2018-2019 Community Health Needs Assessment - UChicago Medicine by UChicago Medicine Community Benefit Report

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

Table of Contents Executive Summary

Introduction

UCMC Overview

Community Health Needs Assessment Process

10 10

STAKEHOLDER ENGAGEMENT DATA AND METHODS

UCMC SERVICE AREA

HISTORICAL INEQUITIES IN UCMCSA

Results

DEMOGRAPHIC CHARACTERISTICS

SOCIAL AND STRUCTURAL DETERMINANTS OF HEALTH

HEALTH OUTCOMES MORBIDITY AND MORTALITY

Conclusion

Endnotes

Appendix 1: Community Profiles

Appendix 2: Evaluation Report 2016 – 2019

157

Appendix 3: Cook County CHNA

196

Community Health Needs Assessment 2018–2019

UChicago Medicine

IRS Form 990, Schedule H Compliance

For non-profit hospitals, a Community Health Needs Assessment (CHNA) also serves to satisfy certain requirements of tax reporting, pursuant to provisions of the Patient Protection & Affordable Care Act of 2010. To understand which elements of this report relate to those requested as part of hospitals’ reporting on IRS Form 990 Schedule H, the following table cross-references related sections. IRS Form 990, Schedule H

See Report Page(s)

Part V Section B Line 3a A definition of the community served by the hospital facility Part V Section B Line 3b Demographics of the community Part V Section B Line 3c Existing health care facilities and resources within the community that are available to respond to the health needs of the community Part V Section B Line 3d How data was obtained

12 16-18 Appendix 1 8-11

Part V Section B Line 3e The significant health needs of the community

Addressed Throughout

Part V Section B Line 3f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

Addressed Throughout

Part V Section B Line 3g The process for identifying and prioritizing community health needs and services to meet the community health needs

Part V Section B Line 3h The process for consulting with persons representing the community’s interests

8 and 10

Part V Section B Line 3i The impact of any actions taken to address the significant health needs identified in the hospital facility’s prior CHNA(s)

Appendix 2

Community Health Needs Assessment 2018–2019

UChicago Medicine

Violence recovery Interventions suggested by the community

Offer conflict resolution services & trauma therapy

Invest in restorative justice programs

Support workforce development and employment resources

Health problems in the community Concerns from the community Top causes of Death

1. Heart disease

Complexity of obtaining and keeping public benefit coverage

2. Cancer 3. Diabetes-related 4. Homicide 5. Stroke and cardiovascular disease

High cost of some private insurance plans

Unequal distribution of health care services and facilities

Poor health care options for LGBTQ community and people of color

Executive Summary

Social Determinants of Health continued

UChicago Medicine’s Community Health Needs Assessment is used to identify community health priorities and make decisions on where to commit resources that can most effectively improve community members’ health and wellness.

For South Side communities, the priorities for 2019-21 are: •

Preventing and managing chronic diseases (asthma and diabetes)

•

Building trauma resiliency with a focus on violence recovery and mental health

•

Reducing health inequities by addressing social determinants of health (access to care, food and employment)

Demographics (12 zip service area) Population:

Change in Total Population

625,707

2012-2016

� �

3.5% .6%

.2%

23%

The Federal Poverty Thresholds for 2016 defines poverty based on household size and age of household members, ranging from $12,486 for a one-person household to $24,339 for a four-person household with two children and $42,075 for an eight person household with four children. 1

Food security is a household-level social and economic condition of limited or uncertain access to adequate food.

UCM_CommunityProfiles_Exec-Summary_v7.1.indd 1-2

of Chicago population

-3.8% Servicearea

Cook County

9/27/19 3:41 PM

Race and Ethnicity

Adult diabetes

Access to care

2012-2016

Zip codes with the most diabetesrelated ER visits (rates per 10,000)

Reports of being uninsured

31%

80%

60%

77% 32%

23%

62%

43%

Chicago

Non-Hispanic Black

60636

Non-Hispanic White

60621

0% Service-area

Chicago

� � 25

Cook County

Non-Hispanic Asian

60636

60621

60637

Adult asthma

60619

60649

17%

Illinois

U.S.

14%

197

of servicearea population

204

60621

Youth asthma Chicago 60636

Service area is a health professional shortage area

93 244 252

60637

Poverty 1

Food insecurity 2 Communities with the highest violent crime rates

53%

Nearly 1 in 2 households are at risk for food insecurity

of servicearea population

Adult mental health ER visits due to mental health (rates per 10,000; 2015-2017)

1. Washington Park 2. Englewood 3. West Englewood 4. Greater Grand Crossing

110

Chicago

205

60636

262

60621

5. Fuller Park

Chicago Children in poverty

UCM_CommunityProfiles_Exec-Summary_v7.1.indd 3-4

60636

Social Determinants of Health

Service-area Population

10%

Asthma-related ER visits (rates per 10,000)

Numbers may not add up to 100 percent due to rounding

almost double the state level

of Illinois population

Chicago %

Hispanic/Latinx

Other 29%

40%

20%

��

Service area

100%

Executive Summary

Social Determinants of Health continued

Demographics (12 zip service area) continued

Chicago: 32% Illinois: 20%

Youth mental health

Education Less than high school grad

Chicago: 32% Illinois: 12%

Unemployment

Chicago: 11% Illinois: 8%

Health issues lead by high violence rates • Chronic stress • Decreased mental well-being

Chicago 60619 60649

47 58 65

• Trauma • Decrease physical activity (reluctance to exercise in unsafe neighborhoods)

9/27/19 3:41 PM

Race and Ethnicity

Adult diabetes

Access to care

2012-2016

Zip codes with the most diabetesrelated ER visits (rates per 10,000)

Reports of being uninsured

31%

80%

60%

77% 32%

23%

62%

43%

Chicago

Non-Hispanic Black

60636

Non-Hispanic White

60621

0% Service-area

Chicago

� � 25

Cook County

Non-Hispanic Asian

60636

60621

60637

Adult asthma

60619

60649

17%

Illinois

U.S.

14%

197

of servicearea population

204

60621

Youth asthma Chicago 60636

Service area is a health professional shortage area

93 244 252

60637

Poverty 1

Food insecurity 2 Communities with the highest violent crime rates

53%

Nearly 1 in 2 households are at risk for food insecurity

of servicearea population

Adult mental health ER visits due to mental health (rates per 10,000; 2015-2017)

1. Washington Park 2. Englewood 3. West Englewood 4. Greater Grand Crossing

110

Chicago

205

60636

262

60621

5. Fuller Park

Chicago Children in poverty

UCM_CommunityProfiles_Exec-Summary_v7.1.indd 3-4

60636

Social Determinants of Health

Service-area Population

10%

Asthma-related ER visits (rates per 10,000)

Numbers may not add up to 100 percent due to rounding

almost double the state level

of Illinois population

Chicago %

Hispanic/Latinx

Other 29%

40%

20%

��

Service area

100%

Executive Summary

Social Determinants of Health continued

Demographics (12 zip service area) continued

Chicago: 32% Illinois: 20%

Youth mental health

Education Less than high school grad

Chicago: 32% Illinois: 12%

Unemployment

Chicago: 11% Illinois: 8%

Health issues lead by high violence rates • Chronic stress • Decreased mental well-being

Chicago 60619 60649

47 58 65

• Trauma • Decrease physical activity (reluctance to exercise in unsafe neighborhoods)

9/27/19 3:41 PM

Violence recovery Interventions suggested by the community

Offer conflict resolution services & trauma therapy

Invest in restorative justice programs

Support workforce development and employment resources

Health problems in the community Concerns from the community Top causes of Death

1. Heart disease

Complexity of obtaining and keeping public benefit coverage

2. Cancer 3. Diabetes-related 4. Homicide 5. Stroke and cardiovascular disease

High cost of some private insurance plans

Unequal distribution of health care services and facilities

Poor health care options for LGBTQ community and people of color

Executive Summary

Social Determinants of Health continued

For South Side communities, the priorities for 2019-21 are: •

Preventing and managing chronic diseases (asthma and diabetes)

•

Building trauma resiliency with a focus on violence recovery and mental health

•

Reducing health inequities by addressing social determinants of health (access to care, food and employment)

Demographics (12 zip service area) Population:

Change in Total Population

625,707

2012-2016

� �

3.5% .6%

.2%

23%

Food security is a household-level social and economic condition of limited or uncertain access to adequate food.

UCM_CommunityProfiles_Exec-Summary_v7.1.indd 1-2

of Chicago population

-3.8% Servicearea

Cook County

9/27/19 3:41 PM

Introduction The Community Health Needs Assessment (CHNA) is a systematic, data-driven approach to determine the health needs in the service area of the University of Chicago Medical Center (UCMC). The CHNA provides information for the hospital to identify issues of greatest need and allocate resources to improve community health and wellness. The Patient Protection and Affordable Care Act added Section 501(r) to the Internal Revenue Service Code, requiring nonprofit hospitals, including UCMC, to conduct a CHNA every three years. UCMC has completed similar needs assessments in 2012 and 2015. To complete the 2018-2019 CHNA, UCMC partnered with 37 nonprofit hospitals in Cook County, Illinois, through a membership collaborative called the Alliance for Health Equity led by the Illinois Public Health Institute (IPHI). The Alliance for Health Equity collaborative CHNA process was designed to meet federal requirements and guidelines in Section 501(r), including: n

n n n

clearly defining the community served by the hospital, and ensuring that defined community does not exclude low-income, medically underserved, or minority populations in proximity to the hospital; providing a clear description of the CHNA process and methods; community health needs; collaboration, including with public health experts; and a description of existing facilities and resources in the community; receiving input from persons representing the broad needs of the community; documenting community comment on the CHNA and health needs in the community; and documenting the CHNA in a written report and making it widely available to the public.

This report provides an overview of the University of Chicago Medical Center, process involved in the CHNA, including data collection methods and sources, UCMCâ&#x20AC;&#x2122;s service area and historical inequities faced by the residents in the service area. The data from the CHNA are presented in two ways. Within the body of the report we present the results by our service area zip codes where we assess the health needs for the entire service area. In Appendix 1, we provide the CHNA results through a community profile for 27 community areas in the UCM service area. This method uses the granular data available by community area and brings to light the differences and similarities within the communities in the UCM service area. Included in Appendix 2 is an evaluation of our past efforts to address the community needs identified in the 2015 CHNA. Lastly, in Appendix 3 we provide the Cook County Community Health Needs Assessment, which provides data for additional indicators and needs identified across the county.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

UCMC Overview The University of Chicago’s Medical Center (Medical Center), one of the nation’s leading academic medical institutions, has been at the forefront of medical care since 1927. Renowned for treating some of the most complex medical cases, UCMC brings the very latest medical treatments to patients in the city of Chicago, Illinois, and throughout the world. In this way, UCMC furthers its commitment to patient care, clinical practice and community health. UCMC partners with the University of Chicago physicians and the University of Chicago’s Pritzker School of Medicine to educate the next generation of physicians and other health care professionals. The Medical Center is a leading provider of complex care in the state of Illinois and UCMC is the largest provider of Medicaid services (by admissions and patient days) on the South Side of Chicago and the largest in the State of Illinois in inpatient and outpatient volumes. The Medical Center’s mission is to provide superior health care in a compassionate manner, ever mindful of each patient’s dignity and individuality. To accomplish our mission, we call upon the skills and expertise of all who work together to advance medical innovation, serve the health needs of the community, and further the knowledge of those dedicated to caring. Our aim to “serve the health needs of our community” anchors our mission statement and shapes the ethos and work of the University of Chicago Medicine. Our community, advises us on strategy, informs our research, and partners with us for collective impact toward improving the health and wellness of our community. On a foundation of mutual respect, we will work together to build the University of Chicago Medicine into one of the finest organizations in the country as measured by the quality of patient care, the satisfaction of patients and their families, and the level of pride among everyone who works here. A designated division, the Urban Health Initiative (UHI) serves as the medical center’s community health division through which we partner with the community to design and execute programs and, achieve community benefit through innovative strategies to improve population health. The UHI fosters and promotes collaborative community-based programs and services for residents on the South Side to strategically improve health and access to quality healthcare. This includes workshops and support groups, providing community-based seminars, and delivering prevention and wellness interventions.

Community Health Needs Assessment 2018–2019

UChicago Medicine

CHNA Process STAKEHOLDER ENGAGEMENT

The CHNA process involved engagement with multiple stakeholders to prioritize health areas to assess as well to collect, curate and interpret the data. UCMC joined the Alliance for Health Equity to conduct the CHNA and participated in its collaborative efforts for Cook County. The Alliance for Health Equity is a collaborative of 37 hospitals working with health departments and regional and community-based organizations to improve health equity, wellness, and quality of life across Chicago and Cook County. The purpose of the Alliance for Health Equity is to improve population and community health by: promoting health equity; supporting capacity building, shared learning, and connecting local initiatives; addressing social and structural determinants of health; developing broad city and county wide initiatives and creating systems; engaging community partners and working collaboratively with community leaders; developing data systems for population health to support shared impact measurement and community assessment; and collaborating on population health policy and advocacy. Leaders from the UCMC Urban Health Initiative guide the strategic direction of the Alliance for Health Equity through roles on the steering committee, various committees and workgroups. UCMC also engaged internal and community stakeholders throughout the CHNA process. Both stakeholder groups provided insight and expertise around the indicators to be assessed, types of focus group questions to be asked to the community, interpretation of results and prioritization of areas of highest need. Internal stakeholders included the Community Benefit Steering Committee. The Community Benefit Steering Committee is comprised of staff and faculty who provide advice and oversight of UCMC’s community benefit programs, reporting and CHNA development and execution. The committee is charged with developing policies, processes and programs that support the community benefit function and activities as well as advising on the implementation of them. The committee meets quarterly, and oversees the development and implementation of the Community Health Needs Assessment and Community Benefit/Implementation Strategy Reports. Input from community stakeholders was also gathered from UCMC’s Community Advisory Council (CAC). In the summer of 2016, UCMC launched a process to recruit and select its first enterprise wide CAC. It was created, and is currently managed, by the Urban Health Initiative. The CAC is comprised of a representative group of 20 volunteer members who live and/or work in the UCMCSA. The CAC members serve as advisors to UCMC on issues of interest to the broader community. The CAC is an essential partner in achieving UCMC’s goals related to the broader community interests, community benefit, access to care, and effective community engagement. The CAC has 3 work groups; 1) Adult Health; 2) Child and Maternal Health and 3) Trauma Care and Violence Prevention. All work groups align with and support our identified CHNA priority health needs. The CAC has advised UCMC leadership on pivotal projects including, but not limited to, designing community communication/engagement plans informing our CHNA, as well as, programming connected to the Strategic Implementation Plan. Specifically, the CAC played a key role in identifying community organizations for our focus groups and helped to ensure that diverse community voices were heard throughout the CHNA process. The Maternal and Child Health Workgroup centered their entire agenda for the 2018 and 2019 on the CHNA. They were instrumental in generating and refining focus group questions for community engagement and several members served as hosts for our focus groups and helped with recruiting participants. Community Health Needs Assessment 2018–2019

UChicago Medicine

DATA AND METHODS The Alliance for Health Equity steering committee (including UCMC) worked with the IPHI and Chicago and Cook County Departments of Public Health to carry out a collaborative CHNA process between March 2018 and March 2019. The CHNA process is adapted from the Mobilizing for Action through Planning and Partnerships (MAPP) framework, a community-engaged strategic planning framework that was developed by the National Association for County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, and data-driven decision-making. The Alliance for Health Equity chose this inclusive, community-driven process to leverage and align with health department assessments and to actively engage stakeholders including community members in identifying and addressing strategic community health priorities to advance health equity. More details about the CHNA process and method are included on page 28 of the Alliance for Health Equity collaborative CHNA report in Appendix 3. Primary data for the CHNA was collected through four methods: n Community resident surveys n Community resident focus groups n Health care and social service provider focus groups n Two stakeholder assessments led by the Chicago Department of Public Health—Forces of Change n Assessment and Health Equity Capacity Assessment Community Resident Surveys Between October 2018 and February 2019, 658 community residents in the UCMCSA provided input to the CHNA process through a community resident survey disseminated by UCMC, CAC partners, and other Alliance for Health Equity partners. (In total, over 5,800 surveys were collected in Cook County as part of the collaborative CHNA process.) The community resident survey was available on paper and online in four languages-- English, Spanish, Chinese, and Polish. The surveys included questions asking respondents about the health status of their communities, community strengths, opportunities for improvement, and priority health needs. The survey was designed to gain insight from priority populations that are typically underrepresented in assessment processes including communities of color, immigrants, LBGTQ+ community members, individuals with disabilities, and low-income communities. The final survey tool included 16 questions—3 questions related to zip code/community of residence, 9 demographic questions, 2 multi-select questions about health problems and what’s needed for a healthy community, and 2 open-ended questions about strengths and improvements. The Community Input Survey tool is included in Appendix 3. Table 1 summarizes the demographics of survey respondents in the UCMCSA.

Community Health Needs Assessment 2018–2019

UChicago Medicine

Table 1. Demographics of Community Input Survey Respondents in UCMC Communities Age (n=627)

Educational Attainment (n=625)

18-24

11.6%

Some or no high school

5.9%

25-34

14.5%

High school graduate or GED

19.7%

35-44

14.2%

Vocational or technical school

5.0%

45-54

15.6%

Some college

28.2%

55-64

18.5%

College graduate or higher

41.3%

65-74

16.1%

Household Size (n=602)

75-84

7.5%

23.3%

85 or older

1.9%

26.2%

Gender Identity (n=630)

19.6%

Female

73.0%

13.6%

Male

26.3%

9.1%

Non-Binary or Genderqueer

0.5%

4.2%

Gender Neutral

0.2%

1.8%

1.0%

0.8% 0.3%

Sexual Orientation (n=594) Straight

94.4%

Gay or Lesbian

2.2%

10+

Bisexual

2.4%

Children in the Household (n=603)

Race/Ethnicity (n=615)

African American/Black

76.7%

No children in my household

58.9%

Children in the household

41.1%

Hispanic/Latino(a)

11.4%

Person(s) in the Household with a Disability (n=610)

Multiracial

5.4%

Yes

27.4%

White

3.7%

72.6%

Asian

2.3%

Native American

0.3%

Middle Eastern/Arab American

0.2%

Annual Household Income (n=534) Less than $10,000

19.1%

$10,000 to $19,999

14.4%

$20,000 to $39,999

23.2%

$40,000 to $59,999

16.5%

$60,000 to $79,999

11.8%

$80,000 to $99,999

5.8%

Over $100,000

9.2%

Community Health Needs Assessment 2018–2019

UChicago Medicine

Community Focus Groups Between August 2018 and February 2019, IPHI worked with Alliance for Health Equity partners across Chicago and Cook County to hold a total of 49 community input focus groups with priority populations such as veterans, individuals living with mental illness, communities of color, older adults, caregivers, teens and young adults, LGBTQ+ community members, adults and teens experiencing homelessness, families with children, faith communities, adults with disabilities, and children and adults living with chronic conditions such as diabetes and asthma. There were six focus groups that took place in the UCMCSA: n Affinity Community Services (with facilitation by IPHI) n Gary Comer Youth Center (coordinated by UCMC with facilitation by IPHI) n South Shore community service providers and residents (coordinated by South Shore Hospital with facilitation by IPHI) n Teen Living Programs (coordinated by Mercy Hospital and Medical Center with facilitation by IPHI) n Theace Goldsberry Community House (coordinated by UCMC with facilitation by IPHI) n Timothy Community Corporation (coordinated by UCMC with facilitation by IPHI) n TCA Health Inc. (coordinated and facilitated by UCMC) n ABJ Services (coordinated and facilitated by UCMC) n Community Faculty Summit on Best Practices in Violence Prevention and Recovery, community stakeholder participation included community behavioral health providers, grassroots organizations, social service agencies, youth groups (coordinated and facilitated by UCMC) Secondary Data Through the Alliance for Health Equity CHNA, UCMC worked with IPHI and the Chicago and Cook County Departments of Public Health to identify, compile, and analyze secondary data. IPHI and the health departments worked with hospitals and stakeholders to identify a common set of indicators, based on an adapted version of the County Health Rankings model (Figure 1). The Alliance for Health Equity has made three main adaptations to the County Health Rankings model, in keeping with local priorities: (1) including behavioral health as a major category of data, (2) applying a racial equity analysis to data where possible, and (3) including additional child and youth data where available. Further information on data collection methods, data sources, and limitations can be found on page 33 of the Alliance for Health Equity collaborative CHNA report in Appendix 3.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Figure 1. Adapted County Health Rankings and Roadmaps Model

Modified from: County Health Rankings and Roadmaps Model, 2014, http://www.countyhealthrankings.org/

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

UCMC SERVICE AREA

The UCMC community benefit service area is represented by 12 zip codes that surround the Medical Center campus. The service area is comprised of 35 Chicago neighborhoods with partial coverage for some neighborhoods (Figure 2). During this CHNA cycle, UCMC determined that is would include the Riverdale neighborhood in its service area based on an assessment that revealed need and UCM presence. A portion of Riverdale is comprised within an existing UCMC zip code, 60628. Since Riverdale is a high economic hardship community area, the decision was made to extend UCMCâ&#x20AC;&#x2122;s service area to include the entire Riverdale community area. In the results section, we describe the demographic and socioeconomic characteristics of our 12 zip code service area population and present the health indicators that are available by zip code. The remainder of this document incorporates community area level data for communities included in the 12 zip codes and presents profiles for 27 community areas. The decision to use community area level data was based on 1) presenting accessible data in a format that Chicago residents easily identify (community areas versus zip codes), 2) aligning with public health departments and other hospital systems that are collecting and analyzing Chicago data by community area, and 3) using available data for disease prevalence, incidence, and mortality which are not available at the zip code level. Figure 2. University of Chicago Medicine Service Area

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

HISTORICAL INEQUITIES IN UCMCSA Chicago has a long history of unfair policies and practices that have burdened communities of color. Taking a closer look within our service area, UCM is located within the Hyde Park neighborhood on the South Side of Chicago. The South Side is a storied and unique collection of vibrant, resilient, culturally rich and diverse communities. Steeped in African-American heritage and history, the South Side is marked by deep social bonds anchored by vital neighborhoods and faith-based organizations. However, generations of structural inequality and neglect have contributed to the erosion of the critical social, economic, and health ecosystem necessary to adequately meet the needs of this community. Today, the South Side of Chicago suffers among the worst economic, health, social, and violence disparities in the United States. Currently, the unemployment rate of those living in the UCM service area (21%) is three times the national unemployment rate. Half of the community members are at risk for food insecurity according to the Greater Chicago Food Depository’s estimates. Residents of the UCM service area suffer significantly higher rates of chronic health conditions such as asthma, diabetes, obesity, breast cancer, STIs and HIV. Furthermore, Chicago’s history of institutional and structural racism has led to disinvestment in the South Side communities, income inequality, and adverse health outcomes. For decades, institutions and systems of power at the national and city level including those located on the South Side have perpetrated racial discrimination through housing, employment, education, health care, and criminal justice policies. Literature demonstrates that residentially segregated neighborhoods have unequal distribution of resources and worse health outcomes– substandard housing, limited opportunities for high quality education and employment, lack of access to quality health care, increased risk of chronic diseases, more exposure to air pollutants, lower life expectancy, and higher crime rates. Structural racism in the form of residential segregation continues to persist in the city of Chicago and the result of this is visible in the limited economic opportunities and adverse health outcomes experienced by residents in UCMCSA. The disparities in life expectancy for South Side residents are evident from this Figure 3, with the life expectancy for residents of one of our service area estimated at 69 years, compared to 81 years for residents in Lincoln Park, a community area on the north side of the city.

Community Health Needs Assessment 2018–2019

UChicago Medicine

Figure 3. Life expectancy across Chicago

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Urban Health Initiative (UHI) UCMC addresses these institutional, structural, and health inequities through the Urban Health Initiative (UHI) – department responsible for advancing health equity within the medical center and UCMCSA. Through asset-based community development and an innovative, diversity and inclusion strategy, the UHI implements strategies to promote health in the community and provide equitable care in the hospital. Asset Based Community Development (ABCD) is a strategy for sustainable community- driven development. Beyond the mobilization of a particular community, ABCD is concerned with how to link micro-assets to the macro-environment. The appeal of ABCD lies in its premise that communities can drive the development process by identifying and mobilizing existing, but often unrecognized assets, and thereby responding to and creating local opportunity. UHI employs ABCD to build on the assets that are already found in the community and mobilizes individuals, associations, and institutions to come together to build on their assets-- not solely concentrating on their needs. An extensive period of time is spent in identifying the assets of individuals, associations, and then institutions before they are mobilized to work together to build on the identified assets of all involved. Then the identified assets from an individual are matched with people or groups who have an interest or need in that asset. The key is to begin to use what is already in the community. UHI’s comprehensive approach to reducing health disparities both inside and outside the hospital is a model for partnering with the community and hospital staff to reduce both inequities in healthcare outcomes and the impact of socio-economic inequality. UHI’s asset based community development approach is executed by the various departments that are housed within UHI: Community Benefit and Evaluation tracks and reports community benefit programs and services across the medical center. This team also assists all UHI departments in developing and implementing evidence based population health programs to improve the health of the community and leads the efforts to embed a sound evaluation framework across all UHI programs. The evaluation team is responsible for developing data collection tools, developing and managing program databases as well as analyzing program data for quality improvement and impact evaluation purposes. Office of Community Affairs promotes and facilitates engagement and collaboration between the medical center and South Side communities. Under the framework of asset-based community development, UCMC’s philosophy is to partner with and leverage the strengths and talents of existing community assets to improve local health and well-being. UCM’s Community Affairs team strengthens relationships between UCMC and the community to foster and promote collaborative communitybased programs and initiatives for residents on the South Side. Examples of initiatives executed by this office include the volunteer services program, community advisory council, community events participation, fitness programs, and the violence recovery program. Diversity, Inclusion and Equity helps build a diverse, inclusive, culturally competent organization representative of the patient populations and communities we serve. They provide training on interpersonal racism, implicit bias, discrimination in health care settings and how to overcome these to improve patient care. They create patient education materials in plain language and foster clear communication to help patients self-manage their care. Strategic Affiliations holds responsibility for managing partner relationships that make up UCM’s care delivery network. With the goal of achieving and sustaining wellness within the community, Strategic Affiliations also connects patients to reliable clinical resources post discharge and provides home based interventions. Among other initiatives, South Side Health Care Collaborative, South Side Pediatric Asthma Center, and Medical Home and Specialty Care Connection Program are a few examples of programs executed by this department to improve population health.

Community Health Needs Assessment 2018–2019

UChicago Medicine

Results DEMOGRAPHIC CHARACTERISTICS

UCMCSA comprises a total population of 625,707 residents. Between 2010 census and the 2012-2016 estimates from the American Community Survey, the service area population decreased by 3.8 percent, this is an inverse trend to the slight increase in population experienced by the County (0.6%) and Chicago (0.7%). Population decrease across the service area zip codes are not uniform, some zip codes 60636 (-12.5%), 60621 (-12.6%) experienced a larger decrease in population and other zip codes 60653 (3.8%) and 60643 (1.1%) experienced an increase in population.

Age distribution of the UCMCSA is comparable to the city and county. Approximately 24.2 percent of the population is under 18 years old and 14.5 percent of the population is over 65 years old.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Majority (76.7%) of UCMCSA population is Non-Hispanic Black/African American and 12.3 percent of the population is Hispanic/Latinx. About 54.7 percent of the UCMCSA population is female, which is slightly more than the approximately equal gender distribution of male and female population in Cook County and Chicago.

In UCMCSA, 2.62 percent of the population lives in a limited English speaking household. A larger proportion of limited English speaking households can be found in zip codes 60609 (25.0%) and 60617 (12.4%). Zip code 60609 is home to very diverse community areas including parts of Armour Square/Chinatown, Bridgeport, and McKinley Park; 86 percent of limited English speaking households in 60609 are Spanish-speakers as well as 11 percent that speak Asian languages. Zip code 60617 includes community areas South Chicago, East Side, and South Deering; 82 percent of limited English speaking households in 60617 are Spanish-speakers as well as 13 percent that speak other Indo-European languages.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Approximately 14.8 percent of UCMCSA population is living with a disability, which is higher than the proportion seen in Chicago (10.6%).

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

SOCIAL AND STRUCTURAL DETERMINANTS OF HEALTH

Community residents who participated in focus groups and the community input survey provided in-depth input about how social and structural determinants of health such as education, economic inequities, housing, food access, access to community services and resources, and community safety and violence impact community and individual health. Key insights from community input are highlighted in each of the sections below, and Figure 4 shows survey respondentsâ&#x20AC;&#x2122; input about the most important things necessary for a healthy community.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Education Education is an important determinant of health because poverty, unemployment, and underemployment rates are highest among those with lower levels of educational attainment. In addition, rates of self-reported poor health, infant mortality, and chronic disease are often higher among individuals with lower levels of educational attainment. Among population age 25 plus, about 16.4 percent of the population do not have a High school or an equivalent degree in UCMCSA. The proportion of people with a bachelor’s degree or higher (22.7%) compared to Cook County (36.5%).

COMMUNITY INPUT The major education-related concerns expressed by focus group participants on the South Side of Chicago included school closures, diminishing education opportunities and poor-quality schools. Youth on the South Side of Chicago mentioned that school closures have led to more student drop-outs. Multiple adult participants across Chicago mentioned serious concerns about the quality of Chicago schools, particularly schools that are majority students of color. Participants identified education as an underlying root cause of unemployment. Additionally, they linked education issues to many of the same problems caused by unemployment such as higher rates of community violence, increases in health issues such as substance use disorders and mental illness, and generational poverty. “Open up some more schools instead of closing them down, generations are getting dumber and dumber” (Teen Living Program – Youth Participant)

“There are a lot of jobs out here, but we are not qualified. We don’t have the education.” (Teen Living Program – Youth Participant)

Community Health Needs Assessment 2018–2019

UChicago Medicine

Poverty Economic inequality including disproportionate levels of poverty and unemployment create barriers to accessing health care and resources to maintain good health. Poverty has been linked with worst health outcomes, increased risk of chronic conditions, mortality, and lower life expectancy. In addition, poverty strongly influences housing stability, educational opportunities, living environment and health behaviors. The Federal Poverty Thresholds for 2016 defines poverty based on household size and age of household members, ranging from $12,486 for a one-person household to $24,339 for a four-person household with two children and $42,075 for an eight person household with four children. Almost a third (30.3%) of UCMCSA population live below 100% of the Federal Poverty Level (FPL) and more than half (53.3%) live below 200% of the FPL. The percentage of people in poverty is higher in UMCSA than it is for Chicago, Cook County, Illinois and the U.S. The poverty rate varies across the service area zip codes and is as high as 74 percent of population living below 200 percent of the FPL in 60621. Similarly, the child poverty rate is 43.2 percent for the service area, which is nearly double the child poverty rate in Cook County (24.2%). More than half of all children are living in poverty in zip codes 60637 (55.8%) and 60621 (55.3%).

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

COMMUNITY INPUT Focus group participants highlighted that segregation results in poor quality housing being concentrated in communities of color with high rates of violence and poverty. Some of the housing quality issues mentioned included dilapidated and crumbling structures, incomplete units, plumbing problems, and pest infestations. Renters described how these issues can be left unaddressed by landlords and property owners for extended periods of time or indefinitely. Some homeowners described these issues within their own homes but stated that they lacked the financial resources to address them. The health problems that were most often associated with these housing quality problems included exposure to mold, asthma, and stress.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

COMMUNITY INPUT Participants on the West and South Sides of the city and county reported a high proportion of fast food restaurants and limited access to grocery stores selling healthier options. Community members living with chronic diseases such as diabetes explained that living in communities with less access to healthy food options and more access to fast food made it more difficult to manage their conditions. Both youth and adults from multiple communities reported that having a healthy diet can be difficult for several other reasons as well including: n youth often find healthy foods unappealing particularly if they have had limited exposure to them; n the cost of healthy foods was frequently described as a barrier, but there was often disagreement among groups on this issue; n food pantries do not always provide healthy options; n fast foods are more convenient particularly for working parents with children; and n many lack the knowledge of how to prepare healthy meals. “Build more stores like Whole Foods, Cermack, and Mariano’s on the low ends instead of places like Popeyes.” (Gary Comer Youth Center)

Community Health Needs Assessment 2018–2019

UChicago Medicine

Unemployment Unemployment and underemployment can create financial instability which can influence access to healthcare services, insurance, healthy foods, stable quality housing, and other basic needs. Unemployment rates for adults over age 16 in UCMCSA (20.9%) is double the unemployment rate in the city of Chicago (10.9%). Unemployment rate is considerably high in zip code 60621 and 60636 at nearly 33 percent. Chicago has the highest racial disparities in young adult employment in the nation. In 2016, the employment rate among African Americans aged 20-24 was 47 percent, the lowest in the nation, and the rate for whites in the same age group was 73 percent, one of the highest in the nation.11 Additionally, among youth 16 – 19 years of age in UCMCSA, 12.4% are not in school nor employed compared to 8.7% in Cook County.

COMMUNITY INPUT A lack of employment opportunities was one of the most frequently discussed issues among focus group participants. Participants living on the South Side of Chicago (and across south and west regions of the city and county) described having the least number of quality job opportunities and employment resources. However certain populations such as those living with mental illness, young adults, homeless individuals, and formerly-incarcerated were highlighted as having significant barriers to employment regardless of their geographic location. In addition, multiple youth of color on the South Side described instances where they felt that their racial or ethnic background prevented them from obtaining employment. Within certain communities, jobs are available, but they are described as lacking benefits, part-time, temporary, and/or low-paying. “I’ve been to multiple temp agencies and there is a racial tension on the job. Certain ones like black people and others don’t.” (Teen Living Program – Youth Participant) “Access is one of the main things within our community - black community, people of color community. There are many stressors when we don’t have benefits, jobs, and access to healthcare.” (Affinity Community Services)

Community Health Needs Assessment 2018–2019

UChicago Medicine

Food Access and Food Security Food security is a household-level social and economic condition of limited or uncertain access to adequate food. Food insecurity can impact health in several ways: n the combination of stress and poor nutrition can make individuals more susceptible to developing chronic diseases and make management of chronic diseases more difficult; n worsening health problems and the associated medical care puts additional strain on household . budgets and leaves less money for essential nutrition and other basic needs; n chronic disease can lead to decreased employability and lower overall household income. In UCMCSA, 18.5 percent of the population is receiving Supplemental Nutrition Assistance Program benefits. Many community residents in the UCMCSA are experiencing food insecurity. The Greater Chicago Food Depository estimates that half (49.5%) of the population in the UCMCSA is at risk for food insecurity. Access to healthy foods is another important factor needed to support a healthy lifestyle. As previously mentioned, research indicates that communities with better access to healthy foods and limited access to convenience stores have healthier diets and lower rates of obesity.Low-income communities of color are less likely to have access to supermarkets and healthy foods and tend to have a higher density of fast-food restaurants and other sources of unhealthy food such as convenience store.14

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Violence and Community Safety Violence and community safety is a very important community health issue that has been emphasized by community residents through their input into this CHNA and also shows up starkly in health data. Respondents to the community input survey in the UCMSA identified violence as a top health problem as well as identifying safety and low crime as the number one priority necessary for a healthy community. As shown in table 3, homicide mortality is a leading cause of death in UCMCSA. COMMUNITY INPUT Community safety and violence was a cross-cutting theme that mentioned by all focus groups on the South Side of Chicago in a variety of contexts. The mostly commonly mentioned safety issues included gun violence, gang activity, drug-related activities, burglaries, and armed robberies. Participants related that the prevalence of violence in their communities has led to health issues such as chronic stress, decreased mental well-being, trauma among children and adults, and decreased physical activity due to a reluctance to exercise in unsafe neighborhoods. n

“My mom has been stuck up a couple times [while running] and she is scared. She saw a guy trying to hurt his girlfriend and she had to hide in a park bathroom and call the police.” (Gary Comer Youth Center)

“Different types of violence within and outside the household cause mental health stress.” (Affinity Community Services)

The UCMCSA community areas with the highest homicide rates for residents are Englewood, Riverdale, West Pullman, South Shore, Washington Park, Fuller Park, West Englewood and New City with homicide rates over 50 per 100,00 compared to the homicide rate of 20.7 per 100,000 in the city. The UCMCSA community areas with the highest violent crime rates were Washington Park, Englewood, West Englewood, Greater Grand Crossing, and Fuller Park with rates greater than 250 per 10,000 compared to 10.4 per 10,000 in the city. Homicide Rates, 2018

Community Health Needs Assessment 2018–2019

UChicago Medicine

Violent Crime Rates, 2018

Shootings Rate, 2018 - Chicago shootings rate for 2018 11.3 per 10,000

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Non-Fatal Shooting Rate, 2018 - Chicago nonfatal shootings rate for 2018 9.5 per 10,000

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

COMMUNITY INPUT In terms of factors that contribute to community violence the participants noted the following: n The legacy of racism and continuing institutional racism contributes to ongoing structural violence and systematic oppression n Housing policies of redlining perpetuate segregation. Environmental factors range from toxic dumping to aesthetics of neighborhoods (lack of trees). Affordability – cost of living increasing. Multifamily housing vs single family. n Transportation to jobs not optimal. Issue of access: bus lines cut off at certain times in certain communities / no way to travel downtown for jobs. n School closures lead to crowding as well as an environment that is disjointed from community. Minimal scholarships affect youth ability to “dream beyond the hood”. n ‘Us’ and ‘them’ phenomenon (Southside vs Northside). Majority white + wealthy people in city are not concerned. n Social exclusion (victims not involved in closed door meetings) - lack of transparency. n Lack of political will from decision makers n Lack of accountability leads to lack of trust (promises made and not delivered erode trustworthiness) n Institutions do not reflect the people in the neighborhood Community members suggested designing interventions to meet the needs of victims of violence and the community including the following: n Culturally competent educators in schools and opportunities for youth voice to support agency n Provide trauma informed mental health care/therapy for all impacted by trauma. n Dedicated case managers + persistent follow up -> Accountable health communities n Informed policing requires investment in training on structural racism that causes, or is induced by, trauma n Investment into a restorative justice program n Conflict resolution services / pre and post traumatic / mediation n Invest in people who have lived in lives of trauma / violence n Programs started by community members fail due to lack of funding and resources for grass root organizations. n No resources for any organizations in general – funders have deliverables that are not attainable -> RFPs need change n University led community-based programs for youth encourage youth to go to college n Provide community and family support for childcare, psychosocial support, rehabilitation n Train community members as first responders n At the medical center provide wrap around services, staff should look like community members with similar experiences n Support workforce development, youth re-entry, training connected to job with livable wage. n Incorporate private sector, incentivize those who hire and place businesses w/in community. Corporations come into the community to employ people who are released from prison. n Resources to create opportunities to promote grown within the community vs doing things “to” the community

Community Health Needs Assessment 2018–2019

UChicago Medicine

Access to Care Access to healthcare is broadly defined as the “the timely use of personal health services to achieve the best health outcomes”.15 Healthy People 2020 describes the three steps required for an individual to access healthcare services: (a) gaining entry into the healthcare system; (b) accessing a location where needed healthcare services are provided; and (c) finding a health care provider whom the patient trusts and can communicate with.16 Access is a complex and multifaceted concept that includes dimensions of proximity; affordability; availability, convenience, accommodation, and reliability; quality and acceptability; openness, culturally responsiveness, appropriateness and approachability. Approximately 13.9 percent of adults are uninsured in UCMCSA, which is very similar to the city of Chicago (14.7%). About 315,212 persons in the UCMCSA are enrolled in Medicaid, this is approximately 48.4 percent of the service area population (Table 2). 17

Table 2. Medicaid Enrollment in UCMCSA17 (As of 6/30/18) Population

Number of persons

Children (0-18)

125,460

Adults with Disabilities (19-64)

34,411

ACA Newly Eligible Adults (19-64)

81,469

Other adults (19-64)

51,895

Seniors (65+)

20,753

Partial Benefits (All Ages)

Community Health Needs Assessment 2018–2019

1,224

UChicago Medicine

COMMUNITY INPUT Multiple participants on the South Side of Chicago mentioned barriers that impede their ability to access the healthcare system and community resources including: n n n n

the complexity of obtaining and keeping public benefit coverage; the high cost of some private insurance plans; an unequal distribution of healthcare services and facilities; and poor quality healthcare options particularly for LGBTQ+ individuals and people of color.

Increasing mobile testing units and health events within communities with low access was a strategy recommended by participants on the South Side of Chicago. In addition, churches were recommended as potential partners for hosting healthcare programs. Community residents in many groups recommended using a variety of communication strategies such as strategically placed community flyers, TV ads, and social media to raise awareness about existing resources. It was also recommended that successful programs be expanded into communities where they are not yet available. “I go to Norwegian because they referred me. I was going to Northwestern, but they had stopped taking my card. They should have left it alone, so you can go anywhere – all this managed care and stuff.” (ABJ Community Services) n “Healthcare doesn’t depend on your level of insurance, they make assumptions when you are black and walk in the door” (Affinity Community Services) n “Healthcare is not looking to provide services to the LGBTQ community in a way that they are providing services to well-to-do, cis-gendered, heterosexual whites.” (Affinity Community Services) n “Now I can get medicine when I want with my medical card.” (ABJ Community Services) n “In certain places there are no stores or resources. In those communities, people don’t have access to the things we talked about. They don’t go to the doctor, they don’t have access to social media. They don’t have access to go to doctor to talk about health or get information about health.” (Timothy Community Corporation) n

Community Health Needs Assessment 2018–2019

UChicago Medicine

All UCMCSA zip codes are classified by the federal Health Resources and Services Administration (HRSA) as health professional shortage areas for primary care. Englewood/West Englewood, Auburn Gresham/Washington Heights/Chatham, Roseland/Pullman/Burnside, South Chicago/South Shore, and South Deering have all been designated as geographic HPSAs, meaning the shortage impacts the whole population in those geographies. The remaining areas in the UCMCSA are health professional shortage areas for the low-income populations living in those communities.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

All UCMCSA zip codes are classified by the federal Health Resources and Services Administration (HRSA) as health professional shortage areas (HPSAs) for mental health. Most of the UCMCSA is designated as a geographic HPSA for mental health, meaning the shortage impacts the whole population in those geographies. The near south area (60615 and 60653) is a HPSA for mental health only for the low-income populations living in those communities.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

HEALTH OUTCOMES MORBIDITY AND MORTALITY

Leading Causes of Death The leading causes of death for the UCMCSA are shown in Table 3 below. UCMCSA has the same 3 top causes of death as the City of Chicago—heart disease, cancer, and diabetes-related deaths. Homicide mortality is substantially higher in the UCMCSA than the city overall. Table 3. Leading causes of death UCMC Service Area

Chicago

Illinois

United States

(2012-2016)

(2016)

(2016) 1. Heart Disease

Heart Disease

Cancer

Accidents

Diabetes-related

Homicide*

Stroke and Cerebrovascular Diseases

Chronic Lower Respiratory Diseases

Accidents

Stroke and Cerebrovascular Diseases

Alzheimers

Diabetes

Kidney Disease

Influenza & Pneumonia

4. Stroke and Cerebrovascular Diseases*

Homicide

Drug Overdose

Chronic Lower Respiratory Diseases

7. 6.

Drug Overdose

Alzheimers

Chronic Lower Respiratory Diseases Alzheimers

* Homicide and Stroke mortality rates across the service area are very similar

Overall Community Input Community residents who participated in focus groups and the community input survey provided in-depth input about how specific health conditions impact community and individual health. Key insights from community input are highlighted in each of the sections below, and Figure 5 shows survey respondents’ input about the most important health problems in the community.

Community Health Needs Assessment 2018–2019

UChicago Medicine

Emergency department Visits Hospitalization and emergency department (ED) visits are indicative of poorly controlled chronic diseases and a lack of access to routine preventive care. Poorly controlled diabetes can lead to severe or life-threatening complications such as heart and blood vessel disease, nerve damage, kidney damage, eye damage and blindness, foot damage and lower extremity amputation, hearing impairment, skin conditions, and Alzheimerâ&#x20AC;&#x2122;s disease. Stress and trauma can be a pathway to chronic diseases and can prohibit seeking care for chronic diseases until emergency care is needed. ED visits for adult and pediatric asthma are indicative of increased exposure to environmental contaminants that can trigger asthma as well as poorly managed asthma. Asthma The rate of asthma related emergency department (ED) visits among youth (18 and younger) and adults is disproportionately high in UCMCSA compared to the rest of the city. UCMCSA zip codes 60637 (252.4 per 10,000) and 60636 (243.6 per 10,000) have the highest rate of asthma ED visits among youth compared to the Chicago rate of 92.6 per 10,000. Asthma-related ED visits among adults is highest in zip codes 60621 (203.6 per 10,000) and 60636 (196.8 per 10,00) compared to the Chicago rate of 62.5 per 10,000.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

COMMUNITY INPUT Youth and adult focus group participants indicated that there were a number of environmental and behavioral factors that could trigger their asthma including: n common allergens such as dust, pollen, paint, pets, perfumes, cleaning supplies, air fresheners, and second or third-hand smoke; n housing-related factors such as carpet, drapes, air-conditioning, heat, humidity, pest infestations, and mold; n weather changes from hot to cold or vice versa; and n behavioral factors such as physical activity. Parents of younger children were more likely to report that their children always carried their rescue medication than older youth or adults themselves. In addition, younger children were more likely to be receiving controller medication. Despite these factors, nearly all parents of young children with asthma reported several repeated visits to the emergency department for severe asthma attacks. Some additional challenges faced by parents of the youngest children included the difficulty of properly administering medication to a young child, their child’s fear of the doctor, and the difficulty of restricting activities of a young child with severe asthma. Many parents found that caring for their children’s asthma significantly restricted their ability to sleep, engage in healthy behaviors, and engage in basic self-care activities. Parents also conveyed that they often stressed about the health of their children both when they are at home and when they are at school. Parents stated that they found educational courses about asthma triggers and how to avoid them to be extremely helpful. They also stated the importance of working with family members and school staff to have emergency plans in place in case of a severe asthma episode. Other parents recommended learning life-saving techniques such as CPR. Most emphasized the importance of expanding educational programs and planning strategies to all parents of children living with asthma. In addition, more comprehensive care options may be needed for some patients to avoid poorly controlled asthma and frequent visits to the emergency department. n

“I can’t keep count of how many times I go to the ER with my child.” (Asthma Parent focus group) “Whatever they give them in the hospital, they perk right up, it’s so frustrating. You’re trying so hard to figure it out at home, for 12 hours, and then it just works right away at the hospital.” (Asthma Parent focus group) “I always take my child to the ER. As he gets older, it’s has gotten more severe, and he is agitated. He asks questions about when he can stop taking medications.” (Asthma Parent focus group) “My child takes a lot of medication. At night he gets frustrated and says, “here we go again.” He takes sleep apnea medication plus 2-3 medications for asthma.” (Asthma Parent focus group) “The children will be running and jumping around despite me telling them to calm down. When I give my son the medicine with steroids, he can’t sit still. He has problems in school because he can’t focus. The medicine helps his asthma, but it makes him too energetic.” (Asthma Parent focus group) “I’m running on no sleep because my child can’t sleep at night. Then the hospital gives him medication to knock him right out – and then I have to carry him off the bus. He’s 69 pounds. Give me the medication so I can give it to him at home, so I can get a break. Let me take a shower and straighten stuff up. You can’t take a break, it’s your child, you do what you have to do.” (Asthma Parent focus group)

Community Health Needs Assessment 2018–2019

UChicago Medicine

COMMUNITY INPUT Many of the youth participants living with severe asthma reported that their symptoms severely restricted their day-to-day activities even if they were receiving treatment. In general, youth with less severe asthma symptoms reported fewer restrictions to their day-to-day activities but commonly reported that they frequently did not carry their rescue medication with them because they felt their risk was lower. However, at least one of these students reported being transported from school to the emergency department via ambulance because she had a severe asthma attack at school and did not have her rescue inhaler. n

“Sometimes it makes me feel like I have a disability. I wanted to go to the army, but I couldn’t because I have asthma. It makes me feel bad, dang why I got asthma.” (Youth Asthma)

“I hate when my lungs close. I cannot do what I want to do”

“I don’t do things that I can’t do because I don’t want it to get worse. I used to play basketball, but my asthma started coming back. I can’t do what I did last year.” (Youth Asthma)

“I don’t’ take my asthma pump to school because I don’t have bad asthma. (Youth Asthma)

“If I go out somewhere, I don’t always have it [inhaler] with me. It’s not the first thing that comes to mind. It just slips my mind.” (Youth Asthma)

“I left my asthma pump at home they had to call an ambulance for me at school.” (Youth Asthma)

Community Health Needs Assessment 2018–2019

UChicago Medicine

Diabetes ED visits due to diabetes among adults in most of the UMCSA zip codes is higher than the Chicago rate of 37.7 per 10,000. Three zip codes with the highest rate of ED visits due to diabetes are 60621 (83.1 per 10,000), 60636 (71.6 per 10,000), and 60628 (68.8 per 10,000).

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

COMMUNITY INPUT Adults living with diabetes all agreed that they understood the importance of healthy diet and physical activity in controlling their conditions, but they mentioned several barriers that made it difficult to engage in healthy behaviors: n chronic stress in everyday life makes it difficult to manage diabetes; n limited access to grocery stores and easy access to fast food can make it difficult to choose healthy food options, particularly for individuals and parents who are busy and work long hours; n the affordability of healthy foods; n physical activity routines can be difficult to begin by yourself; n not everyone knows how to prepare healthy meals; n resistance from non-diabetic family members, other household members, and friends to changes in diet; and lack of knowledge about community resources that may help with disease management. Participants recommended creating support groups for individuals living with diabetes so that they can share information about resources and support each other with lifestyle changes. Several participants mentioned that creating workout groups for individuals with diabetes that accommodate different schedules would help motivate them to exercise more frequently. However, these groups need to be tailored to different levels of fitness and be inclusive of individuals living with disabilities. Programs that teach skills related to meal planning, healthy food choices, and preparing healthy meals were found to be extremely helpful and it was recommended that these programs be expanded. Social media posts and videos about meal prepping, recipes, exercise, and managing diabetes were highlighted as a great opportunity for educating the community. Supporting home gardens and community gardens was described as an excellent way to improve access to fresh fruits and vegetables and increase physical activity. Food pantries were also cited as another important community resource for improving access to fresh fruits and vegetables. n “We have food deserts in Chicago, and you go a long way before you find healthy food, but you find fast food like burger king.” (Timothy Community Corporation) n “One of my concerns is that I have diabetes and so does my daughter. Sometimes when I get home, I make food and sometimes I just grab chicken. I hear some people meal prep. I leave home at 6am and get home at 6 or 7pm, it is hard for me.” (Timothy Community Corporation) n “A lot of people don’t like working out by yourself. They feel they are not doing it right, so they stop doing it.” (Timothy Community Corporation) n “Need to establish a weekly meal plan. For example, on Sunday write down the meals you want to eat and work in time to work out. It’s a matter of making a meal plan and exercise plan for the week so you don’t get bored. Research the food you want to eat.” (Timothy Community Corporation) n “I started a garden and put everything in a bucket. Fresh fruit and herbs.” (Timothy Community Corporation) n “We’ve been able to control it with food. It is expensive. We found a food pantry at Saint Elizabeth’s. They had arugula, grapes, apples, tomatoes. They had some good stuff, really fresh food - it was good food. Every fourth Saturday that’s where we get food.” (Timothy Community Corporation) n “I do look on social media and look at the recipes and I do experiment.” (Timothy Community Corporation) n “Social media, there are a lot of groups on social media - how to eat healthy, how to work out.” (Timothy Community Corporation)

Community Health Needs Assessment 2018–2019

UChicago Medicine

Behavioral Health ED visit rates due to mental health among adults and youth are higher in the UCMCSA zip codes compared to the city. ED visit rates for adults in UCMCSA ranges from 87.4 per 10,000 to 261.9 per 10,000 compared to the city rate of 110.0 per 10,000. ED visit rates for youth in UCMCSA ranges from 40.2 per 10,000 to 64.9 per 10,000 comparted to the city rate of 46.5 per 10,000.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

COMMUNITY INPUT Focus group participants linked chronic stress to several different health effects. Community members and service providers on the South Side of Chicago reported that stress impacted their ability to cope with chronic illnesses such as diabetes and could disrupt their ability to engage in behaviors such as healthy eating and exercise. Parents caring for children with asthma reported that the stress of caring for a family member had negative impacts on their mental and physical well-being. Youth living with asthma reported that stress was a trigger for their asthma attacks. Participants from one focus group directly linked chronic stress to the development of substance use disorders. In addition to chronic stress, focus group participants described multiple situations that have led to trauma among community members living on the South Side including: n child abuse, n domestic violence, n living in high crime neighborhoods, n continual discrimination against marginalized racial and ethnic groups, and n homelessness. The impact of these types of trauma were wide reaching. Examples of the impacts of trauma in these communities are listed below. n Most homeless youth participants reported traumatic events such as abuse as precipitating events to them becoming homeless. n Within the LGBTQ+ community domestic violence is largely underreported and unaddressed. This has had profound negative impacts on the mental health of some community members. n African American community members living in low income, high crime areas reported greater difficulties managing their chronic illnesses, poor mental health, and poor overall physical health as a direct result of continuing trauma. n Youth and adult participants stated that substance use was a common coping mechanism for dealing with trauma among their peers. The majority of recommended strategies and solutions for addressing trauma in communities were focused on early intervention and adequate support. The need to address major gaps in behavioral health services was emphasized particularly for populations such homeless youth and adults, children and youth, communities of color, and individuals exposed to violence.

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Conclusion Prioritization of Health Needs Building on UCM’s past two CHNAs, our Community Benefit and Evaluation Team worked with the Community Benefit Management and Steering Committees, as well as a workgroup of the Community Advisory Council to prioritize health issues for UCM’s next three years of community benefit programming from 2019-2021. Representatives from the UCM Urban Health Initiative, select UCM faculty, and community stakeholders were among the three major constituencies involved in health priority selection process. These constituencies were strategically selected for their respective understanding of community perspectives, community based health engagement, and community health education efforts. Using the CHNA as a foundational tool, the Community Benefit and Evaluation Team reviewed and compared the 2018-2019 UCMCSA health outcome data to previous CHNA health outcome data. New data and health issues that were worse than previous years were slated for consideration. UCM Selected Health Priority Areas UCM retained three of the primary health priority issues from the 2015 CHNA: diabetes, asthma, and violence prevention. We added new issues in response to the needs assessment. These include social determinants of health and mental health. The framework for the priority health areas are organized under three primary domains. These will serve as the designated issue areas for official reporting and are the principle health concern that UCM community benefit efforts will target (Figure 6). Figure 6: Framework for Community Benefit Priorities (2019-2021)

Community Health Needs Assessment 2018–2019

UChicago Medicine

Adoption by the board University of Chicago Medical Center’s Board of Director’s Government and Community Relations Committee received the 2018-2019 CHNA report, 2016-2019 Evaluation Report, and 2019-2021 Strategic Implementation Plan for review and formally approved all three documents on May 23, 2019. Contact for feedback Any questions or concerns regarding the CHNA, Strategic Implementation Plan, and the Evaluation report can be sent to communitybenefit@uchospitals.edu.

Community Health Needs Assessment 2018–2019

UChicago Medicine

Endnotes 1 Chicago Health Atlas. “Riverdale.” Accessed March 5, 2019. https://www.chicagohealthatlas.org/community-areas/ riverdale. 2 Professional Research Consultants. 2015 Community Health Needs Assessment: University of Chicago Medical Center Service Area, Cook County, Illinois. Omaha: Professional Research Consultants, 2015. 3 Hirsch, Arnold R. Making the Second Ghetto: Race and Housing in Chicago, 1940–1960. Chicago: The University of Chicago Press, 1998. 4 Alexander, Michelle. The new Jim Crow: mass incarceration in the age of colorblindness. New York: The New Press, 2010. 5 Bailey, Zinzi D., Nancy Krieger, Madina Agenor, Jasmine Graves, Natalia Linos, and Mary T Bassett. “Structural racism and health inequities in the USA: evidence and interventions.” The Lancet 389 (2017): 1453-63. https://www.thelancet.com/ action/showPdf?pii=S0140-6736%2817%2930569-X 6 Gee, Gilbert C. and Chandra L. Ford. “Structural racism and health inequities: old issues, new directions.” Du Bois Review 8, no. 1 (2011): 115-132. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306458/ 7 Krieger, Nancy. “Discrimination and Its Consequences for Health.” International Journal of Health Services 44, no. 4(2014): 643-710. https://journals.sagepub.com/doi/pdf/10.2190/HS.44.4.b 8 Virginia Commonwealth University Center on Society and Health. “Short Distances to Large Gaps in Health.” Accessed March 5, 2019. https://societyhealth.vcu.edu/media/society-health/pdf/LE-Map-Chicago.pdf 9 Office of Disease Prevention and Health Promotion. “HealthyPeople.gov: Poverty.” Accessed March 5, 2019. https:// www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/poverty#7 10 United States Census Bureau. “Poverty Thresholds” Accessed March 5, 2019. https://www.census.gov/data/tables/ time-series/demo/income-poverty/historical-poverty-thresholds.html 11 Svajlenka, Nicole P. and Martha Ross. “Employment and disconnection among teens and young adults: The role of place, race, and education.” Brookings. August 15, 2017. Accessed March 6, 2019. https://www.brookings.edu/research/ employment-and-disconnection-among-teens-and-young-adults-the-role-of-place-race-and-education/ 12 “Definitions of Food Security.” United States Department of Agriculture – Economic Research Service. September 5, 2018. Accessed March 5, 2019. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/ definitions-of-food-security/ 13 Weinfield, Nancy S., Gregory Mills, Christine Borger, Maeve Gearing, Theodore Macaluso, Jill Montaquila, and Sheila Zedlewski. “Hunger in America 2014.” Feeding America. Accessed March 5, 2019 http://help.feedingamerica.org/ HungerInAmerica/hunger-in-america-2014-full-report.pdf 14 Larson, Nicole I., Mary T. Story, and Melissa C. Nelson. “Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S.” American Journal of Preventive Medicine 36, 1 (2009): 74-81. https://www.sciencedirect.com/science/ article/pii/S0749379708008386?via%3Dihub 15 Institute of Medicine. Access to Health Care in America. Washington, D.C.: National Academy Press, 1993. Accessed March 5, 2019. https://www.ncbi.nlm.nih.gov/books/NBK235882/pdf/Bookshelf_NBK235882.pdf 16 Office of Disease Prevention and Health Promotion. “HealthyPeople.gov: Access to Health Services.” Accessed March 5, 2019. https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services#1 17 Enrollment numbers from state DHFS may include some duplicates since enrollment in Medicaid is a continuous process. The number of person’s enrolled percentage of total populations should be taken as an estimate.

Community Health Needs Assessment 2018–2019

UChicago Medicine

Appendix 1: Community Profiles

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

UChicago Medicine

Community Profile

Auburn Gresham is known for its bungalow-style housing and brick two flat apartments. The Chicago Public Library’s Thurgood Marshall Branch is located in this community and features a large auditorium, and houses community artwork.1

Who lives here?2

97+1+A

Auburn Gresham

Dan Ryan Woods

Race and Ethnicity

Sex

56%

97% Black

Female

44%

1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

45,770 Age

Population change:3

14%

15% 11%

14%

11%

Chicago: 6%

9% 5%

2% 00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

Auburn Gresham

Social Determinants of Health2 Social determinants of health are social, economic, and physical conditions in which people are born, live, and work that affect health and well-being. For example, where you live limits access to healthy foods, these can in turn increase ones risk for obesity and other chronic conditions related to diet.

Economic Factors

$29,285 Chicago: $53,006

Population living in poverty4

7% Associates degree

33%

High school or equivalent

17% Less than high school

29% 19%

29%

Bachelor’s degree or higher Chicago Auburn Gresham

Unemployment

24%

8% Chicago Auburn Gresham

A 7 17 15 29 + 32 Education5

Median household income

of households spend 30% or more of their annual income on housing costs

Some college— no degree

2 in 5 children are living in poverty4

33% of households are receiving food stamps 52% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

8,165 4,491

Chicago Auburn Gresham

Auburn Gresham

Access to Care Access to quality health care services is important for preventing and managing diseases and achieving health equity. High cost of care, inadequate insurance coverage, and lack of availability of quality services generally lead to barriers in clinical care.

of the population are uninsured2

report having a consistent source of primary care provider8

87%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

52% of pregnant women received early and adequate prenatal care9

66% report receiving colorectal cancer screening8

Health Behaviors8 Health behaviors are individual actions we take to prevent illnesses or maintain good health such as exercising and eating a balanced diet. Health behavior is greatly influenced by the social and economic conditions in which people live. For example, it is difficult to walk in the neighborhood to get exercise when you do not feel safe.

33% report not participating in any physical activity or exercise in the past month

43% report drinking soda or sweetened drinks everyday

27% report being a smoker

20% report eating five or more servings of fruits and vegetables daily

Auburn Gresham

Health Outcomes10 Health outcomes are the measures that define the health and wellbeing of the community. Health outcomes are a result of social determinants of health, access to clinical care, and health behaviors. Infant Mortality

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Strokes

72 years

Chicago: 77 years

The Loop: 82 years Chicago Auburn Gresham

Disease Burden Among Adults8

31%

have high blood pressure

42% 14% 17% are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Auburn Gresham are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

17 Schools

110 Faith Based Organizations

3 Fitness Facilities

13 Social Service Organizations

Hospital and Health Services

Community Gardens

11 Grocery Stores

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Auburn Gresham. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/pages/88. html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Avalon Park

Chicago Vocational High School

Avalon Park is called a “hidden gem for its quiet natural, lush green spaces.1 The Don Nash Community Center is located in the middle of this community.

Who lives here?2

97+1+A Race and Ethnicity

Sex

58%

98% Black

Female

<1%

42%

White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

9,840 Age

Population change:3

16%

Chicago: 6%

12%

13%

12%

11% 7%

2% 00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

Avalon Park

A 7 12 23 34 + 24

Economic Factors

Education5

Median household income

$37,208 Chicago: $53,006

Population living in poverty4

7% Associates degree

24%

High school or equivalent

12% Less than high school

21% 19%

35%

23%

Some college— no degree

Bachelor’s degree or higher Chicago Avalon Park

Unemployment

24%

8% Chicago Avalon Park

of households spend 30% or more of their annual income on housing costs

1 in 5

children are living in poverty4

29% of households are receiving food stamps 36% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

6,981 4,491

Chicago Auburn Gresham

Avalon Park

of the population are uninsured2

report having a consistent source of primary care provider8

75%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

51% of pregnant women received early and adequate prenatal care9

65% report receiving colorectal cancer screening8

40% report not participating in any physical activity or exercise in the past month

60% report drinking soda or sweetened drinks everyday

35% report being a smoker

8% report eating five or more servings of fruits and vegetables daily

Avalon Park

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke

75 years

Chicago: 77 years The Loop: 82 years

7 Chicago Avalon Park

Disease Burden Among Adults8

44% 56% 15% 11%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Avalon Park are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

6 Schools

16 Faith Based Organizations

1 Fitness Facilities

2 Social Service Organizations

Hospital and Health Services

2 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Shanabruch, Stephen. “Avalon Park.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 7, 2018. https://www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/avalon-park; 2: American Communities Survey 20122016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Beverly

Givins Irish Castle

Beverly was historically an exclusive streetcar suburb and is known for its large homes and many trees that surround the streets.1 It is home to the Beverly Arts Center.

Who lives here?2

34+59+16A Race and Ethnicity

Sex

51%

58% White

Female

<1%

49%

Asian or Pacific Islander

34%

Black

Hispanic/Latinx

Male

Population:

20,836 Age

Population change:3

15%

Chicago: 6%

17% 12

15%

10%

7% 4%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

2% 85–94

Beverly

Social Determinants of Health3 Social determinants of health are social, economic, and physical conditions in which people are born, live, and work that affect health and well-being. For example, where you live limits access to healthy foods, these can in turn increase ones risk for obesity and other chronic conditions related to diet.

Economic Factors Education5

Median household income

Chicago: $53,006

Population living in poverty4 19%

14% High school or equivalent

20%

14+205637A

$93,037

Some college— no degree

Associates degree

56%

Bachelor’s degree or higher

Less than high school

Chicago Beverly

Unemployment 8%

Chicago Beverly

of households spend 30% or more of their annual income on housing costs

children are living in poverty4

3% of households are receiving food stamps 11% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population 4,491

1,797 Chicago Beverly

Beverly

of the population are uninsured2

having a % report consistent source of

77% of pregnant women received early and adequate prenatal care9

primary care provider8

80%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

58% report receiving colorectal cancer screening8

21% report not participating in any physical activity or exercise in the past month

16% report drinking soda or sweetened drinks everyday

15% report being a smoker

40% report eating five or more servings of fruits and vegetables daily

Beverly

Life Expectancy at Birth

Deaths per 1,000 live births 7

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Stroke 5. Diabetes-related

78 years

Chicago: 77 years The Loop: 82 years Chicago Beverly

Disease Burden Among Adults8

25% 33% 10% 13%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Beverly are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

7 Schools

16 Faith Based Organizations

13 Fitness Facilities

5 Social Service Organizations

Hospital and Health Services

2 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Beverly. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/pages/134.html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Burnside

Greenwood Avenue

Burnside is also known as “The Triangle,” due to the fact that it is surrounded by railroads. It was previously known as Stony Island. The shift occurred when University of Chicago sociologists remapped the area and ultimately, renamed it to Burnside.1 It is home to the organization Illinois Action for Children, which is celebrating its 50th year of being in existence.2

Who lives here?3

+1A 99

Race and Ethnicity

Population:

2,442 Population change:4

16%

48%

99% Black

Female

52%

White

Male

Age

15% 11%

Chicago: 6%

Sex

12%

13%

11%

10%

5% 2%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

Burnside

A 9 19 14 30 + 28

Economic Factors

Education6

Median household income

$23,684 Chicago: $53,006

Population living in poverty5

9% Associates degree

29%

High school or equivalent

19% Less than high school

33%

30%

14%

19%

Some collegeâ&#x20AC;&#x201D; no degree

Bachelorâ&#x20AC;&#x2122;s degree or higher Chicago

Burnside

Unemployment

18%

Chicago Burnside

of households spend 30% or more of their annual income on housing costs

children are living in poverty5

Physical Factors Violent crime incidents8 Per 100,000 Population

29%

6,824 4,491

of housing units are vacant Chicago 2

Burnside

35% of households are receiving food stamps 41% of households are at risk for food insecurity7

Burnside

87%

of the population are uninsured3

report having a consistent source of primary care provider9

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

44% of pregnant women received early and adequate prenatal care10

85% report receiving colorectal cancer screening9

Health Behaviors9 Health behaviors are individual actions we take to prevent illnesses or maintain good health such as exercising and eating a balanced diet. Health behavior is greatly influenced by the social and economic conditions in which people live. For example, it is difficult to walk in the neighborhood to get exercise when you do not feel safe.

46% report not participating in any physical activity or exercise in the past month

Burnside

Health Outcomes11 Health outcomes are the measures that define the health and wellbeing of the community. Health outcomes are a result of social determinants of health, access to clinical care, and health behaviors. Infant Mortality

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Cancer 2. Heart Disease 3. Injury 4. Diabetes-related 5. Homicides

71 years

13 7

Chicago: 77 years The Loop: 82 years Chicago

Burnside

Disease Burden Among Adults9

58%

have high blood pressure

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Burnside are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

1 Schools

8 Faith Based Organizations

0 Fitness Facilities

2 Social Service Organizations

Hospital and Health Services

0 Grocery Stores

Community Gardens

0 Pharmacies

1 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “Burnside.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 7, 2018. https:// www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/burnside; 2: “Who We Are.” Illinois Action for Children, January 15, 2016. https:// www.actforchildren.org/who-we-are/; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Calumet Heights is named after the Calumet River that is located nearby. It is home to the Bronzeville Children’s Museum. This museum is one of its kind, being the first and only African American children’s museum in the country.1

Who lives here?2

94+14A

Calumet Heights

Bronzeville Children’s Museum

Race and Ethnicity

55%

94% Black

Female

45%

1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

Sex

13,306 Age

Population change:3

Chicago: 6%

15%

13%

14%

4% 2% 00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

Calumet Heights

A 10 11 26 27 + 26

Economic Factors

Education5

Median household income

$46,581 Chicago: $53,006

Population living in poverty4

10% Associates degree

26%

High school or equivalent

11% Less than high school

19%

17%

27%

26%

Some college— no degree

Bachelor’s degree or higher Chicago Calumet Heights

Unemployment

14%

Chicago Calumet Heights

of households spend 30% or more of their annual income on housing costs

children are living in poverty4

20% of households are receiving food stamps 35% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

5,300 4,491

Chicago Calumet Heights

Calumet Heights

of the population are uninsured2

having a % report consistent source of

54% of pregnant women received early and adequate prenatal care9

primary care provider8

78%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

44% report receiving colorectal cancer screening8

17% report not participating in any physical activity or exercise in the past month

50% report drinking soda or sweetened drinks everyday

14% report being a smoker

26% report eating five or more servings of fruits and vegetables daily

Calumet Heights

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Cancer 2. Heart Disease 3. Injury 4. Diabetes-related 5. Stroke

75 years

Chicago: 77 years 7

The Loop: 82 years

Chicago Calumet Heights

Disease Burden Among Adults8

have high blood pressure

are obese

24% 15% are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Calumet Heights are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

7 Schools

1 Fitness Facilities

Faith Based Organizations

Social Service Organizations

Hospital and Health Services

1 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Bronzeville Children’s Museum | Building Children’s Minds | African-American museum designed for children to engage in learning through hands-on activities. Accessed June 13, 2019. http://www.bronzevillechildrensmuseum.com/?r; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Chatham

Chatham Market

Chatham is 10 miles from the South Loop and has a strong cultural identity. There is a strong sense of community and community organizations that have stemmed from here including the Greater Chatham Initiative (GCI). GCI promotes strategic investments and economic growth in the communities of Chatham, Greater Grand Crossing, Avalon Park, and Auburn Gresham.1

Who lives here?2

96+21A Race and Ethnicity

Sex

56%

96% Black

Female

44%

White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

30,946 Age

Population change:3

16%

0.3%

12%

Chicago: 6%

13%

12%

6% 3%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

Chatham

Social Determinants of Health Social determinants of health are social, economic, and physical conditions in which people are born, live, and work that affect health and well-being. For example, where you live limits access to healthy foods, these can in turn increase ones risk for obesity and other chronic conditions related to diet.

A 8 12 23 29 + 28

Economic Factors

Education5

Median household income

$34,612 Chicago: $53,006

Population living in poverty4

8% Associates degree

28%

High school or equivalent

12% Less than high school

29%

23%

19%

Some college— no degree

Bachelor’s degree or higher Chicago Chatham

Unemployment

19%

Chicago Chatham

of households spend 30% or more of their annual income on housing costs

children are living in poverty4

35% of households are receiving food stamps 36% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

9,417 4,491 Chicago Chatham

Chatham

of the population are uninsured2

report having a consistent source of primary care provider8

88%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

53% of pregnant women received early and adequate prenatal care9

79% report receiving colorectal cancer screening8

29% report not participating in any physical activity or exercise in the past month

27% report drinking soda or sweetened drinks everyday

26% report being a smoker

24% report eating five or more servings of fruits and vegetables daily

Chatham

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Homicides

74 years

13 7

Chicago: 77 years The Loop: 82 years Chicago

Chatham

Disease Burden Among Adults8

34% 40% 14% 14%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Chatham are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

10 Schools

43 Faith Based Organizations

3 Fitness Facilities

13 Social Service Organizations

Hospital and Health Services

18 Grocery Stores

Community Gardens

1 Pharmacies

3 Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Casiello, Ashley. “The Greater Chatham Initiative.” The Greater Chatham Initiative. The Greater Chatham Initiative, June 13, 2019. https://www.greaterchathaminitiative.org/; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

East Side

Calumet Beach

East Side is surrounded by water and is located on the Calumet River’s eastern bank. Due to its location and access to water, steel mills were able to thrive in this neighborhood.1 It is home to thriving Calumet Beach, a United States Coast Guard station, and Calumet Yacht Club.2

Who lives here?3

Race and Ethnicity

Sex

51%

80%

Hispanic/ Latinx

Female

+17180A

49%

Black

<1%

Male

17% White

Asian or Pacific Islander

Population:

23,013 Age

Population change:4

0.1%

15%

14%

Chicago: 6%

13%

13% 9%

4% 1%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

East Side

Economic Factors

$44,079 Chicago: $53,006

Population living in poverty5

5% Associates degree

34%

High school or equivalent

30% Less than high school

20% 19%

18%

13% Chicago East Side

Bachelor’s degree or higher

Unemployment

18%

Chicago East Side

A 5 30 13 18 + 34 Education6

Median household income

of households spend 30% or more of their annual income on housing costs

Some college— no degree

1 in 3 children are living in poverty5

21% of households are receiving food stamps 47% of households are at risk for food insecurity7

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population 4,491

2,851 Chicago East Side

East Side

of the population are uninsured3

report having a consistent source of primary care provider9

76%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

58% of pregnant women received early and adequate prenatal care10

36% report receiving colorectal cancer screening9

29% report not participating in any physical activity or exercise in the past month

43% report drinking soda or sweetened drinks everyday

28% report being a smoker

38% report eating five or more servings of fruits and vegetables daily

East Side

Life Expectancy at Birth

Deaths per 1,000 live births 7

Top Causes of Death

1. Cancer 2. Heart Disease 3. Diabetes-related 4. Injury 5. Stroke

79 years

Chicago: 77 years The Loop: 82 years Chicago East Side

Disease Burden Among Adults9

18%

have high blood pressure

36% 10% are obese

are diabetic

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in East Side are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

7 Schools

4 Fitness Facilities

Faith Based Organizations

Social Service Organizations

Hospital and Health Services

9 Grocery Stores

Community Gardens

1 Pharmacies

5 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “East Side.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 7, 2018. https:// www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/east-side; 2: “Calumet Beach.” Chicago Park District. Accessed June 13, 2019. https://www.chicagoparkdistrict.com/parks-facilities/calumet-beach; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Englewood

Kennedy King College

Englewood is home to the 200 housing units built by the Antioch Baptist Church, which are public funded apartments for elderly people, one of the first of its kind.1 Teamwork Englewood was started in this community, an enrichment program that helps with economic and neighborhood development.2 In recent years, economic development has been on the rise in this community with the additions of Kennedy King College, Whole Foods, and expansion of the St. Bernard Hospital.

Who lives here?3

95+1+3A Race and Ethnicity

Sex

55%

95% Black

Female

45%

1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

26,020 Age

Population change:4

17%

15%

12%

Chicago: 6%

11%

13%

10% 6%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

4% 75–84

2% 85–94

Englewood

A 7 25 + 36

Economic Factors

Education6

Median household income

$22, 507 Chicago: $53,006

Population living in poverty5

7% Associates degree

36%

High school or equivalent

25% Less than high school

19%

25%

7% Chicago

Some college— no degree

Bachelor’s degree or higher

Englewood

Unemployment

35%

Chicago Englewood

of households spend 30% or more of their annual income on housing costs

1 in 2 children are living in poverty5

54% of households are receiving food stamps 72% of households are at risk for food insecurity7

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population

11,173 4,491 Chicago Englewood

Englewood

population % ofarethe uninsured 3

having a % report consistent source of

44% of pregnant women received early and adequate prenatal care10

primary care provider9

66%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

70% report receiving colorectal cancer screening9

26% report not participating in any physical activity or exercise in the past month

36% report drinking soda or sweetened drinks everyday

33% report being a smoker

26% report eating five or more servings of fruits and vegetables daily

Englewood

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Accidents

72 years

Chicago: 77 years

The Loop: 82 years Chicago Englewood

Disease Burden Among Adults9

42%

have high blood pressure

41% 14% 16% are obese

are diabetic

have asthma

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Englewood are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

16 Schools

73 Faith Based Organizations

2 Fitness Facilities

Hospital and Health Services

Community Gardens

Social Service Organizations

Grocery Stores

Pharmacies

10 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Englewood. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/pages/426.html; 2: “Our Mission and Vision.” Teamworkenglewood. Accessed June 13, 2019. https://www.teamworkenglewood.org/our-mission-and-visiom; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Fuller Park is two miles long and is one of Chicago’s smallest community areas.1 Construction of the Dan Ryan Expressway in the 1950s created a direct link from Fuller Park to downtown Chicago. It is home to the Eden Place Nature Center, an organization that promotes nature conservation and urban agriculture.2

Who lives here?3

91 A 5 + 4

Fuller Park

Eden Place Community Center

Race and Ethnicity

Sex

52%

91% Black

Female

48%

White

Male

Hispanic/Latinx

Population:

2,377 Age

Population change:4

17%

13%

Chicago: 6%

15% 11%

11%

13%

12%

11%

6% 5% 2% 00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

85–94

Fuller Park

A 8 27 11 18 + 36

Economic Factors

Education6

Median household income

$21,437 Chicago: $53,006

8% Associates degree

36%

High school or equivalent

Population living in poverty5

27%

33%

Less than high school 19%

18%

Chicago

Some college— no degree

Bachelor’s degree or higher

Fuller Park

Unemployment

29%

Chicago Fuller Park

of households spend 30% or more of their annual income on housing costs

3 in 5 children are living in poverty5

49% of households are receiving food stamps 57% of households are at risk for food insecurity7

Physical Factors

28%

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population

16,238

4,491 Chicago Fuller Park

Fuller Park

population % ofarethe uninsured

having a % report consistent source of

59%

40% of pregnant women received early and adequate prenatal care10

primary care provider9

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

75% report receiving colorectal cancer screening9

36% report drinking soda or sweetened drinks everyday

Fuller Park

Infant Mortality

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Accidents

67 years

15 7

Chicago: 77 years The Loop: 82 years Chicago Fuller Park

Disease Burden Among Adults9

36%

have high blood pressure

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Fuller Park are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

1 Schools

8 Faith Based Organizations

1 Fitness Facilities

0 Social Service Organizations

Hospital and Health Services

0 Grocery Stores

Community Gardens

1 Pharmacies

1 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Fuller Park. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/pages/232.html. Citation; 2: “Eden Place Nature Center.” Eden Place Nature Center. Accessed June 13, 2019. http://www.edenplacenaturecenter.org/; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Grand Boulevard is home to a large part of the Bronzeville neighborhood, also known as the “Black Metropolis”. The population of Bronzeville increased significantly during the Great Migration. Bronzeville was a center of black businesses, civic organizations and churches and became home to notable African Americans including Louis Armstrong, Ida B. Wells, and Gwendolyn Brooks.1

Who lives here?2

96+12A

Grand Boulevard

Harold Washington Cultural Center

Race and Ethnicity

Sex

58%

93% Black

Female

42%

3% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

22,634 Age

Population change:3

14%

Chicago: 6%

14%

15% 13%

10%

7% 4%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

2% 85–94

Grand Boulevard

A 7 15 28 + 22

Economic Factors

Education5

Median household income

$25,151

Chicago: $53,006

Population living in poverty4

Associates degree

22%

High school or equivalent

15% Less than high school

35%

28%

27%

19%

Some college— no degree

Bachelor’s degree or higher Chicago

Grand Boulevard

Unemployment

21%

8% Chicago Grand Boulevard

of households spend 30% or more of their annual income on housing costs

2 in 5 children are living in poverty4

37% of households are receiving food stamps 50% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

7,178 4,491

Chicago Grand Boulevard

Grand Boulevard

of the population are uninsured2

report having a consistent source of primary care provider8

82%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

54% of pregnant women received early and adequate prenatal care9

64% report receiving colorectal cancer screening8

Health Behaviors7 Health behaviors are individual actions we take to prevent illnesses or maintain good health such as exercising and eating a balanced diet. Health behavior is greatly influenced by the social and economic conditions in which people live. For example, it is difficult to walk in the neighborhood to get exercise when you do not feel safe.

31% report not participating in any physical activity or exercise in the past month

25% report drinking soda or sweetened drinks everyday

24% report being a smoker

32% report eating five or more servings of fruits and vegetables daily

Grand Boulevard

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke

73 years

Chicago: 77 years

The Loop: 82 years Chicago Grand Boulevard

Disease Burden Among Adults8

39% 46% 14% 20%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Grand Boulevard are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

11 Schools

62 Faith Based Organizations

2 Fitness Facilities

17 Social Service Organizations

Hospital and Health Services

3 Grocery Stores

Community Gardens

Pharmacies

Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine. org/community-health. 1: Shanabruch, Stephen. “Bronzeville.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 6, 2018. https:// www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/bronzeville; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Greater Grand Crossing was built up over time as a result of its proximity to railroad crossings.1 It is home to the Gary Comer Youth Center. This is a center that provides after school enrichment for children and young adults of all ages.2 The development of public art spaces has been on the rise in this community because of the investments artists are contributing to it.3

Who lives here?4

95+21A

Greater Grand Crossing

Gary Comer Youth Center

Race and Ethnicity

Sex

55%

97% Black

Female

45%

1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

32,461 Age

Population change:5

0.4%

14% 11%

Chicago: 6%

6% 4% 2%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

85–94

Greater Grand Crossigng

Social Determinants of Health4 Social determinants of health are social, economic, and physical conditions in which people are born, live, and work that affect health and well-being. For example, where you live limits access to healthy foods, these can in turn increase ones risk for obesity and other chronic conditions related to diet.

A 9 15 30 + 31

Economic Factors

Education7

Median household income

$28,154 Chicago: $53,006

Population living in poverty6

37%

19%

8% Associates degree

31%

High school or equivalent

15% Less than high school

30%

15%

Some college— no degree

Bachelor’s degree or higher

Chicago Greater Grand Crossing

Unemployment

24%

Chicago Greater Grand Crossing

of households spend 30% or more of their annual income on housing costs

1 in 2 children are living in poverty6

40% of households are receiving food stamps 55% of households are at risk for food insecurity8

Physical Factors

22%

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”9

Violent crime incidents9 Per 100,000 Population

10,680 4,491

Chicago Greater Grand Crossing

Greater Grand Crossing

77%

of the population are uninsured4

report having a consistent source of primary care provider10

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan10

46% of pregnant women received early and adequate prenatal care11

60% report receiving colorectal cancer screening10

Health Behaviors10 Health behaviors are individual actions we take to prevent illnesses or maintain good health such as exercising and eating a balanced diet. Health behavior is greatly influenced by the social and economic conditions in which people live. For example, it is difficult to walk in the neighborhood to get exercise when you do not feel safe.

26% report not participating in any physical activity or exercise in the past month

28% report drinking soda or sweetened drinks everyday

26% report being a smoker

32% report eating five or more servings of fruits and vegetables daily

Greater Grand Crossing

Health Outcomes12 Health outcomes are the measures that define the health and wellbeing of the community. Health outcomes are a result of social determinants of health, access to clinical care, and health behaviors. Infant Mortality

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke

71 years

Chicago: 77 years

The Loop: 82 years Chicago Greater Grand Crossing

Disease Burden Among Adults10

32%

have high blood pressure

41% are obese

7% 12%

are diabetic

have asthma

Community Resources13 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Greater Grand Crossing are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

15 Schools

80 Faith Based Organizations

5 Fitness Facilities

14 Social Service Organizations

Hospital and Health Services

Community Gardens

Grocery Stores

Pharmacies

Public Parks14

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Greater Grand Crossing. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/ pages/547.html; 2: “Pursue Your Passions.” Gary Comer Youth Center. Accessed June 13, 2019. http://www.garycomeryouthcenter.org/; 3: “Theaster Gates.” Art21. Accessed June 13, 2019. https://art21.org/artist/theaster-gates/; 4: American Communities Survey 2012-2016 estimates; 5: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 6: Under 100% of the Federal Poverty Level; 7: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 8: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 9: Chicago Police Department; 10: Healthy Chicago survey; 11: Illinois Department of Public Health Vital Stats; 12: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 13: MapsCorps 2017 Community asset dataset; 14: Chicago Parks District

Community Profile

Hyde Park

Museum of Science and Industry

Hyde Park is home to the University of Chicago, Museum of Science and Industry, and The DuSable Museum of African American History. The DuSable Museum is one of the largest African American museums in the country. In addition, former President Barack Obama and his family have a home here.1

Who lives here?2

29+48149A Race and Ethnicity

29%

Black

Population:

Sex

47%

51%

White

Female

12% Asian or Pacific Islander

49% Male

8% Hispanic/Latinx

26,573 Age

Population change:3

22%

Chicago: 6%

11%

10%

00–04

05–14

7% 4%

15–24

25–34

35–44

45–54

55–64

65–74

75–84

2% 85–94

Hyde Park

Economic Factors Education5

Median household income

$53,366 Chicago: $53,006

74%

Bachelor’s degree or higher

Associates degree

Population living in poverty4

22%

7+12375A

High school or equivalent

12%

19%

Some college— no degree

Chicago Hyde Park

Less than high school

Unemployment

Chicago Hyde Park

of households spend 30% or more of their annual income on housing costs

children are living in poverty4

9% of households are receiving food stamps 33% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population 4,491

2,473 Chicago Hyde Park

Hyde Park

87%

of the population are uninsured2

report having a consistent source of primary care provider8

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

67% of pregnant women received early and adequate prenatal care9

73% report receiving colorectal cancer screening8

24% report not participating in any physical activity or exercise in the past month

8% report drinking soda or sweetened drinks everyday

17% report being a smoker

35% report eating five or more servings of fruits and vegetables daily

Hyde Park

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Accidents

82 years

9 7

Chicago: 77 years The Loop: 82 years Chicago Hyde Park

Disease Burden Among Adults8

22%

have high blood pressure

12% are obese

11%

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Hyde Park are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

6 Schools

22 Faith Based Organizations

12 Fitness Facilities

11 Social Service Organizations

Hospital and Health Services

Community Gardens

7 Grocery Stores

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “Hyde Park | Chicago Neighborhoods | Choose Chicago.” English. Accessed June 10, 2019. https://www. choosechicago.com/neighborhoods/south/hyde-park/; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Kenwood

Operation Push

Kenwood sits on the shore of Lake Michigan and has a strong architectural presence.1 Many official historical landmarks have been preserved here, such as the George Blossom House built by architect Frank Lloyd Wright.2 Late professional boxer, Muhammad Ali, was a resident of this neighborhood for a long time.

Who lives here?3

69+18+94A Race and Ethnicity

Sex

69%

54%

Black

Female

White

46% Male

8% Asian or Pacific Islander

Hispanic/Latinx

Population:

17,074 Age

Population change:4

17%

4% Chicago: 6%

11%

13%

8% 5%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

2% 85–94

Kenwood

A 7 8 55 18 + 12

Economic Factors

Education6

Median household income

$46,826 Chicago: $53,006

Population living in poverty5

22%

12%

High school or equivalent

Associates degree

18%

Some college— no degree

Less than high school

19%

55% Bachelor’s degree or higher Chicago Kenwood

Unemployment

13%

Chicago Kenwood

of households spend 30% or more of their annual income on housing costs

1 in 5 children are living in poverty5

17% of households are receiving food stamps 35% of households are at risk for food insecurity7

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population 4,491

3,727

Chicago Kenwood

Kenwood

of the population are uninsured3

having a % report consistent source of

61% of pregnant women received early and adequate prenatal care9

primary care provider9

75%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

56% report receiving colorectal cancer screening9

26% report not participating in any physical activity or exercise in the past month

18% report drinking soda or sweetened drinks everyday

14% report being a smoker

38% report eating five or more servings of fruits and vegetables daily

Kenwood

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Cancer 2. Heart Disease 3. Injury 4. Stroke 5. Diabetes-related

79 years

10 7

Chicago: 77 years The Loop: 82 years Chicago

Kenwood

Disease Burden Among Adults9

28% 32% 9%

have high blood pressure

are obese

are diabetic

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Kenwood are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

8 Schools

17 Faith Based Organizations

4 Fitness Facilities

4 Social Service Organizations

Hospital and Health Services

3 Grocery Stores

Community Gardens

1 Pharmacies

4 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Shanabruch, Stephen. “Kenwood.” The Chicago Neighborhoods, The Chicago Neighborhoods, 6 Oct. 2018, www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/kenwood; 2: “Kenwood | Chicago Neighborhoods | Choose Chicago.” English. Accessed June 10, 2019. https://www.choosechicago.com/neighborhoods/south/kenwood/; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Morgan Park Park is laid out in an English country town format. It has many winding streets, small parks, and roundabouts. The Walker Branch library has been renovated and continues to be a main place of attraction. The largest neighborhood-based St. Patrick’s Day parade is based in this community.1

Who lives here?2

56 A 9 1 34 +

Morgan Park

Walker Library

Race and Ethnicity

Sex

56%

54%

Black

Female

34% White

8% Hispanic/Latinx

Population:

28,919

46% Male

<1%

Asian or Pacific Islander

Age

Population change:3

28%

13%

16%

14% 10%

Chicago: 6%

13%

12%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

3% 85–94

Morgan Park

A 10 9 34 25 + 22

Economic Factors

Education5

Median household income

$59,027 Chicago: $53,006

Population living in poverty4

10% Associates degree

22%

High school or equivalent

9% Less than high school

19%

25%

34%

Some college— no degree

Bachelor’s degree or higher Chicago Morgan Park

Unemployment

11%

Chicago Morgan Park

of households spend 30% or more of their annual income on housing costs

1 in 5 children are living in poverty4

16% of households are receiving food stamps 29% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

Violent crime incidents7 Per 100,000 Population

4,214

4,491

of adults report that they feel safe in their neighborhood “most or all of the time”7

Chicago Morgan Park

Morgan Park

of the population are uninsured2

report having a consistent source of primary care provider8

74%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

63% of pregnant women received early and adequate prenatal care9

53% report receiving colorectal cancer screening8

34% report not participating in any physical activity or exercise in the past month

32% report drinking soda or sweetened drinks everyday

27% report being a smoker

34% report eating five or more servings of fruits and vegetables daily

Morgan Park

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke

75 years

13 7

Chicago: 77 years The Loop: 82 years Chicago

Morgan Park

Disease Burden Among Adults8

34%

have high blood pressure

41% 12% 10% are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes.A sample of the community resources necessary for optimal health outcomes and available in Morgan Park are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

8 Schools

29 Faith Based Organizations

5 Fitness Facilities

9 Social Service Organizations

Hospital and Health Services

4 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Morgan Park. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/pages/842.html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

New City

Cornell Square Park

New City was once home to the Union Stock Yards, a meatpacking area of Chicago. Back of the Yards and Canaryville neighborhoods are located in this community area.1 It is home to Cornell Square Park, a vibrant community gathering place.2

Who lives here?3 Race and Ethnicity

Sex

61%

50%

24+13261A

Hispanic/ Latinx

Female

23%

Black

50% Male

12%

Asian or Pacific Islander

White

Population:

41,178 Population change:4

19%

Chicago: 6%

Age

17%

16% 14%

10%

11% 7% 4%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

2% 75–84

0.6% 85–94

New City

Economic Factors

$30,427 Chicago: $53,006

Population living in poverty5

3% Associates degree

45%

High school or equivalent

31% Less than high school

34% 19%

7% Bachelor’s degree or higher Chicago

New City

Unemployment

21%

Chicago New City

A 3 31 7 14 + 45 Education6

Median household income

of households spend 30% or more of their annual income on housing costs

14%

Some college— no degree

1 in 2 children are living in poverty5

36% of households are receiving food stamps 60% of households are at risk for food insecurity7

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population

5,716 4,491

Chicago New City

New City

population % ofarethe uninsured 3

report having a consistent source of primary care provider9

84%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

55% of pregnant women received early and adequate prenatal care10

59% report receiving colorectal cancer screening9

26% report not participating in any physical activity or exercise in the past month

44% report drinking soda or sweetened drinks everyday

15% report being a smoker

23% report eating five or more servings of fruits and vegetables daily

New City

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke/Accidental

75 years

8 7

Chicago: 77 years The Loop: 82 years Chicago New City

Disease Burden Among Adults9

26% have high blood pressure

31% 12%

are obese

have asthma

are diabetic

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in New City are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

24 Schools

49 Faith Based Organizations

7 Fitness Facilities

12 Social Service Organizations

Hospital and Health Services

20 Grocery Stores

Community Gardens

Pharmacies

Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “New City.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 6, 2018. https:// www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/new-city; 2: District, Chicago Park. “The World’s Largest Swimming Lesson at Cornell Sq.” Chicago Park District. Accessed June 13, 2019. https://www.chicagoparkdistrict.com/parks-facilities/Cornell-Square-Park/; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Oakland

41st Street Bridge

Oakland is a very small community area, bordering the coast of Lake Michigan. It is known for its Queen Ann-style homes which feature large porches and multiple chimneys.1

Who lives here?2

92 A 4 2 + Race and Ethnicity

59%

92% Black

Female

41%

2% White

Male

Asian or Pacific Islander

Hispanic/Latinx

Population:

Sex

6,474 Age

Population change:3

14%

Chicago: 6%

15%

13% 9%

5% 3% 00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

1% 85–94

Oakland

A 8 15 24 30 + 23

Economic Factors

Education5

Median household income

$28,084 Chicago: $53,006

Population living in poverty4

8% Associates degree

23%

High school or equivalent

15% Less than high school

32% 19%

30%

24%

Some college— no degree

Bachelor’s degree or higher Chicago Oakland

Unemployment

21%

Chicago Oakland

of households spend 30% or more of their annual income on housing costs

1 in 3 children are living in poverty4

45% of households are receiving food stamps 49% of households are at risk for food insecurity

Physical Factors

of housing units are vacant 2

Violent crime incidents7

of adults report that they feel safe in their neighborhood “most or all of the time”7

Per 100,000 Population

5,373 4,491

Chicago Oakland

Oakland

population %ofarethe uninsured 2

report having a consistent source of primary care provider8

92%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

100%

49% of pregnant women received early and adequate prenatal care9

47% report receiving colorectal cancer screening8

31% report not participating in any physical activity or exercise in the past month

12% report drinking soda or sweetened drinks everyday

52% report being a smoker

Oakland

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Diabetes-related 4. Stroke 5. Injury

70 years

8 7

Chicago: 77 years The Loop: 82 years Chicago Oakland

Disease Burden Among Adults8

45%

have high blood pressure

44% are obese

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Oakland are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

3 Schools

1 Fitness Facilities

Faith Based Organizations

Social Service Organizations

Hospital and Health Services

0 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Shanabruch, Stephen. “Oakland.” The Chicago Neighborhoods, The Chicago Neighborhoods, 6 Oct. 2018, https://www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/oakland; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Pullman

Pullman National Monument

Pullman is known as a “company town.” Historically, it was once known as a planned community, which was spearheaded by George Pullman.The buildings that were built during the inception of this neighborhood have gained National Historic Landmark status, such as the Pullman National Monument.1

Who lives here?2

83+11+15A Race and Ethnicity

Sex

59%

83% Black

Female

10%

41%

White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

6,620 Age

Population change:3

14%

10%

14% 12%

13%

12%

Chicago: 6%

5% 1% 00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

85–94

Pullman

A 7 13 25 30 + 25

Economic Factors

Education5

Median household income

$36,777 Chicago: $53,006

Population living in poverty4

7% Associates degree

25%

High school or equivalent

13% Less than high school

19%

30%

25%

Some college— no degree

Bachelor’s degree or higher Chicago Pullman

Unemployment

20%

Chicago Pullman

of households spend 30% or more of their annual income on housing costs

1 in 3 children are living in poverty4

32% of households are receiving food stamps 40% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

7,915 4,491

Chicago Pullman

Pullman

of the population are uninsured2

report having a consistent source of primary care provider8

96%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

57% of pregnant women received early and adequate prenatal care9

77% report receiving colorectal cancer screening8

26% report not participating in any physical activity or exercise in the past month

46% report being a smoker

21% report eating five or more servings of fruits and vegetables daily

Pullman

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke

72 years

Chicago: 77 years

The Loop: 82 years Chicago

Pullman

Disease Burden Among Adults8

47% 28% 28%

have high blood pressure

are obese

are diabetic

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Pullman are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

5 Schools

2 Fitness Facilities

Faith Based Organizations

Social Service Organizations

Hospital and Health Services

1 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Pullman. Accessed June 13, 2019. http://www.encyclopedia.chicagohistory.org/pages/1030.html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Riverdale

Altgeld Gardens

Riverdale was once home to Sherwin-Williams, one of the biggest paint manufacturers in the nation.1 This neighborhood is home to Altgeld Gardens, a public housing project that consists of row houses, which is a different architectural makeup from that of most public housing communities.2 Embedded within this housing complex is a community farm that unites all residents.

Who lives here?3

93+2+14A Race and Ethnicity

Sex

59%

94% Black

Female

41%

2% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

7,382 Age

Population change:4

14%

19% 14%

Chicago: 6%

11%

10%

10% 6%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

0.6%

65–74

75–84

85–94

Riverdale

A 9 24 5 36 + 26

Economic Factors

Education6

Median household income

$14,415

Chicago: $53,006

Population living in poverty5

Associates degree

26%

High school or equivalent

24% Less than high school

66%

36%

Some college— no degree

Bachelor’s degree or higher

19% Chicago Riverdale

Unemployment

37%

8% Chicago Riverdale

of households spend 30% or more of their annual income on housing costs

3 in 4 children are living in poverty5

59% of households are receiving food stamps 84% of households are at risk for food insecurity7

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population

12,512 4,491 Chicago Riverdale

Riverdale

69%

of the population are uninsured3

report having a consistent source of primary care provider9

46% of pregnant women received early and adequate prenatal care10

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

50% report drinking soda or sweetened drinks everyday

47% report being a smoker

Riverdale

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Homicides

72 years

13 7

Chicago: 77 years The Loop: 82 years Chicago

Riverdale

Disease Burden Among Adults9

19%

have high blood pressure

24% are obese

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Riverdale are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

5 Schools

2 Faith Based Organizations

2 Fitness Facilities

1 Social Service Organizations

Hospital and Health Services

1 Grocery Stores

Community Gardens

Pharmacies

Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Shanabruch, Stephen. “Riverdale.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 6, 2018. https://www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/riverdale; 2: “Altgeld Gardens and Phillip Murray Homes.” The Chicago Housing Authority. Accessed June 13, 2019. https://www.thecha.org/residents/public-housing/find-public-housing/altgeldgardens-and-phillip-murray-homes; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

Roseland

Chicago State University

Roseland is located on the far South Side of Chicago. It is home to Chicago State University, which was recognized by the National Science Foundation as a leading STEM studies program.1

Who lives here?2

96+21A Race and Ethnicity

Sex

55%

96% Black

Female

45%

1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

42,327 Population change:3

Age

16%

14%

14% 12

Chicago: 6%

10%

11% 9%

6% 2%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

85–94

Roseland

Economic Factors

$38,562 Chicago: $53,006

Population living in poverty4

9% Associates degree

25%

High school or equivalent

15% Less than high school

30% 19%

20% Bachelor’s degree or higher

Chicago Roseland

Unemployment

26%

Chicago Roseland

A 9 15 20 31 + 25 Education5

Median household income

of households spend 30% or more of their annual income on housing costs

31%

Some college— no degree

2 in 5 children are living in poverty4

36% of households are receiving food stamps 45% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

7,916 4,491

Chicago Roseland

Roseland

population % ofarethe uninsured

having a % report consistent source of

49% of pregnant women received early and adequate prenatal care9

primary care provider8

83%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

68% report receiving colorectal cancer screening8

37% report not participating in any physical activity or exercise in the past month

32% report drinking soda or sweetened drinks everyday

36% report being a smoker

14% report eating five or more servings of fruits and vegetables daily

Roseland

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Homicides

72 years

12 7

Chicago: 77 years The Loop: 82 years Chicago

Roseland

Disease Burden Among Adults8

45% have high blood pressure

53% 22% 10% are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Roseland are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

15 Schools

95 Faith Based Organizations

5 Fitness Facilities

23 Social Service Organizations

Hospital and Health Services

Community Gardens

6 Grocery Stores

Pharmacies

Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “National Science Foundation Awards Chicago State University $1.3M For STEM Studies.” CBS Chicago. CBS Chicago, September 19, 2018. https://chicago.cbslocal.com/2018/09/19/national-science-foundation-awards-chicago-stateuniversity-1-3m-stem-studies/; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

South Chicago is where the Blues Brothers Movie takes place. It was also known for its steel mills, which were a very crucial part of its identity during the latter part of the 20th century.1 The main tourist attraction is the 95th Street bridge and the Calumet Fisheries seafood stand.1

Who lives here?2

+2121A

South Chicago

Commercial Avenue

Race and Ethnicity

Sex

56%

76%

Black

Female

44%

White

Male

<1%

21%

Asian or Pacific Islander

Hispanic/Latinx

Population:

27,601 Population change:3

12%

Age

13%

12%

13%

Chicago: 6%

11% 7%

4% 1% 00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

South Chicago

Economic Factors

$27,692

7% Associates degree

Chicago: $53,006

Population living in poverty4

31%

High school or equivalent

20% Less than high school

31% 19%

A 8 20 15 31 + 26 Education5

Median household income

15% Bachelor’s degree or higher

Chicago South Chicago

Unemployment

22%

26%

Some college— no degree

Chicago South Chicago

of households spend 30% or more of their annual income on housing costs

children are living in poverty4

39% of households are receiving food stamps 57% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

8,532 4,491

Chicago South Chicago

South Chicago

of the population are uninsured2

report having a consistent source of primary care provider8

79%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

47% of pregnant women received early and adequate prenatal care9

49% report receiving colorectal cancer screening8

29% report not participating in any physical activity or exercise in the past month

47% report drinking soda or sweetened drinks everyday

36% report being a smoker

20% report eating five or more servings of fruits and vegetables daily

South Chicago

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Homicides

73 years

12 7

Chicago: 77 years The Loop: 82 years

Chicago South Chicago

Disease Burden Among Adults8

31%

have high blood pressure

43% 11% are obese

are diabetic

14%

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in South Chicago are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

14 Schools

54 Faith Based Organizations

2 Fitness Facilities

16 Social Service Organizations

Hospital and Health Services

Community Gardens

Grocery Stores

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “South Chicago.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 6, 2018. https://www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/south-chicago; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

South Deering was known as “Irondale” during early years. This was due to the growing amount of steel mills in the area.1 It is home to Trumbull Park, a cornerstone of the community and a hub for many of the community oriented activities.2

Who lives here?3

6+29A 65

South Deering

Skyway Bridge

Race and Ethnicity

Sex

54%

65%

Black

Female

White

46% Male

28% Hispanic/Latinx

Population:

14,635 Age

Population change:3

15% 12%

12%

13%

Chicago: 6%

11% 8%

5% 1%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

South Deering

Economic Factors

$31,878 Chicago: $53,006

Population living in poverty5

6% Associates degree

35%

High school or equivalent

20% Less than high school

30% 19%

A 6 20 12 35 + 27 Education6

Median household income

12% Bachelor’s degree or higher

Chicago South Deering

Unemployment

25%

27%

Some college— no degree

8% Chicago South Deering

of households spend 30% or more of their annual income on housing costs

children are living in poverty5

31% of households are receiving food stamps 53% of households are at risk for food insecurity7

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population

6,149 4,491

Chicago South Deering

South Deering

72%

of the population are uninsured3

report having a consistent source of primary care provider9

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

53% of pregnant women received early and adequate prenatal care10

67% report receiving colorectal cancer screening9

38% report not participating in any physical activity or exercise in the past month

28% report drinking soda or sweetened drinks everyday

20% report being a smoker

22% report eating five or more servings of fruits and vegetables daily

South Deering

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Cancer 2. Heart Disease 3. Injury 4. Diabetes-related 5. Strokes

75 years

11 7

Chicago: 77 years The Loop: 82 years Chicago South Deering

Disease Burden Among Adults9

46% 42% 19% 21%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in South Deering are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

4 Schools

3 Fitness Facilities

Faith Based Organizations

Social Service Organizations

Hospital and Health Services

6 Grocery Stores

Community Gardens

1 Pharmacies

1 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “South Deering.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 6, 2018. https://www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/south-deering; 2: District, Chicago Park. “The World’s Largest Swimming Lesson at Trumbull.” Chicago Park District. Accessed June 13, 2019. https://www.chicagoparkdistrict.com/parks-facilities/trumbull-lyman-park; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Community Profile

South Shore

South Shore Cultural Center

South Shore is a lakefront community with its main attraction being the South Shore Cultural Center, which offers dance studios, golf course, theater and public beaches to the community. Some of the former residents of South Shore include First Lady Michelle Obama and Nobel Prize winner James D. Watson.1

Who lives here?2

94+3+12A Race and Ethnicity

Sex

58%

94% Black

Female

42%

3% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

48,522 Age

Population change:3

13%

14%

13%

15% 12%

Chicago: 6%

7% 4%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

2% 85–94

South Shore

Economic Factors

$26,906 Chicago: $53,006

Population living in poverty4

8% Associates degree

24%

High school or equivalent

12% Less than high school

38%

25%

19%

Bachelor’s degree or higher Chicago

South Shore

Unemployment

21%

8% Chicago South Shore

A 8 12 25 24 + 31 Education5

Median household income

of households spend 30% or more of their annual income on housing costs

31%

Some college— no degree

1 in 2 children are living in poverty4

40% of households are receiving food stamps 58% of households are at risk for food insecurity

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

8,704 4,491

Chicago South Shore

South Shore

population % ofarethe uninsured

76%

report having a consistent source of primary care provider8

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

49% of pregnant women received early and adequate prenatal care9

64% report receiving colorectal cancer screening8

21% report not participating in any physical activity or exercise in the past month

36% report drinking soda or sweetened drinks everyday

19% report being a smoker

26% report eating five or more servings of fruits and vegetables daily

South Shore

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Diabetes-related 4. Injury 5. Stroke

72 years

Chicago: 77 years

The Loop: 82 years Chicago South Shore

Disease Burden Among Adults8

39%

have high blood pressure

31% are obese

11% 12%

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in South Shore are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

13 Schools

44 Faith Based Organizations

5 Fitness Facilities

21 Social Service Organizations

Hospital and Health Services

8 Grocery Stores

Community Gardens

3 Pharmacies

8 Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “South Shore” | Chicago Neighborhoods | Choose Chicago.” English. Accessed June 10, 2019. https:// www.choosechicago.com/neighborhoods/south/south-shore/; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Washington Heights In the past, railroads in this community were the centerpiece of its economy. This community area has over five city parks.1

Who lives here?2

97+1+2A

Washington Heights

Woodson Library

Race and Ethnicity

Sex

Black

56%

<1%

44%

96%

Female

White

Male

Hispanic/Latinx

Population:

27,055 Age

Population change:3

13%

14%

14% 12

12%

Chicago: 6%

10% 7%

2% 00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

Washington Heights

A 8 10 23 29 + 30

Economic Factors

Education5

Median household income

$46,848 Chicago: $53,006

Population living in poverty4

8% Associates degree

30%

High school or equivalent

10% Less than high school

19% 19%

29%

23%

Some college— no degree

Bachelor’s degree or higher Chicago West Englewood

Unemployment

19%

Chicago West Englewood

of households spend 30% or more of their annual income on housing costs

1 in 3 children are living in poverty4

26% of households are receiving food stamps 40% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

5,711 4,491

Chicago Washington Heights

Washington Heights

of the population are uninsured2

report having a consistent source of primary care provider8

77%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

56% of pregnant women received early and adequate prenatal care9

65% report receiving colorectal cancer screening8

31% report not participating in any physical activity or exercise in the past month

41% report drinking soda or sweetened drinks everyday

19% report being a smoker

16% report eating five or more servings of fruits and vegetables daily

Washington Heights

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Strokes

74 years

15 7

Chicago: 77 years The Loop: 82 years

Chicago Washington Heights

Disease Burden Among Adults8

29% 32%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Washington Heights are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

13 Schools

47 Faith Based Organizations

4 Fitness Facilities

7 Social Service Organizations

Hospital and Health Services

2 Grocery Stores

Community Gardens

1 Pharmacies

7 Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Washington Heights. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/ pages/1318.html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Washington Park is home to the city park by the same name which encompasses 372 acres of the community area. Washington Park’s expansive green space offers recreational opportunities for the community and hosts the annual African Festival of the Arts and the Bud Billiken Parade.1

Who lives here?2

96+12A

Washington Park

Fountain of Time

Race and Ethnicity

Sex

61%

94% Black

Female

39%

<1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

11,868 Population change:3

19%

Age

18%

15%

Chicago: 6%

13%

8% 4%

00–04

05–14

15–24

25–34

35–44

45–54

55–64

65–74

2% 75–84

1% 85–94

Washington Park

Economic Factors

$25,716

Chicago: $53,006

Population living in poverty4

Associates degree

28%

High school or equivalent

18% Less than high school

44%

20%

19%

Bachelor’s degree or higher Chicago

Washington Park

Unemployment

27%

8% Chicago Washington Park

A 6 18 20 28 + 28 Education5

Median household income

of households spend 30% or more of their annual income on housing costs

28%

Some college— no degree

1 in 2 children are living in poverty4

54% of households are receiving food stamps 67% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

12,128 4,491 Chicago Washington Park

Washington Park

41%

of the population are uninsured2

report having a consistent source of primary care provider8

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

48% of pregnant women received early and adequate prenatal care9

67% report receiving colorectal cancer screening8

23% report not participating in any physical activity or exercise in the past month

55% report drinking soda or sweetened drinks everyday

43% report being a smoker

Washington Park

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Homicides

69 years

Chicago: 77 years

The Loop: 82 years Chicago Washington Park

Disease Burden Among Adults8

43% 43%

have high blood pressure

are obese

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Washington Park are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

5 Schools

39 Faith Based Organizations

4 Fitness Facilities

6 Social Service Organizations

Hospital and Health Services

3 Grocery Stores

Community Gardens

Pharmacies

Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine. org/community-health. 1: Washington Park. Accessed June 13, 2019. http://www.encyclopedia.chicagohistory.org/pages/1030.html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

West Englewood saw a building boom after the survivors of the Chicago Fire of 1871 started moving to the area. This community is home to the Ogden (William) Park and the highly rated Lindblom Math and Science Academy.1

Who lives here?2

92+1+6A

West Englewood

Peace House

Race and Ethnicity

Sex

53%

92% Black

Female

47%

<1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

30,798 Age

Population change:3

16%

13%

14% 12%

Chicago: 6%

11%

10%

7% 4%

00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

1% 85–94

West Englewood

A 5 7 23 + 42

Economic Factors

Education5

Median household income

$27,911

5% Associates degree

Chicago: $53,006

Population living in poverty4

42%

High school or equivalent

23% Less than high school

36%

23%

19%

Some college— no degree

Bachelor’s degree or higher

Chicago West Englewood

Unemployment

34%

8% Chicago West Englewood

of households spend 30% or more of their annual income on housing costs

1 in 2 children are living in poverty4

44% of households are receiving food stamps 61% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

10,134 4,491 Chicago West Englewood

West Englewood

population % ofarethe uninsured 2

having a % report consistent source of

45% of pregnant women received early and adequate prenatal care9

primary care provider8

81%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

52% report receiving colorectal cancer screening8

31% report not participating in any physical activity or exercise in the past month

36% report drinking soda or sweetened drinks everyday

32% report being a smoker

21% report eating five or more servings of fruits and vegetables daily

West Englewood

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Stroke 5. Diabetes-related

69 years

13 7

Chicago: 77 years The Loop: 82 years

Chicago West Englewood

Disease Burden Among Adults8

48%

have high blood pressure

51% 14% 15% are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in West Englewood are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

8 Schools

68 Faith Based Organizations

3 Fitness Facilities

Hospital and Health Services

Social Service Organizations

Grocery Stores

Community Gardens

1 Pharmacies

3 Public Parks12

Data presented in the profile are part of UChicago Medicineâ&#x20AC;&#x2122;s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: West Englewood. Accessed June 10, 2019. http://www.encyclopedia.chicagohistory.org/pages/1337. html; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

West Pullman has the largest “urban solar plant” in the entire nation. Historically, there has been a large output of agriculture coming from this community, due to its advances in solar energy. It also has one of the city’s largest home ownership rates.1

Who lives here?2

93+15A

West Pullman

Foster House

Race and Ethnicity

55%

93% Black

Female

45%

1% White

Male

<1% Asian or Pacific Islander

Hispanic/Latinx

Population:

Sex

30,793 Population change:3

4% Chicago: 6%

Age

16% 11

12%

13%

12% 9%

4% 1% 00–04

05–14

15–24 25–34

35–44

45–54

55–64

65–74

75–84

85–94

West Pullman

Economic Factors

$37,675 Chicago: $53,006

Population living in poverty4

6% Associates degree

31%

High school or equivalent

17% Less than high school

29% 19%

16% Bachelor’s degree or higher Chicago

West Pullman

Unemployment

25%

Chicago West Pullman

A 6 17 16 30 + 31 Education5

Median household income

of households spend 30% or more of their annual income on housing costs

30%

Some college— no degree

children are living in poverty4

35% of households are receiving food stamps 50% of households are at risk for food insecurity6

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”7

Violent crime incidents7 Per 100,000 Population

6,809 4,491

Chicago West Pullman

West Pullman

population % ofarethe uninsured 2

having a % report consistent source of

47% of pregnant women received early and adequate prenatal care9

primary care provider8

86%

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan8

63% report receiving colorectal cancer screening8

34% report not participating in any physical activity or exercise in the past month

48% report drinking soda or sweetened drinks everyday

14% report being a smoker

21% report eating five or more servings of fruits and vegetables daily

West Pullman

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Heart Disease 2. Cancer 3. Injury 4. Diabetes-related 5. Stroke

72 years

12 7

Chicago: 77 years The Loop: 82 years Chicago

West Pullman

Disease Burden Among Adults9

36% 53% 10% 10%

have high blood pressure

are obese

are diabetic

have asthma

Community Resources11 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in West Pullman are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

4 Schools

43 Faith Based Organizations

2 Fitness Facilities

7 Social Service Organizations

Hospital and Health Services

3 Grocery Stores

Community Gardens

2 Pharmacies

2 Public Parks12

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: “West Pullman Solar Park.” Engage Civil. Accessed June 13, 2019. http://www.engagecivil.com/exelon; 2: American Communities Survey 2012-2016 estimates; 3: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 4: Under 100% of the Federal Poverty Level; 5: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 6: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 7: Chicago Police Department; 8: Healthy Chicago survey; 9: Illinois Department of Public Health Vital Stats; 10: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 11: MapsCorps 2017 Community asset dataset; 12: Chicago Parks District

Community Profile

Woodlawn

63rd Street Beach House

Woodlawn sits very close to Lake Michigan. Its main attractions are the very popular landmarked 63rd Street Bathing Pavilion that serves as the signature indoor portion of the beach and Jackson Park.1 This park was designed by the same person who designed New York’s Central Park, Frederick Law Olmsted.2 The future Obama Presidential Center will also be located in this community.

Who lives here?3

84 A 4 8 + Race and Ethnicity

57%

84% Black

Female

43%

White

Male

Asian or Pacific Islander

Hispanic/Latinx

Population:

Sex

26,024 Population change:4

Age

0.2%

15%

14%

Chicago: 6%

13%

10% 6%

00–04 05–14

15–24

25–34

35–44

45–54

55–64

65–74

75–84

85–94

Woodlawn

Economic Factors

$25,364 Chicago: $53,006

Population living in poverty5

Associates degree

22%

High school or equivalent

15%

Less than high school

40%

A 9 15 25 29 + 22 Education6

Median household income

29%

25%

19%

Bachelor’s degree or higher Chicago

Woodlawn

Unemployment

18%

Chicago Woodlawn

of households spend 30% or more of their annual income on housing costs

Some college— no degree

1 in 2 children are living in poverty5

41% of households are receiving food stamps 54% of households are at risk for food insecurity

Physical Factors

of housing units are vacant 2

of adults report that they feel safe in their neighborhood “most or all of the time”8

Violent crime incidents8 Per 100,000 Population

7,999 4,491

Chicago Woodlawn

Woodlawn

81%

of the population are uninsured3

report having a consistent source of primary care provider9

report that it is “usually” or “always” easy to get the care, tests or treatment they needed through their health plan9

53% of pregnant women received early and adequate prenatal care10

69% report receiving colorectal cancer screening9

28% report not participating in any physical activity or exercise in the past month

30% report drinking soda or sweetened drinks everyday

21% report being a smoker

27% report eating five or more servings of fruits and vegetables daily

Woodlawn

Life Expectancy at Birth

Deaths per 1,000 live births

Top Causes of Death

1. Cancer 2. Heart Disease 3. Injury 4. Diabetes-related 5. Homicides

75 years

11 7

Chicago: 77 years The Loop: 82 years Chicago

Woodlawn

Disease Burden Among Adults9

38%

have high blood pressure

51% 12% are obese

are diabetic

have asthma

Community Resources12 Community resources are necessary to achieve good health outcomes. A sample of the community resources necessary for optimal health outcomes and available in Woodlawn are listed below. For a full list of all resources and their location, visit the Chicago Health Atlas at https://www.chicagohealthatlas.org/resources

10 Schools

30 Faith Based Organizations

4 Fitness Facilities

15 Social Service Organizations

Hospital and Health Services

5 Grocery Stores

Community Gardens

1 Pharmacies

7 Public Parks13

Data presented in the profile are part of UChicago Medicine’s Community Health Needs Assessment (CHNA). Data for the CHNA were extracted by the Alliance for Health Equity or the Chicago Department of Public Health. For Full listing of all data sources refer to the CHNA at uchicagomedicine.org/community-health. 1: Shanabruch, Stephen. “Woodlawn.” The Chicago Neighborhoods. The Chicago Neighborhoods, October 6, 2018. https://www.thechicagoneighborhoods.com/neighborhoods/2018/10/6/woodlawn; 2: District, Chicago Park. “Jackson Tennis Courts.” Chicago Park District. Accessed June 13, 2019. https://www.chicagoparkdistrict.com/parks-facilities/jackson-park; 3: American Communities Survey 2012-2016 estimates; 4: Estimated percent change from 2010 Census to the American Communities Survey 2016 5 year estimates; 5: Under 100% of the Federal Poverty Level; 6: CMAP 2012-2016 5-year estimates. Education level for population age 25 and over; 7: Households under 185% of the Federal Poverty Level are considered at risk for food insecurity; 8: Chicago Police Department; 9: Healthy Chicago survey; 10: Illinois Department of Public Health Vital Stats; 11: Chicago Department of Public Health, Illinois Department of Public Health Vital Stats; 12: MapsCorps 2017 Community asset dataset; 13: Chicago Parks District

Appendix 2: Evaluation Report 2016–2019

Community Health Needs Assessment 2018–2019

157

UChicago Medicine

Community Benefit Evaluation Report Process and Program Evaluation 2016â&#x20AC;&#x201C;2019

Background The University of Chicago Medicine (UChicago Medicine) has a long history of community-based programming designed to improve the health and vitality of residents living on the South Side of Chicago. These initiatives span a myriad of health issues and are implemented using a variety of methods. The results of these endeavors often serve to inform further programming with the ultimate goal of improving health among residents on Chicagoâ&#x20AC;&#x2122;s South Side. In most recent years, as an imperative of the Internal Revenue Service (IRS), UChicago Medicine has been diligently focusing efforts on specific strategic health priorities informed by a population-based Community Health Needs Assessment (CHNA). This includes strengthening the UChicago Medicine structures currently in place for continued community programming and evaluating the impacts of community-based programs. The purpose of this report is to provide key stakeholders with an update on the structures and approaches developed within UChicago Medicine to adequately execute community benefit and the impacts demonstrated by select UChicago Medicine community-based-programs since the adoption of the 2016 UChicago Medicine CHNA strategic implementation plan. In line with the IRS and the Catholic Health Association (CHA), a leader in community benefit guidelines, UChicago Medicine defines community benefit as programs and services undertaken by nonprofit hospitals designed to improve health in the communities they serve and increase access to healthcare. UChicago Medicine recognizes that achieving population-level impacts will be an iterative process that will require piloting and scaling of both UChicago Medicine structures and programs to ensure the most effective systems are in place to implement the most impactful programs.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Introduction The mission of the University of Chicago Medicine is to provide superior healthcare in a compassionate manner, ever mindful of each patient’s dignity and individuality. UChicago Medicine acknowledges that many of the health disparities facing Chicago’s South Side communities are rooted in a nexus of socio-economic, historical, and environmental circumstances that go beyond simply providing medical care. In accordance with an asset-based community development framework, the UChicago Medicine philosophy is to leverage existing UChicago Medicine and community assets to improve local health and well-being. To this end, UChicago Medicine established the Urban Health Initiative (UHI) in 2005. UHI serves as the UChicago Medicine community-facing arm through which population health management and community benefit are executed in collaboration with the community. Chicago’s South Side and the UChicago Medicine Service Area UChicago Medicine is located within the Hyde Park neighborhood on Chicago’s South Side—a storied and unique collection of vibrant, resilient, culturally rich, and diverse communities. Steeped in African American heritage and history, the South Side is marked by deep social bonds and anchored by vital community and faith-based organizations. As a part of community benefit requirements, for the 2015 CHNA, UChicago Medicine defined its service area as 12 contiguous zip codes surrounding UChicago Medicine (see Figure 1). The UChicago Medicine service area spanned 35 locally defined community areas and had a population of approximately 640,000 people. Figure 1: UChicago Medicine Service Area Residents in these communities face many social and economic challenges that contribute to healthcare inequities as compared to other areas of Chicago. Moreover, health disparities across the UChicago Medicine service area are vast as demonstrated by strikingly high rates of asthma, diabetes, obesity, breast cancer, and other chronic diseases. Community Benefit Goal All UChicago Medicine community benefit investments and programming are framed by the community benefit strategic framework. Under the auspices of an overarching goal to improve the health of the community, UChicago Medicine institutes system-wide goals as a pathway to achieve impact in the community.

Community Benefit Overarching Goal: To enhance community health and wellness around CHNA priority health needs in the UChicago Medicine service area UChicago Medicine community benefit goals are rooted in organizational commitment, community engagement, demonstration of value, and equity across all community-based initiatives. Programs presented in this evaluation qualify as community-based programs or services supporting residents in the UChicago Medicine service area. Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Methods for Process and Program Evaluation This report explores the process for developing a robust community benefit program by ensuring structures are in place to achieve consistent and sustainable momentum as well as positive community impacts. Section 1 of this report focuses on process evaluation conducted primarily through careful research and thorough review of the documentation of processes, guidelines, and standardized procedures developed by the community benefit staff. Section 2 includes outcome evaluation, which is conducted by analyzing quantitative and qualitative program data, grant reports, and event logs across priority area programs. UChicago Medicine Program Evaluation Data 2016â&#x20AC;&#x201C;2019 Based on the results of the CHNA, UChicago Medicine is charged with selecting health priority areas in which it will focus its efforts and allocate future resources. The selection of health priority areas is a rigorous process that involves a thorough understanding of community health needs, an inventory of existing internal and external resources, and strategic consideration regarding health area impact. To understand the health needs in its service area, UChicago Medicine contracted with Professional Research Consultants (PRC) to conduct a community health needs assessment (CHNA). PRC conducted primary quantitative data collection through telephone (landline and cell phone) interviews with 515 adults and a supplemental battery of telephone interviews with 462 pediatric guardians to better inform health data for the child and adolescent population. In addition, qualitative health and behavioral data was collected through informational interviewing with 38 key health informants. These key informants included residents, community leaders, public health experts, social service providers, and physicians. Using the CHNA as foundational data, a CHNA multidisciplinary workgroup selected six community health priorities for the 2016â&#x20AC;&#x201C;2019 community benefit cycle as outlined in the 2016 UChicago Medicine strategic implementation plan: adult diabetes, adult breast (women) and colorectal cancer, pediatric obesity, pediatric asthma, violence prevention, and HIV/STIs. These data from the CHNA are compared to benchmark data as demonstrated in Figure 2.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Figure 2: UChicago Medicine Health Priority Issue Areas

UChicago Medicine programming focuses strategically on these health issue areas. Collecting and evaluating programmatic data is central to the continuous quality improvement of community benefit programming and services. Because of the varied program structures and approaches by the UChicago Medicine portfolio of community benefit efforts, rather than one uniform data collection process there are three overarching data collection methods. COMMUNITY PARTNERS Community-based programs provide UChicago Medicine data around established data collection criteria based on their programmatic measures. These data included process and outcome level data often captured through activity logs, standard or custom-designed reporting templates, surveys, electronic medical records, and qualitative reports. UCHICAGO MEDICINE DEPARTMENTS Multiple UChicago Medicine department staff and faculty work collaboratively with community partners to track and log program activities and services to capture process level data on UChicago Medicineâ&#x20AC;&#x201C;designed tracking tools. DATA SYSTEMS UChicago Medicine faculty and/or staff utilize databases and/or internal tracking templates to document and report programs and services as requested or on a regular reporting basis. UChicago Medicine tracks all its programs using a standard database and program dashboards.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Process Evaluation: Building the Community Benefit Infrastructure A chief priority of the 2016â&#x20AC;&#x201C;2019 community benefit cycle was to assess existing community benefit capacity and to develop additional capacity. UChicago Medicine undertook a four-step process to overhaul its community benefit program (Figure 3). Figure 3: Process for Evaluating Community Benefit

Evaluate, iterate & report

Prioritize Community Benefit Organization-wide prioritization of community benefit was a critical first step to the further development of the UChicago Medicine community benefit program. The UChicago Medicine Urban Health Initiative (UHI) spearheaded efforts to increasingly emphasize the value and necessity of the institutionâ&#x20AC;&#x2122;s community benefit objectives. A multifaceted approach was adopted to promote this prioritization. n

Dedicated resources: Invested resources to advance and sustain community benefit programs and partnerships through dollars, staff, and capacity-building efforts.

Sustainable structures: The development of community benefit structures stretches across UChicago Medicine departments. The University of Chicago Medical Center Board of Trustees maintains community benefit oversight at the highest level. However, the following internal structures were developed for ongoing management of community benefit and include representation from multidisciplinary teams/departments: n Community Benefit Steering Committee n Community Benefit Management Team n Community Benefit Grant Review Workgroup

Community benefit framework: The development of a community benefit strategic framework, adopted by UChicago Medicine, served to guide programming from the earliest stage and ensure alignment with the 2016 strategic implementation plan. Concurrently, the development of a larger, overarching, community-based population health logic model was adopted to focus on the collective resources across the institution to achieve a healthy South Side aligned with the community benefit health priority areas.

Goals for each of the UChicago Medicine health issue priority areas are outlined in Figure 4. Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Figure 4: Community Benefit Health Priority Goals

Pediatric Obesity

Surveying existing UChicago Medicine community programs As a large academic medical institution in an urban setting, UChicago Medicine operates numerous community-based programs that target various health issues. To gain a full understanding of the programs at UChicago Medicine, the community benefit team conducted a comprehensive inventory across all departments. n

UChicago Medicine website scan: Initial review of the UChicago Medicine website revealed UHI community-based programs, departmental descriptions of community-based initiatives, and faculty research or program descriptions.

Departmental interviews and meetings: The community benefit staff held continual “meet and greets” with staff and faculty, uncovering more programs and allowing for further inquiry into programs identified via the web. During the year, more than 40 meetings were conducted across UChicago Medicine staff, and these continue to reach more departments and new staff.

UChicago Medicine–wide survey: A UChicago Medicine online survey of services across all departments was conducted to assess if programs had community components.

Internal education campaign Although many faculty were actively engaged in community programs, it was imperative to educate faculty on the community benefit health priority areas. The community benefit team worked to educate the faculty at UChicago Medicine regarding community benefit and to explain the institution’s unified strategic plan to serve the community henceforth. This was conducted through a series of departmental interviews and meetings that concurrently took place during the departmental interviews and meetings described above. Standardizing program reporting and cataloguing All UChicago Medicine faculty and staff identified as working on community-based initiatives were sent monthly requests to submit community benefit activities. This developed into a standardized process for reporting community benefit and synthesizing the data in real time. Resources and tools on community benefit were regularly distributed to faculty/staff to facilitate easy reporting.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

A systemized way to catalogue programs was developed. While UChicago Medicine houses numerous community-based programs, no single centralized repository of programs existed. UChicago Medicine utilizes Community Benefit Inventory for Social Accountability (CBISA) to catalogue all community benefit occurrences to facilitate IRS reporting requirements; however, additional tools were created to assist in regular evaluation of programs. To assist in cataloguing all community-based programs, a taxonomy was developed to categorize programs by a defined approach (see Figure 5). Figure 5: UChicago Medicine Approaches to Community-Based Programs

Care Delivery Initiatives: Direct health, medical, or wellness services and programs to community members that may leverage UChicago Medicine resources and community partners to increase access to care Grantmaking: Grants and technical assistance provided to community-based organizations that implement programs to address the UChicago Medicine health priority areas within the UChicago Medicine service area Medical Education: Faculty advance medical knowledge in the field by educating providers. Medical students learn and serve the community through clinical care at community health centers or by engaging in community services. Community-Based Education and Outreach: Educational forums intended to better inform and educate the community on their health and promote better health self-management practices rather than providing direct patient care Partnerships: Innovative partnerships with a community health lens that leverage technology, cross-sector collaboration, and multidisciplinary application learnings to improve health and engage the community

Additional categories (e.g., health issue area, primary zip codes, population type served, and partnerships) were mapped across all programs where information existed and entered into a searchable database to easily query programs upon request and need. The comprehensive, step-by-step process evaluation in the preceding pages serves to inform the burgeoning community benefit field and also provides context to the necessary steps required to achieve a sustainable infrastructure to support community benefit.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Outcome Evaluation Purpose One of the key goals of outcome evaluation is to demonstrate the reach and impact of UChicago Medicine across its service area and learn from the experience and strategies implemented in the past three years. Although there are limitations in quantifying impact (e.g., program turnover, inconsistent program reporting, adaptations of programs), we have determined key core process and outcome level metrics to establish a snapshot of large level impacts on the community and the issues that are being addressed. Methods The foundation provided by the strategic framework and community-based population health logic model provided clear goals and objectives outlining the steps required to achieve desired outcomes. A robust evaluation framework was developed that mapped metrics to each of the UChicago Medicine health issue area goals based on national standards (e.g., CDC, Healthy People 2020, Healthy Chicago 2.0). UChicago Medicine evaluates community-based health priority area programs on an individual basis to assess impacts and lessons learned. This allows for further iterations of program models to ensure effective implementation and impacts across those served. Programs addressing priority health needs internally as well as those implemented by partner organizations were required to incorporate the metrics from the evaluation framework, which allowed for tracking the same metrics across all programs. Figure 6 highlights some of the key tools put into place to monitor progress across programs and ultimately assess impacts. Figure 6: Pathway to Outcome Evaluation

Through this process, UChicago Medicine is able to conduct program evaluation on community benefit initiatives by actively integrating sound evaluation measures for ongoing monitoring, assessment, and reporting. For programs that have been completed, both process and outcome measures (if available) are presented, whereas for programs that are ongoing or are in their infancy only the process measures are presented. Unless a statistical test is noted, outcome measures (change in knowledge or behavior) presented are pre-post percentage changes for which statistical significance cannot be assessed. When possible, overall reach across focus areas is presented using process-level metrics. The following pages highlight key programs aligned with the UChicago Medicine selected health priority areas identified through the 2016 strategic implementation plan. The overall key impacts across all six health issue areas are presented below. Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Overall Key Impacts

*This represents any active program catalogued over FY 2017–FY 2019 and included in this evaluation report. **This is an average of three years of UChicago Medicine investment in its community, FY 2017–FY 2019: $425.2 million in FY 2016, $462.6 million in FY 2017, and $477.3 million in FY 2018.

The following pages profile evaluation results and impacts across diabetes, cancer, pediatric asthma, pediatric obesity, HIV/STIs, and violence prevention as identified in the 2016 strategic implementation plan. All data included in these sections under the community need category are derived from the 2015/2016 CHNA. Unless otherwise noted all data are for FY 2017–FY 2019.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Adult Diabetes Our mechanism for scaling efforts to address adult diabetes included leveraging the UChicago Medicine community benefit grant program and engaging in community-based education and outreach. While the grant programs served as the primary pillar to addressing diabetes on the South Side, additional programs such as physical fitness and wellness programs were launched or enhanced during this time period.

Community Need

Cook County diabetes age-adjusted mortality rate (20.6%) fares similar to the Healthy People 2020 target (20.5%); however, the mortality rate is notably higher among African Americans (32.5%).1 69% of CHNA key informants perceive diabetes as a major problem 13% of adults report that they have been diagnosed with diabetes n 7% of adults report that they have been diagnosed with prediabetes n n

Goal

Improve the health and quality of life for those living with diabetes Improve glycemic control and diabetes-related care among persons with diabetes n Increase the proportion of persons with diagnosed diabetes who receive formal diabetes education n Increase prevention behaviors in persons at high risk for diabetes with prediabetes n Increase consumption of nutritious food and physical activity among persons with diagnosed diabetes n

Objective

Impact

The UChicago Medicine community benefit grantmaking initiative supported community-based organizations to develop and implement group and individualized education programs to manage adult diabetes in community and clinical settings. Community-based education and outreach enabled UChicago Medicine staff to provide comprehensive diabetes education to community members to promote prevention behaviors. Collectively, diabetes programs increased access to diabetes self-management education and access to places for physical activity and nutrition education.

Overall Adult Diabetes Impacts

1 Professional Research Consultants. 2015 Community Health Needs Assessment: University of Chicago Medical Center Service Area, Cook County, Illinois. Omaha: Professional Research Consultants, 2015.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

The following select programs have been included to demonstrate impacts on diabetes: South Side Fit (SSF) In 2017, UChicago Medicine partnered with the Timothy Community Corporation (TCC) to launch the SSF program to increase community access and capacity to achieve healthy-living lifestyles and manage chronic conditions. With input from community and faith leaders, a four-pronged model was developed: education, disease management, physical activity, and faith messaging. SSF provides participants with assessments of their health, exercise, diet habits, weight, body mass index (BMI), and blood pressure. To meet health goals, participants commit to regular exercise, health consultations, nutritional and lifestyle seminars, and on-site exercise classes, including Zumba, yoga, cycling, low-impact workouts, and walking groups.

Program assessments shed light on the fact that most of the participants are not meeting the fruit and vegetable consumption guidelines or exercise guidelines for adults despite living with multiple chronic conditions. In 2019, SSF hired a health coach to provide one-on-one behavior change counseling to program participants in order to increase prevention behaviors and/or manage chronic conditions such as diabetes, high blood pressure, and high cholesterol. Additionally, the program partners with the South Side Diabetes Project to provide diabetes self-management workshops. Community Fitness Walkers This free program in existence for over 21 years at the Museum of Science and Industry is designed to encourage adults in the community to integrate healthy fitness habits into their lifestyles. The museum is open for all adults to participate in walking three days a week, and a cardio class is offered twice a week. The program also implements health education sessions based on participantsâ&#x20AC;&#x2122; feedback, including the Diabetes Empowerment Education Program. The program reaches approximately 133 community members annually. In 2018, there were 156 community fitness program sessions with an average of 44 attendees per session.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Building staff capacity to provide community-based education The Diabetes Empowerment Education Program (DEEP™) is a diabetes self-management curriculum that has been shown to be successful in helping participants take control of their disease and reduce the risk of complications. DEEP™ was developed for use in low-income, racial and ethnic minority populations. It includes a training-of-trainers curriculum designed to engage community residents. In 2017, three members of the UChicago Medicine Community Relations team became certified Peer Educators and now have the capacity to implement DEEP™ curriculum, applying principles of adult education and participatory techniques in a culturally sensitive manner. The Peer Educators conduct one to two community education programs per month at locations around the South Side, including local libraries and community organizations. Since the community relations staff completed the DEEP™ training, they have conducted 25 community-based diabetes education sessions and educated 248 individuals.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Grant Programs Diabetes Prevention Program for Asians in Chinatown (DPPAC) Asian Health Coalitionâ&#x20AC;&#x2122;s DPPAC reaches out to vulnerable Asian Pacific Islander community members living in the low-income, South Side Chinatown community to raise diabetes awareness, promote prevention behaviors, and connect at-risk individuals to a six-week diabetes self-management workshop. The uniqueness of DPPACâ&#x20AC;&#x2122;s approach is the multi-pronged strategy through: (1) community collaborations with local community-based organizations and (2) culturally tailored diabetes self-management using bilingual, bicultural community health workers. Approximately 46 adults participated in the six-week diabetes self-management workshop and 499 community members received diabetes awareness and basic education at community events. Key outcomes of these two components of DPPAC are highlighted below.

Diabetes Self-Management and Education Program (DSME) UChicago Medicine supported the Roseland Community Hospital DSME program to assist the residents of the Greater Roseland community with diabetes self-management skills and education to properly manage their diabetes in the home environment. The DSME program offers a five-week workshop and participants were recruited from an existing pool of diabetic patients.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Adult Cancer As noted in the 2016 strategic implementation plan, UChicago Medicine partnered with community-based organizations to increase education and screening in community and clinical settings. The work focused on reducing cancer disparities and targeted outreach to African American and Asian Pacific Islander populations. 88% of women 50+ have had a mammogram in the past two years 83% of women 40+ have had a mammogram in the past two years n 78% of adults ages 50â&#x20AC;&#x201C;75 have had an appropriate colorectal cancer screening n

Community Need

Goal

Support and build community-based breast and colorectal cancer education and screening programs Increase cancer education in the community Increase cancer screening in the community n Increase knowledge of cancer screening guidelines n

Objective

Impact

UChicago Medicine focused primarily on increasing access to breast and colorectal cancer screenings for minority populations through community benefit grant-making initiatives. Collectively, programs provided screening mammograms, at-home colorectal cancer screenings, and education on screening guidelines to the broader community and healthcare providers.

Overall Adult Cancer Impacts

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

The following select programs have been included to demonstrate impacts on cancer: The Illinois Breast and Cervical Cancer Program (IBCCP) A state-funded program offering mammograms, breast exams, pelvic exams, and pap tests to eligible women. Since its launch in 1995, more than 66,000 women have been screened for breast and cervical cancers. UChicago Medicine participates in the mammography and breast cancer screening portion of the program in partnership with Chicago Family Health Center, a South Side Health Collaborative partner (SSHC) which serves as a Lead Agency for the IBCCP. UChicago Medicine has seen 404 unique patients through IBCCP. The services provided to these patients are highlighted below (Figure 7). Figure 7. Breast Cancer Services Provided through IBCCP

Office of Community Engagement and Cancer Disparities (OCECD) serves local communities through research, education, advocacy, and outreach. This is accomplished through strategic partnerships with various organizations within UChicago Medicine, as well as with communitybased and faith-based organizations. It is committed to understanding the unique needs and attitudes of its neighbors and to creating innovative programs to serve those needs.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Grant Programs Empower to Live (E2L) Asian Health Coalition’s E2L program targeted vulnerable populations of Asian American Pacific Islanders (AAPI) and African Americans (AA) to provide colorectal cancer (CRC) screening and educational programming, and to provide linkage-to-care services to participants. E2L’s multipronged strategy includes (1) community collaborations with local community-based organizations, (2) education and screening events for local AAPI and AA populations, and (3) training for health providers on the most recent, evidence-based CRC screening guidelines. Following education sessions to community members, E2L distributed fecal immunochemical test (FIT) kits, an at-home screening test for colon cancer. E2L also builds community-based organizations’ capacity to continue to provide CRC education and screening. The program trained eight staff across four organizations. Additional program outcomes include:

Breast Cancer Education and Awareness Movement (BEAM) Sisters Working It Out (S.W.I.O.) works to improve breast cancer mortality rates among women living in medically underserved communities. Through the help of Community Health Educators (CHE), S.W.I.O. has provided health screenings, culturally relevant educational programming, and health resources to low-income communities on Chicago’s South Side. BEAM components include (1) formal Community Health Educator Program to provide an integrated network of engaged educators, (2) community education sessions, (3) S.W.I.O. partnerships to provide breast health education at community events, and (4) continuing facilitation of screening mammograms. BEAM focuses on raising awareness about the severity of breast cancer, creating opportunities for women to become health advocates, and promoting the use of health services and resources available locally.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Pediatric Obesity UChicago Medicine supported school-based programs to obtain greater reach of the pediatric population and provide additional capacity and support for Chicago public and charter schools in the current climate of dwindling school funds. 44% of children are overweight or obese and 29% of children are obese 56% of children are physically active for one hour or longer on every day of the past week n 54% of children have five or more servings of fruits/vegetables per day n

Community Need

Goal

Support school-based or community site programs focused on risk prevention, physical activity, and culturally relevant nutrition management Increase programming that addresses childhood obesity in schools Increase physical activity among children and adolescents n Increase healthy eating habits among children and adolescents n Improve the weight status among children and adolescents n

Objective

Impact

Pediatric obesity initiatives were carried out primarily through community benefit grant making initiatives. These activities supported school-based programs to engage children in exercise programs, provide nutrition education, and offer school-based physical activity programs to all children.

Overall Pediatric Obesity Impacts

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

The following select programs have been included to demonstrate impacts on addressing childhood obesity: Grant Programs Work to Play Urban Initiatives’ flagship program Work to Play (WTP) is designed to reduce the incidence of childhood obesity. WTP runs throughout the school year in two, 12-week sessions. Each week consists of three program sessions: two before- or after-school practices and one after-school game against another Urban Initiatives school. Each session includes at least an hour of exercise through soccer activities, a health or character trait discussion, and a nutritious snack. WTP aims to achieve three primary objectives: increase participants’ physical activity; increase participants’ knowledge of health topics; and influence participants’ eating habits. WTP program was successful at engaging children and teachers and reducing children’s body mass index (BMI) over the course of the program.

Pilot Light Pilot Light’s mission is to empower all children with the knowledge, attitude, and skills they need to have healthy relationships with food. Pilot Light partners with schools to provide students with health and nutrition education and teachers with professional development. Pilot Light partnered with Ray Elementary and Montessori School of Englewood to provide: (1) 16 lessons each for grades 3, 4, and 5; (2) professional development and on-site support for teachers; (3) two chef visits to each participating classroom; (4) one “lunchroom takeover” per school, where the Pilot Light Chefs develop and serve a school lunch that connects to the lessons students learn in their classrooms as a way to extend learning to the cafeteria; and (5) two educational family workshops at each school.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Fresh, Fit, Fun The University of Chicago Charter Schoolâ&#x20AC;&#x2122;s Fresh, Fit, Fun program seeks to promote healthy eating and physical activity in urban schools through the application of the social ecological model. The program developed student- and family-centered interventions to reduce the risk of pediatric obesity and intervene with children with preexisting conditions. The program implemented multiple components to address pediatric obesity: n Weekly fresh fruit and vegetable distribution during snack time followed by a mini-lesson on the snack of the day n Nutrition and health education lessons incorporated into health class curriculum n Physical activity promotion through monthly sports clinics offering swimming lessons, tennis, squash, basketball n Engagement of families and school staff through Fresh, Fit, Fun 5K and Fun Run, professional development, and family, teacher, and community organization participation and buy-in n Roll-out of the Healthy Snack Policy that encouraged healthy food choices in and out of school including the use of healthy alternatives for birthday parties, fundraising, and installation of a healthy snack and beverage vending machine

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Pediatric Asthma Per its 2016 strategic implementation plan, UChicago Medicine collaborated with community hospitals, community-based organizations, and community health centers to implement programs that address environmental factors and asthma management behaviors. UChicago Medicine focused its efforts on the development of the South Side Pediatric Asthma Center in collaboration with partners and with the deployment of community health workers. Community Need

In the UChicago Medicine service area, 20% of children currently have asthma and 55% of them have utilized the ED/Urgent Care for asthma in the past year.

Goal

Strengthen children’s and caregivers’ ability to appropriately manage asthma

Approach

Increase asthma screening and outreach Reduce asthma hospitalization and absenteeism among children n Increase education and treatment plans for children with asthma n Improve provider understanding and treatment of asthma n Increase children’s and caregivers’ understanding of asthma triggers/ environmental modification

Impact

Through our community benefit grantmaking initiative, school-based initiatives were carried out to promote asthma education in community settings. Leveraging existing partnerships, the South Side Pediatric Asthma Center was launched to streamline all efforts to address asthma in the community. Collectively, the implemented strategies led to an increased number of families and children being educated on asthma management.

n n

Overall Pediatric Asthma Impacts

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

The following select programs have been included to demonstrate impacts on combating pediatric asthma: South Side Pediatric Asthma Center (SSPAC) The SSPAC is a multi-institution partnership powered by the UChicago Medicine Urban Health Initiative in collaboration with the UChicago Medicine Comer Children’s Hospital, La Rabida Children’s Hospital, Friend Family Health Center, and St. Bernard Hospital. The SSPAC focuses on improving health outcomes among children with asthma by facilitating access to care and promoting standardized treatment and education through community engagement and outreach. The various components of SSPAC and their impact are highlighted below. Community Health Worker Program Community health workers (CHWs) serve as liaisons between the families and the participant’s clinical provider. CHWs provide home visits, asthma management education, and environmental assessments to identify and mitigate triggers and connect participants to community resources.

Participants in the CHW program who completed six months of programming report statistically significant reduction in asthma morbidity, healthcare utilization, and absenteeism. Daytime symptoms decreased from two days at baseline to zero days at follow-up, and night-time symptoms and days needing rescue medication decreased from one day at baseline to zero days at follow-up (Figure 8). There was a 57% reduction in asthma-related emergency department (ED) visits, hospitalizations (59%), missed school days (56%), and missed workdays (55%) from baseline to six-month follow-up (Figure 9). Figure 8. Median symptom frequency and rescue medication use in the past two weeks— baseline vs. six-month follow-up (all P< .05 per Wilcoxon signed-rank test).

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Figure 9. Long-term outcomes at baseline and six months. Percentage of participants who experienced any (≥ 1 versus none) ED visits, hospitalizations, missed school days, and missed workdays (all P< 0.05 per McNemar’s test).

Education The education arm of the SSPAC develops and distributes standardized and easy-to-understand asthma education materials (reviewed for health literacy); hosts an annual Asthma Summit; provides ongoing asthma training to school staff, day care center staff, parents, and clinical providers; and participates in community events to promote asthma awareness and education to caregivers in community settings.

Asthma Education Summit. The Asthma Education Summit is an annual event for healthcare providers, community members, schools, and other community-based organizations to distribute information about asthma and promote asthma education. Some of the topics the summit focuses on include: understanding the effect of pollution on asthma, asthma control assessments, community health works, school health, medication devices, and identifying asthma patients and getting care. Asthma summits from FY 2017 and FY 2018 reached 193 people. Asthma Resource Line (1-833-3ASTHMA). Free number to call for questions about asthma, to find related community resources, and to get help connecting to the child’s primary care medical home.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Grant Programs Comprehensive, School-Based Approach to Improving Asthma Outcomes UChicago Medicine supported the Chicago Asthma Consortium to develop and pilot a comprehensive asthma program within three charter public schools on the South Side of Chicago. The program consisted of three parts: screening and referral, education, and policy. Through this pilot phase, the project aimed to create a model that can be applied in other Chicago schools to improve identification of children with asthma, education about management, and implementation of policy to support children living with the disease. The program successfully integrated asthma screening with the schoolsâ&#x20AC;&#x2122; registration process and asthma awareness program that reached non-asthmatic students, teachers, and school staff.

St. Bernard Hospital and Healthcare Center: Pediatric Asthma Clinic UChicago Medicine supported a patient advocate position to educate and assist asthma patients and their caregivers in the emergency department and in the asthma clinic at St. Bernard Hospital. The patient advocate educates patients and their caregivers on how to control asthma, and assists patients with identifying and mitigating home and environmental asthma triggers. The patient advocate conducts community outreach events to increase community knowledge of asthma and increase referrals of patients to the Pediatric Asthma Clinic. The patient advocate was successful at referring 79 new patients to the asthma clinic, ensuring that the asthmatic patients receive regular care from an asthma specialist. Asthma education was provided at community health fairs, barber shops, churches, and during individual provider education sessions.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Southside Asthma Management Project UChicago Medicine supported the Respiratory Health Association to provide school-based education to children through the evidence-based, validated Fight Asthma NowÂŠ curriculum and their adult caregivers through the Asthma Management program. This involves educating children with asthma and their adult caregivers on early recognition of asthma symptoms, common triggers, emergency care, proper inhaler use, and medications.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Sexually Transmitted Infections/HIV (STIs/HIV) The efforts of UChicago Medicine were in line with the 2016 strategic implementation plan to execute community-based programs targeting adolescents and adults to provide testing, treatment, case management and linkage to care services. UChicago Medicine collaborated with various organizations including community hospitals, nonprofits, and community health centers to expand reach among the highest risk population.

Community Need

The burden of STIs is particularly high in the UChicago Medicine service area, for example, the chlamydia incidence rate within the UChicago Medicine service area, was 1,735 per 100,000 in 2012, while the Cook County chlamydia incidence rate was 727 per 100,000 in the same year.2 In addition, STI and HIV incidence and mortality rates are disproportionate across race in Cook County, with a considerably higher HIV mortality rate and STI incidence among Blacks than that reported in the White and Hispanic populations.3

Goal

Increase prevention, screening, and treatment of STIs and HIV

Objective

Increase education and awareness around STI and HIV prevention and treatment n Increase STI and HIV identification and screening n Increase access to STI and HIV prevention and care services

Impact

Through strategic partnerships and care delivery initiatives, UChicago Medicine targeted youth and adults with STI/HIV awareness, education, screening, and linkage to care. As a result of these efforts more community members are aware of their STI/HIV status and linked to appropriate services.

Overall STI and HIV Impacts

The following select programs have been included to demonstrate impacts on addressing STIs/HIV: 2 These data were derived by the Chicago Department of Public Health from a record set supplied by the Illinois Department of Public Health (IDPH). IDPH specifically disclaims responsibility for any analysis, interpretations, or conclusions. 3 Chicago Department of Public Health. HIV/STI Surveillance Report, 2015. Chicago: City of Chicago; December 2015.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

The Chicago Center for HIV Elimination (CCHE). Located within the hardest-hit neighborhoods in Chicago, CCHE provides unique opportunities to advance HIV testing and prevention interventions locally, providing tangible results to those most affected and improving the lives of those living with and without HIV infection. CCHE takes an innovative approach to HIV transmission elimination through network science, next-generation testing and notification methods, integrated prevention, and community mobilization. CCHE strives to inform the Chicago communities about HIV by promoting HIV prevention, hosting community events that educate attendees about HIV, providing screenings and testing, and linking individuals to care and case management. Through its wide variety of services, CCHE hopes to eliminate HIV transmission by 2041.

Better 2Gether and Network Services Better 2Gether and Network Services’ (B2GN) mission is to provide a network of prevention services to at-risk teens and adults throughout Chicago and the adjacent southern and western suburbs. These prevention services include: HIV testing and STI screenings, linkage to care for HIV-positive individuals, HIV/STI awareness campaigns on social media, and education for at-risk individuals. B2GN’s campaign focused on addressing the stigma around HIV and increasing public engagement in educational community events and testing. The program referred 231 individuals for pre-exposure prophylaxis (PrEP) and had a 77% PrEP appointment attendance rate. The program also successfully linked 171 HIV-positive individuals to care. Additional outcomes are presented below.

Expanded HIV Testing and Linkage to Care Initiative (xTLC) Through collaboration with its six health center partners on the South Side, xTLC implements routine screening to identify individuals who may have contracted HIV but were unaware of their status. In addition to linking newly diagnosed HIV-positive individuals to care, xTLC works to identify previously diagnosed individuals who were not receiving care and re-engages them to receive the services they need.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

PrEP Chicago PrEP Chicago provides training to peer change agents weekly. The program and peer change agents develop and distribute information about PrEP and referrals to PrEP care through PrEP Line and PrEP Linkage-to-Care. This program also utilizes social media platforms to provide a place for discussion about PrEP for young people who may be interested in and eligible for PrEP care.

Care2Prevent (C2P) C2P is a pediatric and adolescent HIV prevention program that aims to provide comprehensive care and prevention education for youth living with HIV/STIs and individuals who are most vulnerable for new infections. C2P provides services such as HIV/HCV testing, linkage to holistic medical care, non-acute mental health services, support for LGBTQ+ youth and homeless youth with a variety of services, and a WATCH clinic that offers post-exposure prophylaxis (PEP) for infants of mothers with HIV infections. C2P provided 122 clients with mental health services and linked 209 HIV-positive youth to care.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Violence Prevention Urban violence is a complex and systematic issue requiring multiple stakeholders investing across a multitude of approaches and strategies. Care delivery services such as violence recovery programs for patients coming to the trauma center served as a primary pillar to addressing community violence. Additionally, UChicago Medicine continued to expand its reach by growing partnerships with community-based organizations to address violence prevention at the community level. In Cook County, the age-adjusted homicide rate is well above the national rate at 10.5 per 100,000 and is disproportionately high among non-Hispanic African Americans at 32.5 per 100,000. Community Need

Goal

57% of CHNA key informants perceive community violence as a major problem n 10% of adults aged 18 years and older have been a victim of a violent crime in the past five years n 57% of families consider their neighborhood “Slightly” or “Not At All” Safe n

Trauma-informed care on the South Side n

Objective

Impact

Increase access to trauma-informed care Increase at-risk youth and family engagement in violence prevention programs

UChicago Medicine supported 16 community programs to provide immediate support to existing community-based violence prevention programs, which addressed career development, gang and violence prevention, education and trainings, and self-awareness. Hospital-based programs were developed to provide wrap-around services to reinforce continuity of care. Through these strategic partnerships and multi-pronged approach, UChicago Medicine asserts a nontraditional approach to violence prevention and recovery.

Overall Impact of Violence Prevention

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

The following select programs have been included to demonstrate the impact of different violence prevention initiatives: The Violence Recovery Program (VRP) is a hospital-based violence intervention program designed to provide intensive wrap-around services to victims of intentional violence during admission and post-discharge to promote comprehensive recovery and reduce risks of reinjury. VRP services begin when a patient arrives at the emergency department and services provided include: crisis intervention, helping patients and families navigate the healthcare system and social services landscape, and intensive case management post-discharge.

Healing Hurt People Chicago (HHP-C) is a nationally recognized hospital-based violence intervention program in collaboration with the UChicago Medicine Comer Childrenâ&#x20AC;&#x2122;s Hospital and John H. Stroger, Jr. Hospital of Cook County. Through assessment, trauma-focused emotional support and psycho-education, intensive case management, group therapy, and mentoring, HHP-C assists youth who have been violently injured, so they can heal both physically and emotionally. HHP-C reached 715 youth to provide hospital outreach/support and trauma psycho-education and provided follow-up intensive case management to 220 youth. Recovery and Empowerment After Community Trauma (REACT) program is for children who have been exposed to violence but may not themselves be victims of violent injury. REACT addresses the psychological, psychiatric, social, and behavioral effects of exposure to violence by offering psychiatric needs assessments, prescriptions for psychiatric medications, and referrals for ongoing counseling. The program is patient centered and the depth of intervention depends on the needs of the child and family. REACT has served 738 unique patients across numerous encounters.

Stop the Bleed is a national awareness and call-to-action campaign. Stop the Bleed intends to cultivate grassroots efforts that encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives. The mission of the campaign is to help ensure prompt access to life-saving and easy-to-use hemorrhage control resources. UChicago Medicine provides training as well as the printed material and resources for the organization. In 2018, more than 200 community members were trained.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Grant Programs Rapid Cycle Grants were awarded in an effort to support community level violence prevention efforts on the South Side. The awarded groups have been able to expand programing to address juvenile reentry, career development, education, and access to care. Since 2017, UChicago Medicine has collaborated with grassroots organizations to award over $94,000 in grant funding; two of the grantees are highlighted below.

2017 Grant Awardee: Mothers Against Senseless Killing (MASK)

2018 Grant Awardee: Alliance of the SouthEast (ASE)

MASK prevents and disrupts the violence in targeted communities by promoting good health and addressing safety issues. In 2017 with the support of grant funding, MASK was able to serve 100 meals per day for 59 days.

ASE helps minority youth develop a voice in the community by engaging them in positive activities and uniting them around anti-violence initiatives. In 2018 with the support of grant funding, ASE was able to engage 400 youth.

The Urban Resilience Network (TURN) at Bright Star Community Outreach in Bronzeville operates a phone helpline to provide emotional care to families and young people coping with trauma. It is open from 9 a.m. to 6 p.m. on Monday, Wednesday, and Friday. The TURN center is supported by UChicago Medicine, Northwestern Medicine, and the United Way of Metropolitan Chicago. The helpline is staffed by a clinical care coordinator along with Chicago faith and community leaders. It receives calls for a variety of reasons, including loss of loved one, relationship difficulties, bullying, abuse, and other traumas. In addition, the TURN center trains community ambassadors and equips them with the skills necessary to provide community-based education about trauma and how trauma may be impacting individuals. Ambassadors raise awareness about trauma at community events and provide formal education sessions in schools, community events, police departments, and with other community stakeholders. Topics include What Is Trauma?, Children and Trauma, Generational Trauma, Sexual Assault, Bullying, etc. Each session is tailored for the audience and includes variety of activities to keep the participants engaged.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

The Wellness Recovery Arts Program (WRAP) is a trauma-based program for teens that explores their personal experiences with violence through the use of the arts. The art forms that are provided include theater, spoken word, African dance/percussion, and visual arts. Four highly skilled and trauma-informed teaching artists conduct the WRAP workshops. Approximately 56 teens have participated in the WRAP program.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Other Community Benefit Initiatives The 2016 strategic implementation plan did not identify access to care or community-based education as a priority issue. However, recognizing the complexity of issues facing UChicago Medicine service area residents to accessing care, UChicago Medicine continued programming related to access to care services and to expand reach in the community. The foundation of the UChicago Medicine approach to community benefit lies in building community partnerships to bring UChicago Medicine assets to the community. Community-based education and outreach are intended to better inform and educate the community on their health, promote better health, and bring awareness to the UChicago Medicine assets that are available for the community. The following select programs have been included to demonstrate impacts on access to care: Increasing access to adult trauma care. In May 2018, UChicago Medicine launched Level 1 adult trauma care services, adding to the UChicago Medicine pediatric trauma and burn services and providing the community a comprehensive system of high-quality care to treat the full range of trauma injuries in patients of all ages. At the forefront is a team of surgeons and other care providers committed to serving underrepresented communities. With a commitment to excellence in patient care and education, UChicago Medicine engages our communities to meet the clinical needs of adults affected by falls, motor vehicle collisions, or violence, and to address violence prevention and integrated violence recovery. Medical Home and Specialty Care Connection (MHSCC). Since 2011, the MHSCC program has been connecting South Side residents to community health centers and doctors who can provide preventive care, regular treatment for non-emergency health conditions, long-term management of chronic disease, and referrals to specialists. As part of this program, patient advocates educate patients on the importance of regular doctor visits and assist patients at the UChicago Medicine emergency department and on inpatient floors with connecting to a reliable place for their healthcare within the resources of the SSHC.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Patient advocates encountered and educated 30,026 patients on the importance of maintaining a primary care provider and a medical home. On average, 85% of encounters accepted help from patient advocates to set up a follow-up appointment. To date, 25,678 medical home and specialty care connections have been made with an average show-rate for patients to follow up appointments of 63%.

Food Insecurity Screening. Given the fact that the UChicago Medicine service area has many community areas that are food deserts, patient advocates piloted food insecurity screening among patients they encounter in the emergency room using a validated questionnaire. Patient advocates also forged a collaborative partnership with the Greater Chicago Food Depository (GCFD) to use their pantry finder using patient addresses, and to send patient referrals for SNAP/WIC application support.

The South Side Healthcare Collaborative (SSHC) is a collaboration between UChicago Medicine and a network of over 30 federally qualified health centers, free and charitable clinics, and community hospitals. The SSHC focuses on advancing the capabilities of its members through service, education, networking, and advocacy. The SSHC is committed to improving the health of Chicago’s South Side residents by improving access to healthcare services. The following programs take place in SSHC sites and exemplify the complexity of programs and services UChicago Medicine supports through innovative partnerships to ensure community members not only receive care but support and social services as well.

ECHO-Chicago (The Project Extension for Community Healthcare Outcomes). ECHO-Chicago is an innovative effort to expand access to specialized care for vulnerable, underserved communities. By using advanced communications technology to bring academic medical center expertise together with primary care providers on the ground, ECHO enables underserved patients to receive state-ofthe-art, evidence-based care for complex chronic conditions within the familiar surroundings of their medical home. The ECHO model provides a robust, efficient, and cost-effective solution to access to care. ECHO session topics include behavioral health, complex pediatric asthma, serious mental illness, childhood adversity and trauma, hypertension, etc. Across all ECHO sessions, providers’ average self-efficacy from pre-ECHO session to post-ECHO session increased 1.13 points, exceeding the goal of a 0.7-point (10%) increase.

1.13 points increase in self-efficacy

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Student-Run Free Clinics. Pritzker School of Medicine students and physicians provide free health services at five student-run free clinics. The clinics provide access to medical care for underserved patients in several areas of Chicago—Washington Park Children’s Clinic and Maria Shelter Clinic for Women and Children on the South Side; Bridgeport Free Clinic serving Chinese immigrant patients in Bridgeport; NLVS clinic serving South Asian patients near Devon Avenue in the West Ridge community; and the Community Health Clinic (CHC) serving patients on the West Side. The clinics are wholly run by the medical students who bring in faculty to assist with treating patients. The following select programs have been included to demonstrate impacts on community-based education and outreach.

Office of Community Affairs (OCA). OCA was established to promote and facilitate engagement and collaboration between the medical center and South Side communities. Under the framework of asset-based community development, The UChicago Medicine philosophy is to partner with and leverage the strengths and talents of existing community assets to improve local health and wellbeing. OCA strengthens relationships between UChicago Medicine and the community to foster and promote collaborative, community-based programs and initiatives for residents on the South Side. Community Health Focus Hour. A weekly WVON radio broadcast series led by faculty and involving community members and hospital faculty and staff as guests, the program focuses on specific health topics impacting the community. The program has a social media component and also allows live call-in guests. Topics have included: prostate and men’s sexual health, winning the battle against pediatric asthma, breast cancer awareness, high blood pressure and pregnancy, rising rates in preeclampsia, etc. The show airs 44 episodes per year.

Community Grand Rounds. The goal of Community Grand Rounds is to share the knowledge and research of the University of Chicago with the community as a way to improve health on the South Side. Each event is hosted in a community setting, outside of the University’s walls. Topics are vast and include a variety of subjects that are chosen by a well-rounded group of community members in partnership with faculty. Topics included men’s health, obesity and diabetes, LGBTQ+ issues, youth summit, community members standing together against violence, etc.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Community-Based Education for Older Adults and Caregivers The South Side Healthy Aging Resource Experts (SHARE) Network brings older adults, caregivers, primary care providers, and geriatric specialists together to share knowledge, experience, and resources to improve health for older adults on Chicagoâ&#x20AC;&#x2122;s South Side. Through workforce education and community outreach, the SHARE Network bridges the gap between geriatric specialty care and the community. To date, SHARE and partner organizations have reached 2,492 older adults, family members, and caregivers at 138 free healthy aging events across the South Side. Popular topics include memory loss, mental health, nutrition, and stroke awareness.

Healthy Aging Event Outcomes

% Agree or Strongly agree % Agree or Strongly agree

Through faith-based partnerships, SHARE trains Dementia Resource Champions (DRCs), health champions within faith communities who are equipped to educate community members about dementia and caregiving as well as facilitate caregiver support groups within their faith communities.

Community Benefit Evaluation Report 2016â&#x20AC;&#x201C;2019

UChicago Medicine

Lessons Learned The following are overarching key lessons learned that touch on the development of community benefit infrastructure and programming: n

Align programming to a comprehensive community benefit framework. Prioritize planning and implementation time to construct an overarching strategic and evaluation framework to be applied across all community benefit programs. In the early stages of the UChicago Medicine community benefit program, investments in programs without fully developed frameworks usurped signficant resources. These programs lacked smooth executions and/or the necessary services and data outcomes to assess impacts. Once overall community benefit goals and metrics were developed and established, UChicago Medicine was able to move toward greater alignment in programs that mirrored these same objectives. This is leading to a more robust and meaningful evaluation on the collective impacts of programs addressing each health issue area.

Streamline monitoring and evaluation across key programs. Systemize processes and tools across key programs to enable ongoing and regular evaluation. UChicago Medicine supports numerous programs that each provide data and progress reports at varying times in their program cycle. It became increasingly apparent that UChicago Medicine partners could benefit from the support of UChicago Medicine staff and resources to assist in developing the tools required to adequately evaluate their programs. Developing standardized tools around each health-specific area allows greater alignment and timely reporting to assess programs’ progress.

Integrate faculty into programs that align with their interests. As an academic institution, incorporating faculty to assist in strengthening programs is mutually beneficial. UChicago Medicine learned over several iterations of program implementations that those which included the participation of faculty in a specific role (not only as an advisor) resulted in reliable outcomes, stronger program designs, and greater accountabiltiy.

Diversify program approaches and strategies to address a single health issue. Ensure that programs are reaching the targeted community populations by providing multiple portals through which they can access them. Individuals respond to programs differently—this can be based on numerous factors such as the program’s design, setting, and availability. Not only can providing different spaces and formats for programming extend reach in the community, it can also create piloting opportunities that can be scaled over time.

Focus on settings that serve as hubs for greater reach. Position programs with a large pool of participants to engage with. Significant effort goes into executing programs, regardless of the programs’ size and scope. Programs that take place in structured settings such as schools or community centers often provide a structured setting to implement programs and achieve broader reach.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Conclusion The University of Chicago Medicine is continuously iterating and strengthening its processes, structures, and programs to ensure it is providing Chicago’s South Side residents with the highest-quality services. It is UChicago Medicine’s imperative to tirelessly work to improve the health of South Side residents suffering with the health and chronic conditions outlined in this report and to prevent the spread of these conditions. UChicago Medicine will continue to evaluate each individual program on a regular basis and adjust its programming accordingly. Plans to address UChicago Medicine’s community benefit focus over the next three years are outlined in the 2019 strategic implementation plan. More information on UChicago Medicine’s community efforts and current programs, events, and initiatives supported by UChicago Medicine can be found at uchicagomedicine.org/about-us/community.

Limitations in Data n

The CHNA does not measure all of the possible aspects of health in the community, nor does it adequately represent all possible populations. Additionally, data for the most part is self-reported and not based on clinical measurements. School closures and staff turnover throughout Chicago Public Schools affect student enrollment and disrupt/delay programming in schools. Programs are implemented across varying settings and populations, presenting validity and reliability challenges when aggregating data. Small, community-based programs lack evaluation capacity and human resources to provide valid and reliable data.

Community Benefit Evaluation Report 2016–2019

UChicago Medicine

Appendix 3: Cook County CHNA

Community Health Needs Assessment 2018â&#x20AC;&#x201C;2019

196

UChicago Medicine

Alliance for Health Equityď ź1

Collaborative Community Health Needs Assessment (CHNA) for 35 Hospitals Advocate Aurora Children's Hospital Advocate Aurora Christ Medical Center Advocate Aurora Illinois Masonic Medical Center Advocate Aurora Lutheran General Hospital Advocate Aurora South Suburban Hospital Advocate Aurora Trinity Hospital AMITA Adventist Medical Center La Grange AMITA Alexian Brothers Medical Center, Elk Grove Village AMITA Holy Family Medical Center AMITA Resurrection Medical Center AMITA St. Alexius Medical Center and Alexian Brothers Behavioral Health Hospital AMITA Saint Francis Hospital AMITA Saint Joseph Hospital AMITA Saints Mary and Elizabeth Medical Center Ann & Robert H. Lurie Children's Hospital of Chicago Jackson Park Hospital The Loretto Hospital Loyola Medicine- Gottlieb Memorial Hospital Loyola Medicine- Loyola University Medical Center Loyola Medicine- MacNeal Hospital Mercy Hospital & Medical Center Northwestern Memorial Hospital Norwegian American Hospital Palos Community Hospital Roseland Community Hospital Rush Oak Park Rush University Medical Center Sinai Health System- Holy Cross Hospital Sinai Health System- Mount Sinai Hospital Sinai Health System- Schwab Rehabilitation Hospital South Shore Hospital Swedish Covenant Hospital University of Chicago Medicine University of Chicago Medicine-Ingalls Memorial Hospital University of Illinois Hospital and Health Sciences System Key Public Health Partners Chicago Department of Public Health Cook County Department of Public Health and Cook County Health Backbone Organization for the Alliance for Health Equity Illinois Public Health Institute

Alliance for Health Equityď ź2

Table of Contents Executive Summary ............................................................................................................................................... 4 Introduction…………………………………………………………………………………………………...……………..…21 Alliance for Health Equity Structure and Shared Leadership ............................................................................... 21 Purpose, Vision, Values ...................................................................................................................................... 22 Community Engagement .................................................................................................................................... 23 Participating Hospitals and Health Departments ................................................................................................. 23 Collaborative Assessment Model and Methods ................................................................................................. 26 Primary Data ...................................................................................................................................................... 26 Secondary Data .................................................................................................................................................. 31 Data System Needs and Limitations ................................................................................................................... 33 Alliance for Health Equity – Implementation Activities and Accomplishments 2016-2018 .............................. 33 Description of Cook County ...............................................................................................................................344 Community Cohesion as an Asset……………………………………………………….……………..………………….41 Priority Community Health Issues......................................................................................................................422 Overview of Health Inequities .............................................................................................................................433 The Role of Racism in Health and Structural Racism in the Chicago Metropolitan Area .....................................433 Achieving Racial Equity .....................................................................................................................................455 Inequities in Access to Health Care ...................................................................................................................466 Inequities in Mortality, Life Expectancy, and Years of Potential Life Lost ............................................................477 Inequities in Maternal and Child Health ..............................................................................................................511 Inequities in Community Safety and Violence………………………………………..……………………….……….....56 The Relationship Between Inequities, Trauma, and Toxic Stress .......................................................................566 Social and Structural Determinants of Health .................................................................................................... 59 Poverty ............................................................................................................................................................... 59 Unemployment and Underemployment ..............................................................................................................655 Education ..........................................................................................................................................................688 Food Access and Food Insecurity ....................................................................................................................... 70 Housing .............................................................................................................................................................777 Environmental Health and Environmental Justice ..............................................................................................801 Community Safety and Violence ........................................................................................................................844 Access to Quality Health Care ............................................................................................................................. 88 Health Care Coverage .......................................................................................................................................848 Proximity to Health Care Services....................................................................................................................... 91 Mental Health and Substance Use Disorders ..................................................................................................... 98 Key Takeaways and Priority Populations ............................................................................................................ 98 Utilization of Emergency Care.......................................................................................................................... 1022 Other Recent Assessments and Community Input .............................................................................................108 Chronic Conditions: Risk Factors, Prevention, and Management ...................................................................110 Risk Factors and Prevention ..............................................................................................................................110 Mortality.............................................................................................................................................................112 Asthma and Diabetes ........................................................................................................................................118 Sexually Transmitted Infections .........................................................................................................................123 Conclusions.........................................................................................................................................................128 References ...........................................................................................................................................................129 Alliance for Health Equity3

Executive Summary The Alliance for Health Equity is a collaborative of 37 hospitals working with health departments and regional and community-based organizations to improve health equity, wellness, and quality of life across Chicago and Suburban Cook County. The purpose of the Alliance for Health Equity is to improve population and community health by: • promoting health equity; • supporting capacity building, shared learning, and connecting local initiatives; • addressing social and structural determinants of health; • developing broad city and county wide initiatives and creating systems; • engaging community partners and working collaboratively with community leaders; • developing data systems for population health to support shared impact measurement and community assessment; and • collaborating on population health policy and advocacy. The Patient Protection and Affordable Care Act (ACA) requires every non-profit hospital to conduct Community Health Needs Assessments (CHNA) and implement plans that address identified community health needs. The Alliance for Health Equity was developed so that participating organizations can collaboratively assess community health needs, collectively develop shared implementation plans to address community health needs, more efficiently share resources, and have a greater impact on the large population residing in Cook County. Currently, 37 hospitals, 6 local health departments including Chicago Department of Public Health and Cook County Department of Public Health, and nearly 100 community-based organizations are participating in the Alliance for Health Equity (Figure 1). The Illinois Public Health Institute (IPHI) serves as a backbone organization that helps to facilitate the assessment and implementation processes, assists in convening partners across sectors, and provides technical support. The Alliance for Health Equity is comprised of a steering committee and several workgroups and committees working on implementation strategies for several community health priorities (Figure 2).

Alliance for Health Equity4

Figure 1. Alliance for Health Equity – Participating hospitals and health departments

Nonprofit Hospital Members Advocate Aurora Children's Hospital

Loyola Medicine- Loyola University Medical Center

Advocate Aurora Christ Medical Center

Loyola Medicine- MacNeal Hospital

Advocate Aurora Illinois Masonic Medical Center

Mercy Hospital & Medical Center

Advocate Aurora Lutheran General Hospital

Northwestern Memorial Hospital

Advocate Aurora South Suburban Hospital

Norwegian American Hospital

Advocate Aurora Trinity Hospital

Palos Community Hospital

AMITA Adventist Medical Center La Grange

Roseland Community Hospital

AMITA Alexian Brothers Medical Center, Elk Grove Village

Rush Oak Park

AMITA Holy Family Medical Center

Rush University Medical Center

AMITA Resurrection Medical Center

Sinai Health System- Holy Cross Hospital

AMITA St. Alexius Medical Center and Alexian Brothers Behavioral Health Hospital

Sinai Health System- Mount Sinai Hospital

AMITA Saint Francis Hospital

Sinai Health System- Schwab Rehabilitation Hospital

AMITA Saint Joseph Hospital

South Shore Hospital

AMITA Saints Mary and Elizabeth Medical Center

Swedish Covenant Hospital

Ann & Robert H. Lurie Children's Hospital of Chicago

University of Chicago Medicine

The Loretto Hospital

University of Chicago Medicine-Ingalls Memorial Hospital

Loyola Medicine- Gottlieb Memorial Hospital

Public Hospital Partners Cook County Health- Stroger Hospital*

Cook County Health- Provident Hospital*

University of Illinois Hospital and Health Sciences System

Public Health Department Partners Chicago Department of Public Health

Evanston Health and Human Services Department

Cook County Department of Public Health

Village of Skokie Health Department

* Cook County Health is a partner on the Alliance for Health Equity committees, and the Cook County Department of Public Health has been active in the CHNA; however, the hospitals are not required to do a CHNA and have not been part of the collaborative CHNA process. Two additional health departments—Stickney and Oak Park—have participated with the Alliance for Health Equity on different initiatives but have not been direct partners in this CHNA process. Alliance for Health Equity5

Figure 2. Alliance for Health Equity structure

A CHNA summarizes the health needs facing the communities served by hospitals, health departments, and community organizations. Implementation plans serve as a roadmap for how the community health issues identified in the CHNA are addressed. The 2018-2019 CHNA is the second assessment completed by the Alliance for Health Equity.

Alliance for Health Equityď ź6

Priority Community Health Issues Based on the findings from the collaborative assessment methods, the 2019 Alliance for Health Equity CHNA identifies the following community health priorities. Figure 3. Priority Community Health Issues, Alliance for Health Equity, Chicago and Suburban Cook County, 2019

Access to Care, Community Resources, and Systems Improvements

Increased Health Equity, Improved Health, Improved Quality of Life, Increased Life Expectancy

Alliance for Health Equityď ź7

Improved Health and

All assessment and implementation activities are guided by the Allianceâ&#x20AC;&#x2122;s purpose, vision, and values. Figure 4. Alliance for Health Equity â&#x20AC;&#x201C; Purpose, vision, and values

Community Engagement In alignment with the purpose, vision, and values, the Alliance for Health Equity prioritizes engagement of community members and community-based organizations as a critical component of assessing and addressing community health needs. Community partners have been involved in the assessment and ongoing implementation process in several ways both in providing community input and in decision-making processes (Figure 5). The community-based organizations engaged in the Alliance for Health Equity represent a broad range of sectors such as workforce development, housing services, food security, community safety, planning, community development, immigrant rights, primary and secondary education, faith communities, behavioral health services, advocacy, policy, transportation, older adult services, health care services, higher education, and many more. All community partners work with or represent communities that are disproportionately affected by health inequities such as communities of color, immigrants, youth, older adults and caregivers, LGBTQ+, individuals experiencing homelessness or housing instability, individuals living with mental illness or substance use disorders, individuals with disabilities, veterans, and unemployed youth and adults.

Alliance for Health Equityď ź8

Figure 5. Alliance for Health Equity community engagement strategies The Alliance for Health Equity’s methods of community engagement for the CHNA and implementation strategies include: • gathering input from community residents who are underrepresented in traditional assessment and implementation planning processes; • partnering with community-based organizations for collection of community input through surveys and focus groups; • engaging community-based organizations and community residents as members of implementation committees and workgroups; • utilizing the expertise of the members of implementation committees and workgroups in assessment design, data interpretation, and identification of effective implementation strategies and evaluation metrics; • working with hospital and health department community advisory groups to gather input into the CHNA and implementation strategies; and • partnering with local coalitions to support and align with existing community-driven efforts.

Assessment Model and Process The Alliance for Health Equity completed a collaborative CHNA between March 2018 and March 2019. Primary and secondary data from a diverse range of sources were utilized for robust data analysis and to identify community health needs in Chicago and Suburban Cook County. For the 2019 CHNA, the Alliance for Health Equity built on the previous collaborative CHNA work (2016), previous CHNA reports from member hospitals, Healthy Chicago 2.0 (2016), and WePLAN 2020 (2016). The steering committee developed parameters for the 2018-2019 CHNA process that will help drive the Alliance’s equity-focused work. •

The CHNA builds on prior CHNAs from 2015 to 2016 as well as other local assessments, regional assessments, and plans. The Alliance will coordinate closely with health department assessment and planning processes.

•

The CHNA will provide greater insight into community health needs and strategies for ongoing community health priorities.

•

The CHNA leverages expertise of community residents, community partners, and key stakeholders.

•

The CHNA provides an overview of community health status and highlights data related to health inequities.

•

The CHNA informs strategies related to: population health, connections between community and clinical sectors, anchor institution efforts, policy change, and community partnerships.

•

Health inequities and their underlying root causes are highlighted and discussed throughout the assessment.

Primary data collection Primary data for the CHNA was collected through four methods: • community input surveys; • community resident focus groups and learning map sessions; • health care and social service provider focus groups; and • two stakeholder assessments led by partner health departments—Forces of Change Assessment and Health Equity Capacity Assessment. Between October 2018 and February 2019, Alliance for Health Equity partners collected 5,934 community input surveys from individuals 18 or older living in Chicago and Suburban Cook County. The surveys were Alliance for Health Equity9

available on paper and online and were disseminated in English, Spanish, Chinese, and Polish. The surveys included questions asking respondents about the health status of their communities, community strengths, opportunities for improvement, and priority health needs. Hospitals, community-based organizations, and health departments distributed the surveys with the intention of gaining insight from priority populations that are typically underrepresented in assessment processes. Some of the priority populations were communities of color, immigrants, LGBTQ+ community members, individuals with disabilities, and low-income communities. Between August 2018 and February 2019, IPHI worked with Alliance for Health Equity partners to hold a total of 52 community input sessions (focus groups and learning map sessions) with priority populations such as veterans, individuals living with mental illness, communities of color, older adults, caregivers, teens and young adults, LGBTQ+ community members, adults and teens experiencing homelessness, families with children, faith communities, adults with disabilities, and children and adults living with chronic conditions such as diabetes and asthma. The community input sessions included 31 focus groups conducted by IPHI and 21 learning map sessions led by West Side United with notetaking by IPHI. In addition to the 52 community input sessions, there were also three focus groups with health care and social service providers hosted by Swedish Covenant Hospital, MacNeal Hospital, and South Shore Hospital. Focus group facilitators asked participants about the underlying root causes of health issues that they see in their communities and specific strategies for addressing those health needs. This Forces of Change Assessment collects information on the trends, factors, and events that are currently affecting and/or anticipated to affect the public health system in the near future (3-5 years). CDPH led this assessment in partnership with their Partnership for a Healthy Chicago, and CCDPH. 122 respondents representing 86 organizations in Chicago and Suburban Cook County responded to an online survey between November 2018 and January 2019. The Health Equity Capacity Assessment was led by CDPH, the Partnership for a Healthy Chicago, CCDPH, and IPHI. CDPH, CCDPH, and the Partnership worked with faculty from DePaul and UIC Schools of Public Health to develop a tool to score the capacity of the public health system to advance health equity. The tool consists of 5-6 questions for each of the Ten Essential Public Health Services relating to five components of health equity: community engagement/involvement, organizational processes, power/influence, structural inequities, and funding. On March 5, 2019, 80 people from across Chicago and Suburban Cook County came together to score how well the system is functioning around health equity and to identify challenges, strengths, and opportunities to move forward.

Secondary data collection Epidemiologists from CCDPH and CDPH worked with IPHI and the steering committee to select a common set of indicators based on an adapted version of the County Health Rankings and Roadmaps Model (Figure 6).

Alliance for Health Equityď ź10

Figure 6. Adapted County Health Rankings and Roadmaps Model

Modified from (County Health Rankings and Roadmaps, 2014)

The CHNA and steering committees also decided to investigate further into four key community health issues that surfaced as priority needs in the last CHNA and health department assessments: • behavioral health; • food security and food access; • community and economic development; and • housing. Secondary data used in the CHNA were compiled from a range of sources (Figure 7). Figure 7. CHNA data and information sources Secondary data sources • Peer-reviewed literature and white papers • Existing assessments and plans focused on key topic areas • Localized data compiled by several agencies including Chicago Department of Planning and Development, Chicago Metropolitan Agency for Planning, Housing Authority of Cook County, and state and local police departments • Localized data compiled by community-based organizations including Greater Chicago Food Depository and Voices of Child Health in Chicago • Hospitalization and emergency department rates (COMPdata) provided by Illinois Health and Hospital Association and analyzed by the Conduent Healthy Communities Institute • Data compiled by state agencies including Illinois Environmental Protection Agency, Illinois Department of Healthcare and Family Services, Illinois Department of Human Services, Illinois State Board of Education, and Illinois Department of Public Health • Data from federal sources including U.S. Census Bureau American Community Survey data compiled by Chicago Department of Public Health and Cook County Department of Health; Centers for Disease Control and Prevention; Centers for Medicare and Medicaid Services data accessed through the Dartmouth Atlas of Health Care; Health Resources and Services Administration; and United States Department of Agriculture Alliance for Health Equity11

Community Description for Cook County Age and gender U.S. Census Bureau population estimates for 2017 indicate that approximately 22% of the population in Cook County is under 18 years old and 14% is age 65 or older (U.S. Census Bureau, 2017). The percentage of individuals identifying as male or female in Cook County is approximately equal (U.S. Census Bureau, 2017). Data for the transgender and gender non-conforming populations in Cook County is limited. Based on preliminary analyses of Healthy Chicago Survey data, the Chicago Department of Public Health estimates that 10,500 adults living in Chicago identify as transgender or gender non-conforming.

Race and ethnicity In 2017, the U.S. Census Bureau estimated that 42% of the population in Cook County identified as nonHispanic white, 24% identified as non-Hispanic African American/black, 8% identified as non-Hispanic Asian, 2% identified as two or more races, and 26% identified as Hispanic/Latinx (U.S. Census Bureau, 2017).

Immigration An estimated 21% of Chicago residents and 20% of Suburban Cook County residents are foreign-born (U.S. Census Bureau, American Community Survey, 2012-2016). In 2016, 1.6 million Illinois residents were nativeborn Americans who had at least one immigrant parent (American Immigration Council, 2017). In 2015, the top countries of origin for foreign-born individuals living in Illinois were Mexico (38.2% of immigrants), India (8.1%), Poland (7%), the Philippines (5%), and China (4.3%) (American Immigration Council, 2017).

Population density The most densely populated communities are on the North, West, Southwest, and Southeast Sides of Chicago and West suburban communities directly adjacent to the city (Cicero, Berwyn, Oak Park, and Elmwood Park).

Population shifts Since 2000, Cook County as a whole has continued to experience a loss in population. However, the majority of population loss occurred in Chicago, while suburban Cook County’s population has grown by almost one percent. While growth has been modest, the racial and ethnic make-up of Cook County has changed drastically. Overall, there has been a 10% decrease in the white population of Cook County. However, the population loss is not consistent across the area. Suburban Cook County had more than double the decrease in non-Hispanic white populations (14%) compared to Chicago (6%). Between 2000 and 2010, the African American/black population in Chicago has decreased by over 15% and increased 18% in Suburban Cook County. Along with most of the nation, Cook County experienced an increase in the Hispanic/Latinx populations between 2000 and 2010. However, the increase was greatest in Suburban Cook County (47%). Other demographic shifts are not only increasing the size of priority populations in Suburban Cook County, but also shifting the distribution of the social determinants of health geographically. For example, poverty is increasing in the suburbs and decreasing in Chicago. While Chicago saw very little change in poverty and even experienced a 3% decrease in child poverty, Suburban Cook County saw dramatic rises in its poverty levels with child poverty increasing by over 75% between 2000 and 2010.

Additional priority populations In addition to marginalized racial and ethnic groups, the Alliance has identified several additional priority populations including: • homeless individuals and families; • justice-involved youth and adults; • people living with mental health conditions and/or substance use disorders; Alliance for Health Equity12

• • • • • • • •

people living with disabilities; older adults; immigrants and refugees; LGBTQ+; unemployed and underemployed; uninsured; veterans and former military; and children, adolescents, and young adults.

Key Assessment Findings Assessment findings were organized in five areas: • overview of health inequities; • social and structural determinants of health; • mental health and substance use disorders; • access to quality health care and community resources; and • chronic conditions – risk factors, prevention, and management. Health inequities and community input are highlighted throughout the summary of key findings as well as in all of the assessment chapters.

Social and Structural Determinants of Health Research has long established that socioeconomic inequities are key drivers of health outcomes. For example: • children born to mothers without a high school education are twice as likely to die before their first birthday than children born to mothers who are college graduates; • the percentage of individuals reporting poor health increases with decreasing levels of income and education; • low-income individuals are more likely to have a chronic disease; and • low-income individuals have higher rates of diabetes and coronary heart disease (Robert Wood Johnson Foundation, 2008).

Poverty Poverty can create barriers to accessing quality health services, healthy food, recreation opportunities, and other necessities needed for good health status. In addition, it strongly influences housing stability, educational opportunities, living environment, and health behaviors. Assessment data highlights many of the economic inequities in Chicago and Suburban Cook County. Overall, the percentage of individuals living in poverty in Chicago and Suburban Cook County (16%) is higher than the state (14%) and national averages (15%). However, people of color experience higher rates of poverty than non-Hispanic whites. African Americans experience the highest rate with nearly a third of the population living in poverty. In addition, African Americans and Hispanic/Latinxs have the lowest median household incomes. There are inequities in the geographic distribution of poverty as well. Communities with the highest poverty rates are primarily concentrated in the West and South regions of the city and county. These geographic inequities can be directly linked to long-standing historical discrimination and segregation across Cook County. Quote from community resident: “On the West Side there isn’t much funding to create better opportunities like schools and jobs” (Breakthrough Learning Map Session)

Unemployment and underemployment Unemployment and underemployment can create financial instability, which influences access to health care services, insurance, healthy foods, stable quality housing, and other basic needs. Unemployment and underemployment in Chicago and Suburban Cook County are often associated with a history of disinvestment and economic segregation. Currently unemployment rates for adults over age 16 in Cook County (10%) are Alliance for Health Equity13

slightly higher than the state (8%) and national averages (7%) and have shown an overall decline since 2013. However, higher rates of unemployment are concentrated in communities of color in the West and South regions of the city and suburbs. In addition, the rates of unemployment for African American/blacks are more than five times higher than whites in Chicago and more than two times higher than whites in Suburban Cook County. Community Input: A lack of employment opportunities was one of the most frequently discussed issues among focus group participants. Again, participants living in the West and South regions of the county described having the least number of quality job opportunities and employment resources. However, certain populations such as those living with mental illness, young adults, homeless individuals, and formerly-incarcerated individuals were highlighted as having significant barriers to employment regardless of their geographic location. Within certain communities, jobs are available, but they are described as part-time, temporary, and/or low-paying. Eighteen percent of community input survey respondents chose “quality job opportunities” as one of the most important factors in a healthy community. Furthermore, survey respondents frequently identified job opportunities as an area for improvement in their community.

Education Education is an important determinant of health because poverty, unemployment, and underemployment are highest among those with lower levels of educational attainment. In addition, rates of self-reported poor health, infant mortality, and chronic disease are often higher among individuals with lower levels of educational attainment. A 2011 study found that a history of segregation in the United States has not only led to continued racial and ethnic segregation of schools, but that whites and Asians are disproportionately represented in higherperforming schools (Logan, 2011). The same report found that disparities in school performance are likely due to racial and ethnic disparities in poverty and not the racial composition of schools (Logan, 2011). Although overall high school graduation rates in Cook County (85%) are comparable to state (88%) and national rates (84%), there are profound differences between racial and ethnic groups. In Chicago and Suburban Cook County, non-Hispanic whites and Asians have the highest rates of high school graduation and the highest rates of educational attainment overall. Hispanic/Latinx adults are least likely to have a high school education with approximately a third of the population being without a high school diploma or equivalent by age 25. Community Input: More than half of all focus groups discussed education inequities in Cook County. The major education-related concerns expressed by focus groups included: • school closures and diminishing education opportunities on the West and South Sides of Chicago; • poor quality schools particularly on the South Side of Chicago and in the South Suburbs; • limited or nonexistent resources for learning trades; • a lack of support programs such as quality, low-cost tutoring; and • limited adult education programs.

Community safety and violence Violence in Chicago and Suburban Cook County is concentrated in low-income communities of color. The root causes of community violence are multifaceted but include issues such as the concentration of poverty, education inequities, poor access to health services, mass incarceration, differential policing strategies, and generational trauma. Research has established that exposure to violence has significant impacts on physical and mental well-being. In addition, exposure to violence in childhood has been linked to trauma, toxic stress, and an increased risk of poor health outcomes across the lifespan. Violence also has a negative impact on the socioeconomic conditions within communities that contribute to the widening of disparities. Community Input: Focus group participants related that the prevalence of violence in their communities has led to health issues such as chronic stress, decreased mental well-being, trauma among children and adults, and decreased physical activity due to a reluctance to exercise in unsafe Alliance for Health Equity14

neighborhoods. Overall, 37% of community survey respondents chose “safety and low crime” as one of the most important factors for a healthy community. Frequently, survey respondents recognized safety and low crime as one of the greatest strengths in a community, however, safety and low crime was also the most mentioned area for improvement in communities.

Housing Poor housing conditions are associated with a wide range of health conditions including respiratory infections, asthma, lead poisoning, injuries, and mental health (Krieger & Higgins, 2002). As a result, addressing housing issues offers a unique opportunity to address an important social determinant of health (Krieger & Higgins, 2002). Existing research has confirmed that there are at least four direct pathways in which housing impacts health: stability, affordability, quality and safety, and neighborhood. (Taylor, 2018). Assessment findings indicate that: • Providing individuals and families with stable housing can improve health and reduce health care costs (Taylor, 2018). • Community-based programs and policy interventions have been shown to be extremely effective in improving health through improvements in the quality and safety of housing. • Within Cook County there are several regions where more than 40% of households are considered cost-burdened. These regions are primarily concentrated in the far Northwest, West, and South Sides of the city and county. Programs examples from across the country demonstrate that increasing access to affordable housing is associated with improved health outcomes and decreased need for emergency care, increased household discretionary income, increased rates of insurance coverage, decreased personal debt, and increased savings for home ownership and education. • There has been extensive research on the impacts that physical surroundings have on health. Access to public transportation, proximity to grocery stores with healthy foods, and safe spaces to exercise have all been correlated with reduced chronic disease and improved health outcomes (Bell, Mora, Hagan, Rubin, & Karpyn, 2013; Djurhuus, Hansen, Aadahl, & Glümer, 2014; Ou et al., 2016). Community Input: Major themes that rose to the top of focus group discussions related to housing included: segregation prevents communities from having diverse economics, racial/ethnic groups, and resources; gentrification pushes low-income families out of communities; safe, quality housing is often not affordable and affordable housing is often not safe or good quality; older adults are still struggling to recover from the housing crisis; and oversight of landlords and homeowners is lacking in many communities.

Food Access and Food Security Food security is a household-level social and economic condition of limited or uncertain access to adequate food (U.S. Department of Agriculture, 2018). Food insecurity can impact health in several ways: • the combination of stress and poor nutrition can make individuals more susceptible to developing chronic diseases and make management of chronic diseases more difficult; • worsening health problems and the associated medical care puts additional strain on household budgets and leaves less money for essential nutrition and other basic needs; • chronic disease can lead to decreased employability and lower overall household income (Weinfield et al., 2014). Related to food insecurity, access to healthy foods is another important factor needed to support chronic disease prevention. Low-income communities of color are less likely to have access to supermarkets and healthy foods and tend to have a higher density of fast-food restaurants and other sources of unhealthy food such as convenience stores (N. Larson, Story, & Nelson, 2009). Programs such as the Supplemental Nutrition Assistance Program (SNAP), local food pantries, summer meal programs, after school programs, shelters, and food banks provide important assistance to low-income individuals and families that struggle to access adequate nutrition. However, approximately seven percent of households in Cook County overall are below the poverty level and not receiving SNAP benefits. Summer meal programs also play an important role in food access for low-income children and their families during the summer months when schools are closed and Alliance for Health Equity15

access to free or reduced-price meal programs is decreased (Feeding America, 2018). Within Cook County, summer meal sites are widespread, but are most concentrated in communities with high rates of child poverty. Community Input: Focus group participants on the West and South Sides of the city and county reported a high proportion of fast-food restaurants and limited access to grocery stores selling healthier options. Low-income participants on the North Sides of the city and county reported that there were several grocery stores available but that they often could not afford to shop at them. Community residents living with chronic illnesses such as diabetes reported that difficulty accessing healthy foods and a high prevalence of fast-food options made it more difficult for them to manage their conditions. Approximately 29% of community input survey respondents chose “access to healthy food” as one of the most important factors in their community.

Access to Quality Health Care Access to health care is broadly defined as the “the timely use of personal health services to achieve the best health outcomes” (Institute of Medicine, 1993). There are several complex factors that further influence access to health care including proximity; affordability; availability, convenience, accommodation, and reliability; quality and acceptability; openness, cultural responsiveness, appropriateness and approachability. Within Cook County, 11% of the population does not have health insurance coverage which is greater than the statewide average of 9% (U.S. Census Bureau, American Community Survey, 2017b). However, in some Cook County communities, uninsured rates are as high as 30%. In addition, uninsured rates can be even higher among certain population groups such as adults aged 18-64, immigrant households, Hispanic/Latinx communities, children of non-citizen parents, low-income individuals, and the working poor. Recent policies and practices at the federal level have threatened some of the gains in insurance and access that came under the affordable care act particularly for immigrant and LGBTQ+ populations, and data from the American Community Survey shows that the rate of people not insured actually saw a slight increase in the most recent year available (2017). Community input, particularly from immigrant communities and service providers, also emphasized concerns about access to healthcare and other public benefits. Socioeconomic inequities such as segregation often determine a community’s proximity to healthcare services. Previous research has establish that patients living further away from health care facilities have worse health outcomes related to survival rates; length of stay in hospital; non-attendance at follow-up visits; higher rates of asthma deaths; lower than expected five-year survival from cancer; increased overall disease burden; and increased risk of chronic disease-related mortality (Billi, Pai, & Spahlinger, 2007; Campbell et al., 2000; Jones & Bentham, 1997; Kelly, Hulme, Farragher, & Clarke, 2016; Saijo et al., 2018). Health care quality can vary greatly between communities due to several factors including the geographic proximity of a spectrum of emergency or urgent care services, percentage of the population receiving public benefits, funding for community-based services, education and training levels of health care staff, and localized provider shortages. Race and ethnicity also play a critical role in the quality of health care that patients receive. Perceptions of discrimination in health care have been associated with several outcomes among patients of color including decreased use of preventative health care, delayed use of prescription medication and medical tests, and worse chronic disease management and outcomes (Hausmann, Jeong, Bost, & Ibrahim, 2008; Trivedi & Ayanian, 2006; Van Houtven et al., 2005). In addition, research has shown that persistent exposure to racism is traumatic for individuals and that trauma is an underlying root cause of many negative health outcomes. Community Input: Focus group participants that belonged to communities of color frequently described themselves as receiving lower quality healthcare compared to whites. Some of the examples of disparities in quality included poor provider communication including a lack of shared decision making; physician failure to provide surgical alternatives; negative remarks from physicians about a patient’s ability to comply with recommendations even when they are making progress; and delays in treatment for acute illnesses. Multiple participants indicated that their previous experiences with Alliance for Health Equity16

providers made them reluctant to seek needed medical care, less likely to use preventative services, less likely to have a primary care provider, and much less likely to trust different providers in the future. A 2018, landscape analysis conducted by the School Health Access Collaborative identified several opportunities within the school health services system in Chicago that could increase and expand the positive outcomes of school and health care partnerships.

Mental Health and Substance Use Disorders The mental health and substance use disorders section of the assessment was used to distill common findings from existing collaborative assessments, secondary data, and primary data. Six key takeaways were developed that describe major problems, their importance for health equity, and opportunities to address them in the near-term.

Fragmentation of services and integration of care • • •

A common theme in mental health assessments is fragmentation—gaps, bottlenecks, and silos within and between types of providers and health plans and between various state agencies responsible for health and human services. The physical, operational, and financial separation of mental health from general health care creates barriers to timely access to necessary services for individuals and families and interferes with population health approaches that depend on seamless connections between various services. Across Cook County, efforts toward integrating primary and mental health care are underway, from county-wide care coordination strategies to neighborhood partnerships. At the state-level, Illinois’ Behavioral Health Transformation Plan presents opportunities to strengthen and replicate these local projects.

Social and structural determinants of health •

•

Social factors, especially housing, but also poverty, education, employment, food security, interpersonal relationships, and transportation affect mental health status and access to mental health and substance use services. Yet social needs are inadequately assessed and addressed in most health care settings. o Social determinants of health affect communities in the context of social inequities. For example, African Americans in the U.S. are three times more likely to experience homelessness (U.S. Department of Housing and Urban Development, 2010). Failing to embed social needs into health care practice helps reproduce racial inequities by neglecting the root causes of poor health. o The level of community awareness and understanding of mental health symptoms and treatment is another part of the social-environmental background for health, and can be impacted through community mental health awareness and Mental Health First Aid trainings. Health systems increasingly recognize the role of social determinants of health and the importance of collecting information on social needs (Feinglass, Wein, Teter, Schaeffer, & Rogers, 2018; Rizzo, Rowe, Shier Kricke, Krajci, & Golden, 2016). As assessment of social and structural determinants of health becomes more routine, the resulting data will assist advocates and policy makers to implement systemic solutions to health inequities.

Trauma and childhood adversity Alliance for Health Equity17

• •

•

Experiences of trauma and adversity in childhood, including abuse and household instability, extreme discrimination and poverty, or the loss of a parent, is widespread, affecting more than half of all adults in Illinois (Stillerman, n.d.-b). Research is revealing how exposure to trauma and adversity puts individuals at greater risk for mental illness, substance use disorders, and chronic illness across the lifespan. Trauma and adversity disproportionately affect communities of color and sexual and gender minorities, and are particularly prevalent among justice-involved populations, making addressing trauma a priority for achieving health equity (Substance Abuse and Mental Health Services Administration, 2014). Trauma-informed practice protocols are available for health care, schools, law enforcement and corrections, and child welfare systems to mitigate past experiences of stigma and trauma and to prevent further harm (Stillerman, n.d.-a).

Stigma and discrimination •

• •

Assessments of mental health needs in Cook County indicate that stigma and discrimination against people with mental illness and substance use disorder persists in communities, schools, workplaces, and even in health care settings. For older adults, ageism combines with stigma to overshadow mental illness when symptoms are dismissed as part of a normal aging process. Stigma deters people from seeking treatment before a crisis, and the experience of discrimination discourages ongoing engagement with treatment. Insurance parity laws and Mental Health First Aid training resources create opportunities to reduce stigma and fight discrimination, while the national response to the opioid crisis has increased mainstream attention to individual lived experiences of both substance use and harm reduction.

Workforce Shortages and Gaps in Training • •

•

Any progress in reducing stigma and discrimination is likely to increase demand for services. Yet community residents and referring medical providers already report barriers to access due to mental health professional shortages. Low reimbursement rates stifle the potential for workforce growth. A workforce that is linguistically competent and culturally humble is a necessary condition to overcoming the burden of stigma and structural racism. In particular, access to providers of evidencebased practices, such as Assertive Community Treatment, Medication-Assisted Treatment, and peer support, is crucial for people with serious mental illness and opioid use disorders. State programs to increase the number of Medication Assisted Treatment (MAT)-certified prescribers and expand reimbursement for telehealth and telepsychiatry, and local initiatives like Geriatric Worker Enhancement Programs, create opportunities to extend the existing workforce to reach more people in need. But Chicago and Cook County need to advocate for higher state reimbursement rates to address the workforce crisis (Illinois Department of Human Services, 2018; Illinois General Assembly, 2019).

Community Input: Input from community resident focus groups and surveys provided strong evidence that mental health and substance use are key health issues across the entire geography of Chicago and Suburban Cook County. Mental health, substance use, stress, and trauma were key topics of discussion in at least 80% of focus groups, across geography, age, and race/ethnicity. Focus groups discussed how behavioral health impacted the health of their communities. The major themes that emerged from the discussions included: • the prevalence of chronic stress among youth and adults in communities; • a lack of education among youth, adults, and public servants about mental illness and substance use disorders; • difficulties accessing behavioral health treatment resulting from provider shortages, minimal community-based resources, stigma, poor health care coverage, financial cost, and policy issues; • the consequences of untreated conditions; and • the impacts of abuse and other forms of trauma on behavioral health.

Chronic Conditions: Risk Factors and Prevention Alliance for Health Equity18

Worldwide and in the United States, chronic diseases are the leading causes of disability and death (Centers for Disease Control and Prevention, 2019b; World Health Organization, n.d.-c). In addition, chronic disease rates are accelerating globally across all socioeconomic classes (World Health Organization, n.d.-c). However, socioeconomic inequities have profound impacts on which populations and communities have the greatest burden of disease. Chronic conditions such as heart disease, stroke, cancer, diabetes, arthritis, asthma, mental illness, and HIV/AIDs account for 90% of the nation’s $3.3 trillion in annual health care expenditures (Centers for Disease Control and Prevention, 2019a). Prevention and management of chronic illness can help reduce the costly physical and socioeconomic burden of these diseases for individuals and society as a whole. Community Input: Focus group participants across the city and county described several issues related to chronic disease and chronic disease management. The major themes that were mentioned by participants included: • social determinants of health such as poverty, limited access to healthy foods, exposure to violence, and housing conditions are both underlying root causes of chronic disease and are barriers to the management of chronic disease; • education about preventing chronic disease, risk factors, and when to seek medical help is lacking in communities; • chronic illness such as asthma can be isolating for youth, parents, and adults; • taking care of a child with a life-threatening chronic illness can often cause severe chronic stress; and • community groups that share information about resources and support each other with adjusting to healthier lifestyles would be extremely helpful to communities. Forty-three percent of community input survey respondents selected diabetes as the top most important health problem in their communities. Heart disease and cancer were each selected by 27% of respondents as a top 3 health problem.

Asthma and Diabetes Asthma and diabetes are two conditions that demonstrate major disparities both for race/ethnicity and geography. And, the childhood burden for both conditions is concentrated in low-income communities of color across the county. In addition, disease progression and outcomes for these two conditions are strongly tied to the social determinants of health and have large equity-related gaps between communities.

Sexually Transmitted Infections The burden of sexually transmitted infections (STIs) falls disproportionately on low-income communities in Cook County. STIs impact the health care system through high costs for screening and treatment as well as the potential for complications. STIs are preventable with access to adequate education and health services (HealthyPeople 2020, n.d.). In Cook County, African American/black and Hispanic/Latinx communities experience the greatest burden of STIs such as HIV and chlamydia. Research indicates that many of the disparities related STI burden can be linked to broader social inequities such as a lack of funding (or availability) for substance use disorder treatment and harm reduction programs; mass incarceration; differential access to preventative and screening services; poor access to preconception, prenatal, and postnatal care; and poor access to comprehensive sexual education resources.

Mortality In the United States, 60% of adults have a chronic disease and 40% of adults have two or more chronic diseases (Centers for Disease Control and Prevention, 2019b). From 2014 to 2016, 65% of all deaths in Chicago and Suburban Cook County were attributable to chronic diseases. Inequities in the burden of chronic diseases and chronic disease-related mortality within communities is largely driven by the social determinants of health such access to healthy foods, access to safe exercise spaces, household income, access to quality education, housing stability, access to quality healthcare, community safety, and exposure to trauma. Due to inequities in the social determinants of health and the unjust distribution of resources between communities, Alliance for Health Equity19

chronic disease mortality varies across the county and in different population groups. Age-adjusted mortality rates in 2016 reveal that African American/blacks living in the city and suburbs have the highest rates of heart disease, cancer, diabetes-related, and stroke mortality. Between 2012 and 2017, age-adjusted mortality trends for chronic conditions remained consistent. However, drug overdose mortality has significantly increased in Chicago and Suburban Cook County over time. The resources to address opioid overdoses are highly concentrated in Chicago and notably less available in suburban areas.

Community Cohesion as an Asset Community cohesion, also known as social cohesion, refers to the strength of relationships and a sense of solidarity among members of a community (Kawachi & Berkman, 2000). Community cohesion is considered an important social determinant of health and there are numerous examples of how community cohesion can positively impact health. • Community cohesion can decrease the chances of developing PTSD or reduce the severity of PTSD symptoms among individuals living in neighborhoods with high levels of crime (Gapen et al., 2011). • A 2004 study found that women living in high-crime neighborhoods who had higher levels of social connection to their neighbors reported better overall health compared to women with lower levels of social connection (Linares, 2004). • Greater community cohesion is linked to better social and physical outcomes among older adults (Cramm & Nieboer, 2015). • Community cohesion and collective neighborhood efficacy is a protective factor against poor educational, emotional, and health outcomes among school-aged children in socioeconomically disadvantaged communities (Odgers et al., 2009). • Community cohesion has been found to strengthen the resilience of community residents in the aftermath of a natural disaster (Hikichi, Aida, Tsuboya, Kondo, & Kawachi, 2016). Community input collected during the assessment demonstrated that community cohesion is an important asset within the diverse communities of Cook County. Multiple focus groups and 1,779 community survey respondents stated that a shared sense of connection between community members was one of their community’s greatest strengths and assets. In addition, several focus groups described community cohesion as an essential component of a healthy community. Focus group participants emphasized that the knowledge and collective power of communities is often an untapped resource that should be solicited, cultivated, and leveraged in order to develop effective solutions to improve the health and well-being of residents.

Alliance for Health Equity20

Introduction The Alliance for Health Equity is a collaborative of 37 hospitals working with health departments and regional and community-based organizations to improve health equity, wellness, and quality of life across Chicago and Suburban Cook County. The purpose of the Alliance for Health Equity is to improve population and community health by: • Promoting health equity • Supporting capacity building, shared learning, and connecting local initiatives • Addressing social and structural determinants of health • Developing broad city and county wide initiatives and creating systems • Engaging community partners and working collaboratively with community leaders • Developing data systems for population health to support shared impact measurement and community assessment • Collaborating on population health policy and advocacy Collaborative Community Health Needs Assessment (CHNA) in Cook County is an important foundation for the work of the Alliance for Health Equity. The 2019 CHNA is the second consecutive collaborative CHNA in Cook County.i The Illinois Public Health Institute (IPHI) acts as the backbone organization for the Alliance for Health Equity. IPHI works closely with the steering committee to design the CHNA to meet regulatory requirements for nonprofit hospitals and to ensure close collaboration with the Chicago Department of Public Health (CDPH) and Cook County Department of Public Health (CCDPH) on their community health assessment and community health improvement planning processes. For this CHNA, the Alliance for Health Equity has taken a very intentional approach to build on the previous collaborative CHNA work (2016), Healthy Chicago 2.0 (2016), and WePLAN 2020 (2016). See the collaborative methodology section of this report for more information about the CHNA assessment model and methods.

Alliance for Health Equity Structure and Shared Leadership The Alliance for Health Equity is comprised of a steering committee and several workgroups and committees working on implementation strategies for several community health priorities (Figure 1). Figure 1. Alliance for Health Equity Structure

At the time that the 2016 CHNA was produced, the collaborative was operating under the name Health Impact Collaborative of Cook County. The steering committee decided to rename the collaborative as Alliance for Health Equity in June 2017. The steering committee and staffing through the Illinois Public Health Institute have been continuous since the collaborative was formed in February 2015. i

Alliance for Health Equity21

The steering committee is made up of 18 leaders and makes decisions about the strategic direction of the Alliance for Health Equity, guides IPHI staff, oversees collective impact strategies, and ensures that all activities align with its purpose, vision, and values. All member health systems and independent hospitals have representation on the steering committee along with CDPH and CCDPH. A list of steering committee members is available in Appendix B. The steering committee meets quarterly in person with monthly calls in between and makes all decisions by consensus through monthly meetings, designation of ad hoc subcommittees as needed, and through email communications. The data and policy committees assist other workgroups with projects as needed and develop methods for information sharing and alignment of policy agendas. The CHNA committee provides oversight and assistance with the development of assessments and implementation plans. The Alliance for Health Equity also has two implementation strategy committees that meet quarterly on Mental Health and Substance Abuse Disorders (MH&SUDs) and Social and Structural Determinants of Health (SDOH) to plan and implement collective impact strategies. Several workgroups focused on key implementation priorities related to SDOH and MH&SUDs convene more frequently. These include: Mental Health First Aid, Faith Communities, Community Safety, Food Access/Security, Housing and Health, and Transportation Access. All implementation strategy committees and workgroups include membership from hospitals, health departments, and multi-sectoral community and regional stakeholders. The Trauma-Informed Hospitals Collaborative (co-chaired and staffed by the Illinois ACEs Response Collaborative, Health and Medicine Policy Research Group, and CDPH) also falls under the umbrella of the Alliance for Health Equity and is working to build trauma-informed systems and promote community resilience.

Purpose, Vision, Values The Alliance for Health Equityâ&#x20AC;&#x2122;s purpose, vision, and values reflect input from hospital partners, health departments, and community stakeholders (Figure 2). The vision and values were developed in collaboration with community partners as part of the 2015-2016 collaborative CHNA. To collaboratively develop the vision and values, IPHI facilitated three in-person workshop sessions with hospitals and community partners from the southern, western, and northern communities of the city and suburbs, and IPHI coordinated follow-up edits over email to ensure the values represented the input of diverse partners across the collaborative. In 2018, two collaboratives merged to form the Alliance for Health Equity. The merged steering committee decided to keep the vision and values collaboratively developed under the 2015-2016 CHNA, as well as develop a statement of collective purpose. Figure 2. Purpose, Vision, and Values of the Alliance for Health Equity

Alliance for Health Equityď ź22

Community Engagement In keeping with our purpose, vision, and values, the Alliance for Health Equity prioritizes engagement of community members and community-based organizations as a critical component of assessing and addressing community health needs. Community partners have been involved in the assessment and ongoing implementation process in several ways both in providing community input and in decision-making processes. The Alliance for Health Equity’s methods of community engagement for the CHNA and implementation strategies include: •

Gathering input from community residents who are underrepresented in traditional assessment and implementation planning processes;

•

Partnering with community-based organizations for collection of community input through surveys and focus groups;

•

Engaging community-based organizations and community residents as members of implementation committees and workgroups;

•

Utilizing the expertise of the members of implementation committees and workgroups in assessment design, data interpretation, and identification of effective implementation strategies and evaluation metrics;

•

Working with hospital and health department community advisory groups to gather input into the CHNA and implementation strategies; and

•

Partnering with local coalitions to support and align with existing community-driven efforts.

The community-based organizations engaged in the Alliance for Health Equity represent a broad range of sectors such as workforce development, housing services, food security, community safety, planning, community development, immigrant rights, primary and secondary education, faith communities, behavioral health services, advocacy, policy, transportation, older adult services, health care services, higher education, and many more. All community partners work with or represent communities that are disproportionately affected by health inequities such as communities of color, immigrants, youth, older adults and caregivers, LGBTQ+, individuals experiencing homelessness or housing instability, individuals living with mental illness or substance use disorders, individuals with disabilities, veterans, and unemployed youth and adults. See Appendix A for a list of community partners that have been involved in the Alliance for Health Equity and the CHNA process.

Participating Hospitals and Health Departments Hospitals and health systems that are members of the Alliance for Health Equity are very active in designing and implementing a collective health equity purpose. For the CHNA, all hospitals and health systems that are a part of the Alliance for Health Equity: •

collaborate with IPHI, health departments, and community organizations to design and implement the CHNA process;

•

participate in identifying indicators for data analysis, developing survey questions, and prioritizing focus groups for input;

•

share existing data or assessments that are relevant and/or contribute to interpretation of data;

•

engage networks of community partners and hospital staff to collect community input, and take that input into account in defining community health priorities for local service areas;

•

review assessment data and assist with developing findings and identifying priority strategic issues; and

•

designate a steering committee representative to provide strategic guidance to the Alliance for Health Equity and IPHI staff.

Alliance for Health Equity23

A list of participating hospitals and health departments is presented in Figure 3. The locations of hospital partners are displayed in Figure 4. Figure 3. Participating hospitals and health departments in the Alliance for Health Equity

Nonprofit Hospital Members Advocate Aurora Children's Hospital

Loyola Medicine- Gottlieb Memorial Hospital

Advocate Aurora Christ Medical Center

Loyola Medicine- Loyola University Medical Center

Advocate Aurora Illinois Masonic Medical Center

Loyola Medicine- MacNeal Hospital

Advocate Aurora Lutheran General Hospital

Mercy Hospital & Medical Center

Advocate Aurora South Suburban Hospital

Northwestern Memorial Hospital

Advocate Aurora Trinity Hospital

Norwegian American Hospital

AMITA Adventist Medical Center La Grange

Palos Community Hospital

AMITA Alexian Brothers Medical Center, Elk Grove Village

Roseland Community Hospital

AMITA Holy Family Medical Center

Rush Oak Park

AMITA Resurrection Medical Center

Rush University Medical Center

AMITA St. Alexius Medical Center and Alexian Brothers Behavioral Health Hospital

Sinai Health System- Holy Cross Hospital

AMITA Saint Francis Hospital

Sinai Health System- Mount Sinai Hospital

AMITA Saint Joseph Hospital

Sinai Health System- Schwab Rehabilitation Hospital

AMITA Saints Mary and Elizabeth Medical Center

South Shore Hospital

Ann & Robert H. Lurie Children's Hospital of Chicago

Swedish Covenant Hospital

Jackson Park Hospital

University of Chicago Medicine

The Loretto Hospital

University of Chicago Medicine-Ingalls Memorial Hospital

Public Hospital Partners Cook County Health- Stroger Hospital

Cook County Health- Provident Hospital

University of Illinois Hospital & Health Sciences System

Public Health Department Partnersii Chicago Department of Public Health

Evanston Health and Human Services Department

Cook County Department of Public Health

Village of Skokie, Health Department

Two additional health departments—Stickney, and Oak Park—have participated with the Alliance for Health Equity on different initiatives but have not been direct partners in this CHNA process. ii

Alliance for Health Equity24

Figure 5. Hospitals participating in the Alliance for Health Equity

Alliance for Health Equityď ź25

Collaborative Assessment Model and Process The Alliance for Health Equity completed a collaborative CHNA between March 2018 and March 2019. Primary and secondary data from a diverse range of sources were utilized for robust data analysis and to identify community health needs in Chicago and Suburban Cook County. IPHI worked with the CHNA committee and steering committee to design and facilitate a collaborative, community-engaged assessment. As with the 2015-2016 collaborative CHNA, this 2019 CHNA process is adapted from the Mobilizing for Action through Planning and Partnerships (MAPP) framework, a communityengaged strategic planning framework that was developed by the National Association for County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC).iii Both the Chicago and Cook County Departments of Public Health use the MAPP framework for community health assessment and planning. The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, and the dynamic interplay of factors and forces within the public health system. The Alliance for Health Equity chose this inclusive, community-driven process to leverage and align with health department assessments and to actively engage stakeholders, including community members, in identifying and addressing strategic priorities to advance health equity. For the 2019 CHNA, the Alliance for Health Equity has taken a very intentional approach to build on the previous collaborative CHNA work (2016), previous CHNA reports from member hospitals, Healthy Chicago 2.0 (2016), and WePLAN 2020 (2016). From the launch of the CHNA process in mid-2018, the Alliance for Health Equity steering committee defined the following parameters for leveraging this CHNA process to continue collaborative momentum to advance health equity in Chicago and Suburban Cook County: •

The CHNA will build on prior CHNAs from 2015 to 2016 as well as other local or regional assessments and plans, and coordinate closely with health department assessment and planning processes.

•

The CHNA will provide greater insight into community health needs and strategies for ongoing community health priorities.

•

The CHNA will leverage expertise of community residents, community partners, and key stakeholders.

•

The CHNA will provide an overview of community health status and highlight data related to health inequities.

•

The CHNA will inform strategies related to: population health, connections between community and clinical sectors, anchor institution efforts, policy change, and community partnerships.

Collaborative Assessment Methodology Primary Data Primary data for the CHNA was collected through four methods: • Community input surveys • Community resident focus groups and learning map sessions • Health care and social service provider focus groups • Two stakeholder assessments led by partner health departments—Forces of Change Assessment and Health Equity Capacity Assessment iii

https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/community-health-assessment/mapp Alliance for Health Equity26

Community Input Survey Between October 2018 and February 2019, Alliance for Health Equity partners collected 5,934 community input surveys from individuals 18 or older living in Chicago and Suburban Cook County. The surveys were available on paper and online and were disseminated in English, Spanish, Chinese, and Polish. iv The surveys included questions asking respondents about the health status of their communities, community strengths, opportunities for improvement, and priority health needs. Hospitals, community-based organizations, and health departments distributed the surveys with the intention of gaining insight from priority populations that are typically underrepresented in assessment processes. Some of the priority populations were communities of color, immigrants, LGBTQ+ community members, individuals with disabilities, and low-income communities. The intention of the community input survey was to complement existing community health surveys distributed throughout Chicago and Suburban Cook County by local health departments. IPHI and the CHNA committee took the following steps to develop the survey tool: (1) IPHI drafted a survey based on review of 13 example community input surveys, (2) CHNA committee members from hospitals and health departments provided input, (3) IPHI incorporated revisions from CHNA committee members and the University of Illinois at Chicago Survey Research Laboratory, (4) IPHI made edits based on a health literacy review, (5) IPHI and two member hospitals piloted the survey at three community-based events, and (6) IPHI made final edits to address minor challenges identified at the pilot events. The final survey tool included 16 questionsâ&#x20AC;&#x201D;three questions related to zip code/community of residence, nine demographic questions, two multi-select questions about health problems and whatâ&#x20AC;&#x2122;s needed for a healthy community, and two open-ended questions about community strengths and improvements needed. The Survey Tool is included in Appendix C. Paper surveys were entered into the SurveyGizmo online platform so that electronic and paper surveys could be analyzed together. Survey data analysis was conducted using SAS 9.4 statistical analysis software and Microsoft Excel 2016. A map showing the distribution of survey respondents across the city and county is presented in Figure 5.

In addition to English, Spanish, Chinese, and Polish, the survey was also translated into Ukranian, but there were no responses received in Ukranian. Alliance for Health Equityď ź27 iv

Figure 5. Geographic distribution of community input survey respondents in Cook County

Alliance for Health Equityď ź28

Figure 6. Demographics of Community Input Survey Respondents v

Demographics of 5934 Community Input Survey Respondents Language (n=5934) English Spanish Chinese Polish

87% 10% 3% 1% Gender Identity (n=5726)

Female 71% Male 28% Non-Binary or Genderqueer 0.4% Gender Neutral 0.3% Other 0.3% Transwoman 0.1% Transman 0.1% Sexual Orientation (n=5306) Straight 92% Gay or Lesbian 4% Bisexual 3% Other 2% Age (n=5709) 18-24 11% 25-34 13% 35-44 13% 45-54 16% 55-64 20% 65-74 16% 75-84 9% 85 or older 3% Annual Household Income (n=5014) Less than $10,000 21% $10,000 to $19,999 15% $20,000 to $39,999 19% $40,000 to $59,999 15% $60,000 to $79,999 10% $80,000 to $99,999 7% Over $100,000 14%

Children in the Household (n=5472) No children in my household 62% Age 0-4 14% Age 5-12 20% Age 13-17 17% Someone in the Household with a Disability (n=5592) Yes 28% No 72% v Race/Ethnicity (n=5528) White 31% African American/black 27% Hispanic/Latinx 27% Asian 8% Multiracial and/or Multiethnic 5% Middle Eastern/Arab American 1% Native American 0.3% Pacific Islander 0.3% Educational Attainment (n=5652) Some or no high school 11% High school graduate or GED 21% Vocational or technical school 5% Some college 23% College graduate or higher 40% Household Size (n=5355) 1 24% 2 28% 3 16% 4 15% 5 9% 6 or more 9%

Some questions were multi-select in which respondents could choose more than one answer, therefore, not all percentages total 100% when summed. Alliance for Health Equityď ź29 v

Focus Groups and Learning Map Sessions Between August 2018 and February 2019, IPHI worked with Alliance for Health Equity partners to hold a total of 52 community input sessions (focus groups and learning map sessions) with priority populations such as veterans, individuals living with mental illness, communities of color, older adults, caregivers, teens and young adults, LGBTQ+ community members, adults and teens experiencing homelessness, families with children, faith communities, adults with disabilities, and children and adults living with chronic conditions such as diabetes and asthma. The community input sessions included 31 focus groups conducted by IPHI and 21 learning map sessions led by West Side United with notetaking by IPHI. In addition to the 52 community input sessions, there were also five focus groups with health care and social service providers hosted by Swedish Covenant Hospital, MacNeal Hospital, and South Shore Hospital. Figure 5 lists all of the focus group and learning map session host organizations. Figure 7. List of Focus Group and Learning Map Session Host Organizations ABJ Services Affinity Community Services After School Matters (2 groups) Alivio Medical Center AMITA Saints Mary and Elizabeth Medical Center Asian Human Services Family Health Center Breakthrough BUILD, Inc. By the Hand Chicago Public Library ‐ Austin‐Irving Park Chicago Public Library ‐ Edgebrook Branch Chicago Public Library ‐ Jefferson Park Branch Chicago Public Library ‐ Oriole Park Branch Chicago Youth Programs CJE SeniorLife Coalition of Hope CristoRey High School Deborah's Place El Valor Enlace Chicago Evanston General Assistance (2 groups) Friedman Place Frisbie Senior Center Garfield Park Community Council Gary Comer Youth Center

Greater Galilee Baptist Church Habilitative Systems Hanul Family Alliance Housing Forward ‐ Tenant's Club Meeting Kedvale New Mount Zion M.B. Church Maine Community Youth Assistance Foundation NAMI Chicago family members NAMI Chicago individuals with lived experience New Moms (2 groups) New Morning Star MB Church (2 groups) Northwest Side Housing Center Oak Park River Forest Food Pantry Oakley Square Apartments (3 groups) PLOWS Council on Aging Restoration Ministries Rich Township VFW Post 311 Saint Stephen AME Solutions for Care Southwest Organizing Project (2 groups) Teen Living Program Temple of Faith MB Church Theace Goldsberry Community House (2 groups, parents and youth) TCA Health, Inc. Timothy Community Corporation UCAN (2 groups, community residents and youth)

Community leader and provider focus groups Faith Leaders, countywide Immigrant service providers South Shore Hospital community service providers Swedish Covenant Hospital community service providers MacNeal Hospital health care providers Focus group facilitators asked participants about the underlying root causes of health issues that they see in their communities and specific strategies for addressing those health needs. IPHI developed the focus group questions using resources from existing CHNA toolkits and peer-reviewed studies, in consultation with the Alliance for Health Equity30

CHNA committee and colleagues at partner health departments. Each focus group was hosted by a community-based organization or hospital, and participation ranged from three to forty people. Most focus groups were 90 minutes long with an average of 10 participants. A trained facilitator moderated each session and was joined by a notetaker who audio-recorded the session while typing notes and observations on a laptop. Recordings were stored securely on a server at IPHI and not shared due to the use of first names during focus groups. No names were included in any version of the written notes and other potentially identifying details were redacted from the notes. The full-length audio-recordings were reviewed, and codes/sub-codes created. Themes and contrasting thoughts or opinions were highlighted. The software Dedoose 8.1.8 was used to identify and analyze cross-group codes. Community input from all 52 community input sessions (focus groups and learning map sessions) was combined and included in the assessment, along with input from five provider focus groups.

Forces of Change Assessment This Forces of Change Assessment collects information on the trends, factors, and events that are currently affecting and/or anticipated to affect the public health system in the near future (3-5 years). CDPH led this assessment in partnership with their Partnership for a Healthy Chicago, and CCDPH. 122 respondents representing 86 organizations in Chicago and Suburban Cook County responded to an online survey between November 2018 and January 2019. The Healthy Chicago Partnership members discussed and interpreted the survey responses at a February 2019 meeting. The discussion identified the following cross-cutting forces (a more detailed report will be released by CDPH and CCDPH): Overarching threats: • Inequities in funding for projects and services in high hardship communities • Racism: institutional, interpersonal, and internalized • No/limited trust in all levels of government/system/health care system • Lack of diversity in representation and decision making • Policies that penalize lower-income individuals • Lack of comprehensive, evidence-based systems approach Overarching strengths/opportunities: • Opportunity to devise equitable policies • Interest in collaboration across sectors/services • Increased awareness about intersection of health and root causes of health, including workforce development, education, built environment • Leveraging community benefits requirements in other sectors that can be directed to equity and health in high hardship communities • Increased access to data for use with evidence-based and evidence-informed decisions • Integration of health and human services care teams • Increased diversity in organizations

Health Equity Capacity Assessment The Health Equity Capacity Assessment was led by CDPH, the Partnership for a Healthy Chicago, CCDPH, and IPHI. CDPH, CCDPH, and the Partnership worked with faculty from DePaul and UIC Schools of Public Health to develop a tool to score the capacity of the public health system to advance health equity. The tool consists of 5-6 questions for each of the Ten Essential Public Health Services relating to five components of health equity: community engagement/involvement, organizational processes, power/influence, structural inequities, and funding. On March 5, 2019, 80 people from across Chicago and Suburban Cook County came together to score how well the system is functioning around health equity and to identify challenges, strengths, and opportunities to move forward. (Findings from this assessment will be available later this spring.)

Secondary Data Alliance for Health Equity31

Epidemiologists from CCDPH and CDPH have been invaluable partners in identifying, compiling, and analyzing secondary data for the CHNA. IPHI and the Alliance for Health Equity steering committee worked with CDPH and CCDPH to select a common set of indicators based on an adapted version of the County Health Rankings and Roadmaps Model (Figure 8): • Social and Structural Determinants of Health • Physical Environment • Health Behaviors • Health Care and Clinical Care • Behavioral Health - Mental Health and Substance Use • Health Outcomes - Birth Outcomes, Morbidity, and Mortality The Alliance for Health Equity made three main adaptations to the County Health Rankings and Roadmaps model, in keeping with local priorities: (1) including behavioral health as a major category of data, (2) applying a racial equity analysis to data where possible, and (3) including additional child and youth data where available. Figure 8. Adapted County Health Rankings and Roadmaps Framework

Modified from County Health Rankings and Roadmaps, 2014.

Alliance for Health Equity32

Figure 9. CHNA data and information sources Secondary data sources • Peer-reviewed literature and white papers • Existing assessments and plans focused on key topic areas • Localized data compiled by several agencies including Chicago Department of Planning and Development, Chicago Metropolitan Agency for Planning, Housing Authority of Cook County, and state and local police departments • Localized data compiled by community-based organizations including Greater Chicago Food Depository and Voices of Child Health in Chicago • Hospitalization and emergency department rates (COMPdata) provided by Illinois Health and Hospital Association and analyzed by the Conduent Healthy Communities Institute • Data compiled by state agencies including Illinois Environmental Protection Agency, Illinois Department of Healthcare and Family Services, Illinois Department of Human Services, Illinois State Board of Education, and Illinois Department of Public Health • Data from federal sources including U.S. Census Bureau American Community Survey data compiled by Chicago Department of Public Health and Cook County Department of Health; Centers for Disease Control and Prevention; Centers for Medicare and Medicaid Services data accessed through the Dartmouth Atlas of Health Care; Health Resources and Services Administration; and United States Department of Agriculture

Data System Needs and Limitations The Alliance for Health Equity made substantial efforts to comprehensively collect and analyze assessment data. However, there are limitations to consider when reviewing findings. • Population health and demographic data are often delayed in their release, so data is presented for the most recent years available for any given data source. • There is variability in the geographic level at which data sets are available ranging from census tract to statewide or national geographies. Whenever possible, the most relevant localized data is reported. • Due to variations in geographic boundaries, population sizes, and data collection techniques for suburban and city communities, some datasets are not available for the same time spans or at the same level of localization throughout the county. • There are persistent gaps in data systems for certain community health issues such as mental health and substance use disorders (youth and adults), crime reporting, environmental health, and education outcomes. Alliance for Health Equity partners are investigating strategies for addressing data system gaps in future implementation and assessment processes, and data systems needs were a priority identified through both the Forces of Change Assessment and the Health Equity Capacity Assessment that were conducted in partnership with local health departments.

Alliance for Health Equity – Implementation Activities and Accomplishments 2016-2018 The Alliance for Health Equity committees and workgroups have initiated a number of collaborative implementation initiatives based on member hospitals’ and health departments’ 2015 and 2016 CHNA priorities. Appendix D provides details on the Alliance for Health Equity’s implementation activities and accomplishments for 2016-2018.

Alliance for Health Equity33

Community Description for Cook County Cook County, Illinois, comprises 130 suburban municipalities and 77 Chicago community areas. Figures 10a10b can be referenced when viewing maps throughout the CHNA report, and alpha-numeric coordinates allow for localization of individual communities. As of 2016, the estimated population for Cook County is 5,211,263, with 2,716,450 in Chicago and 2,494,813 in Suburban Cook County. Figure 10a. Reference Map The 232 Suburban Cook municipalities and Chicago Community Areas included in the CHNA are provided below. These individual geographies can be located on the map using their reference number and alpha-numeric coordinate.

Alliance for Health Equityď ź34

Figure 10b. Reference Map The 232 Suburban Cook municipalities and Chicago Community Areas vi included in the CHNA are provided below. These individual geographies can be located on the map using their reference number and alpha-numeric coordinate.

Where data is provided for the Oâ&#x20AC;&#x2122;Hare community area, it represents the approximately 16,000 people who live within that community area to the east of the airport. vi

Alliance for Health Equityď ź35

Population composition Age and gender U.S. Census Bureau population estimates for 2016 indicate that approximately 22% of the population in Cook County is under 18 years old and 14% is age 65 or older (U.S. Census Bureau, 2016). The percentage of individuals identifying as male or female in Cook County is approximately equal (U.S. Census Bureau, 2016). Data for the transgender and gender non-conforming populations in Cook County is limited. Based on preliminary analyses of Healthy Chicago Survey data, the Chicago Department of Public Health estimates that 10,500 adults living in Chicago identify as transgender or gender non-conforming.

Race and ethnicity Figure 11 shows estimates of the predominant racial and ethnic groups within communities across Cook County. In 2017, the U.S. Census Bureau estimated that 42% of the population in Cook County identified as non-Hispanic white, 24% identified as non-Hispanic African American/black, 8% identified as non-Hispanic Asian, 2% identified as two or more races, and 26% identified as Hispanic/Latinx (U.S. Census Bureau, 2017). Racial and ethnic segregation in Cook County is well above national median levels (Metropolitan Planning Council, 2017). The consequences of this segregation are discussed further in the Overview of Health Inequities section. Figure 11. Predominant racial and ethnic groups in Cook County, Illinois (2016, 5-year estimates)

U.S. Census Bureau, American Community Survey, 2016 5-year estimates Alliance for Health Equityď ź36

Immigration An estimated 21% of Chicago residents and 20% of Suburban Cook County residents are foreign-born (U.S. Census Bureau, American Community Survey, 2016 5-year estimates). In 2016, 1.6 million Illinois residents were native-born Americans who had at least one immigrant parent (American Immigration Council, 2017). In 2015, the top countries of origin for foreign-born individuals living in Illinois were Mexico (38.2 percent of immigrants), India (8.1 percent), Poland (7 percent), the Philippines (5 percent), and China (4.3 percent) (American Immigration Council, 2017). Within Cook County, there are several communities with large concentrations of individuals that have limited English Proficiency (Figure 12). A 2012 study in California found that individuals who reported limited English proficiency had rates of low health literacy that were three times higher than English speakers (Sentell & Braun, 2012). In addition, individuals with both limited English proficiency and low health literacy reported the highest prevalence of poor health (45%), followed by limited English proficiency only (41%), low health literacy only (22%), and neither (14%) (Sentell & Braun, 2012). The study indicates that English proficiency has the potential to significantly impact health outcomes within immigrant communities. Figure 12. Limited English proficiency – number of foreign-born individuals over age 5 that speak English less than “very well” in Cook County, Illinois (2016, ACS 5-Year Estimates)

U.S. Census Bureau, American Community Survey, 2016 5-year estimates Alliance for Health Equity37

Population trends Population density Figure 13 shows population density across the county as of 2016. Figures 14 and 15 show areas of population growth and population loss between 2010 and 2016. The most densely populated communities are on the North, West, Southwest, and Southeast Sides of the City of Chicago and West suburban communities directly adjacent to the city (Cicero, Berwyn, Oak Park, and Elmwood Park). Figure 13. Population density - persons per square mile, in Cook County, Illinois (2016, ACS 5-Year Estimates)

U.S. Census Bureau, American Community Survey, 2016 5-year estimates Alliance for Health Equityď ź38

Population shifts Since 2000, Cook County as a whole has continued to experience a loss in population. However, the majority of population loss occurred in Chicago, while suburban Cook County’s population has grown by almost one percent. While growth has been modest, there have been substantial changes in the racial and ethnic make-up of Cook County. Cook County is experiencing three trends that are also being seen nationally: • African American/black households moving to suburbs, smaller cities, and/or southern states; • suburban immigrant destinations; and • suburbanization of poverty (Lacy, 2016). Cook County is experiencing what some call “reverse migration” with African American/blacks leaving urban areas for the suburbs. Between 2000-2010, African American/black population in Chicago decreased by over 15% and increased 18% in Suburban Cook County (Figure 14). Figure 14. Percent change in racial and ethnic composition of Cook County, Illinois (2000-2010) Total Population Cook County -3% Chicago -7% Suburban +1% Cook County U.S. Census Bureau, 2000-2010

Non-Hispanic African American/black -8% -17% +18%

Non-Hispanic Asian

Hispanic/Latinx

Non-Hispanic white

+23% +15%

+16% +3%

-11% -6%

+31%

+47%

-14%

Adding to the reverse migration phenomenon, more white households are moving into urban centers. Overall, there has been a 10% decrease of white populations in Cook County. However, the population loss is not consistent across the area. Suburban Cook County had more than double the decrease in non-Hispanic white populations (14%) compared to Chicago (6%). Along with most of the nation, Cook County experienced an increase in the Hispanic/Latinx populations between 2000 and 2010, and the increase was greatest in Suburban Cook County (47%). Other demographic shifts are not only increasing the size of priority populations in Suburban Cook County, but also shifting the distribution of the social determinants of health geographically. Between 2000-2010, Chicago saw very little net change in poverty; however, Suburban Cook County saw dramatic rises in its poverty levels with child poverty increasing by over 75% between 2000 and 2010 (Figure 15). Because social determinants of health such as poverty and lack of opportunity drive health outcomes, ongoing population shifts may define future workforce needs and demands for care in priority populations. Figure 15. Percent change in poverty within Cook County, Illinois (2000-2010) Persons in Poverty Children in Poverty Cook County +20% +13% Chicago +7% -3% Suburban Cook County +66% +77% U.S. Census Bureau, 2000-2010 Additional demographic information about priority populations within Cook County is presented in Figure 16.

Alliance for Health Equity39

Figure 16. Demographic Characteristics of Priority Populations in Cook County Priority Population

Homeless Individuals and Families

Justice-Involved

Demographic Characteristics In 2018, an estimated 16,626 households entered homelessness in Chicago about 5% of these households had previously been through the Housing Management Information System (HMIS). In 2017, an estimated 2,810 homeless individuals were accessing shelter services in Suburban Cook County (Alliance to End Homelessness in Suburban Cook County, 2019; Corporation for Supportive Housing, 2019) In December 2018, an estimated 39,915 individuals were in Illinois prisons. Since 2015, an estimated 40% of individuals released from prison have returned to the prison system. (Illinois Department of Corrections, 2018)

People Living with Mental Health Conditions

An estimated 16% of Illinois residents are living with a mental illness. (Mental Health America, 2015)

People Living with Disabilities

An estimated 10% Chicago residents are living with a disability. An estimated 10% of Suburban Cook County residents are living with a disability. (U.S. Census Bureau, American Community Survey, 2012-2016)

Older Adults Living with Disabilities

An estimated 39% of Chicago residents over the age of 65 are living with a disability. Additionally, an estimated 33% of Suburban Cook County residents over the age of 65 are living with a disability. (U.S. Census Bureau, American Community Survey, 2012-2016)

Immigrants and Refugees

LGBTQ+

Unemployed and Underemployed

Uninsured

An estimated 21% of Chicago residents are foreign-born individuals. Moreover, an estimated 20% of Suburban Cook County residents are foreign-born individuals. “Foreign-born individuals” is a term used by the U.S. Census to describe anyone who was not a U.S. citizen at birth. Analysis from 2011 estimated a population of 307,000 undocumented immigrants in Cook County. (U.S. Census Bureau, American Community Survey, 2012-2016) An estimated 8% of Chicago adults identify as on the LGBTQ+ spectrum. Approximately 10,500 adults living in Chicago identify as transgender or gender non-conforming based on data from the Healthy Chicago Survey. In Illinois, approximately 4% of the population identifies as lesbian, gay, bisexual, or transgender. (Movement Advancement Project, n.d.) In both Chicago and Suburban Cook County, there is a 10% unemployment rate, with much higher rates in some communities. As of 2015, 21,518 youth ages 16-24 in Cook County were out of work, out of school, and without a high school diploma. Additional information about unemployment and underemployment can be found in the social determinants of health section. (U.S. Census Bureau, American Community Survey, 2012-2016) An estimated 10% of Chicago residents and 12% of Suburban Cook County residents are uninsured, with much higher rates in some communities. Additional information about insurance coverage is included in the Access to Care section. (U.S. Census Bureau, American Community Survey, 20122016).

Veterans and Former Military

An estimated 4% of Chicago residents and 5% of Suburban Cook County residents are veterans. (U.S. Census Bureau, American Community Survey, 2012-2016)

Youth

Approximately 22% of the population in Cook County is under 18 years old.

Alliance for Health Equity40

Alliance for Health Equity41

Priority Community Health Issues Based on the findings from the collaborative assessment methods, the 2019 Alliance for Health Equity CHNA identifies the following community health priorities. Figure 17. Priority Community Health Issues, Alliance for Health Equity, Chicago and Suburban Cook County, 2019

Access to Care, Community Resources, and Systems Improvements

Increased Health Equity, Improved Health, Improved Quality of Life, Increased Life Expectancy

Alliance for Health Equityď ź42

Overview of Health Inequities Health inequities can be defined as differences in the incidence, prevalence, mortality, burden of disease, or the distribution of health determinants between different population groups (National Institutes of Health, 2017; World Health Organization, n.d.-b). Health inequities can exist across many dimensions such as race, ethnicity, gender, sexual orientation, age, disability status, socioeconomic status, geographic location, and military status (National Academies of Sciences, Baciu, Negussie, Geller, & Weinstein, 2017). There are four overarching concepts that demonstrate the necessity of addressing health inequities: 1. Inequities are unjust – Health inequities result from the unjust distribution of the underlying determinants of health such as education, safe housing, access to health care, and employment; 2. Inequities affect everyone – Conditions that lead to health disparities are detrimental to all members of society and lead to loss of income, lives, and potential; 3. Inequities are avoidable – Many health inequities stem directly from government policies such as tax policy, business regulation, public benefits, and health care funding and can, therefore, be addressed through policy interventions; and 4. Interventions to reduce health inequities are cost-effective – Evidence-based public health programs to reduce or prevent health inequities can be extremely cost effective particularly when compared to the financial burden of persistent disparities (Metropolitan Planning Council, 2017; National Academies of Sciences et al., 2017; Woodward & Kawachi, 2000).

The Role of Racism Race and ethnicity are socially constructed categories that have profound effects on the lives of individuals and communities as a whole. Racial and ethnic disparities are arguably the most persistent inequities in health over time in the United States (National Academies of Sciences et al., 2017). Racial and ethnic inequities in health are directly linked to racism. “Racism is the system of structuring opportunity and assigning value based on the social interpretation of how one looks. which is what we call “race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.” American Public Health Association (APHA) Past President Camara Jones, MD, PhD, MPH Racism structures opportunity and assigns value based on how a person looks resulting in conditions that unfairly advantage some and unfairly disadvantage others (American Public Health Association, 2019). Racism diminishes the overall health of our nation by preventing some people the opportunity to attain their highest level of health and is a driving force of the social determinants of health (American Public Health Association, 2019). In addition, racism can be traumatic to the individuals and communities that are routinely exposed to it thus causing and exacerbating health inequities. Racism can be unintentional or intentional and operates at several different levels (Figure 18).

Alliance for Health Equity43

Figure 18. Levels of individual and systemic racism

(Race Forward, 2014) There is a common misconception that racism is a rare problem of isolated, individual attitudes and actions or most damagingly—that racism is a thing of the past (Race Forward, 2014). While individual racism is important to address, it is particularly important to understand and address the institutional and structural levels of racism (Race Forward, 2014). When addressing racism, the focus should be shifted from intent or conscious attitudes and beliefs and turned to interventions that acknowledge the systems and structures that are either supporting positive outcomes or hindering them (J. Powell, 2013).

Segregation, Racial Inequities, and Health in the Chicago Metro Area Federal and local policies that established racial and ethnic segregation in Chicago and Suburban Cook County are rooted in racism (Metropolitan Planning Council, 2017). A 2017 study by the Metropolitan Planning Council and The Urban Institute analyzed economic, racial, and ethnic segregation patterns in the 100 largest metropolitan areas in the Unites States to determine what the impacts would be if the Chicago region reduced its levels of segregation to the median levels of the nation’s 100 biggest metros (Metropolitan Planning Council, 2017). The study found that segregation in the Chicago metro area significantly decreases the region’s overall economic performance, results in higher homicide rates and increased loss of life, and results in much lower rates of post-secondary educational attainment among whites and African Americans (Metropolitan Planning Council, 2017).

Alliance for Health Equity44

The study provided several examples of the impacts that could be achieved by reducing the Chicago region’s economic, racial, and ethnic segregation to national median levels: • incomes for African Americans in the region would rise by an average of $2,982 per person per year, which equates to an overall increase of $4.4 billion in additional income in our region; • the Chicago region’s homicide rate would drop by 30 percent, the equivalent of saving 229 lives in 2016; • the lives saved by a decrease in homicide rates have a projected earning potential of $170 million over their lifetimes with an estimated savings of $65 million in law enforcement and $228 million in criminal justice costs; • decreased homicide rates would lead to an estimated $6-billion real estate value increase over the long-term; and • eighty-three thousand more people in the Chicago region would have bachelor’s degrees—in other words, the Chicago region is losing out on some $90 billion in total lifetime earnings as a result of our education gap (Metropolitan Planning Council, 2017).

Achieving Racial Equity Racial equity is reached when race and ethnicity no longer determine an individual or community’s socioeconomic and health outcomes (Center for Social Inclusion, n.d.). Racial equity is achieved when those most impacted by structural and institutional inequity are meaningfully involved in the creation and implementation of institutional policies and practices that impact their lives (Center for Social Inclusion, n.d.). It is important to note that equality and equity are different (Figure 19). Health inequities involve more than unequal access to the resources needed to maintain or improve health (World Health Organization, n.d.-a). Figure 19. The difference between equality and equity

(TEQuity and Robert Wood Johnson Foundation, 2018)

Alliance for Health Equity45

Figure 20 provides a framework of how addressing social and institutional inequities can lead to differences in the physical and social environments impacting health behavior, disease and injury, and mortality. Figure 20. A Public Health Framework for Reducing Health Inequities

(BARHII Bay Area Regional Health Inequities Initiative, 2015)

Examples of Health Inequities As previously mentioned, social determinants of health often vary by geography, sexual orientation, gender identity, age, race, ethnicity, immigration status, disability status, socioeconomic status, education level, and military status. This leads to significant differences in morbidity and mortality between these groups. Many of the inequities leading to differences in health outcomes are more pronounced in Chicago and Suburban Cook County than they are for the nation overall. This section highlights some examples of the geographic and population-specific inequities for communities nationwide and in Cook County.

Inequities in Access to Health Care Access to health care is a complex and multifaceted concept that includes dimensions of proximity; affordability; availability, convenience, accommodation, and reliability; quality and acceptability; openness, cultural responsiveness, appropriateness and approachability. One of the strongest and most researched causes of inequities in health care and health outcomes is income inequality. Around the world, wealthy individuals have better health than low-income individuals. However, the United States has one of the worldâ&#x20AC;&#x2122;s largest health gaps between its wealthiest and poorest citizens (Hero, Zaslavsky, & Blendon, 2017). In a study of 32 middle- and high-income nations, the United States ranked 30th in health outcome disparities between the richest and poorest with only Chile and Portugal fairing worse (Hero et al., 2017). Low-income communities historically have less physical access to hospitals, clinics, doctor offices, skilled professionals, medical technology, essential medicine, and proper procedures to deal with illness and disease (A. Powell, 2016). Additionally, quality of health care services can vary greatly between communities. Inequalities in health insurance are another factor leading to significantly worse health outcomes in low -income communities (A. Powell, 2016). Health insurance is the primary way in which individuals access the U.S. health Alliance for Health Equityď ź46

care system, with 53% of Illinois residents receiving coverage through employer sponsored plans. However, one in five low-income Americans still go without care because of cost compared to 1 in 25 high-income Americans (Amadeo, 2019). Many of the working poor do not qualify for Medicaid and are often employed in professions that do not offer employer benefits. In addition, even with health care marketplace and other subsidies, co-pays and deductibles remain cost-prohibitive for low-income families. Other factors, such as having an undocumented status further impact an individual’s ability to obtain health care coverage. Delays in seeking needed health care frequently lead to the worsening of health problems and an increased need for expensive emergency care which can further increase poverty rates. A recent study found that medical expenses had pushed 4-million people below the federal poverty line (Christopher, Himmelstein, Woolhandler, & McCormick, 2018). These issues highlight that providing access to private or public health insurance will not completely eliminate disparities in access to health care and health outcomes and that solutions that address the underlying social determinants of access are also needed. Community Input Community input gathered through focus groups during the assessment highlighted several inequities in access to health care and health care quality. The most commonly mentioned barriers to accessing health care included: • provider shortages; • the complexity of obtaining and keeping public benefit coverage; • policy changes that have led to severe delays in the distribution of medical cards from the state; • fear within immigrant communities that obtaining benefits will impact their ability to acquire citizenship status; • the high cost of some private insurance plans; • the high cost of deductibles and co-pays; • a lack of knowledge about available insurance and benefit options; and • diminishing access to services that assist individuals with obtaining coverage. Additional community input related to inequities in health care is presented in the Clinical Care section.

Inequities in Mortality There are profound differences in life expectancy and mortality between different communities in Chicago and Suburban Cook County. •

In 2016, national life expectancy at birth was highest for Hispanic persons at 81.8 years, compared to 78.5 years for non-Hispanic whites and 74.8 for non-Hispanic African American/blacks (National Center for Health Statistics, 2017). In Chicago, the life expectancy for non-Hispanic African American/blacks was the lowest (71.9 years) compared to non-Hispanic whites (80.2 years), Hispanic/Latinx (80.7 years), and Asians (83 years).

•

Life expectancy in Chicago and Suburban Cook County has significant geographic variation (Figures 18-19). Communities with lower life expectancies are concentrated in the west and south regions of the county within areas of high poverty (Figure X).

•

The gap between Chicago community areas with the highest and lowest life expectancies is 16 years. In Suburban Cook County, the gap between municipalities with the highest and lowest life expectancies is 19 years (Figures 18-19).

Alliance for Health Equity47

Figure 21. Comparisons of life expectancy in Chicago

Illinois Department of Public Health, Division of Vital Records, 2012-2016 Figure 22. Comparisons of life expectancy in Suburban Cook County

Illinois Department of Public Health, Division of Vital Records, 2016-2017

Alliance for Health Equityď ź48

Figure 23. Life expectancy at birth vs. neighborhood poverty rate Life expectancy (2016 estimates) in Cook County ranges from 60 to 90 years. This map shows the relationship between life expectancy and neighborhood level poverty. Here, life expectancy has been categorized as lower or higher than the average life expected in the U.S for 2016 (78.6 years). Poverty has been categorized as lower or higher than 15% of households in a neighborhood being at or below the federal poverty line.

Illinois Department of Public Health, Division of Vital Records, 2016; U.S. Census Bureau, American Community Survey, 2016 5-year estimates

Alliance for Health Equityď ź49

Inequities in Years of Potential Life Lost (YPLL) Years of Potential Life Lost (YPLL) is a community-level measure that estimates the time community members would have lived had they not died prematurely (Gardner & Sanborn, 1990). YPLL is used to help quantify social and economic loss due to premature death (Gardner & Sanborn, 1990). Like life expectancy, YPLL varies greatly between communities in Chicago and Suburban Cook County with communities in the south region having the greatest burden of premature mortality (Figures 24-25). Although communities with the highest rates of premature mortality suffer significant social and economic loss, inequities in YPLL diminish the economic and social vitality of the city and county overall. Figure 24. Years of Potential Life Lost – Comparison of community areas in Chicago

Illinois Department of Public Health, Division of Vital Records, 2012-2016 Figure 25. Years of Potential Life Lost – Comparison of municipalities in Suburban Cook County

Illinois Department of Public Health, Division of Vital Records, 2012-2016 Alliance for Health Equity50

Inequities in Maternal and Child Health Maternal health is defined as the health of women during pregnancy, childbirth, and in the postpartum period (Illinois Department of Public Health, 2018). This period is a critical time for womenâ&#x20AC;&#x2122;s health since they typically have more interaction with and access to health care services (Illinois Department of Public Health, 2018). In addition, pregnancy provides an opportunity to identify, treat, and manage underlying chronic conditions to improve a womanâ&#x20AC;&#x2122;s overall health (Illinois Department of Public Health, 2018). Severe pregnancy complications (maternal morbidity) and mortality are used on an international level to judge the overall health status of a country, state, or community (Illinois Department of Public Health, 2018). Since the year 2000, maternal mortality rates in the United States have been increasing even though the global trend has been the opposite (MacDorman, Declercq, Cabral, & Morton, 2016). In addition, vast maternal health disparities exist between racial and ethnic groups (Illinois Department of Public Health, 2018). The persistent nature of racial and ethnic disparities in maternal health indicate that inequities are due to more than just access to health care but include factors such as poverty, quality of education, health literacy, employment, housing, childcare availability, and community safety (Illinois Department of Public Health, 2018). As previously mentioned, racism is a driving force of these social determinants (American Public Health Association, 2019). In addition, both systematic racism and provider bias affect the quality of health care that certain communities receive (Hoffman, Trawalter, Axt, & Oliver, 2016). Severe maternal morbidity is a potentially life-threatening condition or complication that occurs during labor and delivery (Illinois Department of Public Health, 2018). African American/black women have rates of severe maternal morbidity that are nearly three times higher than the rate for white women (Figure X). Women on Medicaid have a higher rate of severe maternal morbidity (57.1 per 10,000 deliveries) than women with private insurance (48.6 per 10,000 deliveries) (Illinois Department of Public Health, 2018). Additionally, severe maternal morbidity frequently occurs in conjunction with common chronic conditions such as diabetes and hypertension (Figure 26). Figure 26. Severe maternal morbidity by race and ethnicity in Illinois (per 10,000 deliveries)

Illinois Department of Public Health, 2016-2017

Alliance for Health Equityď ź51

Figure 27. Prevalence of chronic conditions among women who experience severe maternal morbidity

Illinois Department of Public Health, 2016-2017 Pregnancy-related death is the death of a woman during pregnancy or within one year of the end of a pregnancy from a pregnancy complication (CDC Foundation, 2017). The death is due to a chain of events initiated by the pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy (CDC Foundation, 2017). As with severe maternal morbidity, the rate of pregnancy-related deaths is much higher for certain populations compared to others: • African American/black women were about six times as likely to die from a pregnancy-related cause as white women—Hispanic/Latinx women were about twice as likely as white women to die from a pregnancy-related cause; • women in their 40s were about six times as likely to die from a pregnancy-related cause as women in their 20s or 30s; • women with a high school education or less were about twice as likely to die from a pregnancy-related cause as women who had more than a high school education; • women on Medicaid during pregnancy were nearly five times as likely as women with private insurance to die from a pregnancy-related cause; and • a higher BMI was related to a higher likelihood of a pregnancy-related death with obese women being more than twice as likely as normal weight women to die from a pregnancy-related cause (Figure X) (Illinois Department of Public Health, 2018).

Alliance for Health Equity52

Figure 28. Pregnancy-related mortality rate by demographics in Illinois (per 100,000 live births)*

*Mortality rates for additional races suppressed due to insufficient sample size Illinois Department of Public Health, 2015 Between 2005 and 2015, the national infant mortality rate decreased by 14% from 6.86 to 5.90 deaths per 1,000 live births (National Center for Health Statistics, 2017). However, as with maternal health, racial and ethnic disparities persist. • In Illinois, the infant mortality rate per 1,000 live births was 4.4 for whites, 12.6 for African American/blacks, and 5.5 for Hispanic/Latinxs. • In Chicago, infant mortality rates per 1,000 live births ranged from 3.4 for whites to 12.7 for African American/blacks (Figure 22). • In Suburban Cook County, infant mortality rates per 1,000 live births ranged from 4.3 for Asians to 12.7 for African American/blacks (Figure 23). Alliance for Health Equity53

Figure 29. Infant mortality rates per 1,000 live births in Chicago by race and ethnicity*

*The infant mortality rate for Asians is suppressed in Chicago due to insufficient population size Illinois Department of Public Health, Division of Vital Records, 2012-2016 Figure 30. Infant mortality rates per 1,000 live births in Suburban Cook County by race and ethnicity

Illinois Department of Public Health, Division of Vital Records, 2012-2016 Similar to infant mortality, there are racial and ethnic differences in low birth weight infants, preterm births, and teen birth rates (Figures 31-32).

Alliance for Health Equityď ź54

Figure 31. Select maternal and child health indicators for Chicago by race and ethnicity Percent of low birth Percent of preterm weight infants births African American/black 15% 15% Asian 8% 9% Hispanic/Latinx 8% 9% White 6% 9% Illinois Department of Public Health, Vital Statistics, 2012-2016

Teen Birth Rate (per 1,000 population) 32.0 3.2 28.4 5.1

Figure 32. Select maternal and child health indicators for Suburban Cook County by race and ethnicity Percent of low birth Percent of preterm weight infants births African American/black 10% 14% Asian 7% 9% Hispanic/Latinx 6% 9% White 4% 9% Illinois Department of Public Health, Division of Vital Records, 2012-2016

Teen Birth Rate (per 1,000 population) 10.3 0.4 8.7 1.5

As previously mentioned, differences in maternal and child health outcomes can be linked to multiple social and structural determinants of health. For example: •

children born to mothers without a high school education are twice as likely to die before their first birthday than children born to mothers who are college graduates;

•

access to quality preconception, prenatal, and postnatal health care can greatly improve maternal and child health outcomes;

•

maternal poverty has been linked to greater risks for preterm birth, intrauterine growth restriction, neonatal death, and infant death; and

•

maternal poverty has consistently been found to be a significant determinant of delayed cognitive development and poor school performance in children (Kay Johnson et al., 2006; C. P. Larson, 2007; Robert Wood Johnson Foundation, 2009).

Inequities in Education Rates of self-reported poor health, infant mortality, and chronic disease are often higher among individuals with lower levels of educational attainment. A 2011 study found that a history of segregation in the United States has not only led to continued racial and ethnic segregation of schools, but that whites and Asians are disproportionately represented in higher-performing schools (Logan, 2011). The same report found that disparities in school performance are likely due to racial and ethnic disparities in poverty and not the racial composition of schools (Logan, 2011). A study completed by Stanford University in 2016 found additional trends in school performance related to socioeconomic inequities: •

the most and least socioeconomically advantaged school districts nationwide have average performance levels more than four grade levels apart;

•

average test scores of black students are roughly two grade levels lower than those of white students in the same district—the Hispanic-white difference is roughly 1.5 grade levels;

Alliance for Health Equity55

•

achievement gaps are larger in districts where black and Hispanic students attend higher poverty schools than their white peers and where large racial/ethnic gaps exist in parents’ educational attainment; and

•

the size of education gaps have little or no association with average class size, a district’s per capita student spending, or charter school enrollment (Rabinovitz, 2016).

As previously mentioned, a study of segregation in the Chicago metro area projected that the region is losing $90 billion in total lifetime earnings as a result of its education gaps (Metropolitan Planning Council, 2017).

Inequities in Community Safety and Violence Although violence occurs in all communities, it is concentrated in low-income communities of color. The root causes of community violence are multifaceted but include issues such as the concentration of poverty, education inequities, poor access to health services, mass incarceration, differential policing strategies, and generational trauma. Research has established that exposure to violence has significant impacts on physical and mental well-being. In addition, exposure to violence in childhood has been linked to trauma, toxic stress, and an increased risk of poor health outcomes across the lifespan. Not only does exposure to violence directly impact health, but it has socioeconomic effects that can further widen health disparities. For example: •

violence has been associated with less investment in community resources such as parks, recreation facilities, and parks that promote healthy activity (Prevention Institute, 2011a);

•

food resources such as supermarkets are more reluctant to enter communities of color with higher rates of violence further reducing access to healthy foods (Odoms-Young, Zenk, & Mason, 2009; Zenk et al., 2005);

•

gun violence can significantly decrease the growth of new retail and service businesses, decrease the number of new jobs available, and slow home value appreciation (Irvin-Erickson, Lynch, Gurvis, Mohr, & Bai, 2017); and

•

high rates of gun violence are associated with lower home values, credit scores, and home ownership rates (Irvin-Erickson et al., 2017).

The Relationship Between Inequities, Trauma, and Toxic Stress Inequities are particularly injurious to the communities that experience them not only because they limit access to services and other resources, but also because the experiences of marginalization and discrimination are traumatic. Research has established that traumatic experiences can cause stress that is toxic to the body and can result in dysregulation, inflammation, and disease. The effects of trauma and toxic stress are detrimental throughout the lifespan but can be particularly deleterious when exposure begins in childhood. As a result, exposure to trauma and the resulting toxic stress contribute to widening health disparities. Supporting and partnering with communities that have experienced trauma to build resiliency is an important step in reducing health inequities, however, it is critical to address the underlying root causes of traumatizing inequities with a focus on future prevention.

Inequities in Additional Priority Populations As previously discussed, the unequal distribution of resources in communities leads to an inequitable burden of disease within certain communities. Differences in the social determinants of health are both underlying root Alliance for Health Equity56

causes and outcomes of inequities in morbidity and mortality. There are numerous examples of how different sub-populations are impacted by inequities. • The prevalence of adult diabetes is higher among non-Hispanic blacks, Hispanic/Latinx, and those of mixed races than among Asians and non-Hispanic whites (Centers for Disease Control and Prevention, 2013). In Chicago and Suburban Cook County, diabetes mortality rates are highest among African American/blacks at 84.7 and 74.9 per 100,000 total population, respectively. •

Research indicates that issues such as poverty, limited access to health care, exposure to violence, chronic stress, overcrowded housing, deteriorating infrastructure, poor housing conditions, and higher rates of air pollution all contribute to the increased burden of asthma morbidity and mortality in lowincome communities of color (Williams, Sternthal, & Wright, 2009a).

•

Individuals with disabilities are more likely to report being in fair or poor health, to use tobacco, to forgo physical activity, and to be overweight or obese (Lezzoni, 2011).

•

Nationwide, suicide rates are highest among American Indian/Alaskan Natives and non-Hispanic whites for both men and women (Centers for Disease Control and Prevention, 2013). Suicide mortality rates for men and women are highest among non-Hispanic whites in Chicago and Suburban Cook County. The rates for American/Indians and Alaskan Natives in Chicago and Suburban Cook County are unknown due to sample size.

•

Discrimination against LGBTQ+ individuals has been associated with higher rates of psychiatric disorders, substance abuse, and suicide (U.S. Department of Health and Human Services, 2019a).

•

Nearly three-quarters of LGBTQ+ students are verbally bullied and 36% are physically bullied because of their sexual orientation (Gay, Lesbian, and Straight Education Network, 2013). Fifty-five percent of LGBTQ+ students are verbally bullied and 23% are physically bullied because of their gender expression (Gay, Lesbian, and Straight Education Network, 2013). Bullying increases a student’s risk for emotional distress, self-harm, depression, anxiety, sleep difficulties, and death (Ladd, Ettekal, & Kochenderfer-Ladd, 2017; National Center for Education Statistics, 2016).

•

Seventeen percent of immigrants and 39% of undocumented immigrants are uninsured, compared to less than 10% of U.S. born and naturalized citizens (Kaiser Family Foundation, 2017).

Alliance for Health Equity57

Community Input

Discussions about inequities occurred in focus groups across the county. Participants highlighted inequities in social and structural determinants of health, access to health care, and health care quality in particular. Communities of color, older adults, children, LGBTQ+, immigrants, individuals living with disabilities, and individuals living with mental illness or a substance use disorder were described as sharing the greatest burden of these inequities. “It feels like this structural racism is impacting everything. I mean whether we’re talking about the meetings we can attend, whether we’re talking about the properties we can buy because of redlining, whether we’re talking about being able to afford insurance. It really permeates everything from economics to education to even the way that we think.” (Garfield Park Community Council Learning Map Session) “I moved from the South side and predominately black communities. There’s a lack of affordable decent housing, lack of nutritious food—everywhere except the North Side.” (NAMI Chicago – Individuals) “On the West Side there isn’t much funding to create better opportunities like schools and jobs.” (Breakthrough) [Referring to Harvey, Illinois] “They forgot about this place. There are broken down houses, burned houses, abandoned houses, ugly streets, litter, littered parks.” (Restoration Ministries Youth) “Engage youth, start with the education system. As black children, we have poor education.” (After School Matters Learning Map Session). “Soon we will be adults in this community, so they need to give us the education, teachers, and better schools we need because that will advocate for a better Harvey in the future.” (Restoration Ministries) “Health care is not looking to provide services to the LGBTQ community in a way that they are providing services to well-to-do cis-gendered heterosexual whites” (Affinity Community Services) “With my grandma, she tried to go to the hospital, and she didn't have papers, so they didn't help her out like they were supposed to. She didn't get medicine or treatment, they just gave her pills to calm the pain down.” (Restoration Ministries) “How would they handle a sighted person in the ER? Would they just dismiss them?” (Friedman Place) “It took me years to go to a medical professional that would look past my mental illness diagnosis.” (NAMI Chicago - Individuals)

Implications

Given the wide-reaching effects that health inequities are having on the well-being of communities in Chicago and Suburban Cook County, the Alliance for Health Equity has made preventing and reducing health disparities its primary focus since its inception. As a result, this assessment focused on identifying, naming, and building strategies to address the underlying root causes of inequities such as racism, discrimination, trauma, and the unjust distribution of resources.

Alliance for Health Equity58

In 2017, 86.1 percent of people in households with an annual income of less than $25,000 had health insurance coverage, compared with 92.1 percent of people in households with income of $75,000 to $99,999, and 95.7 percent of people in households with income of $125,000 or more (Berchick, Hood, & Barnett, 2018).

•

Research indicates that communities with better access to healthy foods and limited access to convenience stores have healthier diets and lower rates of obesity (Larson, Story, & Nelson, 2009). Low-income communities of color are less likely to have access to supermarkets and healthy foods, and tend to have a higher density of fast-food restaurants and other sources of unhealthy food such as convenience stores (Larson et al., 2009).

•

There tends to be a higher density of tobacco retailers in low-income communities and smoking rates are higher among people living in poverty (Centers for Disease Control and Prevention, 2018; Yu, Peterson, Sheffer, Reid, & Schneider, 2010).

•

Low-income communities of color tend to have fewer recreational resources such as park space and recreational programs (Dahmann, Wolch, Joassart-Marcelli, Reynolds, & Jerrett, 2010). Lower access to parks and recreational programs has been linked to lower physical activity and higher body mass indexes (BMIs) among children (Wolch et al., 2011).

•

Environmental risk factors are higher in low-income communities. Low-income communities are more likely to have higher rates of violence, higher rates of discrimination, under-resourced schools, higher rates of unemployment, higher rates of incarceration, and greater material deprivation such as a lack of housing, heat, water, and electricity (Khullar & Chokshi, 2018). These issues are chronic stressors that are linked to higher rates of chronic disease throughout the lifespan (Khullar & Chokshi, 2018).

•

Child development can be affected by the experience of poverty. Children can have increased chronic stress, food insecurity, and more frequent infectious diseases (Jensen & Nelson, n.d.).

•

In Illinois, white and African American residents in the lowest income group had the highest prevalence of reporting four or more adverse childhood experiences (Health & Medicine Policy Research Group, 2013).

Alliance for Health Equity59

Assessment data highlights many of the economic inequities in Chicago and Suburban Cook County. Overall, the percentage of individuals living in poverty in Chicago and Suburban Cook County (16%) is higher than the state (14%) and national averages (15%). However, people of color experience higher rates of poverty than non-Hispanic whites (Figure 33). African Americans experience the highest rate with nearly a third of the population living in poverty. In addition, African Americans and Hispanic/Latinxs have the lowest median household incomes. There are inequities in the geographic distribution of poverty as well. Communities with the highest poverty rates are primarily concentrated in the West and South regions of the city and county (Figure 34). These geographic inequities can be directly linked to long-standing historical discrimination and segregation across Cook County. Figure 33. Percentage of people living in poverty by race and ethnicity in Chicago and Suburban Cook County People of color experience higher rates of poverty than non-Hispanic whites in Chicago and Suburban Cook County.

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equityď ź60

Figure 34. Geographic distribution of households living at or below the 100% Federal Poverty Level in Cook County, Illinois (2016, ACS 5-Year Estimates)

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equityď ź61

Poverty trends are even more pronounced among children under age 18. Twenty-three percent of the children in Cook County are living in poverty. Children of color have much higher rates of poverty than their white counterparts. In Chicago, more than four out of ten African American children and nearly three out of ten Hispanic/Latinx children live in poverty, compared to less than one in ten white children (Figure 36). Another important indicator that demonstrates the differences in socioeconomic conditions for children across communities is the Child Opportunity Index (Figure 37). The Childhood Opportunity Index is based on several indicators in each of the following categories: demographics and diversity; early childhood education; residential and school segregation; maternal and child health; neighborhood characteristics of children; and child poverty. Children that live in areas of low opportunity have an increased risk for a variety of negative health indicators such as premature mortality, are more likely to be exposed to serious psychological distress, and are more likely to have poor school performance (Ferguson, Bovaird, & Mueller, 2007). Figure 35. Percentage of older adults living in poverty by race and ethnicity in Chicago and Suburban Cook County

U.S. Census Bureau, American Community Survey, 2012-2016 Figure 36. Percentage of children living in poverty by race and ethnicity in Chicago and Suburban Cook County Children of color experience higher rates of poverty than non-Hispanic white children in Chicago and Suburban Cook County.

U.S. Census Bureau, American Community Survey, 2012-2016 Alliance for Health Equityď ź62

Figure 37. Child Opportunity Index for Cook County, Illinois (2007-2013)

Very High Opportunity High Opportunity Moderate Opportunity Low Opportunity Very Low Opportunity

Sources: U.S. Census Bureau: Decennial Census 2010, American Community Survey 2007-2011, Zip Business

Patterns 2009; State Department of Education 2010-2011; National Center for Education Statistics, Common Core of Data 2010-2011; diversitydatakids.org Early Childhood Database (State Early Childhood Care and Education Licensing Database 2012 and 2013, National Center for Education Statistics, Common Core of Data 2009-2010, National Association for the Education of Young Children Accredited Program Database, 2012 and 2013); ESRI Business Analyst 2011; Department of Housing and Urban Development, Neighborhood Stabilization Program 2010; Environmental Protection Agency, Toxic Release Inventory Program 2010

Retrieved From: http://www.diversitydatakids.org/data/childopportunitymap/3310/chicago-joliet-naperville

Alliance for Health Equityď ź63

Community Input Socioeconomic inequities were mentioned in several focus groups. Inequities in community economic investment and development, employment opportunities, transportation resources, quality affordable housing, education opportunities, and food access were highlighted particularly by groups held on the West and South sides of the city and county. In addition, groups held on the North side of the city and county highlighted disparities in resource distribution, with the North region having the most access to economic opportunities and community resources. Focus group participants attributed the lack of business investment and economic resources in the West and South regions to underlying factors such as long-term divestment in certain communities, the loss of locally owned businesses, limited educational resources, low levels of home ownership, and minimal job opportunities. Similarly, community input survey respondents identified areas for improvement in their communities that related to socioeconomic inequities including more job opportunities, lower housing costs, more affordable food options, and increased school funding. Community input survey respondents were asked to choose options from a multi-select question “What do you think are the three most important things necessary for a ‘Healthy Community’?” Community members prioritized several factors including access to health care and mental health services, safety and low crime, access to community services, access to healthy food, affordable housing, and good schools. (Figure 38) Figure 38. Community Input Survey: “What do you think are the three most important things necessary for a ‘Healthy Community”? (N=5717)

Alliance for Health Equity64

Unemployment and Underemployment Unemployment and underemployment can create financial instability, which influences access to health care services, insurance, healthy foods, stable quality housing, and other basic needs. Unemployment and underemployment in Chicago and Suburban Cook County are often associated with a history of disinvestment and economic segregation. In the mid to late 20th century, much of the southern and western regions of the city were thriving due to factory employment. As the factory industry started to move to lower cost locations, so did the job opportunities. The disinvestment in Chicago and Suburban Cook County created a gap in employment opportunities that still has not been closed (Henricks, Lewis, Arenas, & Lewis, 2017). Currently unemployment rates for adults over age 16 in Cook County (10%) are slightly higher than the state (8%) and national averages (7%) and have shown an overall decline since 2013. Furthermore, the economic segregation in Chicago is apparent. In 2015, Chicago was ranked one of the most economically segregated metros in the United States (Florida & Mellander, 2015). The majority of job opportunities are available in the Loop and northwest region (Great Cities Institute, 2017). If the level of economic segregation between white and African American residents decreased, Chicago’s gross domestic product would increase by $8 billion (Metropolitan Planning Council, 2017). For residents living in the South and West regions of the city getting to the available jobs can be an additional barrier. High rates of unemployment are concentrated in communities of color in the West and South regions of the city and suburbs (Figures 23-24). There are significant differences in unemployment across racial and ethnic groups. Chicago has the greatest racial disparities in young adult employment in the nation (Svajlenka, 2016). In 2016, the employment rate among African Americans aged 20-24 was 47%, the lowest in the nation, and the rate for whites in the same age group was 73%, one of the highest in the nation (Svajlenka, 2016). Low-income workers and underemployed workers face many of the same challenges as unemployed individuals. For example, while 58% of the overall population have employer-sponsored health insurance, only 35% of people in households making less than 250% of the federal poverty level have employer-sponsored health insurance (Kaiser Family Foundation, 2018b). Health insurance gaps can lead to a decrease in utilization of preventative health care services. Additionally, underemployed individuals have reported more depression, alcohol abuse, and poorer physical health (America’s Health Rankings, n.d.) Community Input A lack of employment opportunities was one of the most frequently discussed issues among focus group participants. Again, participants living in the West and South regions of the county described having the least number of quality job opportunities and employment resources. However, certain populations such as those living with mental illness, young adults, homeless individuals, and formerly-incarcerated individuals were highlighted as having significant barriers to employment regardless of their geographic location. Within certain communities, jobs are available, but they are described as part-time, temporary, and/or low-paying. Additionally, 18% of community input survey respondents chose “quality job opportunities” as one of the most important factors in a healthy community. Furthermore, survey respondents frequently identified job opportunities as an area for improvement in their community.

Alliance for Health Equity65

Figure 39. Racial and ethnic disparities in unemployment among individuals aged 16 or older in Chicago and Suburban Cook County African American/black residents in both Chicago and Suburban Cook County are more than twice as likely to be unemployed compared to all other racial/ethnic groups.

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equityď ź66

Figure 40. Geographic distribution of unemployment among individuals aged 16 or older in Cook County, Illinois (2016, ACS 5-Year Estimates)

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equityď ź67

U.S. Census Bureau, American Community Survey, 2012-2016

A 2011 study found that a history of segregation in the United States has not only led to continued racial and ethnic segregation of schools, but that whites and Asians are disproportionately represented in higherperforming schools (Logan, 2011). The same report found that disparities in school performance are likely due to racial and ethnic disparities in poverty and not the racial composition of schools (Logan, 2011). Although overall high school graduation rates in Cook County (85%) are comparable to state (88%) and national rates (84%), there are profound differences between racial and ethnic groups. In Chicago and Suburban Cook County, non-Hispanic whites and Asians have the highest rates of high school graduation and the highest rates of educational attainment overall (Figures 42-43). In addition to elementary, secondary, and post-secondary inequities there are disparities in early childhood education and school readiness as well. Socioeconomic status of parents is the biggest driver of schoolreadiness, access to quality childcare, and access to early childhood education resources (Garcia & Weiss, 2015). As a result of the socioeconomic inequities associated with race and ethnicity, children of color often lag behind their white peers when starting kindergarten and these delays can impact school success throughout the lifespan (Garcia & Weiss, 2015).

Alliance for Health Equityď ź68

Figure 42. Differences in educational attainment among adults 25 and older in Chicago and Suburban Cook County Hispanic/Latinx adults over 25 are least likely to have a high school education.

U.S. Census Bureau, American Community Survey, 2012-2016 Figure 43. Racial and ethnic differences in post-secondary education attainment in Chicago and Suburban Cook County

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equityď ź69

Community Input At least 19 different focus groups discussed education inequities in Cook County. The major educationrelated concerns expressed by focus groups included: • school closures and diminishing education opportunities on the West and South Sides of Chicago; • poor quality schools particularly on the South Side of Chicago and in the South Suburbs; • limited or nonexistent resources for learning trades; • a lack of support programs such as quality, low-cost tutoring; and • limited adult education programs. Participants linked education inequities to issues such as higher rates of community violence, increases in health issues such as substance use disorders and mental illness, and generational poverty. Reinvestment in community schools was nearly a universal recommendation from groups that discussed education issues. Community input survey respondents referred to educational opportunities in their community throughout the survey. Approximately one-fifth of respondents reported that good schools were key factors for a healthy community. While some respondents cited education as one of the greatest strengths in the community, other respondents chose education as an area for growth showing the inequities of education throughout Cook County. In addition to poverty, there are other factors that can significantly influence levels of educational attainment and student success such as bullying. More information and data about bullying is included in the Community Safety and Violence section.

Food Access and Food Insecurity Food security is a household-level social and economic condition of limited or uncertain access to adequate food (U.S. Department of Agriculture, 2018). Food insecurity can impact health in several ways: • the combination of stress and poor nutrition can make individuals more susceptible to developing chronic diseases and make management of chronic diseases more difficult; • worsening health problems and the associated medical care puts additional strain on household budgets and leaves less money for essential nutrition and other basic needs; • chronic disease can lead to decreased employability and lower overall household income (Weinfield et al., 2014). Many communities in Chicago and Suburban Cook County are at risk for food insecurity (Figure 44). Community Input Focus group participants across the city and county reported difficulty accessing healthy foods. Participants on the West and South Sides of the city and county reported a high proportion of fast-food restaurants and limited access to grocery stores selling healthier options. Low-income participants on the North Sides of the city and county reported that there were several grocery stores available but that they often could not afford to shop at them. Community residents living with chronic illnesses such as diabetes reported that difficulty accessing healthy foods and a high prevalence of fast-food options made it more difficult for them to manage their conditions. Approximately 29% of community input survey respondents chose “access to healthy food” as one of the most important factors in their community. Respondents expanded upon food accessibility in their responses to the question related to areas for improvement in the community. Frequently, respondents mentioned a need for a grocery store in their community and increased access to healthy, affordable foods.

Alliance for Health Equity70

Figure 44. Greater Chicago Food Depository Network and Program Locations and Risk of Food Insecurity in Cook County, Illinois

Alliance for Health Equityď ź71

Related to food insecurity, access to healthy foods is another important factor needed to support chronic disease prevention. Research indicates that communities with better access to healthy foods and limited access to convenience stores have healthier diets and lower rates of obesity (N. Larson et al., 2009). Lowincome communities of color are less likely to have access to supermarkets and healthy foods and tend to have a higher density of fast-food restaurants and other sources of unhealthy food such as convenience stores leading to food deserts where it is difficult to buy affordable or good-quality food (Figure 45) (N. Larson et al., 2009). Figure 45. Low food access in Cook County, 2015

Low food access areas

US Department of Agriculture, Economic Research Service, USDA - Food Access Research Atlas: 2015 Map Source: CARES Engagement Network

Alliance for Health Equityď ź72

Programs such as the Supplemental Nutrition Assistance Program (SNAP), local food pantries, summer meal programs, after school programs, shelters, and food banks provide important assistance to low-income individuals and families that struggle to access adequate nutrition (Figure 46). In addition, farmers’ markets that accept SNAP benefits have the potential to improve access to healthy fruits and vegetables within lowincome communities with high rates of food insecurity (Figure 47). Figure 46. Geographic distribution of households receiving SNAP benefits in Cook County, Illinois (2016, ACS 5-Year Estimates)

0 – 5.5%

5.6 – 9.9% 10.0 – 15.7% 15.8 – 25.9% 26.0 – 61.9% Chicago Border Forest Preserve

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equity73

Figure 47. Farmers’ Markets Accepting SNAP, 2017

US Department of Agriculture, USDA - Agriculture Marketing Service: 2017 Map Source: CARES Engagement Network

Alliance for Health Equity74

Summer meal programs also play an important role in food access for low-income children and their families during the summer months when schools are closed and access to free or reduced-price meal programs is decreased (Feeding America, 2018). In Cook County, summer meal sites are widespread, but are most concentrated in Chicago within communities that have high rates of child poverty (Figure 48). Figure 48. Summer meal sites and child poverty rates in Cook County, Illinois

Alliance for Health Equityď ź75

As previously mentioned, research indicates that communities with better access to healthy foods and limited access to convenience stores have healthier diets and lower rates of obesity (N. Larson et al., 2009). Urban agricultural and community gardens provide a cost-effective opportunity to improve access to healthy foods for farmers and their communities. Urban agriculture and community garden sites have proliferated in Cook County over the last several years (Figure 49). However, the highest concentration of sites occurs within the city of Chicago indicating an opportunity to expand these resources further into Suburban Cook County. Figure 49. Urban Agriculture and Community Garden Sites

Chicago Urban Agriculture Mapping Project, 2019

Alliance for Health Equityď ź76

(Taylor, 2018)

Stability and Affordability Homelessness and housing instability can have profound effects on health throughout the lifespan. Individuals who are homeless are more likely to become ill, have greater hospitalization rates, and have an increased burden of premature mortality (Maness & Khan, 2014). Caregivers of children aged 0 to 2 years old who have experienced unstable housing or homelessness are more likely to report fair or poor health, maternal depressive symptoms, and household material hardships (Sandel et al., 2018). In addition, their children have higher rates of lifetime hospitalizations and fair or poor child health (Sandel et al., 2018). Housing instability is associated with multiple health problems among youth and young adults including increased risk of teenpregnancy, early drug use, and depression (Robert Wood Johnson Foundation, 2011). Experiencing foreclosure is associated with negative behavioral health outcomes such as depression, anxiety, increased alcohol use, psychological distress, and suicide (Tsai, 2015). Unstable housing can decrease the effectiveness of health care by making the proper storage of medications difficult or impossible (Maqbool, Viveiros, & Ault, 2015). Providing individuals and families with stable housing can improve health and reduce health care costs (Taylor, 2018). In Oregon, the provision of affordable housing to housing unstable residents reduced Medicaid expenditures by 12%, use of primary care increased by 20%, and emergency department use decreased by 18% within the housed population (Center for Outcomes Research and Education, 2016). Programs aimed at stabilizing housing such as HUD assistance programs have been shown to decrease uninsured rates and lower rates of unmet medical needs due to cost (Simon, Fenelon, Helms, Lloyd, & Rossen, 2017). In addition, receipt of foreclosure assistance has been linked with improved physical and mental health outcomes (Tsai, 2015). Alliance for Health Equity77

Quality and Safety Environmental factors within homes are correlated with several poor health outcomes (Robert Wood Johnson Foundation, 2011). Lead exposure can lead to permanent brain and nervous system damage in children (World Health Organization, 2018b). Housing issues such as water leaks, poor ventilation, carpeting, and pest infestations have been associated with poor health outcomes such as allergies and asthma (Robert Wood Johnson Foundation, 2011). Insufficient heating and cooling is associated with higher blood pressure and increased risk of cardiovascular events particularly among older adults (Saeki, Obayashi, & Kurumatani, 2015). Within Cook County, it is estimated that 39 percent of housing units have one or more substandard conditions (U.S. Census Bureau, American Community Survey, 2017a). Crowded housing has been found to have negative impacts on a childâ&#x20AC;&#x2122;s school achievement, behavior, and physical health (Solari & Mare, 2012). Throughout Chicago and Suburban Cook County, there are several communities in which 5% or more of households are considered overcrowded (Figure 51). Figure 51. Geographic distribution of crowded housing in Cook County, Illinois (2016, ACS 5-Year Estimates)

U.S. Census Bureau, American Community Survey, 2012-2016 Alliance for Health Equityď ź78

Community-based programs and policy interventions have been shown to be extremely effective in improving health through improvements in the quality and safety of housing. Community-based interventions that remove potential asthma triggers from households have created improvements in quality of life, reduced emergency department visits, reduced hospitalizations, and reduced health care costs for both children and adults (Bhaumik et al., 2013; “Green and Healthy Homes Initiative,” n.d.). A 2006 study found that children of families in an energy assistance program had healthier weight and were at less nutritional risk compared to those not enrolled in the program (Frank et al., 2006). Another community-based program in which occupational therapists assisted with home modifications reduced falls among older adults by 39 percent (Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008). In a 2012 study, severely asthmatic adults that received legal assistance forcing their landlords to improve environmental conditions experienced reduced emergency department visits, reductions in the need for steroid treatment, reductions in the dose and/or number of medications needed, and an overall reduction in the severity rating of their asthma (O’Sullivan et al., 2012). Smoking bans in public and affordable housing have led to reductions in the number of smokers, reductions in the number of cigarettes smoked per smoker, and reductions in secondhand smoke exposure among nonsmokers (Kingsbury & Reckinger, 2016).

Affordability A lack of affordable housing can significantly impact an individual or family’s ability to access food, health care, community services, and other basic needs. Low-income families that have difficulty paying their rent, mortgage, or utility bills are less likely to have a primary care provider and are more likely to delay needed medical treatment (Robert Wood Johnson Foundation, 2011). In addition, severely cost-burdened renters and homeowners who are behind in their mortgage payments are more likely to be food insecure and go without prescribed medications (Alley et al., 2011; Joint Center for Housing Studies of Harvard University, 2017). In contrast, a 2010 study found that individuals and families that had affordable rent payments as a result of low income housing credits increased their discretionary income by 77%, which put them in a position to buy health insurance, pay down debt, or amass savings to pay for education or to buy a home (Walker, 2010). Within Cook County, there were approximately 493 assisted housing properties in 2016 that were primarily concentrated within the City of Chicago (U.S. Department of Housing and Development, 2016). A household is considered cost-burdened when 35% or more of its monthly gross income is dedicated to housing. Severely cost-burdened households have 50% or more their monthly gross income dedicated to housing. Within Cook County there are several regions where more than 40% of households are considered cost-burdened (Figure 52). These regions are primarily concentrated in the far Northwest, West, and South sides of the city and county.

Neighborhoods There has been extensive research on the impacts that physical surroundings have on health. Access to public transportation, proximity to grocery stores with healthy foods, and safe spaces to exercise have all been correlated with reduced chronic disease and improved health outcomes (Bell et al., 2013; Djurhuus et al., 2014; Ou et al., 2016). A Safe Routes to School Program that improved the number of sidewalks, bicycle lanes, and safe crossings increased the rate of bicycling and walking among school-aged children (DiMaggio, Brady, & Li, 2015). Remediated abandoned buildings and vacant lots have been associated with significantly decreased heart rates among those that walk past and significantly reduced firearm violence in the community (South, Kondo, Cheney, & Branas, 2015). In addition to physical characteristics, social characteristics of neighborhoods including segregation, crime, and social capital can have tremendous impacts on health (Taylor, 2018). As mentioned in the health inequities section, structural issues such as neighborhood segregation have been associated with a number of adverse health outcomes and has been shown to widen health disparities by determining access to resources such as quality schools, jobs, and health care.

Alliance for Health Equity79

Community Input Major themes that rose to the top of focus group discussions related to housing included: • segregation prevents communities from having diverse economics, racial/ethnic groups, and resources; • gentrification pushes low-income families out of communities; • safe, quality housing is often not affordable and affordable housing is often not safe or good quality; • older adults are still struggling to recover from the housing crisis; and • oversight of landlords and homeowners is lacking in many communities.

Figure 52. Geographic distribution of cost burdened households in Cook County, Illinois (2016, ACS 5Year Estimates) U.S. Census Bureau, American Community Survey, 2012-2016

Environmental Health Ensuring environmental health requires a focus on the prevention of illness and injury and the promotion of well-being by identifying and evaluating hazardous agents and limiting exposures to hazardous physical, chemical, and biological agents in air, water, soil, food, and other environmental media or settings that may adversely affect human health (National Environmental Health Association, 2013). As with other social determinants of health, safe, hazard free environments are not equally distributed throughout Cook County. The West and South regions of the city and suburbs have the highest burden of vulnerabilities to Alliance for Health Equity80

environmental pollution (Geertsma, 2018). There are city and suburban communities located adjacent to Oâ&#x20AC;&#x2122;Hare airport that have a high burden of vulnerability to environmental pollution as well (Geertsma, 2018).

Outdoor air pollution â&#x20AC;&#x201C; particulate matter Particulate matter is a proxy indicator for air pollution and it affects more people than any other pollutant (World Health Organization, 2018a). The major components of particulate matter pollution are sulfate, nitrates, ammonia, sodium chloride, black carbon, mineral dust, and water (World Health Organization, 2018a). The smallest particles measure 2.5 microns (PM2.5) or less and are the most damaging to health (World Health Organization, 2018a). These particles can penetrate and lodge deeply in the lungs and can penetrate the lung barrier to enter the blood system (World Health Organization, 2018a). There is a dose-response relationship between exposure to PM2.5 and premature mortality due to cardiovascular disease, respiratory disease, and cancers (World Health Organization, 2018a). Figure 53 highlights the communities with the highest risk of exposure to PM2.5 in Cook County. Risk of exposure is based on national percentiles. The areas of high exposure are concentrated in primarily non-white, low income communities. As shown in Figures 74 and 8283, many of these same communities have a disproportionate burden of chronic disease mortality and asthma morbidity.

Hazardous waste proximity Hazardous waste is a waste with properties that make it dangerous or capable of having a harmful effect on human health or the environment (U.S. Environmental Protection Agency, 2015). A review of previous research found that there is evidence of a causal relationship between residential proximity to hazardous w aste sites and negative health outcomes including liver, bladder, breast and testis cancers; non-Hodgkin lymphoma; asthma; congenital anomalies overall and anomalies of the neural tube, urogenital, connective and musculoskeletal systems; low birth weight; and pre-term birth (Fazzo et al., 2017). Figure 54 demonstrates that like PM2.5, the risk of proximity to hazardous waste sites is not equally distributed across the city and county.

The importance of environmental health Inequities in environmental health extend beyond risk of exposure to particulate matter and proximity to hazardous waste. For example, a study conducted in Chicago found that non-whites and low-income residents were more likely to live in zones near toxic release sites (Wang & Feliberty, 2010). Proximity to sites where releases of toxic substances have been reported has been linked to a higher risk of health conditions such as lymphoma (Bulka et al., 2016). In addition, people living within poor housing infrastructure or experiencing housing instability are more likely to have environmental diseases and injuries (Jacobs, 2011). Data clearly indicate that addressing environmental health inequities and environmental injustices such as these are an important component to improving health equity. And, health stakeholders also have an important role to play in adapting and responding to climate change through emergency response, sustainability initiatives, and partnering to ensure our local communities have the resources needed for climate resilience.

Alliance for Health Equityď ź81

Figure 53. Environmental Justice Index PM2.5, Cook County, Illinois (2014)

EJ Index PM2.5 National Percentiles

U.S. Environmental Protection Agency, Office of Air and Radiation, 2014 Map Source: EJ Screen: EPA's Environmental Justice Screening and Mapping Tool (Version 2018)

Alliance for Health Equityď ź82

Figure 54. Environmental Justice Index Hazardous Waste Proximity, Cook County, Illinois (2014)

EJ Index Hazardous Waste Proximity National Percentiles

U.S. Environmental Protection Agency, RCRAInfo database, (2018) U.S. Environmental Protection Agency, LQG data calculated from the Biennial Hazardous Waste Report, 2017 Map Source: EJ Screen: EPA's Environmental Justice Screening and Mapping Tool (Version 2018)

Alliance for Health Equityď ź83

Community Safety and Violence As previously mentioned, although violence occurs in all communities, it is concentrated in low-income communities of color. The root causes of community violence are multifaceted but include issues such as the concentration of poverty, education inequities, poor access to health services, mass incarceration, differential policing strategies, and generational trauma. Research has established that exposure to violence has significant impacts on physical and mental well-being. In addition, exposure to violence in childhood has been linked to trauma, toxic stress, and an increased risk of poor health outcomes across the lifespan. Violence also has a negative impact on the socioeconomic conditions within communities that contribute to the widening of disparities. Research has long established that exposure to interpersonal and/or community violence is strongly linked to the development of mental illness, Post Traumatic Stress Disorder (PTSD), and substance use disorders. The following examples demonstrate the impact that exposure to violence can have on the behavioral health of children, youth, and adults: • Youth that are exposed to interpersonal violence have a significantly higher risk for PTSD, major depression, and substance use disorders (Kilpatrick et al., 2003). • Women who experience intimate partner violence are three times more likely to have symptoms of depression, four times more likely to have PTSD, and six times more likely to have suicidal ideation (Houry, Kemball, Rhodes, & Kaslow, 2006; Prevention Institute, 2011b). • Thirty-five percent of urban youth exposed to community violence develop PTSD compared to 20% of soldiers deployed to combat areas in the last six years (U.S. Department of Veterans Affairs, 2019). • Teens who witness a stabbing are three times more likely to attempt suicide (Pastore, Fisher, & Friedman, 1996). • Teens who witness a shooting are twice as likely to abuse alcohol (Pastore et al., 1996). Numerous studies have shown that violence not only affects behavioral health but physical health as well. In addition to the physical scars, acute injuries, and disabilities that often result from surviving a violent incident, exposure to violence increases an individual’s risk for developing chronic diseases, increased hospitalizations and emergency department visits, and negative health behaviors. Examples include: • Adults with asthma who are exposed to community violence have increased rates of hospitalizations and emergency department visits for asthma (Apter et al., 2010). • Children of mothers experiencing chronic intimate partner violence have twice the risk of developing asthma than children who are not exposed (Suglia, Enlow, Kullowatz, & Wright, 2009). • Increased exposure to violence is linked to a higher number of days of significant asthma symptoms in children; the greater the exposure, the greater the number of symptomatic days (Wright et al., 2004). • Adults who are exposed to violence as children have an increased likelihood of developing several different chronic health conditions such as ischemic heart disease, cancer, stroke, chronic obstructive lung disease, diabetes, and hepatitis (Carver, Timperio, & Crawford, 2008; Felitti et al., 1998). • Adults exposed to intimate partner violence have an increased risk of developing chronic disease compared to those not exposed (Coker, Smith, Bethea, King, & McKeown, 2000; Shonkoff, Boyce, & McEwen, 2009). • Individuals who have been exposed to interpersonal or community violence have a greater chance of developing negative health behaviors such as smoking, eating disorders, substance abuse, decreased physical activity, and poor sleep habits (Carver et al., 2008; Centers for Disease Control and Prevention (CDC), 2008; Coker et al., 2000; McNutt, Carlson, Persaud, & Postmus, 2002; Plichta, 2004; Prevention Institute, 2011a; Salzinger, Feldman, Stockhammer, & Hood, 2002). • Children of women who experience intimate partner violence are more likely to be obese than other children and the effect is higher for families living in unsafe neighborhoods (Kendall-Tackett & Marshall, 1999). • Women who perceive their neighborhoods to be unsafe are 25% more likely to be obese (BoyntonJarrett, Fargnoli, Suglia, Zuckerman, & Wright, 2010). • Parents who perceive their neighborhood as unsafe are four times more likely to have overweight children than parents who perceive their neighborhood as safe (Burdette, Wadden, & Whitaker, 2006). Alliance for Health Equity84

•

People who described their neighborhood as unsafe are nearly three times more likely to be physically inactive than people who describe their neighborhood as extremely safe (Johnson et al., 2009).

Violence has profound direct and indirect impacts on health in communities, and violence can have broader socioeconomic effects that further impact the health of communities. Violence in communities has been associated with reduced investment in community resources such as parks, recreation facilities, and programs that promote healthy activity (Prevention Institute, 2011a). Food resources such as supermarkets are more reluctant to enter communities of color with higher rates of violence further reducing access to healthy foods (Odoms-Young et al., 2009; Zenk et al., 2005). Gun violence can significantly decrease the growth of new retail and service businesses, decrease the number of new jobs available, and slow home value appreciation (IrvinErickson et al., 2017). In addition, high rates of gun violence are associated with lower home values, credit scores, and home ownership rates (Irvin-Erickson et al., 2017). Community Input At least twenty focus groups discussed the importance of safety in creating healthy communities and the detrimental effects that violence can have on individuals and the community overall. The mostly commonly mentioned safety issues included gun violence, gang activity, drug-related activities, burglaries, and armed robberies. Gun violence was mentioned as an issue across the city and county; however, it was most often mentioned by participants living in the West and South regions. The same geographic trend occurred in discussions about gang and drug-related activity. Burglaries and armed robberies were reported by focus group participants predominately in the City of Chicago, but it was spread across the city’s North, West, and South Sides. Participants related that the prevalence of violence in their communities has led to health issues such as chronic stress, decreased mental well-being, trauma among children and adults, and decreased physical activity due to a reluctance to exercise in unsafe neighborhoods. Within community input surveys, respondents shared the importance of safety and low crime in their communities. Overall, 37% of respondents chose “safety and low crime” as one of the most important factors for a healthy community. Frequently, survey respondents recognized safety and low crime as one of the greatest strengths in the community. Safety and low crime was also the most mentioned area for improvement by respondents. Although violence occurs in all communities, it is concentrated in low-income communities of color. African American residents in both Chicago and Suburban Cook County have the highest burden of homicide and firearm-related mortality (Figure 55). The Voices of Child Health in Chicago initiative reports that Chicago parents that responded to the 2017-18 Healthy Chicago Jr. survey identified gun violence, bullying, poverty, and racism/discrimination as four of the top five social issues facing children in the city. Moreover, respondents identified child abuse and neglect as one of the top three health problems for youth. (Voices of Child Health, 2018-2019)

Alliance for Health Equity85

Figure 55. Age-adjusted rates of homicide and firearm-related mortality per 100,000 in Chicago and Suburban Cook County

IDPH, Division of Vital Records, 2016 (Chicago), 2012-2016 (Suburban Cook County) Historically, violent crime data in the Unites States has been difficult to assess due to differences in reporting standards and reliability of measurements between police jurisdictions. There is some limited ability to compare violent crime rates between community areas in Chicago (Figure 56). It is clear that there are substantial geographic differences in violent crime rates between community areas with the West and South sides of the city having the greatest burden of violent crime. These geographic comparisons are currently not possible for Suburban Cook County due to the structure of its numerous independent police jurisdictions that often do not share uniform policies for data collection and reporting. Figure 56. Community areas with the highest and lowest violent crime rates* in Chicago, 2016 Crude Rate Crude Rate Lowest (per 100,000 population) (per 100,000 population) Fuller Park 16237.8 Forest Glen 1086.0 West Garfield Park 13904.8 North Center 1292.9 East Garfield Park 13103.5 Edison Park 1340.8 North Lawndale 12714.4 Mount Greenwood 1456.0 Riverdale 12511.6 Lincoln Park 1531.6 Washington Park 12127.7 Norwood Park 1680.0 Englewood 11173.1 Clearing 1776.2 Greater Grand Crossing 10680.3 Beverly 1796.9 West Englewood 10133.8 Dunning 1845.8 Chatham 9417.3 Jefferson Park 1945.1 *Number of reported crime incidents relating to violence, including homicide, criminal sexual assault, robbery, aggravated assault, and aggravated battery per 100,000 population Highest

Chicago Police Department Research and Development Division, 2016; U.S. Census Bureau 2010 Census Alliance for Health Equityď ź86

Community areas with high rates of violent crime also rank high on the Social Vulnerability Index. The index is comprised of four measures: percent of households below the poverty level; percent of persons age 25 years or older without a high school diploma; unemployment rate for persons in the labor force age 16 or older; and the homicide rate per 100,000 residents. In addition, these communities share the greatest number of years of potential life lost from gun deaths (Chicago HEAL Initiative, 2018; University of Chicago Crime Lab, n.d.). As a result, Alliance hospitals that are participating in the Chicago HEAL Initiative have chosen to focus on violence reduction and health improvement efforts in the 16 Chicago community areas with the highest social vulnerability, highest rates of violent crime, and highest burden of gun deaths.

Bullying Bullying is a form of violence that is defined as any unwanted aggressive behavior by a youth or group of youths that involves a real or perceived power imbalance and is repeated multiple times or likely to be repeated (National Center for Injury Prevention and Control, 2018). It can be physical, verbal, social, or through technology and can inflict physical, psychological, social, or education harm on the targeted youth (National Center for Injury Prevention and Control, 2018). Bullying increases a student’s risk for emotional distress, selfharm, depression, anxiety, sleep difficulties, death, lower academic achievement, and dropping out of school (Ladd et al., 2017; National Center for Education Statistics, 2016). Bullying is common with approximately 20% of students between sixth and twelfth grade reporting that they have been bullied at some point (National Center for Education Statistics, 2016). However, some student populations report much higher rates of bullying including students with physical or intellectual disabilities, students of color, and students who identify as or are perceived as LGBTQ+ (Figure 57). Given the high prevalence of bullying and the profound effects it can have on health, educational outcomes, and educational attainment the Centers for Disease Control and Prevention recommends that evidence-based bullying prevention interventions be implemented in all schools (National Center for Injury Prevention and Control, 2018). Tailored interventions may be needed to address the high rates of bullying for certain student sub-populations. Figure 57. Estimated national rates of bullying for different student populations Population Overall student population

Estimated percentage of population that experiences bullying • 20% • 34% of students with behavioral or emotional disorders • 34% of students with autism Students with disabilities • 24% of students with intellectual disabilities • 21% of students with health impairments • 19.0% of students with specific learning disabilities • 25% of non-Hispanic African American students • 22% of non-Hispanic white students Students of color • 17% of Hispanic/Latinx students • 9% of Asian students • 74% of LGBTQ+ students are verbally bullied because of their sexual orientation • 55% of LGBTQ+ students are verbally bullied because of their gender expression LGBTQ+ students • 36% of LGBTQ+ students are physically bullied because of their sexual orientation • 23% of LGBTQ+ students are physically bullied because of their gender expression (Gay, Lesbian, and Straight Education Network, 2013; National Center for Education Statistics, 2016; National Center for Injury Prevention and Control, 2018; Rose & Espelage, 2012)

Alliance for Health Equity87

Access to Quality Health Care Access to health care is broadly defined as the “the timely use of personal health services to achieve the best health outcomes” (Institute of Medicine, 1993). Healthy People 2020 describes the three steps required for an individual to access health care services: • gaining entry into the health care system; • accessing a location where needed health care services are provided; and • finding a health care provider whom the patient trusts and can communicate with (U.S. Department of Health and Human Services, 2019b). There are several complex factors that further influence access to health care including proximity; affordability; availability, convenience, accommodation, and reliability; quality and acceptability; openness, cultural responsiveness, appropriateness and approachability.

Health care coverage Entry into the health care system is usually gained through health care coverage which includes private and public insurance benefits (U.S. Department of Health and Human Services, 2019b). Fifty-three percent of Illinois residents receive insurance coverage through employer-sponsored plans. The 2014 coverage expansions that occurred as a result of the Affordable Care Act have allowed more people in Illinois to obtain health insurance and better afford the health care they need. In 2018: • 334,979 Illinois residents had insurance coverage through a HealthCare Marketplace plan; • 82% of those covered under HealthCare Marketplace plans received financial assistance (premium tax credits) to purchase coverage; and • 2,955,463 children and adults in Illinois (18%) were enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) (The Commonwealth Fund, 2018). Within Cook County, 11% of the population does not have health insurance coverage which is greater than the statewide average of 9% (U.S. Census Bureau, American Community Survey, 2017b). However, uninsured rates can be even higher among certain population groups. For example: • in Cook County, uninsured rates are highest among the population aged 18-64 (16%) compared to children under 18 (4%) and adults over age 65 (2%); • in Cook County, uninsured rates among the Hispanic/Latinx population (20%) are more than double those of the non-Hispanic/Latinx population (8%); • in the U.S., among the non-elderly population, 23% of lawfully present immigrants and 45% of undocumented immigrants are uninsured compared to 8% of naturalized and native-born citizens; • in the U.S., among citizen children, those with at least one non-citizen parent are more likely to be uninsured compared to those with citizen parents (7% vs 4%); • one in five low-income Americans still go without care because of cost compared to 1 in 25 high-income Americans; and • many of the working poor do not qualify for Medicaid and are often employed in professions that do not offer employer benefits (Amadeo, 2019; Kaiser Family Foundation, 2019; U.S. Census Bureau, American Community Survey, 2017b; Williamson, Antonisse, Tolbert, & Garfield, 2016). The geographic distribution of uninsured individuals in Cook County is presented in Figure 58. In some communities, uninsured rates are as high as 30%. Uninsured individuals are significantly less likely to access needed health care services. Nationwide, only 38% of uninsured adults visited a doctor in 2018 compared to 70% of those privately insured, and 74% of those with Medicaid coverage (Kaiser Family Foundation, 2018a). Medicaid coverage rates for children age 0-17 are presented in Figure 59.

Alliance for Health Equity88

Figure 58. Geographic distribution of uninsured individuals in Cook County, Illinois (2016, ACS 5-Year Estimates)

U.S. Census Bureau, American Community Survey, 2012-2016

Alliance for Health Equityď ź89

Figure 59. Geographic distribution of children receiving Medicaid coverage in Cook County, Illinois (2016, ACS 5-year Estimates)

U.S. Census Bureau, American Community Survey, 2012-2016 Map source: CARES Engagement Network

Alliance for Health Equityď ź90

Community Input Focus group participants mentioned several common barriers that prevent them from accessing the health care system: • the complexity of obtaining and keeping public benefit coverage; • policy changes that have led to severe delays in the distribution of medical cards from the state; • fear within immigrant communities that obtaining benefits will impact their ability to acquire citizenship status; • the high cost of some private insurance plans; • a lack of knowledge about available insurance and benefit options; • diminishing access to services that assist individuals with obtaining coverage; • logistical issues related to making health care appointments and arranging needed transportation; • provider shortages particularly for specialists; and • structural racism and discrimination that lead to differences in the quality and availability of health care services between communities. Focus group participants stated that lacking health care coverage can lead to multiple issues that are linked to poor health outcomes including severe stress, an inability to access preventative services, worsening of health conditions due to delayed care, an increased need for emergency care, and substantial personal debt.

Proximity to health care services Previous research has established that patients living further away from health care facilities have worse health outcomes related to survival rates, length of stay in hospital, and non-attendance at follow-up visits than those who live closer (Kelly et al., 2016). Similar studies in the United Kingdom have found additional poor health outcomes related to greater distance from health care services including a higher rate of asthma deaths and lower than expected five-year survival from cancer (Campbell et al., 2000; Jones & Bentham, 1997). Additional studies have found that increased travel time to primary care facilities or physicians increased disease burden and increased the risk of some types of chronic disease related mortality (Billi et al., 2007; Saijo et al., 2018). Socioeconomic inequities play a role in geographic proximity to health care services. For example, one study found that walk-in clinics and primary care physician offices are less concentrated in geographic areas containing low-income communities (Chen, Revere, & Ramphul, 2016). A study in Texas found that African American communities had a significantly lower density of physician’s offices (Anderson, 2018). A study based in Washington D.C. found that there were racial and socioeconomic disparities in pediatric provider density despite a citywide overabundance of pediatric primary care providers (Guagliardo, Ronzio, Cheung, Chacko, & Joseph, 2004). Residential segregation of racial and ethnic minorities can both cause and exacerbate these geographic inequities in health care access (White, Haas, & Williams, 2012). The Health Resources and Services Administration designates Health Professional Shortage Areas for primary care, dental health, and mental health. Shortage areas are either due to geography (shortage of providers for the entire population within a defined geographic area) or are population specific for low-income residents in an area. Health Professional Shortage Areas for primary care and mental health in Cook County are shown in Figures 60-61. Federally Qualified Health Centers (FQHCs) have an important role in eliminating disparities in access to health care. For example, nationwide, most FQHC patients have low-incomes with 93% falling below the 200% Federal Poverty Level (FPL) and 72% below the 100% FPL (National Association of Community Health Centers, 2015). Besides primary and preventative care, most FQHCs provide behavioral, oral, vision, and pharmacy services (National Association of Community Health Centers, 2015). By law FQHCs must: • serve a federally-designated medically underserved area or a medically underserved population; • serve all individuals regardless of ability to pay;

Alliance for Health Equity91

• •

charge no more than a “nominal fee” to uninsured and underinsured individuals with incomes below 100% FPL, and charge uninsured and underinsured individuals between 101% - 200% FPL based on a sliding fee scale; and provide non-clinical enabling services to increase access to care, such as transportation, translation, and case management (National Association of Community Health Centers, 2015).

The geographic distribution of FQHCs is shown in Figure 62, indicating that FQHCs are heavily concentrated within Chicago, potentially leaving suburban areas under-resourced. Figure 60. Health Professional Shortage Areas in Cook County, Illinois – Primary Care (2019)

Health Resources and Services Administration, 2019 Map source: CARES Engagement Network Alliance for Health Equity92

Figure 61. Health Professional Shortage Areas in Cook County, Illinois – Mental Health Care (2019)

Health Resources and Services Administration, 2019 Map source: CARES Engagement Network

Alliance for Health Equity93

Figure 62. Geographic distribution of Federally Qualified Health Centers in Cook County, Illinois (2018)

CMS Providers of Service (POS) database, 2018 Map source: CARES Engagement Network

Alliance for Health Equityď ź94

Community Input The majority of focus groups that discussed health care access gave examples of the difficulties they encountered when trying to access a location where needed health care services are provided including a lack of reliable transportation services, limited availability of local providers accepting public benefits, and overall provider shortages. Direct quotes from community residents: • “Patients need to have access to health care financially, geographically, and logistically.” (NAMI Chicago – Family) • “I was going to physical therapy and the transportation company blew me off a few times and so my physical therapy got canceled.” (Housing Forward) • “I had a friend who fell sick and she couldn't get an appointment for two months and couldn't pay bill without insurance and she couldn't take care of kids.” (Asian Human Services Family Health Center) • “My primary care physician was a two and half month wait to get an appointment to get into there. It was for pressing matters. I needed some x-rays, a MRI, a prostate exam, but it is such a process just to get in there.” (Housing Forward)

Health care quality Health care quality can vary greatly between communities due to several factors including the geographic proximity of a spectrum of emergency or urgent care services, percentage of the population receiving public benefits, funding for community-based services, education and training levels of health care staff, and localized provider shortages. Race and ethnicity also play a critical role in the quality of health care that patients receive. Previous studies have established that racial and ethnic disparities in health care are in part a result of differential access to care and differing socioeconomic conditions. However, previous research has also established that when these differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received (Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003). For example, • In an equal-access military health care system in California, African American and whites had similar postoperative outcomes. However, when compared to the civilian health care system within the state, racial disparities in outcomes were evident, especially among those without private insurance (Schoenfeld et al., 2017). • A study of patient weight, race, and provider communication quality found that overweight/obese African American patients and healthy weight Hispanic patients experienced disparities in provider communication quality (Wong, Gudzune, & Bleich, 2015). • In a study of providers, physicians were more likely to rate their African American patients as less educated, less intelligent, more likely to abuse drugs and alcohol, and less likely to adhere to treatment regimens (van Ryn & Burke, 2000). The differences in perceptions persisted even after controlling for confounding variables (van Ryn & Burke, 2000). Perceptions of discrimination in health care have been associated with several outcomes among patients of color including decreased use of preventative health care, delayed use of prescription medication and medical tests, and worse chronic disease management and outcomes (Hausmann et al., 2008; Trivedi & Ayanian, 2006; Van Houtven et al., 2005). In addition, research has shown that persistent exposure to racism is traumatic for individuals and that trauma is an underlying root cause of many negative health outcomes.

Alliance for Health Equity95

Community Input Focus group participants that belonged to communities of color frequently described themselves as receiving lower quality healthcare compared to whites. Some of the examples of disparities in quality included poor provider communication including a lack of shared decision making; physician failure to provide surgical alternatives; negative remarks from physicians about a patient’s ability to comply with recommendations even when they are making progress; and delays in treatment for acute illnesses. Multiple participants indicated that their previous experiences with providers made them reluctant to seek needed medical care, less likely to use preventative services, less likely to have a primary care provider, and much less likely to trust different providers in the future.

School-based health services School-based health services are an important health care resource for young people in communities. The use of school-based health centers is associated with: • improved educational achievement and attainment including higher GPA, higher grade promotion, reduced suspension rates, and reduced non-completion rates; • increased use of vaccination and preventive services; • reduced asthma morbidity; • fewer emergency department visits and hospital admissions; • higher contraceptive use among females; • improved prenatal care and higher birth weights; • lower illegal substance use and alcohol consumption; and • reduced violence (American Public Health Association, 2018).

School Health Access Collaborative – Summary of 2018 Landscape Analysis The School Health Access Collaborative (SHAC) is convened by the Public Health Institute of Metropolitan Chicago and Healthy Schools Campaign to bring together key stakeholders such as schools, students, families, and health care providers. The goal of the collaborative is to collectively work on improvements to the school health services infrastructure in Chicago and to increase student access to comprehensive, sustainable, and quality health care services. In 2018, the collaborative conducted a landscape analysis to determine the strengths, weaknesses, and opportunities within the school health services system. The findings of the analysis are summarized below. Capacity and Resources An overarching gap is the lack of resources and investment in school health services in general. The resources needed range from additional school staff or providers to funding for additional services. The need is so great that even schools that have school-based health centers or established relationships with mobile providers and partners don’t have enough to match the need for services. Furthermore, there is a need for consistent services throughout the year. Frequent staff turnover creates a moving target on who school contacts are to coordinate health care services. Also, students need services during the summer, but most schools are not open. Mental and Behavioral Health There are gaps in mental health services on the South and West Sides of Chicago. Students that experience ongoing stress and trauma need ongoing support. Often there is only one social worker for the entire student population. Additionally, funding for behavioral health often gets reduced because of budget cuts. Social and Structural Determinants of Health Students are not experiencing education in a vacuum. Additional factors such as housing can impact the health and learning environment for students. Moreover, there are schools and community areas that may be overlooked because they don’t fall within certain data markers, which can result in certain communities being oversaturated and others not receiving services. Data Sharing Alliance for Health Equity96

The opportunities emerged for more effective and efficient school-based health: data collection, data analysis, and data sharing. Currently, the barriers to data collection and sharing are HIPAA, FERPA, and the capacity required to manage and collect consistent and accurate data. Additionally, most hospital systems and electronic health records focus on adult health measures, not child and adolescent health. A system that maintains all student health records could reduce redundancies and point out gaps in student health care needs. Coordination of Services Health care and school systems have complex organizational structures that can lead to inconsistent communications and duplication of services. The infrastructure for managing relationships between schools and providers is in the development phase because there are overlaps in services at some schools and other schools are not receiving any services. School champions can assist in coordination of services by maintaining relationships with parents, community partners, and health care partners and advocating for school-based health programs. Addressing the gaps identified by the analysis will provide opportunities to increase the positive outcomes of school and health care partnerships.

Alliance for Health Equityď ź97

Mental Health and Substance Use Disorders Key Takeaways This section summarizes the mental health needs facing Chicago and Suburban Cook County communities. In surveys and focus groups, community residents in Cook County identified access to health care services in general and to mental health services in particular as major concerns. Perhaps responding to the sense of urgency among communities, several collaborative projects have emerged among providers and advocates to address mental health needs in Cook County and in Illinois. We have distilled common findings from existing collaborative assessments, secondary data, and primary data collected through this CHNA process into six key takeaways related to mental health and substance use disorders that describe major problems, their importance for health equity, and opportunities to address them in the near-term.

Overarching need: Quality NAMI Chicago’s “Roadmap to Wellness: Reframing the Mental Health Conversation for Chicago” explicitly makes the case for an understanding of mental health that is inclusive of all people and is “seen as primary health care” (NAMI Chicago, 2019). The tendency to regard mental health as something distinct from overall wellness and as a special concern for an unfortunate segment of the general population is subtle, but widespread and pernicious. It shows itself in the separation of mental health from general health providers and state agencies, and in our everyday language, in which “mental health” is detached from a general concept of wellness in a way that “cardiac health,” for example, is not. As a result, mental health services are provided in a distinct, stigmatized silo that is not subject to the same demand for quality as most other health care sectors. Validated symptom rating scales for monitoring outcomes of mental health interventions, for example, are rarely used, and incentives for implementing such measurement-based care practices are missing (The Kennedy Forum, 2015). Reliable, actionable quality measures for mental health and substance use disorder outcomes are woefully lacking, and process measures that track encounters—such as 7-day follow-up appointments after a hospitalization—do not monitor compliance with evidence-based practices during the encounter (Lloyd, 2015). For too many, the experience of mental health care does not meet cultural needs, is not incentivized to be high-quality, and is deeply discouraging for the individual, their family, and their community.

Fragmentation of services and integration of care • • •

Social and structural determinants of health • •

Alliance for Health Equity98

o o

The level of community awareness and understanding of mental health symptoms and treatment is another part of the social-environmental background for health and can be impacted through community mental health awareness and Mental Health First Aid trainings. Health systems increasingly recognize the role of social determinants of health and the importance of collecting information on social needs (Feinglass et al., 2018; Rizzo et al., 2016). As assessment of social and structural determinants of health becomes more routine, the resulting data will assist advocates and policy makers to implement systemic solutions to health inequities.

Trauma and childhood adversity • •

•

Experiences of trauma and adversity in childhood, including abuse and household instability, extreme discrimination and poverty, or the loss of a parent, is widespread, affecting more than half of all adults in Illinois (Stillerman, n.d.-b). Research is revealing how exposure to trauma and adversity puts individuals at greater risk for mental illness, substance use disorder, and chronic illness across the lifespan. Trauma and adversity disproportionately affect communities of color and sexual and gender minorities, and are particularly prevalent among justice-involved populations, making addressing trauma a priority for achieving health equity (Substance Abuse and Mental Health Services Administration, 2014). Trauma-informed practice protocols are available for health care, schools, law enforcement and corrections, and child welfare systems to mitigate past experiences of stigma and trauma and to prevent further harm (Stillerman, n.d.-a).

Stigma and discrimination •

• •

Workforce shortages and gaps in training • •

•

Overview The Alliance for Health Equity recognizes that health is more than the absence or successful management of disease, but that it includes overall mental and social well-being as well. While affirming the fundamental unity of physical and mental health, it is important to acknowledge that existing inequities demand a special focus on mental illness and substance use disorder. In a seminal text on the topic of mental health disparities, Joseph Alliance for Health Equity99

Parks and colleagues reported that people with serious mental illness die on average 25 years earlier than the general population and that 60% of those premature deaths are due to physical health conditions such as cardiovascular and infectious diseases (Mauer, 2006). Mental health disparities research continues to explore this issue and to search for potential solutions. One 2017 study found that the mortality rate for opioid use disorder patients in a large university health system was 10 times higher than the rate for the general patient population (Hser et al., 2017). Again, cardiovascular and infectious disease were among the leading causes of death, contributing more to excess mortality than overdose deaths. Both of these studies pointed to integrated care as a step to eliminate these alarming disparities in longevity for people with mental illness and substance use disorders. Providers and policy makers increasingly recognize the necessity of an integrated approach to physical, mental health, and social services. The Agency for Healthcare Research and Quality assembled a panel to develop a consensus definition of behavioral health-primary care integration: “The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patientcentered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization” (Peek & The National Integration Academy Council, 2013). Research has demonstrated that integrating primary and mental health care can improve access to care and outcomes related to physical and mental health (Collins, Hewson, Munger, & Wade, 2010; Scharf et al., 2014). Integrated care models prioritize social determinants of health that interfere with and engagement with treatment plans, but most integration models are provider-centric, with a starting point of a physician’s office or a mental health clinic. Ideally integrated providers intersect with communities that invest in the overall wellbeing of their residents, so that health care interventions reinforce stabilizing elements already present in homes and communities. Well-being models supply a framework for the community-side of this formula. Well-being models identify essential community conditions that are necessary not only to prevent or manage illness, but also to support the best possible overall quality of life for community members (Larry Cohen, Rachel Davis, Larissa Estes, Leslie Mikkelsen, & Sheila Savannah, 2017). These conditions include the quality of housing and the built environment, education and employment, opportunities for civic engagement, and access to quality health care services. The Full Frame Initiative outlines five domains of well-being: social connectedness in a supportive, accepting community; stability to withstand adversity; safety to express one’s identity without fear of harm; mastery to feel empowered to influence the events that impact one’s life; and meaningful access to relevant resources “to meet basic needs without shame, danger or great difficulty” (“The Full Frame Approach and The Five Domains of Wellbeing,” n.d.). These often-intangible qualities of communities contribute to health and are essential to convert detrimental determinants such as stigma, racism and homophobia, isolation and disempowerment, that are such powerful barriers to mental health and wellbeing, into protective and nurturing elements of strong communities (Larry Cohen et al., 2017). CHNA data (secondary data, community input, and stakeholder input) shows that progress toward integrated care and community well-being still faces formidable barriers in Chicago and Cook County communities. Shortages of mental health and substance use treatment professionals in the community exacerbate an overreliance on institutions, including jails and prisons, for initiation of treatment. In the community input survey and focus groups, community members reported difficulty accessing services and described mental health center closures in Chicago and an overall shortage of providers, especially on the South Side of Chicago and south Suburban Cook County. But building more workforce “pipelines” into a system that does not effectively deploy team-based integrated care cannot sustainably improve access. Without changes to financing from state and national policy, attrition from turnover and burnout will limit the reach of evidence-based treatment. Evaluations of integrated care have highlighted the role of financing structures in building effective, sustainable integrated practices. Core components of integration models, such as outreach and engagement and communication between providers, is not reimbursed under fee-for-service nor are the full costs covered by most managed care and per-member-per-month care coordination payment arrangements (Gerrity, 2016). Alliance for Health Equity100

Finally, integrated approaches to health and well-being must include housing needs. Housing instability is a stressor on many Cook County residents, as reflected in focus group responses, and it is especially damaging to people managing mental health conditions. Stable housing with wraparound services can be a platform for recovery and wellness, and meaningful de-institutionalization is impossible without investing in supportive housing (Illinois Housing Task Force, 2017).

Priority populations Mental health plays a role in the lives of all kinds of people and communities, but certain populations are impacted more severely or experience inequities due to structural factors including trauma, racism, and poverty. The following groups were identified as priority populations for community responses to mental health needs: • Children whose needs are distinct from adults and require specific systems to support their mental health in their homes, schools, and communities • African Americans and Native Americans who have the highest rates of mental illness • LGBTQ+ individuals who are two or more times more likely to have a mental health condition and who have reported feeling unwelcome in many health care settings • Immigrants who encounter linguistic and cultural barriers to care, and cite fear that accessing services or public aid may endanger themselves or their families • Low-income individuals who struggle to afford out-of-pocket expenses and are vulnerable to changes in program funding and closures of public mental health centers • Individuals in the justice population who, despite their extremely high rates of mental illness and substance use disorder and nearly universal eligibility for Medicaid under the ACA, frequently fall through the cracks when transitioning from correctional facilities to the community (TASC Inc., 2016) • People who have experienced trauma and adversity who are at greater risk for depression, substance use disorder, and chronic disease, and are also more likely to forgo care if it is offered in settings or by individuals that do not implement trauma-informed approaches (National Council for Behavioral Health, n.d.; Stillerman, n.d.-b) • Children and adults with intellectual or developmental disabilities who have a higher prevalence of mental health disorders • One in three veterans returning from Iraq and Afghanistan have mental health conditions related to their military service, but only about half receive treatment. Community Input Input from community resident focus groups and surveys provided strong evidence that mental health and substance use are key health issues across the entire geography of Chicago and Suburban Cook County. Mental health, substance use, stress, and trauma were key topics of discussion in at least 80% of focus groups, across geography, age, and race/ethnicity. Focus groups discussed how behavioral health impacted the health of their communities. The major themes that emerged from the discussions included: • the prevalence of chronic stress among youth and adults in communities; • a lack of education among youth, adults, and public servants about mental illness and substance use disorders; • difficulties accessing behavioral health treatment resulting from provider shortages, minimal community-based resources, stigma, poor health care coverage, financial cost, and policy issues; • the consequences of untreated conditions; and • the impacts of abuse and other forms of trauma on behavioral health. Focus group input showed that closure of mental health centers and community-based services and ongoing difficulty accessing behavioral health providers continues to be a top concern for Cook County communities. Exacerbating overall behavioral health provider shortages is an inadequate pool of providers who accept public insurance. Focus groups also described complex, often confusing, changes to Medicaid rules and the high cost and benefit gaps of private insurance as barriers to care.

Alliance for Health Equity101

Utilization of emergency care Mental illness The mental health crisis that the U.S. is currently undergoing is hitting emergency departments particularly hard in part due to the fact that EDs are one of the last remaining safety nets in communities (Laderman, Dasgupta, Henderson, & Waghray, 2018). One in eight ED visits in the U.S. is related to mental health or a substance use issue, a number that has increased every year in the past decade (Laderman et al., 2018). EDs are traditionally not equipped to cope with behavioral health needs and combined with the increasing demand for services this has contributed to poor health outcomes in patients, traumatization and stigmatization, poor connection to follow-up care, and repeat ED visits (Laderman et al., 2018; Niedzwiecki, Sharma, Kanzaria, McConville, & Hsia, 2018). Previous research on ED utilization patterns has found that 50% of frequent ED users have a mental health diagnosis and that usage increases with the severity of that mental health diagnosis (Hunt, Weber, Showstack, Colby, & Callaham, 2006; Niedzwiecki et al., 2018). In addition, frequent ED users are often dealing with other factors such as homelessness, food insecurity, and addiction which have historically been viewed as non-medical problems (Kushel, Perry, Bangsberg, Clark, & Moss, 2002). Mental health-related ED visit rates for adults in Cook County communities range from 21 per 10,000 to 661 per 10,000 illustrating that the need for quality community-based and preventative behavioral health treatment is very high in some communities (Figure 63). Although mental health related ED visit rates are lower for youth in Cook County, large disparities are still apparent (Figure 64). As previously mentioned, ED admission rates in these communities are heavily influenced by socioeconomic inequities such as poverty, housing instability, food insecurity, and poor access to health care.

Suicide and intentional injury Not only do ED visits for suicide and intentional injury indicate a failure of the behavioral health system to provide adequate community-based treatment and prevention, but they also indicate a future risk for suicide or self-harm (Suicide Prevention Resource Center, n.d.). The risk of suicide attempt or death is highest within 30 days of discharge from an ED or inpatient psychiatric unit (Knesper, 2011). Compounding this problem is the fact that up to 70% of patients who leave the ED after a suicide attempt never attend their first outpatient appointment (Knesper, 2011). Patients without behavioral health diagnoses could also benefit from improved ED interventions. For example, one study found that approximately 37% of individuals without a mental health or substance use disorder diagnosis who die by suicide make an ED visit within a year of their death (Ahmedani et al., 2014). Although high ED rates indicate a need for system-level changes, ED visits present a unique opportunity to screen, provide brief intervention, and better connect individuals to ongoing care (Suicide Prevention Resource Center, n.d.). In Cook County, adult and child ED rates for suicide and intentional injury are typically higher in communities with higher rates of ED visits for mental illness. ED admission rates range from 7 per 10,000 to 279 per 10,000 among Cook County adults and range from 11 per 10,000 to 135 per 10,000 for children aged 10-17 (Figures 65-66).

Substance use disorders As detailed in the mortality section of the Chronic Disease chapter, drug overdose deaths are on the rise in Chicago and Suburban Cook County. In addition, there have been dramatic increases in opioid overdose deaths within the county since 2015. EDs provide unique opportunities to screen patients, initiate evidencebased treatment, provide overdose prevention, and connect patients to ongoing community-based care. ED admission rates for substance use disorders and alcohol use in Cook County (Figures 67-68) combined with the drug and opioid overdose data presented in the Chronic Disease chapter indicate a need for enhanced approaches to substance use treatment in several communities.

Alliance for Health Equityď ź102

Figure 63. Age-adjusted mental health emergency department visit rates per 10,000 in Cook County, Illinois (Adults)

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equityď ź103

Figure 64. Age-adjusted mental health emergency department visit rates per 10,000 in Cook County, Illinois (Children under 18)

22.0 – 40.0 40.1 – 48.0 48.1 – 58.0 58.1 – 71.0 71.1 – 162.0 Chicago Border Forest Preserve Data Unreliable

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equity104

Figure 65. Age-adjusted suicide/self-inflicted injury emergency department visit rates per 10,000 in Cook County, Illinois (Adults)

7.0 – 20.0 20.1 – 28.0 28.1 – 34.0 34.1 – 47.0 47.1 – 279.0 Chicago Border Forest Preserve

Data Unreliable

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equity105

Figure 66. Age-adjusted suicide/self-inflicted injury emergency department visit rates per 10,000 in Cook County, Illinois (Children 10- to 17-years old)

11.0 – 34.0 34.1 – 43.0 43.1 – 54.0 54.1 – 70.0 70.1 – 135.0 Chicago Border Forest Preserve

Data Unreliable

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equity106

Figure 67. Age-adjusted substance use emergency department visit rates per 10,000 in Cook County, Illinois (Youth under 18)

7.0 – 16.0 16.1 – 24.0 24.1 – 35.0 35.1 – 65.0 65.1 – 532.0 Chicago Border Forest Preserve

Data Unreliable

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Figure 68. Age-adjusted alcohol use emergency department visit rates per 10,000 in Cook County, Illinois (Adults) Alliance for Health Equity107

17.0 – 37.0 37.1 – 52.0 52.1 – 65.0 65.1 – 92.0 92.1 – 366.0 Chicago Border Forest Preserve Data Unreliable

Illinois COMPdata, 2015-2017, Analysis Conducted by Healthy Communities Institute Another important emergency room utilization concern related to substance use disorders is opioid overdose. Data on opioid-related mortality and a map of opioid overdose is in the mortality section of this report on page 117.

Other Recent Assessments Mental health has received more attention amidst the opioid crisis affecting the entire nation. Expansion of Medicaid under the ACA brought greater access to mental health and substance use services, but also concern about the cost and quality of treatment provided through public funds. These drivers of heightened interest have produced new resources for assessing the mental health needs of Illinois’ communities from a variety of perspectives. Statewide organizations with strong connections to Cook County have produced assessments of needs and opportunities to build a mental health system that can both respond to the current opioid crisis and invest in prevention and early treatment. Cook County Health formed a Behavioral Health Consortium as part of its strategic plan, NAMI Chicago assembled a “Roadmap” for mental health, and Chicago-based nonprofit Health & Medicine Policy Research Group led a Behavioral Health-Primary Care Integration Learning Collaborative. Each of these initiatives sought to assess and respond to mental health needs in Cook County and statewide.

Alliance for Health Equity108

Community Input In addition to bureaucratic and financial obstacles, focus groups explained that stigma and trauma are sometimes reinforced by providers who dismiss behavioral health patients’ complaints of physical symptoms. Participants conveyed that more education about mental illness and substance use is needed for community members, health care professionals, and public officials. Focus group participants linked chronic stress to several different health effects. Community members reported that stress impacted their ability to cope with chronic illnesses such as diabetes and could disrupt their ability to engage in behaviors such as healthy eating and exercise. Parents caring for children with asthma and caregivers for older adults reported that the stress of caring for a family member had negative impacts on their mental and physical well-being. Youth living with asthma reported that stress was a trigger for their asthma attacks. Individuals living with mental illness or a substance use disorder from two different focus groups mentioned that stress negatively impacts their recovery process. Participants from three focus groups directly linked chronic stress to the development of substance use disorders. Among community input survey respondents: • 50% ranked “Access to health care & mental health services” as one of “the three most important things necessary for a ‘Healthy Community’” • 40% selected “Mental health” as one of “the three most important health problems in your community,” and 30% selected “Substance Use”

Conclusions – Mental Health and Substance Use Community input, public health data, and findings from other assessments produce a compelling narrative that can guide mental health system improvements in Cook County: Cook County’s communities need a mental health system that aligns programs, public agencies, and funding to provide accessible, affordable, culturally competent, and trauma-informed prevention and early treatment services as well as crisis intervention through partnerships that include schools and the justice system. Building and maintaining that system will require investments in housing, workforce development, data-sharing infrastructure, payment reform, and eliminating stigma. Many of the assessments conducted by learning collaboratives and provider coalitions were primarily focused on the Medicaid program, which accounts for 25% of total national spending on mental health services and 21% of substance use disorder spending. However, it is clear from focus group responses that Cook County community residents remain anxious about access to insurance and about limited coverage of services in public and private insurance plans. Therefore, the circumstances of people who are uninsured and people covered by private insurance, Medicare, or Veterans benefits must also be considered when responding to Cook County communities’ mental health needs. Moreover, just as various state agencies involved in mental health could be better coordinated with local governments and providers, so too can public and private insurers become more aligned to smooth out disruptions from “churn” between Medicaid and private insurance from the Health Insurance Marketplace and employer-sponsored insurance. The key issues identified in all the assessments of the mental health system are immensely challenging—providing housing, fine-tuning payments to produce better outcomes, expanding the pool of highly-sophisticated professionals for integrated care teams, and eliminating stigma. The multiplicity of learning collaboratives may carry its own lesson; that solutions to these problems will require deep and sustained cooperation and sharing of knowledge and resources across traditional divisions in the health care and social service delivery system.

Alliance for Health Equity109

Chronic Conditions The definition of chronic disease varies widely in the United States and across the globe. However, chronic diseases are often defined as having the following characteristics: • complex causality with multiple factors leading to onset including socioeconomic determinants of health and health behaviors; • a long development period; • a prolonged course of illness that often requires ongoing medical attention; • are non-communicable; and • cause functional impairment in daily activities or disability (Australian Institute of Health and Welfare, 2016; Bernell & Howard, 2016; Centers for Disease Control and Prevention, 2019b; World Health Organization, n.d.-c). Worldwide and in the United States, chronic diseases are the leading causes of disability and death (Centers for Disease Control and Prevention, 2019b; World Health Organization, n.d.-c). In addition, chronic disease rates are accelerating globally across all socioeconomic classes (World Health Organization, n.d.-c). However, socioeconomic inequities have profound impacts on which populations and communities have the greatest burden of disease. Many of the socioeconomic inequities that are underlying root causes of chronic illness are explored in depth in the health inequities and social determinants of health chapters on. As a result, this chapter will primarily focus on examining the burden of chronic diseases within Cook County communities.

Prevention Chronic conditions such as heart disease, stroke, cancer, diabetes, arthritis, asthma, mental illness, and HIV/AIDs account for 90% of the nation’s $3.3 trillion in annual health care expenditures (Centers for Disease Control and Prevention, 2019a). Prevention and management of chronic illness can help reduce the costly physical and socioeconomic burden of these diseases for individuals and society as a whole. The Centers for Disease Control and Prevention have identified four domains of chronic disease prevention (Figure 69). Figure 69. Four domains of chronic disease prevention Four domains of chronic disease prevention 1. Epidemiology and surveillance: to monitor trends and track progress. 2. Environmental approaches: to promote health and support healthy behaviors. 3. Health care system interventions: to improve the effective delivery and use of clinical and other high-value preventive services. 4. Community-clinical linkages: connections between community and clinical sectors to improve population health The four domains defined by the Centers for Disease Control and Prevention focus on strategies that: •

collectively address the behaviors and other risk factors that can cause chronic diseases;

•

work to simultaneously prevent and control multiple diseases and conditions;

•

reach more people by strengthening systems and environments to support health; and

•

link community and health care efforts to prevent and control disease.

(Centers for Disease Control and Prevention, 2012) Both current and future implementation strategies developed by the Alliance focus on the four domains and are strongly guided by available data and input from communities on the best approaches for preventing and addressing chronic disease. Alliance for Health Equity110

Risk Factors for Chronic Disease A small number of common risk factors contribute to most of the main chronic diseases: • Unhealthy diet, • Physical Inactivity, • Tobacco use, • Stress and/or depression, • Maternal and infant health, • Poverty and other social and structural determinants of health (World Health Organization, n.d.; Egger & Dixon, 2014; Illinois Department of Public Health, n.d.) Figure 70. Self-reported risk factors, adults, 2017

Adults that report eating vegetables LESS than one time daily No leisure-time physical activity Smoker - current E-Cigarettes or other vaping products At least one mentally unhealthy day in past month Obesity

Chicago (2017) 25%

Suburban Cook County (2017) 22%

Illinois (2017) 21%

United States (2017) 19%

23%

22%

24%

27%

15%

17%

2.6% (current) 16% (ever) 40%

3.2% (current) 18% (ever) 35%

4.4% (current) 20% (ever) 38%

4.6% (current) 20% (ever) 35%

30%

31%

30%

(Behavioral Risk Factor Surveillance Survey (BRFSS), 2017; Healthy Chicago Survey, 2017) Figure 71. Self-reported risk factors, adolescents, 2017

Did not eat vegetables at least once a day

Chicago (2017) 50%

Illinois (2017) n/a

United States (2017) n/a

Did not eat breakfast all 7 days of the week

76%

n/a

65%

Were not physically active (60 minutes) on all 7 days of the week Screen time – video games or computer more than 3 hours a day Obesity

81%

77%

74%

41%

42%

43%

18%

15%

Smoker - current

6.0%

7.6%

8.8%

6.6% (current) 37% (ever) 12%

13% (current) 41% (ever) 10%

13% (current) 42% (ever) 7%

E-Cigarettes or other vaping products * Attempted suicide (Youth Risk Surveillance Survey (YRBS), 2017)

* The 2018 Illinois Youth Survey found higher current rates of e-cigarette use among adolescent respondents in the 12-15% range in Chicago and Suburban Cook County. (Illinois Youth Survey, 2018) Alliance for Health Equity111

• •

• • •

Thirty percent of adults and nearly 30% of adolescents identified as obese (self-reported height and weight) in Chicago and Suburban Cook County in 2017. Nearly a quarter of adults in suburban Cook County (22%) and Chicago (25%) report eating vegetables less than daily. Only 30% of adults in Chicago report consuming the recommended 5 servings of fruits and vegetables a day, and the rate varies greatly across communities (from less than 15% to nearly 50%). Nearly a quarter of adults in suburban Cook County (22%) and Chicago (23%) report not engaging in physical activity during leisure time. Over three-quarters of youth report not engaging in physical activity at all in the previous seven days Rates of E-cigarette and vaping product use are increasing in Chicago and Cook County, particularly among adolescents and young adults.

The Voices of Child Health in Chicago initiative reports that adult survey respondents in 2018 identified childhood obesity as the second biggest health concern for children (62%) alongside drug abuse, child abuse, stress, and depression. More data and information about risk factors related to food access, healthy communities, and social and structural determinants is included in the social and structural determinants chapter of this report.

Mortality In the United States, 60% of adults have a chronic disease and 40% of adults have two or more chronic diseases (Centers for Disease Control and Prevention, 2019b). Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States and are a leading driver of healthcare costs (Centers for Disease Control and Prevention, 2019b). From 2014 to 2016, 65% of all deaths in Chicago were attributable to chronic diseases (Figure 72). Figure 72. Leading causes of death in Chicago, 2014-2016

Illinois Department of Public Health, Division of Vital Records, 2014-2016 Age-adjusted mortality rates in 2016, reveal significant racial disparities in chronic disease mortality within Chicago (Figure 73). African American/blacks have the highest rates of mortality for heart disease, cancer, diabetes, and stroke.

Alliance for Health Equity112

Figure 73. Age-adjusted mortality rates per 100,000 population in Chicago by race and ethnicity

Illinois Department of Public Health, Division of Vital Records, 2016 From 2014 to 2016, the same trends in the leading causes of death were observed in Suburban Cook County with 65% of all deaths being attributed to chronic disease (Figure 74). Figure 74. Leading causes of death in Suburban Cook County, 2014-2016

Illinois Department of Public Health, Division of Vital Records, 2014-2016 Alliance for Health Equityď ź113

Age-adjusted mortality rates in 2016, reveal that significant racial disparities in mortality are present in Suburban Cook County as well (Figure 75). African American/blacks living in the suburbs have the highest rates of heart disease, cancer, diabetes-related, and stroke mortality. Figure 75. Age-adjusted mortality rates per 100,000 population in Suburban Cook County by race and ethnicity

Illinois Department of Public Health, Division of Vital Records, 2012-2016 Inequities in the burden of chronic diseases and chronic disease-related mortality within communities is largely driven by the social determinants of health such access to healthy foods, access to safe exercise spaces, household income, access to quality education, housing stability, access to quality healthcare, community safety, and exposure to trauma. Due to inequities in the social determinants of health and the unjust distribution of resources between communities, chronic disease mortality varies across the county (Figure 76).

Alliance for Health Equityď ź114

Figure 76. Age-adjusted chronic disease-related mortality rates per 100,000 in Cook County

Illinois Department of Public Health, Division of Vital Records, 2012-2016

Alliance for Health Equityď ź115

Mortality Trends Between 2012 and 2017, age-adjusted mortality trends for chronic conditions remained consistent (Figures 77-78). However, drug overdose mortality has increased in Chicago and Suburban Cook County over time (Figures 79-80). Opioid overdose deaths have increased over time in county as well, however, the burden of opioid-related mortality is unevenly distributed across communities (Figure 80). In addition, the resources to address opioid overdoses are highly concentrated in Chicago and notably less available in suburban areas. Figure 77. Trends in age-adjusted chronic disease-related mortality rates per 100,000 in Chicago 2012

2013

2014

2015

2016

2017

Diabetes-related 65.1 64.5 64.8 64.6 63.4 59.5 Stroke 39.1 40.7 41.4 45.4 46.0 51.7 Cancer 186.1 190.0 186.4 190.4 185.9 179.2 Heart Disease 210.5 207.5 204.8 207.4 207.1 201.3 Illinois Department of Public Health, Division of Vital Records, 2012-2017 Figure 78. Trends in age-adjusted chronic disease-related mortality rates per 100,000 in Suburban Cook County 2012 2013 2014 2015 2016 2017 Diabetes-related 49.8 44.2 50.4 48.8 39.4 40.0 Stroke 36.3 33.4 36.9 36.7 35.6 40.3 Cancer 173.6 168.9 168.1 168.9 161.2 163.3 Heart Disease 165.0 164.0 164.8 164.4 149.5 158.9 Illinois Department of Public Health, Division of Vital Records, 2012-2017 Figure 79. Trends in age-adjusted drug overdose mortality rates per 100,000 in Chicago

Illinois Department of Public Health, Division of Vital Records, 2012-2017

Alliance for Health Equityď ź116

Figure 80. Trends in age-adjusted drug overdose mortality rates per 100,000 in Suburban Cook County

Illinois Department of Public Health, Division of Vital Records, 2012-2017 Figure 81. Incidence of opioid overdoses in Cook County, Illinois (2017)

Cook County Medical Examinerâ&#x20AC;&#x2122;s Office via Chicago Department of Public Health, 2017 Alliance for Health Equityď ź117

Asthma and diabetes The 2016 CHNA established asthma and diabetes as priority health conditions for several communities throughout the county. As a result, several hospital and health department partners have coalesced around these issues. In addition, development, progression, and outcomes for these two diseases are strongly tied to the social determinants of health and have large equity-related gaps between communities. As a result, two sections specifically related to asthma and diabetes were added to the assessment.

Diabetes Hospitalization and emergency department (ED) visits are indicative of poorly controlled chronic diseases and a lack of access to routine preventive care. Poorly controlled diabetes can lead to severe or life-threatening complications such as heart and blood vessel disease, nerve damage, kidney damage, eye damage and blindness, foot damage and lower extremity amputation, hearing impairment, skin conditions, and Alzheimer’s disease. There are several examples of factors that can influence an individual’s risk for development of diabetes and their ability to manage the disease. • Acute and chronic stress can cause hormonal changes that have a direct impact on blood glucose levels in healthy individuals and those with type 1 and type 2 diabetes (Harris et al., 2017; Marcovecchio & Chiarelli, 2012). In addition, stress can impact patient behaviors related to treatment, monitoring, meal planning, and exercising (Marcovecchio & Chiarelli, 2012). • Concentrated poverty within a neighborhood is associated with an increased prevalence of diabetes, particularly for communities of color (Gaskin et al., 2014). Concentrated poverty influences disease burden by determining access to reasonably priced fruits and vegetables, access to recreational facilities, access to health care services, crime rates, and levels of exposure to environmental toxins (Gaskin et al., 2014). • Unstable housing is associated with a significantly increased risk of diabetes-related emergency department visits and inpatient stays (Berkowitz, Kalkhoran, Edwards, Essien, & Baggett, 2018). Diabetes-related ED visits for adults are shown in Figure 82. ED visits for diabetes are heavily concentrated in the West and South Sides of Chicago and the southern region of Suburban Cook County. The areas with high rates of ED visits largely overlap with communities with high rates of poverty, unemployment, and costburdened households. Community Input Several focus groups mentioned diabetes as a major health concern in their communities and two focus groups were composed entirely of adults living with diabetes. Adults living with diabetes all agreed that they understood the importance of healthy diet and physical activity in controlling their conditions, but they mentioned several barriers that made it difficult to engage in healthy behaviors: • chronic stress in everyday life makes it difficult to manage diabetes; • limited access to grocery stores and easy access to fast food can make it difficult to choose healthy food options, particularly for individuals and parents who are busy and work long hours; • the affordability of healthy foods; • safety concerns that limit outdoor activities; • physical activity routines can be difficult to begin by yourself; • not everyone knows how to prepare healthy meals; • resistance from non-diabetic family members, other household members, and friends to changes in diet; and • lack of knowledge about community resources that may help with disease management. Community input survey respondents selected diabetes as the top most important health problem, with 43% of respondents selecting diabetes among their top three most important health problems. Both African American/black and Hispanic/Latinx respondents selected diabetes as the top issue, whereas diabetes ranked 6th among white respondents. Alliance for Health Equity118

Figure 82. Age-adjusted diabetes emergency department visit rates per 10,000 in Cook County, Illinois (Adults)

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equityď ź119

Asthma Although asthma occurs in all racial and ethnic groups, low-income and communities of color share a disproportionate burden of asthma morbidity and mortality (Forno & CeledĂłn, 2012). In the City of Chicago, non-Hispanic African American/black children and adolescents are five times more likely to visit the emergency department for an asthma-related condition than white children and adolescents (Figure 83). Previous research indicates that issues such as poverty, limited access to healthcare, exposure to violence, chronic stress, overcrowded housing, deteriorating infrastructure, poor housing conditions, and higher rates of air pollution all contribute to the increased burden of asthma morbidity and mortality in certain communities (Williams, Sternthal, & Wright, 2009b). Figure 83. Racial and ethnic disparities in asthma ED visits, age-adjusted rates for Chicago children aged 0-17, 2009-2015

(Respiratory Health Association, 2018) The inequities related to asthma outcomes are evident when viewing maps of ED visits for adults and children. Similar to diabetes, asthma-related emergencies are concentrated in low-income communities of color in the west and south regions of the city and county (Figures 84-85).

Alliance for Health Equityď ź120

Figure 84. Age-adjusted asthma emergency department visit rates per 10,000 in Cook County, Illinois (Adults)

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equityď ź121

Figure 85. Age-adjusted asthma emergency department visit rates per 10,000 in Cook County, Illinois (Children under 18)

Illinois COMPdata, 2015-2017, Analysis conducted by Conduent Healthy Communities Institute

Alliance for Health Equityď ź122

Community Input Direct quotes from community residents that participated in focus groups demonstrate the tremendous toll that asthma is having of their well-being and the well-being of their families. • “I can’t keep count of how many times I go to the ER with my child.” • “I always take my child to the ER. As he gets older, it’s has gotten more severe, and he is agitated. He asks questions about when he can stop taking medications.” • “My child takes a lot of medication. At night he gets frustrated and says, “here we go again.” He takes sleep apnea medication plus 2-3 medications for asthma.” • “I’m running on no sleep because my child can’t sleep at night. Then the hospital gives him medication to knock him right out – and then I have to carry him off the bus. He’s 69 pounds. Give me the medication so I can give it to him at home, so I can get a break. Let me take a shower and straighten stuff up. You can’t take a break, it’s your child, you do what you have to do.”

Sexually Transmitted Infections The burden of sexually transmitted infections (STIs) in Cook County is disproportionately high in communities of color. Higher STI rates are not caused by ethnicity or heritage, but are due to socioeconomic inequities such as poverty, large income gaps, fewer jobs, and low education levels (Centers for Disease Control and Prevention, 2019e; Gonzalez, Hendriksen, Collins, Durán, & Safren, 2009). For example: • STI risk decreases with increasing income and this association is strongest for non-whites; • uninsured and underinsured individuals carry a higher burden of STIs; • residential segregation and concentration of poverty lead to higher rates of intravenous drug use and sexual exploitation for money which are both significant risk factors for STIs; • many people of color distrust the health care system, fearing or previously experiencing discrimination from health care providers, which could decrease rates of screening and treatment for STIs; • lack of access to treatment for depression and substance use disorders contributes to a higher risk for STIs among certain communities of color; • homelessness and housing instability have been associated with increased risk for most health conditions including STIs; and • current incarceration and recent incarceration are significant risk factors for STIs and African American/blacks and Hispanic/Latinxs have been disproportionately impacted by mass incarceration policies (Adimora & Schoenbach, 2005; Centers for Disease Control and Prevention, 2019e; Gonzalez et al., 2009; Harling, Subramanian, Bärnighausen, & Kawachi, 2013; Nijhawan, 2016). STIs impact the health care system through high costs for screening and treatment as well as the potential for complications. STIs are preventable with access to adequate education and health services (HealthyPeople 2020, n.d.). Detailed STI surveillance is available through CDPH and CCDPH. Data for Human Immunodeficiency Virus (HIV), chlamydia, syphilis, and gonorrhea are included below.

HIV prevalence and incidence HIV prevalence is the number of existing HIV cases at a given time per 100,000 people. Not only does the number of people living with HIV vary significantly by race and ethnicity, but it also varies geographically. Communities on the Northeast Side of Chicago have the highest rates of HIV prevalence (Figure 86). The suburban communities with the highest prevalence of HIV are located in the southern region (Figure 87).

Alliance for Health Equity123

Figure 86. Comparison of HIV prevalence rates per 100,000 population in Chicago community areas, 2016

(Chicago Department of Public Health, 2016) Figure 87. Comparison of HIV prevalence rates per 100,000 population in Suburban Cook County municipalities, 2012-2016

Cook County Department of Public Health, 2012-2016

Alliance for Health Equityď ź124

HIV incidence is the rate of new HIV cases per 100,000 people. Overall, HIV incidence rates have declined substantially over the past 10 years in Chicago and Suburban Cook County. However, there are disparities between populations and geographies. In Chicago, men who have sex with men accounted for the majority of new HIV cases in 2015 (76%) (Chicago Department of Public Health, 2016). The community areas with the highest incidence of HIV cases from 2014-2015 were located on the Northeast and South Sides of Chicago (Figure 88). In Suburban Cook County, the highest rates of new HIV diagnoses occurred in the southern region (Figure 89). Figure 88. Comparison of HIV incidence rates per 100,000 population in Chicago community areas, 2016

(Chicago Department of Public Health, 2016) Figure 89. Comparison of HIV incidence rates per 100,000 population in Suburban Cook County municipalities, 2012-2016

Cook County Department of Public Health, 2012-2016 Alliance for Health Equityď ź125

Chlamydia incidence Chlamydia incidence is the number of new cases of chlamydia per 100,000 people. As Figure 90 reflects, the incidence of chlamydia is highest for African American/black residents in Chicago and Suburban Cook County. Like HIV, chlamydia incidence rates vary dramatically in Cook County by geographic location. The highest incidence rates in Chicago occur on the West and South Sides (Figure 91). The highest incidence rates occur in the southern region of Suburban Cook County (Figure 92). As previously mentioned, these racial, ethnic, and geographic differences are largely due to socioeconomic inequities such as poor access to health care, segregation, poverty, discrimination, unemployment, and poor access to quality education. Figure 90. Chlamydia incidence rates per 100,000 in Chicago and Suburban Cook County by race and ethnicity

Chicago Department of Public Health, 2015; Cook County Department of Public Health, 2012-2016 Figure 91. Comparison of chlamydia incidence rates per 100,000 population in Chicago community areas, 2016

(Chicago Department of Public Health, 2016)

Alliance for Health Equityď ź126

Figure 92. Comparison of chlamydia incidence rates per 100,000 population in Suburban Cook County municipalities, 2012-2016 (Cook County Department of Public Health, 2016)

Primary, Secondary, and Congenital Syphilis Primary and secondary syphilis infections follow the same patterns as chlamydia and HIV with the majority of new cases reported in non-Hispanic African American/blacks. Incidence rates are again highest in communities on the Northeast and South Sides of the city and in the southern region of the suburbs. Congenital syphilis is transmitted from mother to baby during pregnancy. Across the nation, there has been a dramatic increase in congenital syphilis cases among newborns (Centers for Disease Control and Prevention, 2018). Between 2013 and 2017, the rates of congenital syphilis in the U.S. more than doubled (362 in 2013 to 918 in 2017), outpacing overall increases in STIs nationwide (Centers for Disease Control and Prevention, 2018). Congenital syphilis can cause miscarriage, stillbirth, prematurity, low birth weight, or death shortly after birth (Centers for Disease Control and Prevention, 2019c). For babies born with congenital syphilis, the disease can cause deformed bones, severe anemia, enlarged liver and spleen, jaundice, brain and nerve problem s like blindness or deafness, meningitis, and skin rashes (Centers for Disease Control and Prevention, 2019c). In 2015, Chicago experienced the highest number of cases in the past five years (Chicago Department of Public Health, 2016). Between 2014 and 2016, rates of congenital syphilis in Suburban Cook County have remained fairly consistent and lower than the rates for Chicago (Cook County Department of Public Health, 2018).

Gonorrhea Gonorrhea is the second most commonly reported STI. Gonorrhea infection is a major cause of pelvic inflammatory disease in women (Centers for Disease Control and Prevention, 2019d). Complications that can be caused by untreated gonorrhea include the formation of scar tissue blocking the fallopian tubes, ectopic pregnancy, infertility, and long-term pelvic/abdominal pain (Centers for Disease Control and Prevention, 2019d). Potential complications for men include chronic pain and infertility (Centers for Disease Control and Prevention, 2019d). Antibiotic resistant gonorrhea is a growing concern among providers (Centers for Disease Control and Prevention, 2019d). Increased emergence of additional strains of antibiotic resistant gonorrhea would significantly complicate the ability of providers to treat the disease successfully (Centers for Disease Control and Prevention, 2019d). Gonorrhea incidence is highest among communities on the South Side of Chicago and in the southern region of Suburban Cook County (Chicago Department of Public Health, 2016; Cook County Department of Public Health, 2018). Gonorrhea incidence follows the same trends as other STIs with African American/blacks having the highest burden of disease in the city and suburbs. Alliance for Health Equityď ź127

Conclusion The Alliance for Health Equity collaborative Community Health Needs Assessment (CHNA) combined robust public health data, community input, existing research, existing plans, and existing assessments to document the health status of communities within Chicago and Suburban Cook County and to highlight systemic inequities that are negatively impacting health. The CHNA also provided insight into community-based assets and resources that should be supported and leveraged during the implementation of health improvement strategies. Based on the information provided in the CHNA, input from Alliance for Health Equity stakeholders, and community feedback, six major focus areas were identified for implementation: •

addressing the social and structural determinants of health including addressing structural racism, advancing policies that promote health equity, creating environments that support healthy eating and active living, and advancing community-driven decision making;

•

improving access to care and community resources through interventions, programs, and policy and systems improvements;

•

improving mental health and reducing substance use disorders;

•

addressing the risk factors, prevention, and management of chronic conditions;

•

improving maternal and child health including reducing maternal and infant mortality; and

•

preventing overall injury and violence-related injury

By implementing strategies and supporting existing work within the six focus area domains, Alliance for Health Equity partners seek to increase health equity, improve physical and mental health, improve quality of life, and increase life expectancy for all community members. To be successful, the Alliance will continue to partner with health departments, community-based organizations, and community residents to adopt shared and aligned strategies while leveraging shared resources to increase collective impact.

Alliance for Health Equity128

References Adimora, A. A., & Schoenbach, V. J. (2005). Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. The Journal of Infectious Diseases, 191 Suppl 1, S115-122. https://doi.org/10.1086/425280 Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., … Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870–877. https://doi.org/10.1007/s11606-014-2767-3 Alley, D. E., Lloyd, J., Pagán, J. A., Pollack, C. E., Shardell, M., & Cannuscio, C. (2011). Mortgage Delinquency and Changes in Access to Health Resources and Depressive Symptoms in a Nationally Representative Cohort of Americans Older Than 50 Years. American Journal of Public Health, 101(12), 2293–2298. https://doi.org/10.2105/AJPH.2011.300245 Alliance to End Homelessness in Suburban Cook County. (2019). Alliance to End Homelessness in Suburban Cook County 2019 Project Prioritization Discussion. Amadeo, K. (2019). See for Yourself If Obamacare Increased Health Care Costs. Retrieved from The Balance website: https://www.thebalance.com/causes-of-rising-healthcare-costs-4064878 American Immigration Council. (2017). Immigrants in Illinois. Retrieved from American Immigration Council website: https://www.americanimmigrationcouncil.org/research/immigrants-in-illinois American Public Health Association. (2018). School-Based Health Centers: Improving Health, Well-being and Educational Success (pp. 1–8). Retrieved from https://www.apha.org//media/files/pdf/sbhc/well_being_in_schools.ashx?la=en&hash=F54F7A314E6EB201C8B91F0EF8DDC673E6A3 5187 American Public Health Association. (2019). Racism and Health. Retrieved from https://www.apha.org/topics-andissues/health-equity/racism-and-health America’s Health Rankings. (n.d.). Underemployment Rate in Illinois | 2018 Annual Report. Retrieved April 2, 2019, from America’s Health Rankings website: https://www.americashealthrankings.org/explore/annual/measure/Underemployed/state/IL Anderson, K. (2018). Racial/Ethnic Residential Segregation, the Distribution of Physician’s Offices and Access to Health Care: The Case of Houston, Texas. Social Sciences, 7(8), 1–18. Apter, A. J., Garcia, L. A., Boyd, R. C., Wang, X., Bogen, D. K., & Ten Have, T. (2010). Exposure to community violence is associated with asthma hospitalizations and emergency department visits. The Journal of Allergy and Clinical Immunology, 126(3), 552–557. https://doi.org/10.1016/j.jaci.2010.07.014 Australian Institute of Health and Welfare. (2016). About Chronic disease. Retrieved from Australian Institute of Health and Welfare website: https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronicdisease/about BARHII Bay Area Regional Health Inequities Initiative. (2015). A Public Health Framework for Reducing Health Inequities. Retrieved from http://barhii.org/framework/ Bell, J., Mora, G., Hagan, E., Rubin, V., & Karpyn, A. (2013). Access to Healthy Food and Why it Matters: A Review of the Research. Retrieved from PolicyLink website: http://thefoodtrust.org/uploads/media_items/access-to-healthyfood.original.pdf Berkowitz, S. A., Kalkhoran, S., Edwards, S. T., Essien, U. R., & Baggett, T. P. (2018). Unstable Housing and DiabetesRelated Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients. Diabetes Care, 41(5), 933–939. https://doi.org/10.2337/dc17-1812 Bernell, S., & Howard, S. W. (2016). Use Your Words Carefully: What Is a Chronic Disease? Frontiers in Public Health, 4. https://doi.org/10.3389/fpubh.2016.00159 Bhaumik, U., Norris, K., Charron, G., Walker, S. P., Sommer, S. J., Chan, E., … Woods, E. R. (2013). A Cost Analysis for a Community-Based Case Management Intervention Program for Pediatric Asthma. Journal of Asthma, 50(3), 310–317. https://doi.org/10.3109/02770903.2013.765447 Billi, J. E., Pai, C.-W., & Spahlinger, D. A. (2007). The effect of distance to primary care physician on health care utilization and disease burden. Health Care Management Review, 32(1), 22. Boynton-Jarrett, R., Fargnoli, J., Suglia, S. F., Zuckerman, B., & Wright, R. J. (2010). Association Between Maternal Intimate Partner Violence and Incident Obesity in Preschool-Aged Children: Results From the Fragile Families Alliance for Health Equity129

and Child Well-being Study. Archives of Pediatrics & Adolescent Medicine, 164(6), 540–546. https://doi.org/10.1001/archpediatrics.2010.94 Bulka, C., Nastoupil, L. J., Koff, J. L., Bernal-Mizrachi, L., Ward, K., Williams, J. N., … Flowers, C. R. (2016). Relations Between Residential Proximity to EPA-Designated Toxic Release Sites and Diffuse Large B-Cell Lymphoma Incidence. Southern Medical Journal, 109(10), 606–614. https://doi.org/10.14423/SMJ.0000000000000545 Burdette, H. L., Wadden, T. A., & Whitaker, R. C. (2006). Neighborhood safety, collective efficacy, and obesity in women with young children. Obesity (Silver Spring, Md.), 14(3), 518–525. https://doi.org/10.1038/oby.2006.67 Campbell, N. C., Elliott, A. M., Sharp, L., Ritchie, L. D., Cassidy, J., & Little, J. (2000). Rural factors and survival from cancer: analysis of Scottish cancer registrations. British Journal of Cancer, 82(11), 1863–1866. https://doi.org/10.1054/bjoc.1999.1079 Carver, A., Timperio, A., & Crawford, D. (2008). Perceptions of neighborhood safety and physical activity among youth: the CLAN study. Journal of Physical Activity & Health, 5(3), 430–444. CDC Foundation. (2017). Maternal Mortality Review Committee Facilitation Guide. Retrieved from http://reviewtoaction.org/sites/default/files/national-portalmaterial/Maternal%20Mortality%20Review%20Committee%20Facilitation%20Guide_V9.pdf Center for Outcomes Research and Education. (2016). Health in Housing: Exploring the Intersection between Housing and Health Care (p. 44). Retrieved from https://www.enterprisecommunity.org/download?fid=5703&nid=4247 Center for Social Inclusion. (n.d.). What Is Racial Equity? Retrieved from CSI: Center for Social Inclusion website: https://www.centerforsocialinclusion.org/our-work/what-is-racial-equity/ Centers for Disease Control and Prevention. (2012). The Four Domains of Chronic Disease Prevention: Working Toward Healthy People in Healthy Communities (p. 4). Retrieved from Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion website: https://stacks.cdc.gov/view/cdc/27508/cdc_27508_DS1.pdf Centers for Disease Control and Prevention. (2013). CDC Health Disparities and Inequalities Report - United States 2013. Morbidity and Mortality Weekly Report, 62(3), 1–189. Centers for Disease Control and Prevention. (2018). 2017 STD Surveillance Report | CDC. Retrieved from https://www.cdc.gov/nchhstp/newsroom/2018/2017-STD-surveillance-report.html Centers for Disease Control and Prevention. (2019a). Health and Economic Costs of Chronic Disease. Retrieved from https://www.cdc.gov/chronicdisease/about/costs/index.htm Centers for Disease Control and Prevention. (2019b). National Center for Chronic Disease Prevention and Health Promotion: About Chronic Diseases: Retrieved from https://www.cdc.gov/chronicdisease/about/index.htm Centers for Disease Control and Prevention. (2019c). STD Facts - Congenital Syphilis. Retrieved from https://www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm Centers for Disease Control and Prevention. (2019d). STD Facts - Gonorrhea. Retrieved from https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm Centers for Disease Control and Prevention. (2019e). STD Health Equity. Retrieved April 22, 2019, from https://www.cdc.gov/std/health-disparities/default.htm Centers for Disease Control and Prevention (CDC). (2008). Adverse health conditions and health risk behaviors associated with intimate partner violence--United States, 2005. MMWR. Morbidity and Mortality Weekly Report, 57(5), 113–117. Chen, A., Revere, L., & Ramphul, R. (2016). Assessing the Proximity Relationship of Walk-in Clinics and Primary Care Physicians. The Journal of Ambulatory Care Management, 39(4), 325–332. https://doi.org/10.1097/JAC.0000000000000152 Chicago Department of Public Health. (2016). HIV/STI Surveillance Report December 2016 (pp. 1–87). Retrieved from https://www.chicago.gov/content/dam/city/depts/cdph/HIV_STI/2016HIV_STI_SurveillanceReport.pdf Chicago HEAL Initiative. (2018). Chicago HEAL Initiative: An Action Plan from Chicago Hospitals & U.S. Senator Richard J. Durbin on Strengthening Neighborhood Engagement to Reduce Violence & Improve Health. Retrieved from https://www.durbin.senate.gov/imo/media/doc/Chicago%20HEAL%20Initiative%20FINAL.pdf Chicago Urban Agriculture Mapping Project. (2019). Chicago Urban Agriculture Mapping Project. Retrieved from https://cuamp.org/ Alliance for Health Equity130

Christopher, A. S., Himmelstein, D. U., Woolhandler, S., & McCormick, D. (2018). The Effects of Household Medical Expenditures on Income Inequality in the United States. American Journal of Public Health, 108(3), 351–354. https://doi.org/10.2105/AJPH.2017.304213 Clemson, L., Mackenzie, L., Ballinger, C., Close, J. C. T., & Cumming, R. G. (2008). Environmental Interventions to Prevent Falls in Community-Dwelling Older People: A Meta-Analysis of Randomized Trials. Journal of Aging and Health, 20(8), 954–971. https://doi.org/10.1177/0898264308324672 Coker, A. L., Smith, P. H., Bethea, L., King, M. R., & McKeown, R. E. (2000). Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine, 9(5), 451–457. Collins, C., Hewson, D., Munger, R., & Wade, T. (2010). Models of Behavioral Health Integration. Retrieved from Milbank Memorial Fund website: https://www.milbank.org/publications/evolving-models-of-behavioral-health-integration-inprimary-care/ Cook County Department of Public Health. (2018). Annual Sexually Transmitted Infections Surveillance Report 2016 (p. 22). Retrieved from http://cookcountypublichealth.org/files/pdf/std-sti/2016-ccdph-sti-surveillance-report-final.pdf Corporation for Supportive Housing. (2019). Corporation for Supportive Housing HMIS Data. County Health Rankings and Roadmaps. (2014). How Healthy is your County? | County Health Rankings. Retrieved from County Health Rankings & Roadmaps website: http://www.countyhealthrankings.org/homepage Cramm, J. M., & Nieboer, A. P. (2015). Social cohesion and belonging predict the well-being of community-dwelling older people. BMC Geriatrics, 15(1), 30. https://doi.org/10.1186/s12877-015-0027-y DiMaggio, C., Brady, J., & Li, G. (2015). Association of the Safe Routes to School program with school-age pedestrian and bicyclist injury risk in Texas. Injury Epidemiology, 2(1), 15. https://doi.org/10.1186/s40621-015-0038-3 Djurhuus, S., Hansen, H. S., Aadahl, M., & Glümer, C. (2014). The Association between Access to Public Transportation and Self-Reported Active Commuting. International Journal of Environmental Research and Public Health, 11(12), 12632–12651. https://doi.org/10.3390/ijerph111212632 Fazzo, L., Minichilli, F., Santoro, M., Ceccarini, A., Della Seta, M., Bianchi, F., … Martuzzi, M. (2017). Hazardous waste and health impact: a systematic review of the scientific literature. Environmental Health, 16. https://doi.org/10.1186/s12940-017-0311-8 Feeding America. (2018). Summer Food Service Program. Retrieved from https://www.feedingamerica.org/ourwork/hunger-relief-programs/summer-food-service-program Feinglass, J., Wein, S., Teter, C., Schaeffer, C., & Rogers, A. (2018). A qualitative study of urban hospital transitional care. Qualitative Research in Medicine and Healthcare, 2(2). https://doi.org/10.4081/qrmh.2018.7216 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8 Ferguson, H., Bovaird, S., & Mueller, M. (2007). The impact of poverty on educational outcomes for children. Paediatrics & Child Health, 12(8), 701–706. Florida, R., & Mellander, C. (2015). Segregated City: The Geography of Economic Segregation in America’s Metros. Retrieved from http://martinprosperity.org/wp-content/uploads/2015/02/Segregated-City.pdf Forno, E., & Celedón, J. C. (2012). Health Disparities in Asthma. American Journal of Respiratory and Critical Care Medicine, 185(10), 1033–1035. https://doi.org/10.1164/rccm.201202-0350ED Frank, D. A., Neault, N. B., Skalicky, A., Cook, J. T., Wilson, J. D., Levenson, S., … Berkowitz, C. (2006). Heat or Eat: The Low Income Home Energy Assistance Program and Nutritional and Health Risks Among Children Less Than 3 Years of Age. Pediatrics, 118(5), e1293–e1302. https://doi.org/10.1542/peds.2005-2943 Gapen, M., Cross, D., Ortigo, K., Graham, A., Johnson, E., Evces, M., … Bradley, B. (2011). Perceived Neighborhood Disorder, Community Cohesion, and PTSD Symptoms Among Low-Income African Americans in an Urban Health Setting. American Journal of Orthopsychiatry, 81(1), 31–37. https://doi.org/10.1111/j.1939-0025.2010.01069.x Garcia, E., & Weiss, E. (2015). Early Education Gaps by Social Class and Race Start U.S. Children Out on Unequal Footing: A Summary of the Major Findings in Inequalities at the Starting Gate (pp. 1–13). Retrieved from Economic Policy Institute website: https://www.epi.org/publication/early-education-gaps-by-social-class-and-racestart-u-s-children-out-on-unequal-footing-a-summary-of-the-major-findings-in-inequalities-at-the-starting-gate/ Gardner, J. W., & Sanborn, J. S. (1990). Years of potential life lost (YPLL)--what does it measure? Epidemiology (Cambridge, Mass.), 1(4), 322–329. Alliance for Health Equity131

Gaskin, D. J., Thorpe, R. J., McGinty, E. E., Bower, K., Rohde, C., Young, J. H., … Dubay, L. (2014). Disparities in Diabetes: The Nexus of Race, Poverty, and Place. American Journal of Public Health, 104(11), 2147–2155. https://doi.org/10.2105/AJPH.2013.301420 Gay, Lesbian, and Straight Education Network. (2013). The 2013 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools (pp. 1–168). Retrieved from https://www.glsen.org/sites/default/files/2013%20National%20School%20Climate%20Survey%20Full%20Report_ 0.pdf Geertsma, M. (2018). New Map Shows Chicago Needs Environmental Justice Reforms. Retrieved from NRDC website: https://www.nrdc.org/experts/meleah-geertsma/new-map-shows-chicago-needs-environmental-justice-reforms Gerrity, M. (2016). Behavioral Health Integration: Evidence Update (pp. 1–58). Retrieved from Milbank Memorial Fund website: https://www.milbank.org/publications/evolving-models-of-behavioral-health-integration-evidence-update2010-2015/ Gonzalez, J. S., Hendriksen, E. S., Collins, E. M., Durán, R. E., & Safren, S. A. (2009). Latinos and HIV/AIDS: examining factors related to disparity and identifying opportunities for psychosocial intervention research. AIDS and Behavior, 13(3), 582–602. https://doi.org/10.1007/s10461-008-9402-4 Great Cities Institute. (2017). The High Costs for Out of School and Jobless Youth in Chicago and Cook County. Retrieved from https://greatcities.uic.edu/wp-content/uploads/2017/06/HighCostsforYouth-v1.5-min.pdf Green and Healthy Homes Initiative. (n.d.). Retrieved from Green & Healthy Homes Initiative website: https://www.greenandhealthyhomes.org/ Guagliardo, M. F., Ronzio, C. R., Cheung, I., Chacko, E., & Joseph, J. G. (2004). Physician accessibility: an urban case study of pediatric providers. Health & Place, 10(3), 273–283. https://doi.org/10.1016/j.healthplace.2003.01.001 Harling, G., Subramanian, S., Bärnighausen, T., & Kawachi, I. (2013). Socioeconomic disparities in Sexually Transmitted Infections among young adults in the United States: examining the interaction between income and race/ethnicity. Sexually Transmitted Diseases, 40(7), 575–581. https://doi.org/10.1097/OLQ.0b013e31829529cf Harris, M. L., Oldmeadow, C., Hure, A., Luu, J., Loxton, D., & Attia, J. (2017). Stress increases the risk of type 2 diabetes onset in women: A 12-year longitudinal study using causal modelling. PLoS ONE, 12(2). https://doi.org/10.1371/journal.pone.0172126 Hausmann, L. R. M., Jeong, K., Bost, J. E., & Ibrahim, S. A. (2008). Perceived discrimination in health care and use of preventive health services. Journal of General Internal Medicine, 23(10), 1679–1684. https://doi.org/10.1007/s11606-008-0730-x HealthyPeople 2020. (n.d.). Sexually Transmitted Diseases | Healthy People 2020. Retrieved March 21, 2019, from https://www.healthypeople.gov/2020/topics-objectives/topic/sexually-transmitted-diseases Henricks, K., Lewis, A. E., Arenas, I., & Lewis, D. G. (2017). A Tale of Three Cities: The State of Racial Justice in Chicago Report. https://doi.org/10.31235/osf.io/9wgs5 Hero, J. O., Zaslavsky, A. M., & Blendon, R. J. (2017). The United States Leads Other Nations In Differences By Income In Perceptions Of Health And Health Care. Health Affairs, 36(6), 1032–1040. https://doi.org/10.1377/hlthaff.2017.0006 Hikichi, H., Aida, J., Tsuboya, T., Kondo, K., & Kawachi, I. (2016). Can Community Social Cohesion Prevent Posttraumatic Stress Disorder in the Aftermath of a Disaster? A Natural Experiment From the 2011 Tohoku Earthquake and Tsunami. American Journal of Epidemiology, 183(10), 902–910. https://doi.org/10.1093/aje/kwv335 Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113 Houry, D., Kemball, R., Rhodes, K. V., & Kaslow, N. J. (2006). Intimate partner violence and mental health symptoms in African American female ED patients. The American Journal of Emergency Medicine, 24(4), 444–450. https://doi.org/10.1016/j.ajem.2005.12.026 Hser, Y.-I., Mooney, L. J., Saxon, A. J., Miotto, K., Bell, D. S., Zhu, Y., … Huang, D. (2017). High Mortality Among Patients With Opioid Use Disorder in a Large Healthcare System. Journal of Addiction Medicine, 11(4), 315–319. https://doi.org/10.1097/ADM.0000000000000312

Alliance for Health Equity132

Hunt, K. A., Weber, E. J., Showstack, J. A., Colby, D. C., & Callaham, M. L. (2006). Characteristics of frequent users of emergency departments. Annals of Emergency Medicine, 48(1), 1–8. https://doi.org/10.1016/j.annemergmed.2005.12.030 Illinois Department of Corrections. (2018). CY18 Adult Offender Population Data. Illinois Department of Human Services. (2018). Access to Medication Assisted Treatment (MAT) Pilot Grant. Retrieved from https://www.dhs.state.il.us/page.aspx?item=105474 Illinois Department of Public Health. (2018). Illinois Maternal Morbidity and Mortality Report (pp. 1–44). Retrieved from http://dph.illinois.gov/sites/default/files/publications/publicationsowhmaternalmorbiditymortalityreport112018.pdf Illinois General Assembly. Public Act 100-1019. , (2019). Illinois Housing Task Force. (2017). 2017 Supportive Housing Working Group: Report on Activities and Recommendations (pp. 1–63). Retrieved from https://www.ihda.org/wp-content/uploads/2015/07/SHWG-Final_1-18-17.pdf Institute of Medicine. (1993). Access to Health Care in America (M. Millman, Ed.). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK235882/ Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (B. D. Smedley, A. Y. Stith, & A. R. Nelson, Eds.). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK220358/ Irvin-Erickson, Y., Lynch, M., Gurvis, A., Mohr, E., & Bai, B. (2017). Gun Violence Affects the Economic Health of Communities (p. 4). Retrieved from Urban Institute website: https://www.urban.org/sites/default/files/publication/90666/eigv_brief_0.pdf Jacobs, D. E. (2011). Environmental Health Disparities in Housing. American Journal of Public Health, 101(Suppl 1), S115–S122. https://doi.org/10.2105/AJPH.2010.300058 Johnson, S. L., Solomon, B. S., Shields, W. C., McDonald, E. M., McKenzie, L. B., & Gielen, A. C. (2009). Neighborhood violence and its association with mothers’ health: assessing the relative importance of perceived safety and exposure to violence. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 86(4), 538–550. https://doi.org/10.1007/s11524-009-9345-8 Joint Center for Housing Studies of Harvard University. (2017). The State of the Nation’s Housing (pp. 1–44). Retrieved from http://www.jchs.harvard.edu/sites/default/files/harvard_jchs_state_of_the_nations_housing_2017.pdf Jones, A. P., & Bentham, G. (1997). Health service accessibility and deaths from asthma in 401 local authority districts in England and Wales, 1988-92. Thorax, 52(3), 218–222. Kaiser Family Foundation. (2017). Health Coverage of Immigrants. Retrieved from The Henry J. Kaiser Family Foundation website: https://www.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/ Kaiser Family Foundation. (2018a). Medicaid in Illinois Fact Sheet. Retrieved from http://files.kff.org/attachment/factsheet-medicaid-state-IL Kaiser Family Foundation. (2018b, December 7). Key Facts about the Uninsured Population. Retrieved January 25, 2019, from The Henry J. Kaiser Family Foundation website: https://www.kff.org/uninsured/fact-sheet/key-facts-aboutthe-uninsured-population/ Kaiser Family Foundation. (2019). Health Coverage of Immigrants. Retrieved from The Henry J. Kaiser Family Foundation website: https://www.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/ Kawachi, I., & Berkman, L. (2000). Social Cohesion, Social Capital, and Health. In Social Epidemiology (pp. 174–190). New York: Oxford University Press. Kay Johnson, Samuel Posner, Janis Biermann, José Cordero, Hani Atrash, Christopher Parker, … Michele Curtis. (2006). Recommendations to Improve Preconception Health and Health Care -United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. Retrieved from Centers for Disease Control and Prevention and Agency for Toxic Substance and Disease Registry website: https://www.cdc.gov/mmwr/preview/mmwrhtmL/rr5506a1.htm Kelly, C., Hulme, C., Farragher, T., & Clarke, G. (2016). Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open, 6(11). https://doi.org/10.1136/bmjopen-2016-013059 Kendall-Tackett, K. A., & Marshall, R. (1999). Victimization and diabetes: an exploratory study. Child Abuse & Neglect, 23(6), 593–596. https://doi.org/10.1016/S0145-2134(99)00033-2 Alliance for Health Equity133

Kilpatrick, D., Ruggiero, K., Acierno, R., Saunders, B., Resnick, H., & Best, C. (2003). Violence and Risk of PTSD, Major Depression, Substance Abuse/Dependence, and Comorbidity: Results From the National Survey of Adolescents. Journal of Consulting and Clinical Psychology, 71(4), 692–700. Kingsbury, J. H., & Reckinger, D. (2016). Clearing the Air: Smoke-Free Housing Policies, Smoking, and Secondhand Smoke Exposure Among Affordable Housing Residents in Minnesota, 2014-2015. Preventing Chronic Disease, 13, E111. https://doi.org/10.5888/pcd13.160195 Knesper, D. (2011). Continuity of Care for Suicide Prevention and Research. Retrieved from American Association of Suicidology; Suicide Prevention Resource Center; University of Michigan Health System website: http://www.sprc.org/sites/default/files/migrate/library/continuityofcare.pdf Krieger, J., & Higgins, D. L. (2002). Housing and Health: Time Again for Public Health Action. American Journal of Public Health, 92(5), 758–768. Kushel, M. B., Perry, S., Bangsberg, D., Clark, R., & Moss, A. R. (2002). Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study. American Journal of Public Health, 92(5), 778–784. Lacy, K. (2016). The New Sociology of Suburbs: A Research Agenda for Analysis of Emerging Trends. Annual Review of Sociology, 42(1), 369–384. https://doi.org/10.1146/annurev-soc-071312-145657 Ladd, G. W., Ettekal, I., & Kochenderfer-Ladd, B. (2017). Peer victimization trajectories from kindergarten through high school: Differential pathways for children’s school engagement and achievement? Journal of Educational Psychology, 109(6), 826–841. https://doi.org/10.1037/edu0000177 Laderman, M., Dasgupta, A., Henderson, R., & Waghray, A. (2018). Tackling The Mental Health Crisis In Emergency Departments: Look Upstream For Solutions. Health Affairs. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20180123.22248/full/ Larry Cohen, Rachel Davis, Larissa Estes, Leslie Mikkelsen, & Sheila Savannah. (2017). Back to Our Roots (pp. 1–69). Retrieved from Prevention Institute website: https://www.preventioninstitute.org/sites/default/files/publications/Back%20to%20Our%20RootsCatalyzing%20Community%20Action%20for%20Mental%20Health%20and%20Wellbeing.pdf Larson, C. P. (2007). Poverty during pregnancy: Its effects on child health outcomes. Paediatrics & Child Health, 12(8), 673–677. Larson, N., Story, M. T., & Nelson, M. C. (2009). Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S. American Journal of Preventive Medicine, 36(1), 74-81.e10. https://doi.org/10.1016/j.amepre.2008.09.025 Lezzoni, L. I. (2011). Eliminating Health And Health Care Disparities Among The Growing Population Of People With Disabilities. Health Affairs, 30(10), 1947–1954. https://doi.org/10.1377/hlthaff.2011.0613 Linares, L. O. (2004). Social Connection to Neighbors, Multiple Victimization, and Current Health Among Women Residing in High Crime Neighborhoods. Journal of Family Violence, 19(6), 347–358. https://doi.org/10.1007/s10896-0040680-y Lloyd, D. (2015). Conversation with David Lloyd, Director of Policy and Programs, Kennedy Forum Illinois. Retrieved from https://aspe.hhs.gov/basic-report/development-and-testing-behavioral-health-quality-measures-health-plans-finalreport Logan, J. (2011). Whose schools are failing? (pp. 1–15). Retrieved from Russell Sage Foundation and Brown University website: https://s4.ad.brown.edu/Projects/Diversity/Data/Report/report5.pdf MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues Short title: U.S. Maternal Mortality Trends. Obstetrics and Gynecology, 128(3), 447–455. https://doi.org/10.1097/AOG.0000000000001556 Maness, D. L., & Khan, M. (2014). Care of the Homeless: An Overview. American Family Physician, 89(8), 634–640. Maqbool, N., Viveiros, J., & Ault, M. (2015). The Impacts of Affordable Housing on Health: A Research Summary (p. 12). Retrieved from Center for Housing Policy website: https://www.nhc.org/wp-content/uploads/2017/03/The-Impactsof-Affordable-Housing-on-Health-A-Research-Summary.pdf Marcovecchio, M. L., & Chiarelli, F. (2012). The effects of acute and chronic stress on diabetes control. Science Signaling, 5(247), pt10. https://doi.org/10.1126/scisignal.2003508 Mauer, B. (2006). Morbidity and Mortality in People with Serious Mental Illness (p. 87). Retrieved from National Association of State Mental Health Program Directors website: Alliance for Health Equity134

http://www.recoverywithinreach.org/healthandwellness/sm_files/2006ParksSvendsen%20Singer%20FotiMortality %20and%20Morbidity%20Final%20Report%2008182008.pdf McNutt, L.-A., Carlson, B. E., Persaud, M., & Postmus, J. (2002). Cumulative abuse experiences, physical health and health behaviors. Annals of Epidemiology, 12(2), 123–130. Mental Health America. (2015). The State of Mental Health in America. Retrieved March 18, 2019, from Mental Health America website: http://www.mentalhealthamerica.net/issues/state-mental-health-america Metropolitan Planning Council. (2017). The Cost of Segregation (pp. 1–24). Retrieved from http://www.metroplanning.org/uploads/cms/documents/cost-of-segregation.pdf Movement Advancement Project. (n.d.). Illinois’ Equity Profile. Retrieved from http://www.lgbtmap.org/equalitymaps/profile_state/IL NAMI Chicago. (2019). Roadmap to Wellness: Reframing the Mental Health Conversation for Chicago. Retrieved from https://namichicago.org/wp-content/uploads/2019/01/NAMI_roadmap_FINAL-012319.pdf National Academies of Sciences, E., Baciu, A., Negussie, Y., Geller, A., & Weinstein, J. N. (2017). The State of Health Disparities in the United States. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK425844/ National Association of Community Health Centers. (2015). Qualified Health Plans & Health Centers: A Primer (pp. 1–3). Retrieved from http://www.nachc.org/wp-content/uploads/2016/02/QHP_FS_2015.pdf National Center for Education Statistics. (2016). Student Reports of Bullying: Results from the 2015 school crime supplement to the National Crime Victimization Survey (pp. 1–51). Retrieved from U.S. Department of Education website: https://nces.ed.gov/pubs2017/2017015.pdf National Center for Health Statistics. (2017). Health, United States, 2017, With Special Feature on Mortality (p. 87). Retrieved from Centers for Disease Control and Prevention website: https://www.cdc.gov/nchs/data/hus/hus17.pdf National Center for Injury Prevention and Control. (2018). Preventing Bullying (pp. 1–2). Retrieved from Centers for Disease Control and Prevention, Division of Violence Prevention website: https://www.cdc.gov/violenceprevention/pdf/bullying-factsheet508.pdf National Council for Behavioral Health. (n.d.). Trauma-Informed Primary Care Initiative. Retrieved from National Council website: https://www.thenationalcouncil.org/trauma-informed-primary-care-initiative-learning-community/ National Environmental Health Association. (2013). Definitions of Environmental Health. Retrieved from https://www.neha.org/about-neha/definitions-environmental-health National Institutes of Health. (2017). Health Disparities. Retrieved from https://www.nhlbi.nih.gov/health/educational/healthdisp/#source1 Niedzwiecki, M. J., Sharma, P. J., Kanzaria, H. K., McConville, S., & Hsia, R. Y. (2018). Factors Associated With Emergency Department Use by Patients With and Without Mental Health Diagnoses. JAMA Network Open, 1(6), e183528–e183528. https://doi.org/10.1001/jamanetworkopen.2018.3528 Nijhawan, A. E. (2016). Infectious Diseases and the Criminal Justice System: A Public Health Perspective. The American Journal of the Medical Sciences, 352(4), 399–407. https://doi.org/10.1016/j.amjms.2016.05.020 Odgers, C. L., Moffitt, T. E., Tach, L. M., Sampson, R. J., Taylor, A., Matthews, C. L., & Caspi, A. (2009). The Protective Effects of Neighborhood Collective Efficacy on British Children Growing Up in Deprivation: A Developmental Analysis. Developmental Psychology, 45(4), 942–957. https://doi.org/10.1037/a0016162 Odoms-Young, A. M., Zenk, S., & Mason, M. (2009). Measuring Food Availability and Access in African-American Communities: Implications for Intervention and Policy. American Journal of Preventive Medicine, 36(4, Supplement), S145–S150. https://doi.org/10.1016/j.amepre.2009.01.001 O’Sullivan, M. M., Brandfield, J., Hoskote, S. S., Segal, S. N., Chug, L., Modrykamien, A., & Eden, E. (2012). Environmental Improvements Brought by the Legal Interventions in the Homes of Poorly Controlled Inner-city Adult Asthmatic Patients: A Proof-of-Concept Study. Journal of Asthma, 49(9), 911–917. https://doi.org/10.3109/02770903.2012.724131 Ou, J. Y., Levy, J. I., Peters, J. L., Bongiovanni, R., Garcia-Soto, J., Medina, R., & Scammell, M. K. (2016). A Walk in the Park: The Influence of Urban Parks and Community Violence on Physical Activity in Chelsea, MA. International Journal of Environmental Research and Public Health, 13(1). https://doi.org/10.3390/ijerph13010097 Pastore, D. R., Fisher, M., & Friedman, S. B. (1996). Violence and mental health problems among urban high school students. Journal of Adolescent Health, 18(5), 320–324. https://doi.org/10.1016/1054-139X(95)00063-X Alliance for Health Equity135

Peek, C., & The National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus (p. 57). Retrieved from Agency for Healthcare Research and Quality website: http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. Plichta, S. B. (2004). Intimate partner violence and physical health consequences: policy and practice implications. Journal of Interpersonal Violence, 19(11), 1296–1323. https://doi.org/10.1177/0886260504269685 Powell, A. (2016). The costs of inequality: Money = quality health care = longer life. Harvard Gazette. Retrieved from https://news.harvard.edu/gazette/story/2016/02/money-quality-health-care-longer-life/ Powell, J. (2013). Pursuing Racial Justice in the 21st Century: Understanding Structural Racialization. Journal of Poverty Law and Policy, 47(5–6), 1–10. Prevention Institute. (2011a). Fact Sheet: Violence and Chronic Illness. Retrieved from Urban Networks to Increase Thriving Youth Through Violence Prevention website: https://www.preventioninstitute.org/sites/default/files/publications/Fact%20Sheet%20Links%20Between%20Violen ce%20and%20Chronic%20Illness.pdf Prevention Institute. (2011b). Fact Sheet: Violence and Mental Health (pp. 1–3). Retrieved from Urban Networks to Increase Thriving Youth Through Violence Prevention website: https://www.preventioninstitute.org/sites/default/files/publications/Fact%20Sheet%20Links%20Between%20Violen ce%20and%20Mental%20Health.pdf Rabinovitz, J. (2016). Local education inequities across U.S. revealed in new Stanford data set. Stanford News. Retrieved from https://news.stanford.edu/2016/04/29/local-education-inequities-across-u-s-revealed-new-stanford-data-set/ Race Forward. (2014). Moving the Race Conversation Forward. Retrieved from Race Forward website: https://www.raceforward.org/research/reports/moving-race-conversation-forward Respiratory Health Association. (2018). Persisting Racial Disparities Among Chicago Children with Asthma (pp. 1–8). Rizzo, V. M., Rowe, J. M., Shier Kricke, G., Krajci, K., & Golden, R. (2016). AIMS: A Care Coordination Model to Improve Patient Health Outcomes. Health and Social Work, 41(3), 191–195. https://doi.org/10.1093/hsw/hlw029 Robert Wood Johnson Foundation. (2008). Overcoming Obstacles to Health. Retrieved from http://www.commissiononhealth.org/PDF/ObstaclesToHealth-Report.pdf Robert Wood Johnson Foundation. (2009). Educaiton Matters for Health (No. 6; pp. 1–15). Retrieved from Commission to Build a Healthier America website: http://www.commissiononhealth.org/PDF/c270deb3-ba42-4fbd-baeb2cd65956f00e/Issue%20Brief%206%20Sept%2009%20-%20Education%20and%20Health.pdf Robert Wood Johnson Foundation. (2011). Housing and Health (No. 7; pp. 1–11). Retrieved from https://www.rwjf.org/en/library/research/2011/05/housing-and-health.html Rose, C. A., & Espelage, D. L. (2012). Risk and Protective Factors Associated with the Bullying Involvement of Students with Emotional and Behavioral Disorders. Behavioral Disorders, 37(3), 133–148. https://doi.org/10.1177/019874291203700302 Saeki, K., Obayashi, K., & Kurumatani, N. (2015). Short-term effects of instruction in home heating on indoor temperature and blood pressure in elderly people: a randomized controlled trial. Journal of Hypertension, 33(11), 2338–2343. https://doi.org/10.1097/HJH.0000000000000729 Saijo, Y., Yoshioka, E., Kawanishi, Y., Nakagi, Y., Hanley, S. J. B., & Yoshida, T. (2018). Relationships between roaddistance to primary care facilities and ischemic heart disease and stroke mortality in Hokkaido, Japan: A Bayesian hierarchical approach to ecological count data. Journal of General and Family Medicine, 19(1), 4–8. https://doi.org/10.1002/jgf2.140 Salzinger, S., Feldman, R. S., Stockhammer, T., & Hood, J. (2002). An ecological framework for understanding risk for exposure to community violence and the effects of exposure on children and adolescents. Aggression and Violent Behavior, 7(5), 423–451. https://doi.org/10.1016/S1359-1789(01)00078-7 Sandel, M., Sheward, R., Cuba, S. E. de, Coleman, S. M., Frank, D. A., Chilton, M., … Cutts, D. (2018). Unstable Housing and Caregiver and Child Health in Renter Families. Pediatrics, 141(2), e20172199. https://doi.org/10.1542/peds.2017-2199 Scharf, D. M., Eberhart, N. K., Schmidt Hackbarth, N., Horvitz-Lennon, M., Beckman, R. L., Han, B., … Burnam, M. A. (2014). Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program (pp. 1–141). Retrieved from RAND Corporation website: https://www.rand.org/pubs/research_reports/RR546.html

Alliance for Health Equity136

Schoenfeld, A. J., Jiang, W., Harris, M. B., Cooper, Z., Koehlmoos, T., Learn, P. A., … Haider, A. H. (2017). Association Between Race and Postoperative Outcomes in a Universally Insured Population Versus Patients in the State of California. Annals of Surgery, 266(2), 267–273. https://doi.org/10.1097/SLA.0000000000001958 Sentell, T., & Braun, K. L. (2012). Low Health Literacy, Limited English Proficiency, and Health Status in Asians, Latinos, and Other Racial/Ethnic Groups in California. Journal of Health Communication, 17(sup3), 82–99. https://doi.org/10.1080/10810730.2012.712621 Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA, 301(21), 2252– 2259. https://doi.org/10.1001/jama.2009.754 Simon, A. E., Fenelon, A., Helms, V., Lloyd, P. C., & Rossen, L. M. (2017). HUD Housing Assistance Associated With Lower Uninsurance Rates And Unmet Medical Need. Health Affairs, 36(6), 1016–1023. https://doi.org/10.1377/hlthaff.2016.1152 Solari, C. D., & Mare, R. D. (2012). Housing crowding effects on children’s wellbeing. Social Science Research, 41(2), 464–476. https://doi.org/10.1016/j.ssresearch.2011.09.012 South, E. C., Kondo, M. C., Cheney, R. A., & Branas, C. C. (2015). Neighborhood blight, stress, and health: a walking trial of urban greening and ambulatory heart rate. American Journal of Public Health, 105(5), 909–913. https://doi.org/10.2105/AJPH.2014.302526 Stillerman, A. (n.d.-a). Developmental Adversity, Neurobiology, Trauma-Informed Care and Resilience. Stillerman, A. (n.d.-b). Health Brief: ACEs for Health Systems and Providers (p. 13). Retrieved from Health and Medicine Policy Research Group website: http://hmprg.org/wpcontent/themes/HMPRG/backup/ACEs/Toolkit/ACEs%20intro%20presentation.pptx Substance Abuse and Mental Health Services Administration. (2014). Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015–2018. 40. Suglia, S. F., Enlow, M. B., Kullowatz, A., & Wright, R. J. (2009). Maternal Intimate Partner Violence and Increased Asthma Incidence in Children: Buffering Effects of Supportive Caregiving. Archives of Pediatrics & Adolescent Medicine, 163(3), 244–250. https://doi.org/10.1001/archpediatrics.2008.555 Suicide Prevention Resource Center. (n.d.). Emergency Departments. Retrieved from https://www.sprc.org/settings/emergency-departments Svajlenka, M. R. and N. P. (2016). Employment and disconnection among teens and young adults: The role of place, race, and education. Retrieved from Brookings website: https://www.brookings.edu/research/employment-anddisconnection-among-teens-and-young-adults-the-role-of-place-race-and-education/ TASC Inc. (2016). Medicaid Changes Needed for Criminal Justice Reform: Recommendations for States (pp. 1–4). Retrieved from http://www2.centerforhealthandjustice.org/sites/www2.centerforhealthandjustice.org/files/publications/MedicaidPol icySeries-Recs4States.pdf Taylor, L. (2018). Housing And Health: An Overview Of The Literature. Health Affairs Health Policy Brief, 1–6. https://doi.org/DOI: 10.1377/ hpb20180313.396577 Tequity. (2018). Equity vs. Equality. Retrieved from Tequity website: http://tequityworks.com/portfolio-items/equity-vsequality/ The Commonwealth Fund. (2018). The State of Health Care Coverage & Access in Illinois (p. 1). Retrieved from https://interactives.commonwealthfund.org/2018/october/coverage-access-factsheets/Illinois.pdf The Full Frame Approach and The Five Domains of Wellbeing. (n.d.). Retrieved from The Full Frame Initiative website: https://fullframeinitiative.org/resources/about-the-full-frame-approach-and-five-domains/ The Kennedy Forum. (2015). Fixing Behavioral Health Care in America A National Call for Measurement-Based Care in the Delivery of Behavioral Health Services (pp. 1–37). Retrieved from https://chp-wpuploads.s3.amazonaws.com/www.thekennedyforum.org/uploads/2017/06/KennedyForumMeasurementBasedCare_2.pdf Trivedi, A. N., & Ayanian, J. Z. (2006). Perceived Discrimination and Use of Preventive Health Services. Journal of General Internal Medicine, 21(6), 553–558. https://doi.org/10.1111/j.1525-1497.2006.00413.x Tsai, A. C. (2015). Home Foreclosure, Health, and Mental Health: A Systematic Review of Individual, Aggregate, and Contextual Associations. PLoS ONE, 10(4). https://doi.org/10.1371/journal.pone.0123182 Alliance for Health Equity137

University of Chicago Crime Lab. (n.d.). Crime Lab | UChicago Urban Labs. Retrieved from https://urbanlabs.uchicago.edu/labs/crime U.S. Census Bureau. (2017). U.S. Census Bureau QuickFacts: Cook County, Illinois. Retrieved from https://www.census.gov/quickfacts/fact/table/cookcountyillinois# U.S. Census Bureau, American Community Survey. (2017a). Housing - Substandard Housing (5-Year Estimates). U.S. Census Bureau, American Community Survey. (2017b). U.S. Census Bureau, American Community Survey, 5-year estimates 2013-2017. U.S. Department of Agriculture. (2018). USDA ERS - Definitions of Food Security. Retrieved from https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security/ U.S. Department of Health and Human Services. (2019a). Access to Health Services | Healthy People 2020. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services#1 U.S. Department of Health and Human Services. (2019b). Access to Health Services | Healthy People 2020. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services#1 U.S. Department of Housing and Development. (2016). Assisted Housing Properties - All Project-Based Properties. U.S. Department of Housing and Urban Development. (2010). Homelessness Assessment Report (pp. 1–207). Retrieved from https://www.onecpd.info/resources/documents/2010HomelessAssessmentReport.pdf U.S. Department of Veterans Affairs. (2019). PTSD: National Center for PTSD. Retrieved from https://www.ptsd.va.gov/ U.S. Environmental Protection Agency. (2015). Learn the Basics of Hazardous Waste [Overviews and Factsheets]. Retrieved from US EPA website: https://www.epa.gov/hw/learn-basics-hazardous-waste Van Houtven, C. H., Voils, C. I., Oddone, E. Z., Weinfurt, K. P., Friedman, J. Y., Schulman, K. A., & Bosworth, H. B. (2005). Perceived Discrimination and Reported Delay of Pharmacy Prescriptions and Medical Tests. Journal of General Internal Medicine, 20(7), 578–583. https://doi.org/10.1111/j.1525-1497.2005.0123.x van Ryn, M., & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science & Medicine (1982), 50(6), 813–828. Walker, C. (2010). Affordable Housing for Families and Neighborhoods: The Value of Low-Income Housing Tax Credits in New York City (pp. 1–16). Retrieved from LISC and Enterprise Community Partners website: https://www.enterprisecommunity.org/download?fid=8099&nid=3831 Voices of Child Health in Chicago. (2018-2019). Reports 1-4. Retrieved from Lurie Children's Hospital website: https://www.luriechildrens.org/en/voices-of-child-health-in-chicago/ Wang, F., & Feliberty, Y. C. (2010). Spatial Distribution of Toxic Release Inventory Sites in Chicago Area: Is There Environmental Inequity? In P. S. Showalter & Y. Lu (Eds.), Geospatial Techniques in Urban Hazard and Disaster Analysis (pp. 157–177). https://doi.org/10.1007/978-90-481-2238-7_8 Weinfield, N., Mills, G., Borger, C., Gearing, M., Macaluso, T., Montaquila, J., & Zedlewski, S. (2014). Hunger in America 2014 (pp. 1–177). Retrieved from Feeding America website: http://help.feedingamerica.org/HungerInAmerica/hunger-in-america-2014-fullreport.pdf?s_src=W191DIRCT&s_subsrc=https%3A%2F%2Fwww.feedingamerica.org%2Fresearch%2Fhungerin-america&_ga=2.205382032.1426857533.1548784583-807146896.1548784583 White, K., Haas, J. S., & Williams, D. R. (2012). Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation. Health Services Research, 47(3 Pt 2), 1278–1299. https://doi.org/10.1111/j.1475-6773.2012.01410.x Williams, D. R., Sternthal, M., & Wright, R. J. (2009a). Social determinants: taking the social context of asthma seriously. Pediatrics, 123 Suppl 3, S174-184. https://doi.org/10.1542/peds.2008-2233H Williams, D. R., Sternthal, M., & Wright, R. J. (2009b). Social Determinants: Taking the Social Context of Asthma Seriously. Pediatrics, 123(Suppl 3), S174–S184. https://doi.org/10.1542/peds.2008-2233H Williamson, A., Antonisse, L., Tolbert, J., & Garfield, R. (2016). ACA Coverage Expansions and Low-Income Workers Issue Brief. Retrieved from The Henry J. Kaiser Family Foundation website: https://www.kff.org/reportsection/aca-coverage-expansions-and-low-income-workers-issue-brief/ Wong, M. S., Gudzune, K. A., & Bleich, S. N. (2015). Provider communication quality: influence of patients’ weight and race. Patient Education and Counseling, 98(4), 492–498. https://doi.org/10.1016/j.pec.2014.12.007 Alliance for Health Equity138

Woodward, A., & Kawachi, I. (2000). Why reduce health inequalities? Journal of Epidemiology & Community Health, 54(12), 923–929. https://doi.org/10.1136/jech.54.12.923 World Health Organization. (2018a). Ambient (outdoor) air quality and health. Retrieved from https://www.who.int/newsroom/fact-sheets/detail/ambient-(outdoor)-air-quality-and-health World Health Organization. (2018b). Lead poisoning and health. Retrieved from https://www.who.int/news-room/factsheets/detail/lead-poisoning-and-health World Health Organization. (n.d.-a). Equity. Retrieved from WHO website: https://www.who.int/healthsystems/topics/equity/en/ World Health Organization. (n.d.-b). Glossary of terms used: Health inequality and health inequitiy. Retrieved from WHO website: https://www.who.int/hia/about/glos/en/index1.html World Health Organization. (n.d.-c). WHO | Integrated chronic disease prevention and control. Retrieved from WHO website: https://www.who.int/chp/about/integrated_cd/en/ World Health Organization. (n. d.-d). Causes of chronic disease. Retrieved from WHO website: https://www.who.int/chp/chronic_disease_report/part2_ch1/en/index12.html Wright, R. J., Mitchell, H., Visness, C. M., Cohen, S., Stout, J., Evans, R., & Gold, D. R. (2004). Community violence and asthma morbidity: the Inner-City Asthma Study. American Journal of Public Health, 94(4), 625–632. Zenk, S. N., Schulz, A. J., Israel, B. A., James, S. A., Bao, S., & Wilson, M. L. (2005). Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. American Journal of Public Health, 95(4), 660–667. https://doi.org/10.2105/AJPH.2004.042150

Alliance for Health Equity139