge about the neighborhood. I succeeded in getting representation from most groups in the neighborhood, interviewing 13 Hmong Americans, 6 Mexican Americans, 2 African immigrants, 3 African Americans, 2 whites, and 1 Vietnamese American. I conducted interviews in English and Spanish and a research assistant conducted the interviews in Hmong while I was present.

The gender ratio of the participants was not balanced, with a total of 21 female and 6 male respondents. The sample is varied in terms of age, however, with the youngest participants being 20 years old, the oldest 79 years old, and the average 53. Participants lived at Bayview for between 1 and 40 years, with half of them living there for at least 20 years. I make no specific claims about the comparability of the sample to the larger population. My intent is not to generalize, but rather to generate an in-depth analysis in which I can base my hypotheses about vital places in the neighborhood.

Interviews and Focus Groups

Interview questions focused on daily routines and the ways that residents interact with places in the neighborhood. For example, residents described a typical weekday and weekend day, and I asked them specifically about where they go, what they do, and with whom they interact. I also asked them to identify and describe places in the neighborhood that were important. See Appendix A for the full interview template. Interviews and focus groups took place in a private room at the Bayview community center or in residents’ homes. I asked all interviewees to take a walk around the neighborhood, while we discussed their feelings about places they identified as important. The “walk-along” interview (Carpiano, 2009) is particularly valuable for understanding people’s interpretations of places while they are interacting with the social and physical environment, as it encourages context-sensitive reactions and enhances recall of memories.

The three focus groups all took place after completion of the interviews. Focus groups were organized by language in English, Spanish, and Hmong, so that respondents could participate comfortably. My intent was to validate the themes that had emerged from the study. I asked participants to respond to photos of the neighborhood, prompting them to discuss what they saw and what the photos made them feel. While the interviews were generative of themes and ideas around vital places at Bayview, the dynamic interchange of respondents in the focus group format allowed for deeper insights and an exploration of consensus among participants.

Analytic Approach

Following an abductive research approach (Timmermans & Tavory, 2012), I came to the data with some social and behavioral place-based theoretical health frameworks in mind to aid in my analysis, but also remained open to ideas and themes that emerged from the data. I was particularly aware of the fact that this neighborhood seemed anomalous in that it appeared to have more health-related resources than other comparable subsidized-housing neighborhoods, so I cultivated the data to examine this anomaly through systematic methodological analysis. I used the constant comparative analysis technique (Charmaz, 2006; Glaser & Strauss, 1967) to explore the ways in which residents spoke about using and interpreting nearby neighborhood places. I began analysis from the first interview and as the study went on I constantly revisited the data, comparing newly-collected data with emerging themes, finding relationships between themes, and going back and forth between data collection and analysis. My research assistant and I separately coded transcripts within a week of collection, and cross-checked our codes with a group of between 4 and 6 qualitative researchers at the University of Wisconsin Institute for Clinical and Translational Research (ICTR). I applied case study logic to the sampling procedures (Yin, 2009), where each case provided an increasingly accurate understanding of the questions at hand, and yielded a set of findings that informed the next case, proceeding until we had reached saturation. The protocol for this study was approved by the Social and Behavioral Science Institutional Review Board at the University of Wisconsin – Madison (# SE-2011-0447).

The theoretical and empirical meaning of vital places derives principally from the interview question that asked, “Can you identify some places in the community that are important to you?” Residents listed places and we discussed each in depth. Throughout the interviews, residents listed 45 unique places that were important to them, places like the public library, the nearby hospital, individual health clinics, the zoo, shopping malls, large discount grocery stores, and the veteran’s museum. The ethnic grocery store, the park across the street, and the neighborhood courtyards were validated by multiple residents as very important, nearby and frequently-used. I discuss these three locations as vital places because of the frequency with which they were mentioned, as well as the ways residents spoke about the importance of these places in their daily lives, the nearby location, and the potential relationships with social and behavioral mechanisms relating to health. The ethnic grocery emerged as important in 23 out of 27 interviews, while the park and courtyards were discussed as important in 18 and 15 interviews respectively. Details revealing the extent and depth of their importance to residents emerged in the ways residents spoke about the places and through my observations of their interactions with places as we walked around the neighborhood. I asked about how they used the places they identified as important, in what ways they were important, and, through in-depth coding and analysis, created abstract categories of subjective meaning for the respondents. In the focus groups we discussed photographs of the vital places, allowing for some validation of the themes that emerged throughout the study.

Limitations

There are two main limitations of this study. First, I rely on a relatively small sample of residents living in one neighborhood in a mid-sized Midwestern city, raising questions of generalizability. In addition, while my investigation focuses on a poor, non-white community, the neighborhood is not typical in the sense that nearly half of the residents are Asian American, and though African Americans are a substantial proportion of residents, they are in the minority. Thus, the findings presented here may not fully reflect the experiences of individuals living low-income, subsidized-housing neighborhoods in general. On the other hand, the exceptional nature of this neighborhood is one of the reasons I chose it to be the subject of this study. I argue that we should be studying exceptional neighborhoods, as understanding the strengths and assets that allow residents to overcome hardship may give us some purchase on the types of interventions that could improve disadvantaged neighborhoods.

Second, I do not directly measure health outcomes in this study, but I do consider the ways in which residents perceive and talk about health-related behavioral and social mechanisms. Participants often spoke about well-established health behaviors, like physical activity, a diet including whole foods, and social support, and they often related perceptions of their health outcomes in interviews. Moreover, this study was designed with a health framework in mind, such that a primary goal was to elucidate details about already-established pathways of the social determinants of health. Thus, the presence of a relationship between neighborhoods and health is implicit, but empirically well-established in the literature. The qualitative nature of the study allows for a deeper exploration of how and why neighborhood places are potentially meaningful for the health of residents.

Results

Ethnic Grocery: Convenient, Comprehensive, Affordable Food Source

The first vital place I consider is the small ethnic grocery store, Asian Midway. Of the five grocery and convenience stores within a ten-minute walk of Bayview (see Figure 2), only Asian Midway can be considered a vital place because it rises to prominence as an important, frequently-used destination for most residents and it stocks a comprehensive variety of healthy ethnic foods. The other nearby markets include Fraboni’s (an Italian deli and grocery), Kelley’s Market (a convenience store serving some prepared foods), Capitol Centre Market (a small grocery catering to University of Wisconsin students), and Fresh Madison Market (a medium-sized grocery with upscale selection and prices). While Kelley’s Market was deemed important to some residents, the other markets were not mentioned in any of the interviews. As shown in Figure 1, I suggest that Asian Midway’s convenience, comprehensiveness, and affordability make it a vital place that may facilitate a healthy diet among Bayview residents.

A major advantage of Asian Midway is its convenience, which is particularly important for residents of multiethnic, low-income neighborhoods, who often have limited mobility and limited English proficiency. One elderly resident put it bluntly, “You can walk there and [it is] convenient for old people.” An elderly African American woman also spoke about being able to walk, “Most times I go to Asian [Midway] ‘cause it is close [and] I don’t drive. But then, if I have somebody pick me up, we go to Walmart or the Dollar Store. So, every now and then I’ll go [to another store].” While it is possible to reach these large, discount stores on the bus, it is certainly much easier if one has their own transportation; for those without a car, getting to the store often requires having friends with resources who are willing to help out. Convenience can mean more than just being easy to travel to. One Hmong woman simply said this about Asian Midway, “It’s not complicated.” For her, an elderly woman who does not drive and does not speak English, the ethnic grocery is an easy place to shop; she knows the products and can get the food she needs to feed her family without the complications of travel and the work required to communicate in English.

But, Asian Midway is far more than convenient; it is also comprehensive in ways that serves the needs of this particular community. Though Asian Midway is a tiny market in terms of square footage, it carries a varied selection of produce, specialty meat and seafood, large bags of rice, packaged food, and some basic kitchen staples. While it does sell processed, packaged food, it also sells a variety of whole foods from the residents’ native cuisines that are necessary components of a healthy diet (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2010). While many residents did grocery shopping at large chain grocery stores on the weekends when they had access to transportation, many of the neighborhood’s diverse residents, including individuals of African, African American, Southeast Asian, Latino, and white descent, were able to meet their weekday grocery shopping needs at Asian Midway. A long-time African American female resident spoke about the types of foods she could get at the store, “I go for the fresh fish and the meat. Well, they have ox tails, which I haven’t found at other stores. And, if I do find it in other stores, it is higher [price]. The ribs are much cheaper at Midway, and they have the riblets. Midway has always been the neighborhood store to go to.” Another woman, an African immigrant, said, “Oh yeah, [Asian Midway] is normal, [Asian Midway] is ‘all the time’. That’s where you get indigenous food, like Asian, Nigeria[n], Ghana[ian] food. So we pretty much get food from there.” A Mexican American woman says, “We have that Asian food store down here, which sells a lot of products that I would buy anyways at a Mexican store. Mostly, it is what we use most, like tortilla, tomato, chiles, […] galletes, cans for making pozole, frozen shrimp. There are many things that [Asian Americans] use, but we also use.” The examples the residents describe above are representative of the types of whole, ethnic foods many neighborhood residents bought at Asian Midway which were not available at other groceries.

These residents are also incredibly savvy shoppers, and price matters. An elderly Hmong resident makes that point well, “Asian Midway is cheaper! A bag of rice at the Hmong store for 25 lbs. is $22.95. [The] Hmong store is expensive. At Asian Midway rice is $21.90 and it’s just walking distance.” This nicely demonstrates that even small differences in prices are very important; even a difference of a dollar influences shopping location choices. In support of this idea, another young Mexican American resident said, “It is a little more economical also. There are some things that we use a lot. We know they are of better quality and cheaper; we will buy them there.” Later, she went on to say, “I can get things in any place. What happens is that things are cheaper here. Like the meat is cheaper. There are some days, like Tuesday and Wednesday, when the meat is fresh, so it is better.” Not only are the products cheaper, but they are often of higher quality. In short, Asian Midway is successful in part because they know their market; it has risen in importance to the residents as a community fixture because it understands and responds to the community’s needs and preferences.

Locating a comprehensive, affordable ethnic grocery within walking distance of a poor, multiethnic neighborhood likely improves the chances that limited-mobility residents will partake in a nutritious diet because they are more able to access a variety of healthy ethnic foods. By their very nature, ethnic foods representative of residents’ native cuisines may be healthier because they are more likely to meet dietary guidelines for total fat consumption, fiber, and nutrients than typical American food (Dixon et al., 2000; Guendelman & Abram, 1995). Scholars are increasingly concerned with “dietary acculturation”, where individuals adopt the (less-healthy) dietary practices of the United States as they spend more time in the country (Satia-Abouta et al., 2002). Dietary acculturation may be an important risk factor for diet-related chronic diseases, such as type-2 diabetes (Pérez-Escamilla & Putnik, 2007) and colorectal cancer (Monroe et al., 2003), and has been demonstrated among Latinos (Ayala et al., 2008) and Asian immigrants (Satia et al., 2001) in the United States. Therefore, it is possible locating an ethnic food store nearby a multiethnic neighborhood may increase healthy food options simply by virtue of the ethnic food options it offers.

The current analyses suggest that Bayview residents do much of their food shopping at the ethnic grocery because it is convenient (they can walk there and it is “not complicated”), it stocks a variety of ethnic foods that appeal to residents, and the prices are affordable. One elderly Hmong man summed up his reasons for shopping at Asian Midway, “I always go. It’s close! It’s not far and you can buy whatever you want…rice, peppers, meat. And then you come home. It’s easy for Hmong people.” I argue that “easy”, in the case of Bayview residents, means both geographically-proximate and socially-comfortable. It has been shown that availability of Latino grocery stores (tiendas) in low-income areas may improve access to quality, fresh produce (Ayala et al., 2005). These authors find that women who are less-acculturated prefer tiendas, speculating that they are more comfortable shopping in small, ethnic stores where they do not face language barriers and unavailability of certain ethnic food products. Similarly, a recent qualitative study of Hmong immigrants’ dietary habits found that less-acculturated individuals were less likely to consume a more “Americanized” diet because of difficulty speaking English at restaurants and buying food in large grocery stores (Franzen & Smith, 2009). I depict this possible association of the ethnic grocery with a healthy diet in the conceptual model Figure 1, where I suggest that a convenient, comprehensive, and affordable source of healthy food is a vital place which may impact the behavioral mechanism of a healthy diet in the association of neighborhood structural disadvantage with health.

Nearby Park: Attractive, Accessible, Safe Recreational Facility

A second vital place is Brittingham Park, which more than half of the participants identified as an important and frequently-used place in the neighborhood. While city parks are often considered uncritically as boons for deprived areas of the city, Jacobs (2011 [1961]) argues that city parks are volatile, and that without people “conferring use on them” they can be doomed to failure. She finds that well-used parks share a number of features: an effective center, multiple land-uses in adjacent areas that encourage convenience-use of the park at many times of day, and a diverse combination of activities within the park that operate effectively as ‘demand goods’. Given these criteria, it is not clear that Brittingham Park should be a popular destination. The park lacks an effective center; rather, it takes the shape of a long crescent on 26 acres of land. It is not near multiple land-use areas, but is bounded by a walkway along a lake’s edge on one side and a high-traffic, four-lane, arterial street on the other.

In its favor, Brittingham Park does have a number of amenities, or ‘demand goods’, that attract people to the park as a destination for recreational physical activity and offer space where residents can maintain social ties. The park has fishing access, designated sports fields, and lakeside scenery in the middle of the city. A number of Bayview residents spoke about the park’s amenities as facilitators of the behavioral mechanism of physical activity. For instance, a young Nigerian woman with several health limitations said, “When I’m strong enough and feel like walking, I go to the park, which is very nice. Sometimes we go fishing around there too.” Similarly, a Hmong mother of older children, who stays home during the day, talked about going to the park with her friends, “Later in the day, when the kids come home, the aunts and I go walk around the park until it is time to eat.”

The park’s comfort and amenities also mean that residents use it to maintain social ties, an important social mechanism through which neighborhoods impact health. An older Mexican American woman said she uses the park to be with her friends, “If I want a picnic, I go to the park with my friends. There are many friends who go on picnics with me.” An African immigrant woman with young children agreed, “We just go and sit down and talk. It’s nice when the weather is nice to pack a lunch. It’s just nice to be out there; [it is] relaxing.” Somewhat less intuitively, a Mexican American woman with young children said that the park helps her maintain her relationships with her own family who does not live at Bayview, “It is exactly for this reason that my brothers come here to visit me. They say, ‘Our kids can’t go out and play because there are cars and there is no place for them to play.’ They want to come and play at the park here [at Bayview].” In these ways, the park acts somewhat as an extension of home, offering a comfortable social space where residents can meet friends and maintain their family relationships, and they can do so in a natural, relaxing setting amidst the hustle and bustle of the city. It is important to acknowledge that the park is not a year-round destination, as the harsh winter weather in Madison means many people don’t venture outside except for necessity.

Accessibility is another reason Bayview residents are frequent park users. Brittingham Park is located within a 5-minute walk of the neighborhood and connected by a pedestrian bridge leading over the busy street (see Figure 2). The park’s proximity improves access; it has been shown that those who live farther from recreational areas are less likely to visit (Sallis et al., 1990). The pedestrian bridge is also important for access because heavy traffic in surrounding areas can be a substantial barrier for park use (Troped et al., 2001). Both elderly residents and families with young children at Bayview spoke about going to the park because it is nearby and easy to access. An older resident, who had a number of health conditions that limited her mobility, said, “I use the cross bridge to get across the street to the lake. I do not walk too far in case I may come up with a problem because of my high blood pressure and my heart conditions.” Another woman emphasized how the pedestrian bridge improved access for her children, “There was always that bridge, that walkway. Going to the park wasn’t hard. Most of the time [the children] wouldn’t take [the pedestrian bridge] but if I [was] watching, they had to. So, there was a safe way for them to get to Brittingham Park and back, because if the cars were not coming one way, they [were] coming the other way.”

In addition to being accessible, residents perceived the park to be a very safe place to walk. While the association is intuitive, there is little research linking perceived safety with park use, but some studies indicate that lack of neighborhood safety is associated with lower physical activity levels (Centers for Disease Control and Prevention, 1999; Humpel et al., 2002). One Hmong man said, “You can go alone. There are a lot of people and nothing to be afraid about. People in those areas are friendly.” A Hmong woman also said, “Sometimes my friends and I go walk and exercise there at nighttime. If you go [in a group of] 2 or 3 people, it is safe. There aren’t any issues or problems that occur.” A young Mexican American woman related the safety in the park to its open layout and heavy traffic, “I am very safe when I go walking because I’m in an open place. Cars go by all the time. There is nothing for me to be frightened about when I go walking alone.” Another elderly Hmong man, who walks in the park twice a day, spoke about safety in a different way; his level of comfort at the park was related to emotional safety. He likes walking in the park because there are “good people” there, unlike when he walks downtown where “the people are different and they look at you as if you are lower class.” For him, the park is a place where he feels like he fits in and is not being judged, which makes the park a desirable destination for him.

Neighborhood Courtyard: Shared, Casual, Focused Social Space

The final vital place I consider is right outside residents’ front doors: the neighborhood courtyards. The courtyards are shared spaces that allow for observation of and acquaintance with neighbors; offer a venue for casual socialization without commitment; and contain certain focal points (e.g., barbeques and picnic tables) which enable both the establishment and maintenance of supportive relationships among neighbors.

The shared aspect of the courtyards allows for observation and provides a space to make acquaintance and develop relationships with neighbors over time. One African American woman said, “The courtyard gives me an opportunity to see [my neighbors] and introduce myself. I get to know other people and families.” Another African American woman described the courtyards this way, “If you’re out in a courtyard area, then you see people coming and going, being outside. So, you get to know them. You may not speak the same language, but you know, you do say ‘hi’ to each other. They’ll ask me how I’m doing. I’ll ask them how they’re doing. So, it’s more like a family”. In this passage, she transitions quickly from surface-level sociability in the courtyards to expressing that her neighbors feel like family. This is typical of many residents, who described just saying “hi” to a lot of people, but simultaneously feeling well-known and accepted in the community. The ability to see people come and go frequently in the courtyards was a solid foundation for the development of trusting, familiar relationships among neighbors.

The courtyards also provide a casual venue for socializing that is away from the private sphere of home. One older white woman described the social interaction in the courtyards this way, “I guess we’re just passing by and we stop and talk a few minutes. I mean, I don’t go to anybody’s doors and stuff, but it’s more or less when you’re out and around, it’s good to communicate.” Specifically, she was not willing to make the commitment to enter her neighbors’ private spaces, nor invite them into hers, but she was more than happy to socialize in the shared courtyard. Another young woman, an immigrant from Cameroon, revealed a similar sentiment, “My neighbors down there, I think they are from Mexico, we talk. I don’t go to their house and sit. They don’t come to mine. We meet outside, we talk, ask how things are going.” The courtyards provide a space where neighbors can casually make acquaintance without making a commitment; they allow neighbors to build a kind of rapport over time that may not be possible in an apartment building or even on a street lined with single-family homes.

Within the courtyards, barbeques and picnic tables serve as focal points of interaction. An older woman described the ubiquitous barbeques as being conversation starters, saying, “If we’re out there barbequing, [neighbors] come by and look at the grill.” A college-aged Hmong woman talked about meeting one particular neighbor often while she was out studying at the picnic table in front of her apartment. She said, “There’s a picnic table right in front of my house, so that’s convenient. My neighbor here, he’s Hmong too. He’s really friendly. He always talks to me when I go out there.” The neighbor she spoke of, an elderly Hmong man, pointed out the very same picnic table on our walk around the neighborhood, “This table is used for sitting, gathering, talking. Sometimes relatives and friends come and we sit and have a good time.” It is the shared aspect of the courtyards that brings people together when they are barbequing or sitting at an outdoor table. Residents feel perfectly at ease stopping by and chatting about what’s on the grill, or sitting down at the table to talk; in this way, the barbeques and picnic tables serve as the “focus of attention” (Goffman, 1963) that allows for gathering and acquaintanceship to happen in the courtyards.

While we have good evidence that social support impacts health (Umberson & Montez, 2010), this study suggests that certain neighborhood places might actually contribute to the generation and maintenance of supportive social relationships among low-income neighbors. These analyses demonstrate that the shared courtyard area in front of residents’ homes enable casual social contact that may eventually lead to the provision of health-related social support among neighbors. An older Mexican American woman talked about her Hmong neighbors greeting her in the courtyard when they haven’t seen her in a while, “They ask me, have you been sick? I tell them I’m ok. They tell me, ‘oh my legs hurt.’ They touch their legs because, you know, they can’t express what they want to say [in English]. We all make an effort and come together.” She demonstrates here that her neighbors express concern for her and feel comfortable sharing their own pains and worries, despite a language barrier between them, and that meeting them in the courtyard regularly has facilitated their supportive relationship. I found that shared, casual, focused social spaces are vital in that they seem to facilitate the social mechanism of social support in the relationship of neighborhood structure with health (see Figure 1). The courtyards at Bayview are places where residents can observe each other and make acquaintance casually, without the commitment of inviting each other into their private spaces. The barbeques and picnic tables are focal points in the courtyards that give even those unknown to each other an excuse for starting conversation, for having a brief connection that could eventually lead to checking in or calling for a favor. Importantly, many of the types of social connections I have described here hinge upon being outside and casually bumping into neighbors, which is hampered in winter months.

Discussion

Scholars and policy makers increasingly recognize that factors outside of the health care system, such as the social and built environments of neighborhoods, can have profound impacts on population health. In the current study, I propose the concept of vital places, which articulates an organizational framework for integrating relatively-independent public health and the social science literatures on neighborhood effects. Vital places are destinations located within a ten-minute walk from home that are agreed-upon by neighborhood residents to be both important and frequently-used; acknowledging the vitality of certain neighborhood places also means that they have a theoretical relationship with health through behavioral and social mechanisms. In the current study I conduct a qualitative inquiry into how and why vital places may facilitate both behavioral and social mechanisms related to better health within the context of a federally-subsidized, low-income housing neighborhood. I examine residents’ subjective perceptions and uses of three particular vital places in the neighborhood – an ethnic grocery store, a nearby park, and neighborhood courtyards. Based on the analyses of particular places, I generate a set of broad principles about the features of vital places that may enable both healthy lifestyles and supportive social relationships. Exploring the ways residents use and interpret each of these places offers policy insight into the utility of investing in vital places in order to support health in low-income neighborhoods.

Bayview residents identified the ethnic grocery as a vital place in their neighborhood. Recent studies show that, compared to predominantly-white neighborhoods, minority neighborhoods have half as many supermarkets, which tend to offer nutritious foods at lower cost (Eisenhauer, 2001), and fewer stores that offer fruit and vegetables (Moore & Diez Roux, 2006). Similarly, Horowitz and colleagues (2004) found that those stores that are located in minority neighborhoods are less likely to carry a selection of healthy foods; eighteen percent of bodegas in minority neighborhoods carry health foods compared to 58% in predominantly-white areas. Affordability seems to be especially important in food choices, given research showing that having a low income is a substantial deterrent of a healthy diet (Curtis & McClellan, 1995), and that the poor engage in various adaptive strategies to meet daily caloric demands, like purchasing more energy-dense and processed foods at convenience stores to avoid travel-related costs (Adelaja et al., 1997). Thus, it may truly be unusual, and therefore particularly important, for a poor, multiethnic neighborhood to have access to the variety of healthy, affordable foods that the ethnic grocery offers.

The convenience, comprehensiveness, and affordability of the ethnic grocery make it an important destination among the residents of Bayview. These findings suggest policies aimed at supporting the location of an ethnically-responsive store within walking distance of poor neighborhoods (by providing financial incentives or enabling the formation of partnerships between businesses and local communities) have the potential to reduce health disparities by facilitating a healthy diet among those with limited resources. Though these analyses focused on an ethnic grocery store, understanding the features that make the grocery vital allows us to make connections to other healthy food sources, like community gardens (Armstrong, 2000), farmers’ markets (Larsen & Gilliland, 2009), street vendors (Morales & Kettles, 2009), and programs connecting local farmers with neighborhood convenience stores (Levy, 2007; Sandoval et al., 2012). Conceiving of healthy food sources as vital places that can sustain health in multiple ways provides an expanded notion of food access with direct policy implications. Not only do we need to think about locating healthy food options in underserved areas (Story et al., 2008), but we should consider the particular neighborhood context and the characteristics that make a food source vital to residents. In the case of the Bayview neighborhood, where residents come from a diversity of national origins and have limited access to private transportation, the considerations of comprehensiveness and convenience are especially consequential for understanding residents’ use of the store, and thus have direct implications for the place’s ability to serve a vital function in their lives.

These analyses also suggest that certain features of neighborhood parks may facilitate both the behavioral and social mechanisms linking neighborhoods with health. Research clearly demonstrates inequality in the built environment of neighborhoods in terms of availability and quality of parks and recreation areas (Dahmann et al., 2010; Moore et al., 2008). Park use may be particularly problematic for individuals from low-income neighborhoods, who often experience real and perceived barriers to park use (D. K. Wilson et al., 2004) and are less likely to use parks for physical activity (D. A. Cohen et al., 2012). Not only did Bayview residents use the nearby park for physical activity, but residents spoke about using the park as a gathering place, a place that allows them to nurture and sustain their relationships with family and friends. We know that supportive social ties matter for health, and this is particularly true for disadvantaged groups, because they often rely on instrumentally- and emotionally-supportive resources that come with social ties to make up for lack of socioeconomic resources (Morenoff & Lynch, 2004). A recent study argues that neighborhood built and social environments are inextricably linked, finding that individuals who perceive both high walkability and social connectedness in their neighborhoods display the highest levels of physical activity (Kaczynski & Glover, 2012); the authors discuss how people base their physical activity decisions on their interpretations of the everyday spaces in which they spend time and the social interactions they have with people in those spaces. Brittingham Park’s apparent facilitation of both behavioral and social mechanisms toward health suggests that researchers and policy-makers should attend to both in their attempts to understand and improve neighborhood vital places.

While these analyses were concentrated on a park in this particular neighborhood, the qualities that made it a vital place may be relatable to other neighborhood recreational areas that support both behavioral and social processes in cities, like schoolyards (Brink et al., 2010), open spaces (Sugiyama et al., 2010), and green spaces (Maas et al., 2009). In support of the idea that parks are vital places that can facilitate both behavioral and social pathways to health, Cattell and colleagues (2008) find that people derive a range of therapeutic benefits from open spaces in cities, such as the ability to escape daily routines, find restorative pleasure in being alone, and nurture the bonds of place attachment. The vital places concept is particularly valuable in explicating the dual roles that neighborhood parks and other open spaces can have in supporting health; appreciating that places can impact health in multiple, synergistic ways increases the potential for making a difference in a community by improving one neighborhood place.

Finally, the neighborhood courtyards are vital places at Bayview. Jacobs (2011 [1961]) discusses the importance of having a mixture of private and public spaces in cities, arguing that the fleeting or momentary encounters that happen in public places sum to a larger whole, a “web of public respect and trust and a resource in time of personal or neighborhood need” (p.73). For Jacobs, an important aspect of the trivial encounters is that they take place naturally, in public, because while people enjoy a certain degree of contact, they don’t want to be overly committed to others in their private spaces. Bayview residents’ observations about the courtyard design suggest that a combination of public and private space in front of people’s homes contributes to repeated, casual interaction that may lead to supportive relationships in the long term. The neighborhood courtyards are shared spaces for observation and acquaintanceship, casual socialization without commitment, and they contain features that serve as focal points for initiating acquaintanceship; in these ways neighborhood courtyards serve as vital places that can facilitate social support, a well-established health mechanism.

The courtyards are vital because of their shared nature, the casual opportunities for socialization, and the focal points that act as acquaintance opportunities. Each of these aspects contributes to the courtyards’ ability to enable the social support mechanism in the relationship of neighborhood structure to health (see Figure 1). The courtyards’ features that make them vital to health may be similar to other types of community gathering spaces, like barber shops and beauty salons (Sánchez-Jankowski, 2008), and “third places” (Oldenburg, 1989), like coffee shops and bookstores, that are used for social interaction away from home and work. Some recent work has investigated how, beyond providing a local source of healthy food, community gardens can cultivate healthy social processes, like collective efficacy (Teig et al., 2009). Similarly, Cattell and colleagues (2008) describe how regular, mundane social encounters in a public market form the basis for sustaining bonding ties and bridging differences among neighbors. Conceiving of all these places (courtyards, barbershops, and third places) as vital for health in their ability to facilitate social support among residents provides an abstract category to organize the literature and conceptualize how neighborhood places influence individual health.

Motivated by a desire for more complexity in the research and policy discussions related to urban neighborhoods, I investigate the anomalous case of an apparently-successful, yet low-income neighborhood in this study. This research orientation aligns with a group-empowerment policy agenda (Briggs, 2005), which suggests that rather than move residents out of disadvantaged neighborhoods (Rubinowitz & Rosenbaum, 2000), we might better-focus our interventions with an understanding of the assets that already exist in the places they live (Sánchez-Jankowski, 2008). Because the neighborhood environment is particularly consequential for people with limited mobility and limited English proficiency, policies that build up the “vital” aspects of places in low-income neighborhoods might be a good way to improve quality of life while allowing residents to stay in the places in which they often have established strong social support networks (Keene & Geronimus, 2011).

In contrast with the past, when subsidized housing often meant the construction of massive projects surrounded by wasteland and decay (Vale, 2002), today, housing revitalization focuses on building livable communities, composed of mixed-use spaces and mixed income residents (Kleit, 2005). This research helps us understand the aspects of places that make them vital, which can assist us in integrating health outcomes into our revitalization and growth strategies in urban areas. For example, this study showed that shopping convenience can mean both being able to walk to a destination nearby and get what you need in an uncomplicated way for those with limited English and the elderly, and that comprehensiveness means stocking ethnic foods, unique meats, and fresh vegetables. Knowing the ways that diverse populations respond to and interact with vital places such as the ethnic grocery may help us tailor our interventions to the particular needs of different groups and the settings in which they live, as well as provide useful information to guide funding decisions through programs such as the Partnership for Sustainable Communities. The federal Partnership agencies (HUD, DOT, and EPA) provide “funding and technical assistance to support communities creating vibrant, healthy neighborhoods that provide more housing options, economic opportunities, and efficient transportation while reinforcing existing investments” (Partnership for Sustainable Communities, 2010).

In sum, this study is important for both scholars and policy makers, who can benefit from a better understanding of the vital places in neighborhoods that have the potential to synergistically improve residents’ health through behavioral and social mechanisms. I argue that an important reason residents appear to be doing well in the Bayview neighborhood is that they have a variety of vital places within walking distance of their homes and that these vital places facilitate empirically-established behavioral and social processes that enable better health.

Appendix A. Interview Questions

1. Where were you born? What is your birth date? What racial or ethnic group do you identify with?

2. Tell me the story of how you came to live in Bayview.

   1. What is the same about this neighborhood and other neighborhoods you’ve lived in?

   2. What is different about this neighborhood?

3. Can you please describe your typical day?

   1. Where do you go?

   2. What do you do there?

   3. Who do you interact with?

   4. Is this a week day? Weekend day?

4. Can you identify some places in this neighborhood that are important to you?

5. What does “community” mean to you?

6. Is Bayview a community? What is it about this place that makes it feel like it is a community?

7. Do you feel attached to Bayview?

8. Do you trust your neighbors?

9. Do you talk with people from other ethnic groups? Do you see other people talking together much?

10. Do you help your neighbors in any way? Do they help you?

11. What sort of image do you think people who do not live in this area have of it?

12. What would you change about this neighborhood if you could?

13. I would like to show you some photos. Please tell me what you see in the photo. How does the photo make you feel?

14. Can we take a walk around your neighborhood together so you can show me the places that are important to you?

15. What should I have asked about your neighborhood that I didn’t think to ask?

16. Are there any other important ways you would describe yourself?