Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

Abstract

Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [-4.40 percentage points; 95 % confidence intervals (CI) -5.80, -3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

Keywords: Health care reform; Multilevel analysis; Neighborhood; Philadelphia; Primary health care; Safety net providers; Vulnerable populations.

FIG. 1

Directed acyclic graph of the hypothesized causal structure linking neighborhood socioeconomic status (SES) and primary care use. Circle with black triangle in the center represents the exposure (neighborhood SES); circle with black I in the center represents the outcome (primary care use). All other circles represent confounders and mediators. Unidirectional-pointed arrows represent effects. Diagram produced by DAGitty (http://www.dagitty.net/dags.html#).

FIG. 2

Time trends in the adjusted association of usual sources of care (USC) with low-income and middle-income neighborhoods, relative to high-income neighborhoods in Greater Philadelphia. Associations were adjusted for confounders per model 2 specification. CI: confidence interval. Light gray line curves in dark gray confidence bands are association trends for low-income neighborhoods. Dark gray lines in light gray confidence bands are association trends for middle-income neighborhoods. Horizontal gray lines at Y = 0 represent the null. Source: Author analysis of the Southeastern Pennsylvania Household Health Survey, 2002–2012 (n = 55,528).