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Building healthy places: how are community development organizations contributing?
Abstract
During the past 50 years, community development organizations have worked in the low-income communities that face the greatest barriers to good health. While recent changes in the American health care system and philanthropic sector provide new opportunities to partner with community development organizations to address health disparities, knowledge of current health-focused strategies and partnerships among local community-based organizations is limited. Through a survey conducted by NeighborWorks America of 242 high-performing community development organizations across the United States, we examine health strategies, partnerships, and services delivered by community development organizations and professionals. In 2015, 218 organizations (88.62%) engaged in activities at the nexus of health, housing, and community development; strategies focused on healthy homes and food access were the most common. Among respondents, 205 (83.3%) organizations engaged partners to support their work. In addition, three case studies illustrate diverse strategies by community development organizations to document health outcome improvements and medical cost reductions. While our results show significant efforts by community development organizations to explicitly target health, they also highlight opportunities for increased engagement. We elevate calls to address gaps between formal medical care and community health needs through more locally based services and partnerships.
... 12 Another examined how community development organizations have addressed health disparities. 13 However, research identifying the dimensions of health that have been integrated into community development grants is limited. To address this gap, we conducted a descriptive study of the dimensions of health that funders have, and have not, supported through community development grants in one U.S. city. ...
... 17 Some community development organizations are addressing these health disparities across the United States, especially in food and environmental health. 13 However, our findings suggest that some funders may not be supporting as many health issues within community development grants as some community developers are already addressing. Given the connections between health and social outcomes, as community developers seek to increase economic and social opportunities for communities, a lack of funding for a wider range of health issues may limit the success community development initiatives may attain. ...
Purpose: Achieving health equity requires addressing the social determinants of health, which philanthropy has supported through community development grants. This study analyzes health topics that have been integrated into community development grants.
Methods: Community development grants from 2010 to 2017 were analyzed for health topics in Baltimore, MD.
Results: Food and nutrition, chronic disease, reproductive health, adolescent health, violence prevention, health care access, and infectious disease were the least common health topics in community development grants.
Conclusion: To support health equity efforts, funders should consider a broader range of health issues to integrate into community development investments.
Not all homes across America are “healthy” homes. This contributes to the poor health of Americans and exacerbates existing health conditions costing millions each year in health-care cost. Newer research is being conducted into strategies to alleviate biological, chemical, and physical hazards in the home, and various programs exist to assist the homeowner in making improvements in the quality of their home. Not every homeowner or renter nationwide or within community localities has access to these strategies or programs that could potentially improve their home environment and therefore the health of their family. The objective of this article is to propose elements of a policy to address this inconsistency and variation. This proposal centers around the federal enactment of a national policy demanding that each state implements a healthy homes program tailored to fit their specific state housing and health needs. Members of Congress from States that have successfully implemented healthy home programs should champion this policy. Organizations that recognize the impact of housing on health should support the development of a national healthy homes strategy. This article will discuss the need, outcomes, stakeholders, and minimum requirements of such a policy.
Measurement can help community development and health practitioners align and optimize their investments and leverage additional resources to achieve shared goals. However, there is no clear guidance for reconciling the established systems for measuring community development activities and outputs-such as housing units built, jobs created, and people served-with the outcomes and impacts of health. We therefore reviewed community development measurement systems-encompassing assessment, monitoring, evaluation, and standards-and identified strategies for using those systems to support health in community development decision making. We highlight promising innovations by organizations such as the Reinvestment Fund and NeighborWorks America and place these in an ecosystem framework to illustrate opportunities for shared measurement. We then discuss policies and processes to build the ecosystem's infrastructure, balance stakeholders' priorities within the ecosystem, and use it to drive investments in health.
Promoting child wellbeing necessarily goes beyond the clinic as risks to child health and development are embedded in the social and physical environmental conditions in which children live. Pediatricians play a vital role in promoting the health of children in the communities they serve and can maximize their impact by advocating for and supporting efficacious, evidence-based strategies in their communities.
To provide a succinct guide for community pediatric efforts to advance the wellbeing of all children and particularly disadvantaged children in a community, we conducted a theory-driven and structured narrative review to synthesize published systematic and meta-analytic reviews of policy-relevant, local-level strategies addressing potent and malleable influences on child health and development. An exhaustive list of policy-relevant, local-level strategies for improving child health was used to conduct a comprehensive search of recent (1990--2012), English language peer-reviewed published meta-analyses and systematic reviews in the 10 core databases of scientific literature. Our review of the literature encompassed six key conceptual domains of intervention foci, including distal influences of child health (i.e., income and resources, social cohesion, and physical environment) and proximal influences (i.e., family, school and peer). We examined intervention effects on four key domains of child health and development: cognitive development, social and emotional competence, psychological and behavioral wellbeing, and physical health.
Published reviews were identified for 98 distinct policy-relevant community interventions, evaluated across 288 outcomes. We classified 46 strategies as meeting scientific criteria for efficacy by having consistent, positive outcomes from high-quality trials (e.g., tenant-based rental assistance, neighborhood watch programs, urban design and land use policies, access to quality childcare services, class size reductions, after-school programs that promote personal/social skills). Another 21 strategies were classified as having consistent evidence of positive outcomes from high-quality observational studies only, while 28 strategies had insufficient evidence available to assess their effectiveness based on published reviews. We did not limit the review to studies conducted in the United States, but the vast majority of them were U.S.-based, and the results therefore are most applicable to the U.S. context.
Based on our synthesis of published literature on community development strategies, we provide an illustration combining a comprehensive set of evidence-based strategies to promote child health and development across a wide-range of child health outcomes.
This report assessed the effects of school mobility on achievement and dropout in 16 studies from 1990-2008 that included pre-mobility achievement. 13 of the studies found that mobility from kindergarten to high school was independently associated with outcomes. Findings indicated that children who moved 3 or more times had rates of school dropout that were nearly one-third of a standard deviation higher than those who were school stable net of prior achievement other factors. Frequent mobility was also associated with significantly lower reading and math achievement by up to a third of a standard deviation. In marginal effects, each additional move was associated with a reduction in reading and math achievement of about one- tenth of a standard deviation. Further analysis of one of the included studies--the Chicago Longitudinal Study--that controlled for residential moves and school factors in an urban context revealed that students who move frequently or beyond third grade experience the most detrimental effects. Evidence also is presented that mobility contributes indirectly to school performance and later well-being. The Child-Parent-Center preventive intervention is illustrated to show the benefits of preschool-to-third-grade approaches to reducing the prevalence of mobility.
The implementation of the Affordable Care Act of 2010 and the Obama administration's urban policy create an opportunity to link community development with health in new and powerful ways. The administration's policy emphasizes improved access to and quality of care through coordinated local and regional approaches, expansion of access to healthy food, and the support of environmental health-including clean air, water, and soil-and healthy homes. New federal programs, such as the Affordable Care Act's Community Transformation Grants, seek to prevent death and disability through policy, environmental, programmatic, and infrastructure changes. But fragmented congressional jurisdiction and budget "scoring" rules pose challenges to needed reform. We argue that government agencies need to adopt so-called systems of innovation, or organizational practices and support mechanisms that seek continuously to test new models, refine promising ones, bring to scale those that work best, and restructure or terminate what does not. We also argue that a strong and well-focused policy advocacy coalition is needed to help drive reform focused on the social determinants of health.
Improved access to health care is essential if we are to fill the striking gaps between how healthy Americans are and how healthy they could be. But access alone is not enough. Health and longevity are also profoundly influenced by where and how Americans live, learn, work, and play. Recognizing this, the Robert Wood Johnson Foundation's Commission to Build a Healthier America has identified concrete, feasible actions outside of medical care that constitute an urgent agenda for improving America's health. These recommendations require action at all levels of society to promote development and health in childhood, good nutrition, and communities conducive to good health.
We examine the question of whether living in a disadvantaged neighborhood damages health, over and above the impact of personal socioeconomic characteristics. We hypothesize that (1) health correlates negatively with neighborhood disadvantage adjusting for personal disadvantage, and that (2) neighborhood disorder mediates the association, (3) partly because disorder and the fear associated with it discourage walking and (4) partly because they directly impair health. Data are from the 1995 Community, Crime, and Health survey, a probability sample of 2,482 adults in Illinois, with linked information about the respondent's census tract. We find that residents of disadvantaged neighborhoods have worse health (worse self-reported health and physical functioning and more chronic conditions) than residents of more advantaged neighborhoods. The association is mediated entirely by perceived neighborhood disorder and the resulting fear. It is not mediated by limitation of outdoor physical activity. The daily stress associated with living in a neighborhood where danger, trouble, crime and incivility are common apparently damages health. We call for a bio-demography of stress that links chronic exposure to threatening conditions faced by disadvantaged individuals in disadvantaged neighborhoods with physiological responses that may impair health.
We describe a method to facilitate routine monitoring of socioeconomic health disparities in the United States.
We analyzed geocoded public health surveillance data including events from birth to death (c. 1990) linked to 1990 census tract (CT) poverty data for Massachusetts and Rhode Island.
For virtually all outcomes, risk increased with CT poverty, and when we adjusted for CT poverty racial/ethnic disparities were substantially reduced. For half the outcomes, more than 50% of cases would not have occurred if population rates equaled those of persons in the least impoverished CTs. In the early 1990s, persons in the least impoverished CT were the only group meeting Healthy People 2000 objectives a decade ahead.
Geocoding and use of the CT poverty measure permit routine monitoring of US socioeconomic inequalities in health, using a common and accessible metric.
We analyzed neighborhood heterogeneity in associations among mortality, race/ethnicity, and area poverty.
We performed a multilevel statistical analysis of Massachusetts all-cause mortality data for the period 1989 through 1991 (n=142836 deaths), modeled as 79813 cells (deaths and denominators cross-tabulated by age, gender, and race/ethnicity) at level 1 nested within 5532 block groups at level 2 within 1307 census tracts (CTs) at level 3. We also characterized CTs by percentage of the population living below poverty level.
Neighborhood variation in mortality across CTs and block groups was not accounted for by these areas' age, gender, and racial/ethnic composition. Neighborhood variation in mortality was much greater for the Black population than for the White population, largely because of CT-level variation in poverty rates.
Neighborhood heterogeneity in the relationship between mortality and race/ethnicity in Massachusetts is statistically significant and is closely related to CT-level variation in poverty.
Racial disparities in mortality over time reflect divergent pathways to the current large racial disparities in health. The residential concentration of African Americans is high and distinctive, and the related inequities in neighborhood environments, socioeconomic circumstances, and medical care are important factors in initiating and maintaining racial disparities in health. Efforts are needed to identify and maximize health-enhancing resources that may reduce some of the negative effects of psychosocial factors on health. Health and health disparities are embedded in larger historical, geographic, sociocultural, economic, and political contexts. Changes in a broad range of public policies are likely to be central to effectively addressing racial disparities.
The number of Americans over the age of 65 has been growing much faster than the overall population's growth rate. These changes can be largely attributed to the improvement in life expectancy. This demographic shift yields a unique and exciting opportunity to provide both expedient and cost-efficient care to a growing patient population.
Epidemiology is often referred to as the science of public health. However, unlike other major sciences, its theoretical foundations are rarely articulated. While the idea of epidemiologic theory may seem dry and arcane, it is at its core about explaining the people's health. It is about life and death. It is about biology and society. It is about ecology and the economy. It is about how myriad aspects of people's lives - involving work, dignity, desire, love, play, conflict, discrimination, and injustice - become literally incorporated into our bodies and manifest in our health status, individually and collectively. And it is about essential knowledge critical for improving the people's health and minimizing inequitable burdens of disease, disability, and death. Tracing the history and contours of epidemiologic from ancient societies on through the development of - and debates within - contemporary epidemiology worldwide, this book shows how epidemiologic theory has long shaped epidemiologic practice, knowledge, and the politics of public health. Outlining an ecosocial theory of disease distribution that situates both population health and epidemiologic theory in societal and ecologic context, it offers a more holistic picture of how we embody the human experience.
This Viewpoint discusses motivating health care organizations to consider a new set of tools and approaches to disparities in health outcomes by race/ethnicity and income status such as payment systems that reward better outcomes and building equity into program design.
Disparities in health outcomes by race and ethnicity and by income status are persistent and difficult to reduce. For more than a decade, infant mortality rates have been 2 to 3 times higher among African American populations, rates of potentially preventable hospitalization have been substantially higher among African American and Latino populations, and the complications of diabetes have disproportionately afflicted African American and Latino populations.¹ These and other disparities have persisted despite recognition that inequity costs the economy an estimated $300 billion per year.² In addition, health disparities threaten the ability of health care organizations to compete fiscally as insurers increasingly base payments on quality and outcomes, such as reducing preventable admissions and readmissions.
Large medical centers have begun to tackle the kinds of persistent health challenges that no surgery or drug can fix.
Collaboration between the health and community development sectors has gained increased attention as a means of accelerating progress to improve community health. This article offers an empirical perspective on the general status of such collaboration based on results from a national survey of practitioners in the community development and health fields. Study results show that cross-sector efforts to improve health are widespread across the United States. Community development organizations, including community development financial institutions, support a wide spectrum of activities addressing both social determinants of health and the immediate needs of communities. However, the means of assessing the impacts of these joint community health improvement initiatives appear limited. We highlight opportunities for building on present momentum and for measuring results in a way that expands the evidence base on effective collaborative efforts between the two sectors.
This paper uses the 2004-2009 Consumer Expenditure Surveys to examine whether housing affordability affects expenditures on children in families with income at or below 200 percent of the poverty line. After accounting for selection using propensity score matching, estimating effects using nonlinear GLM, and performing sensitivity tests, we find that child enrichment expenditures have an inverted U-shaped relationship with housing cost burden, our measure of housing affordability. This result is similar to the concave pattern of the association between housing cost burden and measures of children’s cognitive achievement in reading and math. Thus, child expenditures, particularly for enrichment, may be one mechanism by which housing affordability affects children’s cognitive outcomes. The inflection point for enrichment spending occurs at roughly the 30 percent housing cost-to-income ratio, the longstanding rule-of-thumb for defining housing affordability.
For many years, the housing environment has been acknowledged as one of the main settings that affect human health. Living and housing conditions are the basis of many factors influencing residential health. Still, to date there is no commonly agreed upon definition of 'healthy housing', and there are still major gaps in the knowledge on how housing conditions may affect health. Epidemiological findings suggest strong associations between housing conditions and health effects. This paper explores the relevance of housing conditions as a key factor influencing mental health, sleep quality, indoor air, home safety, accessibility, obesity, mould growth, hygrothermal conditions and energy consumption, perception of crime, and residential quality.
Objectives:
We assessed the extent to which living near foreclosed properties is associated with individuals' subsequent weight gain.
Methods:
We linked health and address information on 2068 Framingham Offspring Cohort members (7830 assessments) across 5 waves (1987-2008) to records of all Massachusetts foreclosures during that period. We used counts of lender-owned foreclosed properties within 100 meters of participants' homes to predict body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) and the odds of being overweight (BMI ≥ 25), adjusted for individual and area-level covariates.
Results:
Mean BMI increased from 26.6 in 1987-1991 to 28.5 in 2005-2008; overweight prevalence increased from 59.0% to 71.3%. Foreclosures were within 100 meters of 159 (7.8%) participants' homes on 187 occasions (1.8%), in 42 municipalities (21%). For each additional foreclosure, BMI increased by 0.20 units (95% confidence interval [CI] = 0.03, 0.36), and the odds ratio for being overweight associated with proximity to a foreclosure was 1.77 (95% CI = 1.02, 3.05).
Conclusions:
We found a robust association between living near foreclosures and BMI, suggesting that neighbors' foreclosures may spur weight gain.
Racial residential segregation is a fundamental cause of racial disparities in health. The physical separation of the races by enforced residence in certain areas is an institutional mechanism of racism that was designed to protect whites from social interaction with blacks. Despite the absence of supportive legal statutes, the degree of residential segregation remains extremely high for most African Americans in the United States. The authors review evidence that suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining access to education and employment opportunities. SES in turn remains a fundamental cause of racial differences in health. Segregation also creates conditions inimical to health in the social and physical environment. The authors conclude that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences.
The Patient Protection and Affordable Care Act (ACA) requires tax-exempt hospitals to conduct assessments of community needs and address identified needs. Most tax-exempt hospitals will need to meet this requirement by the end of 2013.
We conducted a national study of the level and pattern of community benefits that tax-exempt hospitals provide. The study comprised more than 1800 tax-exempt hospitals, approximately two thirds of all such institutions. We used reports that hospitals filed with the Internal Revenue Service for fiscal year 2009 that provide expenditures for seven types of community benefits. We combined these reports with other data to examine whether institutional, community, and market characteristics are associated with the provision of community benefits by hospitals.
Tax-exempt hospitals spent 7.5% of their operating expenses on community benefits during fiscal year 2009. More than 85% of these expenditures were devoted to charity care and other patient care services. Of the remaining community-benefit expenditures, approximately 5% were devoted to community health improvements that hospitals undertook directly. The rest went to education in health professions, research, and contributions to community groups. The level of benefits provided varied widely among the hospitals (hospitals in the top decile devoted approximately 20% of operating expenses to community benefits; hospitals in the bottom decile devoted approximately 1%). This variation was not accounted for by indicators of community need.
In 2009, tax-exempt hospitals varied markedly in the level of community benefits provided, with most of their benefit-related expenditures allocated to patient care services. Little was spent on community health improvement.
The recession of the late 2000s has increased interest in the consequences of housing instability. Previous research has shown poorer health among those experiencing housing instability, but extant studies generally have focused on selected populations (e.g., homeowners or renters) or studied only one type of housing instability (e.g. homelessness). Using new data from the Michigan Recession and Recovery Study, a population-based sample of working-aged adults from Southeastern Michigan, U.S.A., in late 2009-early 2010, we found that about one-third of respondents recently experienced some type of housing instability. Many, but not all, types of instability were associated with health. Even after adjustment for sociodemographic characteristics and earlier health, individuals who had moved for cost reasons in the past three years were more likely than those with no housing instability to report a recent anxiety attack, while those who experienced homelessness in the past year had a higher likelihood of reporting fair/poor self-rated health and of meeting criteria for major or minor depression. Renters behind on rental payments were more likely to meet criteria for depression, while mortgage-holders behind on their mortgage or in foreclosure had a higher likelihood of reporting fair/poor self-rated health or a recent anxiety attack. Among respondents who had ever owned a home, those who completed a foreclosure recently were more likely to report major or minor depression or an anxiety attack. However, frequent moves were not associated with poorer health, and doubling up and eviction were not associated with poorer health after adjustment for characteristics that sort people into different housing instability experiences. Our findings suggest the importance of considering multiple types of housing instability and using appropriate risk groups and comparison categories.
Large differences in the opportunities and resources that Americans have to be healthy have led to sizable variations in health by geography, race and ethnicity, income level, and education. By enhancing the opportunities for good health in the places where we live, learn, work, play, and worship, community development initiatives can be important drivers of improved health. As articles in this month's issue of Health Affairs attest, community development and public health are two forces that often have the same goals. Because there has been little research to date documenting which aspects of community development could have the greatest impact on health, it will be increasingly necessary to rigorously evaluate the impact of various interventions to guide policy makers in identifying the most important measures to take in an environment of constrained financial resources.
The persistence of the black health disadvantage has been a puzzling component of health in the United States in spite of general declines in rates of morbidity and mortality over the past century. Studies that have focused on well-established individual-level determinants of health such as socio-economic status and health behaviors have been unable to fully explain these disparities. Recent research has begun to focus on other factors such as racism, discrimination, and segregation. Variation in neighborhood context-socio-demographic composition, social aspects, and built environment-has been postulated as an additional explanation for racial disparities, but few attempts have been made to quantify its overall contribution to the black/white health gap. This analysis is an attempt to generate an estimate of place effects on explaining health disparities by utilizing data from the U.S. National Health Interview Survey (NHIS) (1989-1994), combined with a methodology for identifying residents of the same blocks both within and across NHIS survey cross-sections. Our results indicate that controlling for a single point-in-time measure of residential context results in a roughly 15-76% reduction of the black/white disparities in self-rated health that were previously unaccounted for by individual-level controls. The contribution of residential context toward explaining the black/white self-rated health gap varies by both age and gender such that contextual explanations of disparities decline with age and appear to be smaller among females.
Features of neighborhoods or residential environments may affect health and contribute to social and race/ethnic inequalities in health. The study of neighborhood health effects has grown exponentially over the past 15 years. This chapter summarizes key work in this area with a particular focus on chronic disease outcomes (specifically obesity and related risk factors) and mental health (specifically depression and depressive symptoms). Empirical work is classified into two main eras: studies that use census proxies and studies that directly measure neighborhood attributes using a variety of approaches. Key conceptual and methodological challenges in studying neighborhood health effects are reviewed. Existing gaps in knowledge and promising new directions in the field are highlighted.
Racial residential segregation is a fundamental cause of racial disparities in health. The physical separation of the races by enforced residence in certain areas is an institutional mechanism of racism that was designed to protect whites from social interaction with blacks. Despite the absence of supportive legal statutes, the degree of residential segregation remains extremely high for most African Americans in the United States. The authors review evidence that suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining access to education and employment opportunities. SES in turn remains a fundamental cause of racial differences in health. Segregation also creates conditions inimical to health in the social and physical environment. The authors conclude that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences.
Existing evidence demonstrating a relationship between racial residential segregation and health has been based on aggregate analysis. Using a multilevel analytical framework, we assess the extent of geographic variation in black/white disparities in self-rated health across US metropolitan areas, and whether racial residential segregation accounts for such variation. We estimated multilevel regression models of poor self-rated health among 51,316 non-Hispanic white and non-Hispanic black adults nested within 207 metropolitan areas to assess the multilevel relationship between segregation and racial disparities in health. We found statistically significant variation in the black/white disparity in poor self-rated health across metropolitan areas, after controlling for individual level factors (age, sex, marital status, education and income) and residential segregation. High black isolation was associated with increased odds of reporting poor health among blacks (p<0.05). While a similar pattern was observed for white/black dissimilarity and white isolation, they were not statistically significant. Our multilevel analysis only partially supports the previously reported aggregate findings linking segregation to health. Additional multilevel statistical investigations across different health outcomes are required to draw firmer conclusions regarding the adverse effects of segregation on health.
This review considers the broad area of housing and public health, one of the traditional and core areas of public health research and intervention. The review takes into account the range of factors, acting at different levels, directly and indirectly, through which housing affects health. In public health terms, housing affects health in a myriad of relatively minor ways, in total forming one of the key social determinants of health. The paper closes by considering how the improvement of housing and neighborhoods has been a core activity of public health and a central component in tackling poverty. Investment in housing can be more than an investment in bricks and mortar: It can also form a foundation for the future health and well-being of the population. Addressing poor-quality housing and detrimental neighborhoods, in the broadest sense, is thus a task that should be grasped with vigor and determination by all those involved in public health.
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The role of anchor institutions in restoring neighborhoods: health institutions as a catalyst for affordable housing and community development
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The roots of the widening racial wealth gap: explaining the black-white economic divide
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Not safe at home: how America’s housing crisis threatens the health of its children
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Exploring strategies for the promotion of children's physical activity in the afterschool setting: a pilot evaluation of Foundation Communities Southwest trails afterschool program
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Jeansonne, M. and Johnson, A., 2014. Exploring strategies for
the promotion of children's physical activity in the afterschool
setting: a pilot evaluation of Foundation Communities
Southwest trails afterschool program. University of Texas
School of Public Health -Austin Regional Campus.