De las diferencias existentes entre el saber y la práctica

To communicate study findings to community residents, we developed a lay poster describing the study and neighborhood stressors themes identified through focus group discussions (see Appendix D), which was distributed to the CBOs who participated in recruitment and hosted focus groups.

4.3 DISCUSSION

A nuanced understanding of perceived neighborhood stressors is needed to help elucidate complex psychosocial pathways to ill health and susceptibility, and to understand potential synergies with chemical exposures. Community-engaged, qualitative research methods allowed us to capture local experiences and perceptions, towards refining survey instruments, study hypotheses, and ultimately will improve the accuracy of epidemiology attempting to understand complex exposure pathways among social and physical exposures. Using focus group discussions to document perceived neighborhood stressors across diverse urban communities, we identified inter-related stressor themes – police and safety, physical disorder and neglect, and gentrification and racism – and discuss here how our findings can inform emerging issues and approaches for social-environmental health research.

In our study, participant reports of navigating around perceived unsafe places as a protective strategy, as is consistent with previous qualitative research in low-income NYC communities of color (Fullilove et al. 1998; Green et al. 2002).In addition, our findings highlight the previously less documented role of community-police dynamics as a source of chronic stress. Specifically, police behaviors associated with the NYC Police Department (NYPD) Stop-and- Frisk crime reduction initiative, which broadly authorized officers to question and search citizens (NY State Criminal Procedure Law section 140.50), were identified as important stressors for the community at large. Many participants shared personal experiences and observations of abuse of police authority and racial profiling, rather than referencing news stories regarding high profile abuse cases, for example. Though a federal judge has since ruled that Stop-and-Frisk tactics violated the constitutional rights of racial minority populations in NYC, this work adds to the small but growing literature documenting the ways in which public policies, such as immigration enforcement (Hacker et al. 2011; Sabo et al. 2014), may inadvertently induce community distress. Given other research indicating that perceived lack of safety may be particularly important for mental (Aneshensel and Sucoff 1996; Wilson-Genderson et al. 2013) and respiratory health (Subramanian and Kennedy 2009; Vengeepuram et al. 2012), investigators interested in understanding the role of safety-related distress may benefit from also evaluating community-police dynamics from residents’ perspectives.

Distinguishing effects of social and physical factors in the built environment and neighborhood settings is a longstanding challenge in health research (Schulz and Northridge 2004), as pathogenic (e.g., cockroach endotoxin, insecticide use) and social (e.g., poverty) exposures may co-occur. Despite the use of structured cues in the moderator’s guide to facilitate discussion of social and physical neighborhood stressors, this distinction did not seem intuitive to

participants. This could be an artifact of discussion facilitation, but may also reflect how intertwined these domains are with regard to how individuals experience perceived stress. For example, neighborhood attributes commonly used as indicators of ‘physical disorder’ in health research [e.g., sanitation, housing quality (Ross and Mirowsky 2001; Sampson and Morenoff 2004)] were described by study participants as representing community accountability – suggesting perhaps that social capital [i.e., norms of reciprocity, cooperation, and trust (Kawachi et al. 1997)] may be a potential buffer against stress-related effects of physical disorder. These findings also suggest that psychosocial pathways may be inadvertently captured in “objective” measures of the built environment [e.g., traffic volume (McGinn et al. 2007), housing dilapidation (Kroeger et al. 2012)], creating confounding between psychosocial and physical environmental pathways.

Though local pollution and its sources were not widely discussed, other studies have found evidence for stress effects across a range of perceived pollution exposures, including malodor (Horton et al. 2009), industrial chemicals (Couch and Coles 2011), and unconventional natural gas drilling emissions (Ferrar et al. 2013). This possibility for environmental pollution to act along both traditional (i.e., dermal, inhalation, ingestion) and psychosocial exposure pathways is another area of potential confounding, or synergism, particularly for EJ communities.

Mechanisms through which gentrification may impact health [e.g., distress due to social network disruptions, or rising housing costs (Murdie and Teixeira 2011) are not well understood, and are further complicated by its perceived potential to bring about both positive and negative neighborhood changes. In our study, while participants acknowledged both risks and benefits of gentrification, as in other studies (Formoso et al. 2010; Betancur 2011), adult and youth

participants emphasized unfair treatment and displacement of long-term residents of color in this process. This emphasis on the inter-relation between gentrification and experiences of racism suggests that discrimination may be an important factor [generally negatively appraised (Williams 1999)] for understanding distress related to gentrification. Further, the perceived importance of gentrification among neighborhood stressors reinforces the need for longitudinal studies (Diez Roux 2001; Rauh et al. 2001)to explore the role of neighborhood change on stress- related outcomes.

Somewhat to our surprise, youth participants identified similar sets of neighborhood stressors as did adult participants. The adults’ discussion of racism and safety concerns, for example, were mirrored in the youth’s discussions of experiences of racism and a low sense of

safety in their schools. Identifying this unique domain of potential stressor exposures supports growing attention to school-based stress and coping interventions (Pincus and Friedman 2004).

We identified three broad methodological challenges for population-level studies of psychosocial pathways and multiple neighborhood exposures. First, because community-scale administrative indicators are often used in social epidemiology, we attempted to match the stressors identified by community members with publically-available NYC agency data. We were able to locate plausible area-level administrative counterparts for some perceived stressors (e.g., rodent violations, noise complaints, felony violent crimes), but other important stressors had no reliable population-level available data (e.g., police stops, sexual assault, experiences of racism). While it is not realistic (or necessarily advisable) for agencies to fill these gaps, these gaps do create the potential for omitted variable bias in research, particularly in neighborhood effects studies. Additionally, there is a need to directly validate whether these administrative statistics accurately reflect community perceptions. Second, we compared our findings on

important community perceived stressors to individual psychosocial stress assessment instruments, such as the Ross-Mirowsky Neighborhood Disorder Scale (Ross and Mirowsky 1999), and found similar gaps. In the context of survey-based assessments, researchers must weigh the trade-offs between missing locally-important response variables, and limiting the interpretability of validated scales by adding items. Third, in our study, participants’ perceptions of stressors in their neighborhood were frequently stated relative to other areas of the city, across a range of stressors, suggesting that perceived inequality in stressor distribution may be as important, if not more so, than absolute prevalence. There is substantial evidence for health effects of income inequality, independent of absolute income, and likewise it is plausible that both absolute and relative community stressor exposures matter for stress-related health effects.

4.3.1 Limitations

Because our study identified perceived neighborhood stressors in economically disadvantaged communities, with predominantly African American and Latino participants, we do not know how perceptions may differ from those of residents in higher-income communities. Likewise, resources did not allow for male- and female-only groups, and thus we may have omitted some stressors that participants may be reluctant to share in mixed-gender groups. Perceived stigma and sensitivity of the research questions may also have influenced the range of stressors discussed. While we cannot know how participants’ prior relationships with each other

influenced their comfort in talking about neighborhood stressors, all discussions were lively and lasted the full hour.

4.3.2 Strengths

Participants frequently remarked on the value of having an opportunity to discuss community concerns, and, in fact, requested more focus groups. Given this positive experience, these focus groups may have strengthened the likelihood of future engagement and participant trust in this research process. Dependability of our data are supported by using a structured moderator’s

guide for consistent data collection, and participant ranking of stressors complemented content analysis to identify prominent stressors and themes. Data collection and analysis were performed by different study team members, with reflexive discussions and iterative data interpretation. Facilitating an open focus group discussion, rather than defining the set of stressors a priori, enabled us to explore a broad set of locally-specific perceived stressors.

4.4 CONCLUSION

Engaging community expertise is instrumental for accurate assessment of social stressors for health research. The broad range of neighborhood stressors discussed by community members demonstrates the inter-relatedness of social, political and economic factors that may impact health through chronic stress pathways. Public health community initiatives, policy interventions, and epidemiological studies may benefit from considering community perceptions. Further studies are needed to understand the complex relationships among multiple neighborhood stressors, how they relate to individual stress experience, and how these social and physical stressors may operate through separate and synergistic pathways for health effects.

5.0 DEVELOPING AND VALIDATING A GIS-BASED ONLINE SURVEY