Neighborhood Context and Substance Use Disorder Risk: Comparing Immigrants and Nonimmigrants in a Community Health Setting

Substance use disorders remain a major public health concern, yet less is known about how neighborhood context shapes clinically documented substance use disorder diagnoses among immigrants and other underserved patients. We linked de identified electronic medical record data from a large integrated care facility serving uninsured and underinsured adults in Central Florida from 2010 to 2019 with American Community Survey 5-year census tract measures from 2013 to 2017 using ArcGIS. The analytic sample included 2,725 adults at or below 200 percent of the federal poverty line, including 403 immigrants. The outcome was a binary substance use disorder diagnosis based on ICD 9 CM codes. We examined neighborhood concentrated disadvantage and neighborhood immigrant density, with immigrant status as a potential moderator, using multilevel Bernoulli models estimated in HLM. Overall, 10.4 percent of patients had a documented substance use disorder diagnosis, with lower prevalence among immigrants (5.2 percent) than nonimmigrants (11.3 percent). In adjusted models, immigrant status was strongly protective (OR 0.27, p < .01). Higher neighborhood immigrant density was also protective, with each 1 percentage point increase associated with lower odds of diagnosis (OR = 0.96, p < .01). Neighborhood concentrated disadvantage was not significant, and moderation by immigrant status was not supported. These findings extend the immigrant paradox to clinically documented substance use disorder diagnoses in a low-income safety net population and suggest that immigrant dense neighborhoods may confer community level protection. Future research should test mechanisms such as social cohesion, collective efficacy, cultural norms, stigma, and service access using longitudinal and mixed methods approaches, and should examine heterogeneity across immigrant subgroups, generations, and local contexts.