Health equity in the built environment is becoming of increasing interest to public health agencies and healthcare systems in the United States, especially as a function of socio-spatial inequalities exacerbated by 20th century urban development patterns. The proliferation of automobiles and highways during this period reshaped American cities, with the rapid expansion of metropolitan areas further cementing the rigid separation of neighborhoods along racial, ethnic, and socioeconomic lines. The health inequities borne from this segregation remain clearly observable in contemporary urban areas.

In relatively wealthy and growing regions, health equity concerns may not receive sufficient attention, as region-wide rates of chronic disease appear low. Healthcare system leaders in such regions may see aggregate numbers as evidence of success, not seeing persistent health inequities lurking beneath them. Put another way, a ‘rising tide’ does not ‘lift all boats’ when years of disinvestment and neglect abruptly give way to redevelopment and gentrification.

The rise and popularization of indices representing the complex influence of the built environment signifies an important inflection point in research in our team’s overlapping fields (particularly as it relates to engagement between medical geographers and the healthcare system). While indices serve an important purpose in communicating information to local stakeholders, they also offer the opportunity to distill multiple built environment variables into one composite score. In places such as Grand Rapids and Kent County, Michigan, understanding local-level variation can inform interventions in neighborhoods left behind by historical disinvestment, recent prosperity, and ongoing neglect of health equity concerns.

Our team members previously established a healthfulness index for Flint, Michigan: a community that exhibits some of the poorest health outcomes in the state. To create the Flint healthfulness index, our team consulted with community and academic partners involved in an NIH center grant: the Flint Center for Health Equity Solutions. The purpose of that collaboration was to solicit viewpoints from a diverse group of partners to understand which aspects of the built environment they viewed as the strongest predictors of community health. The resulting healthfulness index was deployed as part of two intervention studies that fell under the umbrella of the center. (Sadler et al., 2019)

In the current study, our goal is to establish a healthcare partner-informed healthfulness index for Grand Rapids and Kenty County, Michigan, for the use of healthcare system partners in subsequent health equity work. We sought to break down silos between public health and healthcare leaders by engaging Corewell Health partners who are newly embarking on health equity initiatives (in part as a function of identity formation after a major healthcare system merger), and who are increasingly concerned with the uneven distribution of wealth and opportunity in the Grand Rapids area. This partnership also allows for the linkage of such healthfulness indices to objectively measured health conditions, an approach often underutilized because of the challenges of conveying data among hospital systems, public institutions, and researchers. We hope to build understanding and linkages among these sectors.

Health equity emerged as an important concept in public health in the late 1990s as scholars began adapting advances from social justice into health research. (Bambas and Casas, 2001) Health equity has come to refer to the absence of structural or systematic differences arising from disparities in access to resources and deliberate patterns of discrimination. (Braveman and Gruskin, 2003) Health equity is closely bound up in pursuits of social justice, with a central aim of dismantling historical structures that created barriers to health and well-being. (Peter, 2001) Society and healthcare systems now collectively seek to redress years of discrimination and disinvestment that created parallel worlds for the wealthy and/or dominant racial/ethnic groups when compared to lower-income and/or minoritized populations. (Braveman, 2006)

As a function of decades of inequitable and racist urban development, health outcomes can vary substantially from one neighborhood to another. Historical and ongoing practices of racial/ethnic segregation are increasingly pointed to as causal agents of poor health in the contemporary environment. In recent years, evidence has emerged regarding the adverse effects of many of these place-based forms of structural racism beyond redlining, which despite its ease of use is not necessarily the only or best way to represent this phenomenon. (Blatt et al., 2024; Sadler et al., 2021)

But the way neighborhoods evolve is not mechanistically determined only by one or more of these patterns. In combination with historical practices, ongoing land use and zoning conflicts—as well as urban development momentum—can drive once-similar neighborhoods in different directions, enacting divergent trajectories of place-based resource availability within and across regions. Given the complex origins of contemporary neighborhood inequality, capturing multiple aspects of the built environment is necessary to fully understand, quantify, and address its impacts on health equity. This links with the concepts of equity in the built environment, the social determinants of health, and environmental health promotion, which collectively consider the wide-ranging needs of different groups co-existing in built environments shaped by historical contexts as well as proximate and distal stressors. (Seyedrezaei et al., 2023; Northridge and Freeman, 2011; Schulz and Northridge, 2004)

Healthcare systems were historically built on a biomedical model that placed little emphasis on distal (e.g. environmental) causes of disease. But many have begun to focus more on social determinants of health and health equity. Healthcare systems have embraced a wide range of philosophies and approaches to dismantle the inequitable structures that lead to inequities in health, including via a refocusing on how care is provided (e.g. from volume-based to outcomes-based systems).

Some have sought to increase consensus on and knowledge of what health equity means, citing a lack of understanding by healthcare workers. (Uehling et al., 2023) Others note that helping employees recognize unconscious bias, reforming systems to better serve low-income populations, and increasing the resources available for addressing social determinants of health can all contribute to health equity. (Chen et al., 2021) For example, culturally tailored care and a culturally affirming approach can help elicit buy-in from patients historically overlooked by the healthcare system. (Chisolm et al., 2023; Nickel et al., 2018; O’Kane et al., 2021) Some healthcare systems now also directly engage with issues of patient mistrust and past experiences of discrimination. (O’Kane et al., 2021; Salisu et al., 2023)

Scholars and practitioners argue for structural and practical changes to the healthcare system (e.g. the importance of improving data-driven approaches). (O’Kane et al., 2021; Williams et al., 2016) Relatedly, others cite the need for capturing better measures of healthcare access and wait times, including among socioeconomically distressed patients. (Lee-Foon et al., 2023) Others have suggested that healthcare systems should play a wider role in their communities, for example, by increasing community engagement. (O’Kane et al., 2021; Salisu et al., 2023) As healthcare systems’ health equity initiatives scale up, more intensive work could include establishing housing screening programs, housing trust funds, and creating regional health planning entities. (Fedorowicz et al., 2020) Ultimately, the intention is to pull these systems into whole community investment. (Chisolm et al., 2023)

For health equity initiatives to succeed, healthcare systems should have a delineated path. Potential value exists in a healthy built environment framework to guide such work; for our colleagues, this included the creation of a timeline for linking the built environment to health equity work. (Janzen et al., 2018) A short set of roles can be filled by hospitals inside their walls and throughout their communities. (Dave et al., 2021) These include harnessing their own economic power, engaging more directly in community health service provision, and centering equity in all of their work.

Understanding health equity requires not only examining outcomes within healthcare systems, but integrating such knowledge with the composition of the surrounding built environment. One way of conceptualizing this issue is the ‘groundwater metaphor for structural racism’. (Dave et al., 2021) Upon finding a pond full of dead fish, we would not look only at the fish, or at the pond; instead, we might ask whether the input of fresh water into this pond was contaminated. In the same way, in health equity work we do not focus on individual or proximal forces, but instead move farther upstream (or via the groundwater) to more structural forces. (Dave et al., 2021) Similarly, identifying health disparities does not on its own afford a full picture of where to intervene or how to address health equity; rather, finding the intersections of poor health and poor built environment may help us better respond in our advocacy toward reducing exposures or increasing resources in overexposed and underserved neighborhoods.

One such way of enhancing understanding of the built environment by healthcare system partners may be via the solicitation and translation of expert or community partner knowledge. Earlier applications of the method known as the analytic hierarchy process (AHP) have included papers on land conservation, (Chow and Sadler, 2010; Malczewski, 2004) and it has more recently been applied to the context of public health and medical field-related interventions. (Sadler et al., 2019; Sadler et al., 2022) Other public health researchers have taken a similar tack using different methods, constructing indices from a variety of sources. Two interrelated teams have been leaders in this regard, building a nationwide health index for Aotearoa New Zealand. (Marek et al., 2023; Marek et al., 2021; Hobbs et al., 2021) Other popular indices have been cited in past work, and include a spatial urban livability index, (Higgs et al., 2021) a multicomponent obesogenic built environment measure, (Hughey et al., 2019) a neighborhood destination accessibility index, (Witten et al., 2011) an expansion of that index, (Badland et al., 2015) an objectively-measured walkability index, (Lam et al., 2022) and a school-specific walkability index. (Giles-Corti et al., 2011)

In another project, the authors constructed a multi-criteria index based on social components (i.e. race, poverty status, food, and healthcare assistance) and access components (i.e. distance to healthcare and roads, and access to broadband and vehicles). (Khairat et al., 2019) Even so, there remains a gap in that other studies have not incorporated community engagement into the development of such indices, with the exception of our work nearby in Flint, Michigan. (Sadler et al., 2019; Sadler et al., 2022)

Malczewski created multi-criteria decision analysis (MCDA) to help decision-makers weigh the relative importance of multiple variables against one another. Part of our team has previously shown the benefits of using MCDA to create expert-informed multi-criteria healthfulness indices (Sadler et al., 2019; Sadler et al., 2022)—borrowing ideas from past work (Bell et al., 2007; Faghri et al., 2002)—generated via map algebra, rather than using unweighted indices or treating variables individually. In our previous work, we consulted community and academic stakeholders who were connected to specific research projects, mirroring other past work. (Malczewski, 1999; Burger et al., 2007)

Our partnership was created as an extension of the work of the NIMHD-funded Flint Center for Health Equity Solutions, as Michigan State University (MSU) researchers began looking beyond Flint to address regional health equity concerns. This foundational work to establish a healthfulness index was deemed a priority for Corewell Health partners. Corewell Health—headquartered in Grand Rapids—is now the largest health system in Michigan, employing over 60,000 people, serving approximately 1.3 million individuals throughout the state, and providing care at 22 different hospitals. (Corewell Health 2022) The MSU-Corewell Health collaboration meaningfully if unwittingly benefitted from past efforts to engage community and incorporate health into the planning process in the Grand Rapids region. (Harger, 2008; Ricklin and Kushner, 2013)

Grand Rapids anchors the second largest metropolitan area in Michigan (behind Detroit), and contrasts with other mid-sized urban regions in key ways. The economy has long been well-diversified, with an emphasis on the furniture sector and a growth pattern not premised as heavily on the automotive sector. (Gupta and Subramanian, 2008; Louis, 2018) Despite its consistent economic success, Grand Rapids exhibits similar segregation patterns as less economically-resilient cities in Michigan and throughout the industrial heartland. (Robinson, 2006)

Similar to other Michigan cities, Grand Rapids experienced a period of rapid suburbanization in the 1940s and 1950s. The defeat of regional consolidation efforts in the late 1950s benefitted suburban growth and stymied urban redevelopment. Support for eliminating racial redlining and addressing needs for urban renewal pushed many suburban governments to oppose this consolidation. This widened socio-spatial rifts in the urban form whereby gentrifying and often predominantly white neighborhoods abutted lower-income and often minoritized communities. (Bratt, 2010)

In recent years, rapid growth and gentrification have widened economic inequality. In a study of 117 mid-sized urban regions, Grand Rapids placed 23rd lowest (and 2nd lowest in Michigan) in poverty, but landed at 69th in inequality, 90th in segregation, 98th in sprawl, and 78th in fragmentation. (Sadler et al., 2020) The better score in poverty helped it land squarely in the middle of these cities (54th) in terms of prosperity risk. It contrasts sharply with Flint’s prosperity risk metrics, thus we sought a fresh approach to considering built environment influences that may be important to stakeholders in the much more typical/growing Grand Rapids (as compared to the more atypical/declining Flint).