Geographic Access

There are many different types of access to facilities and resources. One major type is geographic access. Numerous studies show that living in urban, suburban, or rural areas affects one’s health (de la Barra, 2000; Dearry, 2004; Frist, 2005; Hartley, 2004; Kain, 1968; Northridge et al., 2003; Renalds et al., 2010; Sallis et al., 2006; Srinivasan et al., 2003; Wilson, 1996). Nowadays, nearly eighty percent of North Americans live in metropolitan statistical areas— urban agglomerations of towns and cities of 50,000 people or more (Northridge et al., 2003; Srinivasan et al., 2003). De la Barra (2000) states that “cities are the physical expression of the societies that build them, and the political, social, and economic interactions of their inhabitants” (p. 7). What is interesting about urban areas is their juxtaposition of health outcomes. Higher density areas are more associated with walking and biking, and people who live in urban areas report more physical activity than those living in suburban or rural areas (Dearry, 2004).

Although many disadvantaged areas exist in the central city, rural areas are subject to health issues all their own. In fact, Hartley (2004) states that there may be environmental and cultural factors unique to towns, regions, or USDA economic types that affect health behavior and health. Opposite of urban areas, those living in sprawling counties with small populations are more likely to weigh more, walk less, and have a higher prevalence of hypertension (Dearry, 2004). In fact, rural residents are at a high risk of multiple poor health outcomes due to worse health behaviors (Sallis et al., 2006). Rural residents tend to smoke more, exercise less, have less nutritional diets, and are more likely to be obese than other residents (Hartley, 2004). However, these health behaviors have all been correlated with income and education, and may be more influenced by those factors than by rural residence (Hartley, 2004). Rural residents who live in the southern United States have higher rates of poverty, smoking, physical inactivity, death due

52 to heart disease, and teen births (Hartley, 2004). Further, rural areas rank poorly on population health indicators such as the health behaviors mentioned above, as well as mortality, morbidity, and maternal and child health (Hartley, 2004). Unfortunately, in areas with consistently lower wages and low economic influence, economic development is much more likely to trump healthy design (Hartley, 2004). Finally, residents of rural neighborhoods are most often affected by poor access to facilities such as supermarkets (Larson, Story, & Nelson, 2009).

The growth of suburbia exploded in the mid-twentieth century, but has slowed in recent years (Wilson, 1996). Compared to those living in urban or rural areas, those living in suburban areas tend to be healthier (Hartley, 2004). Access to health facilities, including healthcare facilities, supermarkets, and parks and recreational facilities tends to be higher for suburban areas compared to rural areas. However, there are some negative factors associated with living in suburban areas. Like rural residents, suburban residents who live in sprawling areas tend to perform less physical activity and to have a higher body mass index (BMI). Further, long commutes lead to an increase in sedentariness (Renalds et al., 2010). In conclusion, while

suburban areas tend to have greater access to health facilities, the residents are still susceptible to health issues, including low physical activity and obesity.

Regardless of geographic location, disadvantaged groups tend to live in worse

environments with respect to food stores, places to exercise, aesthetic issues, and other facilities. There are disparities in access regarding socioeconomic status and race. For example, Williams & Collins (2001) found that there was unequal access to services provided by the tax dollars paid in African-American neighborhoods. The disparities in access to facilities based on race, income, and socioeconomic status will be lined out in greater detail below.

53 The built environment of any community has features that promote energy expenditure through physical activity and energy intake through the presence of food stores (Duncan et al., 2012). A few years ago, a systematic review of the built environment and health found that most studies examined the following metrics of access to facilities: population density, density of fast food restaurants, full service restaurants, convenience stores, grocery stores, and county sprawl index (Feng, Glass, Curriero, Stewart, & Schwartz, 2010). According to built environment studies, researchers found the strongest support for the importance of food stores, exercise facilities, and safety as the most important characteristics of the built environment (Lovasi et al., 2009). Access to food outlets, parks and recreational facilities, pharmacies, alcohol stores, and others have been linked to health as well (Cohen et al., 2008). The exposure to poor quality food and physical activity environments amplifies individual risk factors for health issues, such as diabetes and obesity (Cummins & Macintyre, 2006). In fact, the most disadvantaged

neighborhoods are the most likely to have the highest rates of obesity, which is a major risk factor for diabetes. These neighborhoods face a paradox of hunger and obesity, because residents in poor neighborhoods tend to consume energy dense inexpensive foods, such as processed and frozen foods high in carbohydrates and sodium (Cummins et al., 2006). These types of

neighborhoods are obesogenic, defined by Lake et al. (2006) as “the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals and populations” (p. 262). There is a robust association of lower income and higher food insecurity with lower intakes of fruits and vegetables (Cummins et al., 2006). Both negative and positive aspects of the built environment exist in every community. I will outline the major facilities below along with the literature associated with them.

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