Our environment—where we work, live, and play—can significantly impact our health and even affect how we heal. After being severely injured, whether from firearm violence, a motor vehicle crash, or a bad fall, people need support systems and resources to optimize recovery. LDI Senior Fellow Therese Richmond says focusing only on the individual and encouraging safer behavior to assist healing “doesn’t do it.” Historic divestment in neighborhoods can make finding resources difficult and rehabilitating from severe injuries even harder.

Dr. Marta Bruce, PhD, RN, a recent graduate of Penn Nursing’s PhD program and Richmond, the Andrea B. Laporte Endowed Professor of Nursing and Associate Dean for Research & Innovation at Penn’s School of Nursing, researched how environmental factors affect the healing process for Black men who had suffered traumatic injuries. 

Their study, published recently in the Journal of Racial and Ethnic Health Disparities, found that neighborhood characteristics affected the likelihood of depression and post-traumatic stress disorder (PTSD) among injured Black men as they healed. In addition, certain environmental factors influenced symptom severity, including a neighborhood’s disconnectedness, concentrated disadvantage or deprivation, crime rate, and racial and ethnic makeup.

We spoke to Richmond and Bruce to discuss the importance of their research and what policymakers and clinicians might do to make a difference.

What motivated you to research this question with a particular focus on the social and physical environment and specifically Black men instead of other marginalized groups?

Richmond:

This paper is from a larger NIH/National Institute of Nursing Research-funded study where we followed a large cohort of injured Black men. We focused on Black men versus other marginalized groups because the rate of death from firearms disproportionately affects injured Black men and boys. If we want to have any way of improving the health of ethnic minority men, we have to take on firearm violence, serious injury, and violence in general.

Bruce:

If you think about a lot of the history of health research, not just for injury but for many conditions, in the past, it tended to focus on more individualized risk factors like genetic conditions and looking for health outcomes and solutions at an individual level. We aimed to go beyond that and look at human beings as living and interacting in a complex web of social and environmental conditions that have a huge impact on their health. For example, where you are born, what resources you were born into, your access to health care, property ownership, what type of education you received, what kinds of stressors you were exposed to, etc.— all of these different factors have a true impact on your life course.

Richmond:

It’s important to understand that injured patients are going back to the same neighborhoods in which they were injured. The neighborhood in which you recover affects how you recover.

What makes it difficult for injured men to recover in the neighborhood where they were injured?

Richmond:

In other work we’ve done with our team about men who are severely injured, we found that our participants talk about what it is like to go back to a neighborhood where [they] don’t know who shot [them], [they] don’t know who to trust, [they] don’t know if the person next to [them] is somebody [they] should be scared of.

Bruce:

Many discussed being worried about where they would stay and having to move out of the neighborhood for fear of injury because they didn’t feel safe. There was also this feeling of being triggered by the environment itself from where they were. Participants would say, “I walked down that block and it all came back to me – I was reliving it.” People are adjusting their walking paths for their day – how they go buy gas, get groceries, and pick up their children—because of these traumatic memories that are rooted in the environment now.

What are actions policymakers could take to make a difference?

Bruce:

Well, correcting the policies that led to this legacy of disenfranchisement and unequal public spending and investment in neighborhoods is important. Policies such as redlining contributed to these stark inequities and neighborhood environments. Policymakers have to think about making neighborhood resource allocation more equitable.

Our work underscores the importance of safe and affordable housing. We found that housing is a huge stressor for people after injury. [Patients] are trying to go to appointments, take medication, and deal with their emotions, but then they have to move because they don’t feel safe. So that’s a huge burden for people.

One of our findings was that those who reported Medicaid coverage or lack of health insurance had higher post-traumatic stress and depression symptoms. So, access to health care is a big barrier for people. If we want to help people recover better from injury and prevent further injury, we have to get people into health care, especially mental health care.

Richmond:

If we think about Philadelphia as a microcosm, we’re the most impoverished of the top ten big cities in the country. Within one county, we see tremendous variation across neighborhoods. And if indeed we’re committed as healthcare providers and as policymakers to help people be as healthy as they can be, we need to invest in the health and well-being of people, and that means investing in safe neighborhoods. We need to buy into the foundational principle that we must invest in communities to improve the health and well-being of all people, not select people. That is not a quick fix, but committing to that is the most important thing.

In the short term, as clinicians, we need to consider, “where is the patient going back to? What additional resources might [they] need? How can we better connect [them] with mental health resources available to [them] in the community?” whether through behavioral health or federally qualified health clinics. That focuses on the individual versus investing in neighborhoods, but the latter is more sustainable.

Is there anything surprising about the findings?

Bruce:

We have a huge range of environmental factors that can affect psychological symptom severity—how the factors studied in our paper fit together was surprising to me. For example, I didn’t expect neighborhood disconnectedness (the extent to which you know your neighbors and feel part of a community) to be so significant in depressive symptom severity. So, I think we have this idea that the environment impacts health but seeing it powerfully in the data was tremendous. Our findings are important because they show that where you live impacts recovery.

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The study, “The Contribution of Neighborhood Characteristics to Psychological Symptom Severity in a Cohort of Injured Black Men” was published in the Journal of Racial and Ethnic Health Disparities on September 9, 2022 by Marta Bruce, Andrew Robinson, Douglas Wiebe, Justine Shults, and Therese Richmond.

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