BUILDING BRIDGES Community-University Partnerships for Health
OBJECTIVES 1. Provide overview of CARE: Community Alliance for Research and Engagement at Yale, and our flagship initiative, Community Interventions for Health. Global health initiative with focus on chronic disease 2. Document current health status of New Haven children and adults based on >2400 surveys conducted this fall, including mental and physical health. 3. Invite collaborative research.
CARE Mission To improve the health of New Haven residents through visionary leadership, community engagement, collaborative community-based research, and dissemination of findings. Yale Center for Clinical Investigation Schools of Public Health, Medicine, Nursing
CARE S UNIQUE STRENGTHS COMMUNITY ALLIANCE RESEARCH ENGAGEMENT
CARE S UNIQUE STRENGTHS COMMUNITY
COMMUNITY New Haven Rich historical and cultural traditions Vital to economy of south central CT Ideal population size (130,000 people): small enough to create close partnerships Large and diverse enough for robust engagement, research, and action
New Haven: Community Challenges Wealth disparity CT is one of the richest states New Haven is one of poorest US cities Food insecurity: 163 of 169 towns/cities in CT Economic insecurity: 78% NHPS eligible for free/reduced price meals Health disparity From birth to death, New Haven residents face risk of illness and disability 1.5 to 7 times higher than others in the state
OUR RESPONSE Unacceptable poor health status in New Haven We can prevent or reduce many adverse health outcomes Revitalize our community by promoting health of our citizens
CARE S UNIQUE STRENGTHS ALLIANCE
CREATE/STRENGTHEN PARTNERSHIPS Take action with many partners to improve health in New Haven Create programs and policies to prevent disease and promote health Evaluate impact ALLIANCE.
ALLIANCE DIVERSE CITYWIDE COALITION o Residents and grass roots coalitions o City of New Haven officials o New Haven Public Schools o Health centers/health providers o Business community. o Leadership of community-based organizations o Faith-based communities o Organized philanthropy o Senior leadership and faculty across Yale
CARE S UNIQUE STRENGTHS RESEARCH
RESEARCH COMMUNITY INTERVENTIONS FOR HEALTH International collaborative to prevent chronic disease New Haven is first US city to participate http://www.3four50.com/cih/
Knowledge = Power Identify and document community issues Learn about experiences, priorities, and concerns of community members Mobilize community members and leaders Identify areas for improvement and solutions Determine whether solutions have worked Convince funders to provide resources Persuade policymakers to support needed programs and services
CARE S UNIQUE STRENGTHS ENGAGEMENT
ENGAGEMENT Build trust, visibility, integrity, leadership 2007 Future Search Consensus Conference Diabetes Awareness Day 2008 Heart Health Childhood Obesity Summit Sexual Health: Real Life, Real Talk 6 Community forums on Public Health & Health Disparities 2009 Arts and Ideas Festival CIH LAUNCH Conference /Workshops on Ethics, Dissemination, &Translation Community Forum on Health Equity 2010 Community conversations Active work with neighborhood groups
CARE S UNIQUE STRENGTHS COMMUNITY ALLIANCE RESEARCH ENGAGEMENT
Community Interventions for Health Prevent chronic disease
Risk Factors 3 Four 70 Unhealthy Diet Lack of exercise Tobacco Use Mokdad et al. JAMA. 2004;291:1238-45
Why Chronic Disease? It s costly! It s preventable! 75% of the nation s $2.5 trillion health care expenditures
Chronic Disease in the US Prevalence: 133 million, 50% >1 chronic condition Mortality: 70% of all deaths Premature Mortality: 33% yrs life lost before age 65 Costs: >75% of the nation s $2.5 trillion annually (direct + indirect, 2005) Smoking: $193 billion Obesity: $117 billion Heart disease & stroke: $448 billion Diabetes: $174 billion Cancer: $89 billion http://www.cdc.gov/nccdphp/overview
Preventable Hospitalizations, CT 2008 >47,000 preventable hospitalizations accounting for 255,000 patient days and $1.2 billion in charges These patients utilized more health care resources in hospital and post-discharge New Haven County - highest per capita rates for 12 of 19 conditions (e.g., asthma, CHF, COPD, diabetes-related, LBW babies) Reflect gaps in primary care, disease management, access to health services that lead to increased disease severity and hospitalization (CT Office of Health Care Access, 2010)
CT Cost: Preventable Hospitalizations Ambulatory Care Sensitive Conditions, linked to Chronic Disease $1,500,000,000 1,160,000,000 $1,000,000,000 893,000,000 611,000,000 $500,000,000 $0 2000 2004 2008 (CT Office of Health Care Access, 2010)
Prevention is Cost-Effective Clinical smoking cessation interventions cost an estimated $2,587 for each year of life saved, the most cost-effective of all clinical preventative services. $1 spent on preconception care programs for women with diabetes, can reduce health costs by up to $5.19, by preventing complications for both mothers and babies. http://www.cdc.gov/nccdphp/overview
Barriers Time and monetary constraints for engaging in healthy behaviors Accessibility/availability of healthy options Lack of knowledge and risk perception Institutional awareness of evidencebased practices to prevent chronic disease Community Interventions for Health (CIH) is a solution
CIH: A Solution Action: Intervention Programs Framework for effective intervention strategies to promote healthy lifestyles and healthy communities: programs and policies that address health and social indicators. Evidence: Research Study Large multinational cohort study to identify best practice approaches in chronic disease prevention; comparative analyses. New Haven is first US city in CIH collaborative.
Long Empirical Tradition CIH: Comprehensive Community Interventions CIH focuses on developing populations using structural interventions at the ground level AND includes a strong evaluation component Case control Biomarker Specific: Interheart Risk Factor CARMELA Cohorts: Brazil 1982 Cohort Pelotas British Cohort 1970 (BCS70) DONALD Study Germany 1985 Danish National Birth Cohort 1996 Framingham USA Bogalusa Heart Study for Children (USA) Region/Country Specific: AGITA(Brazil) Stanford 5(USA) Minnesota Heart Healthy (USA) Pawtucket (US) Isfahan(Iran) North Karelia (Finland) German CVD Prevention Study Finnmark Study (Norway) Tromsø (Norway) Finbalt Study MRFIT (USA) Setting Specific: CATCH (school) Wisewomen (HC) Sorenson Well- Work Study (W) Glasglow Take Heart(W) Surveillance MONICA EPIC Interventions Comprehensive Cardiovascular Community Control Program CINDI CARMEN
CIH: Strategies for Change 1. Strengthen broad collaborative partnerships to improve individual and community health, reduce disparities. 2. Develop and implement targeted program and policy interventions. 3. Evaluate impact of interventions through rigorous assessment over time; ensure effectiveness and sustainability.
Examples of Structural Interventions Neighborhoods Safe routes for walking and bicycling Affordable/accessible fruit carts or farmers markets Schools/Worksite Healthy food/drink in cafeteria and vending machines Advertisement-free schools Incentives for participation in on-site and off-site physical activity Before and after school programs: students, teachers, staff, families Health care settings Smoke-free hospitals with healthy food options Incentives and training for providers to screen for and prevent chronic disease
Importance of CIH Comprehensive community interventions rare. Most studies target single setting populations with mixed success and challenges regarding sustainable change. Structural interventions work. Systemic changes are cost-effective and sustainable given focus on policy, environmental and economic change rather than isolated individual behavioral change. CIH includes an extensive evaluation that include both process and outcome/impact evaluation. Urgent need to understand evidence based programs/policies to prevent chronic disease, preserve quality of life, strengthen neighborhoods, and reduce costs.
Benefits to New Haven and to Yale Improve community health and reduce health disparities with an eye to become our nation s healthiest city. Visible collaboration between City and Yale through expansion of community/university partnership; leverage world-class health research; first/only US site of large international collaborative to improve health. Improve Wellness Programs for City and University employees to reduce absenteeism, increase productivity, save money. Increase financial resources for neighborhoods, schools, health centers, and worksites, with oversight to ensure new initiatives follow a best practice road map. Strengthen network of collaborations for more robust translation of research into practice as well as active dissemination of important research findings
General Methodological Approach Framework to translate/evaluate interventions Environmental Scan/Neighborhood Asset Mapping Large prospective cohort (N 4000) Neighborhoods, schools, worksites, health centers Repeated measures, biennially Biomarkers for subset
Evaluation Indicators Prevalence D Behavioral risk factors e.g. consumption, exercise patterns D Biometric measures e.g. BMI, blood pressure Program/policy implementation Cost-benefit
Accelerated Timeline 2009-2010 Aug: Asset Map Sept: Hire/Train Oct/Nov: Surveys Dec: Preliminary Reports Feb-Apr: Reports & Community Dialogues
Focus on Six Neighborhoods Dixwell Fair Haven Hill North Newhallville West River/Dwight West Rock
Documenting New Haven s Health CARE s Neighborhood Mapping
CARE s Neighborhood Mapping MAJOR PARTNERS Neighborhoods of Choice The Community Foundation For Greater New Haven
Asset Mapping Inventory of community assets Describe assets visibly on a map Focus on assets rather than needs Tool for raising awareness
How Is Asset Mapping Done? 1) Walk neighborhood streets 2) Find, collect and map information 3) Enter info into handheld computers
What CARE Mapped: STORES Healthy and unhealthy foods Fresh produce Junk food Tobacco products
What CARE Mapped: RESTAURANTS Sit down/fast food Availability of healthy foods Nutrition information posted
What CARE Mapped Parks Gardens Recreation
Neighborhood Health Surveys
Community-Level Surveys October-November 2009, we conducted community-level surveys to get a real-time snapshot of health in New Haven 1205 randomly selected residents (adults) in 6 high-need neighborhoods 1175 5 th and 6 th grade students from 12 randomly selected schools >85% participation across both
Neighborhood Survey Demographics (N=1205) 61% women Mean age = 40 years (range18-64) Race/Ethnicity African American/Black: 64% Latino/Hispanic: 21% White: 15% Other: 4% Foreign born: 17%
Survey Findings New Haven residents report poorer health than U.S. average
Self-Rated Health
Health Insurance
Heart Disease/Attack Diabetes Asthma Obesity High Blood Pressure High Cholesterol Rate Reported (%) Health Conditions 40 35 30 25 20 15 10 5 0 All New Haven Participants National Average* *Behavioral Risk Factor Surveillance System, 2008 (Centers f or Disease Control)
Nutrition 38% eat fruit 7 days/week 48% eat vegetables 7 days/week Most had just 1-2 servings, compared to recommended 5/day
Nutrition 53% drink soda daily; 76% >2 sodas/day 32% eat sweets daily
Food Insecurity 20 18 16 14 12 18 Chart Title 11 10 8 6 All New Haven Participants National Average* US Dept of Agrilculture, 2009 4 2 0 Food Insecurity
Exercise 53% report no vigorous exercise 38% report doing no moderate exercise
Exercise Feelings of safety limit exercise 65% strongly agree or somewhat agree that it is unsafe to go for walks in their neighborhood at night
Daily Smoking
Smoking Most smokers said they would be motivated to quit by saving the money they spend on cigarettes
Stress and Depression 28% feel down, depressed or hopeless 24% report moderate to extreme stress
Mental & Physical Health STRESS DEPRESSION Self-rated Health *** *** Obesity * *** Heart Disease *** *** High Blood Pressure * NS Diabetes NS ** Lung Disease ** ** Asthma ** NS Food Insecurity * * Use ER for Care *** *** * p < 0.05; ** p < 0.01; *** p < 0.001
SUMMARY NEW HAVEN NEIGHBORHOODS Lack healthy options in stores/restaurants Parks and gardens an asset Lower self-rated health and insurance More health damaging behaviors More chronic conditions High levels of stress and depression, which are related to adverse physical health outcomes
New Haven Public Schools Working in close collaboration with Board of Education leadership 12 randomly selected K-8 schools 5th and 6th graders N=1,175, 88% participation rate 2% parental non-consent 10% absent
New Haven Public Schools Surveys Physical Measures Blood pressure
Survey Data: General Health Self-report Health 35% excellent 30% very good 28% good 7% fair/poor 68% report having regular doctor 14% illness/injury restricts activity 18% used ER since beginning of school because sick or hurt
Exercise & Limitations 56% exercise >30 minutes 5-7 days/week 46% don t feel safe in their neighborhood 27% report limitations to physical activity because of fears of safety
Meals 39% family meals 3+ times/week 26% fast food 3+ days/week 12% food insecurity
Screens 82% have TV in bedroom 3+ hours of screen time Per school day: 41% Per week-end day: 62%
Daily Food/Beverage Consumption: Students
BMI Category, School Surveys 50 40 49 49 30 31 28 Underweight 20 19 19 Healthy weight Overweight Obese 10 0 2 Boys (n=529) 4 Girls (n=612)
Blood Pressure Category, School Surveys 100 80 90.5 91.8 60 40 Normal BP Pre-HTN HTN 20 0 4.9 4.6 Boys (n=525) 3.1 5.1 Girls (n=609) PLUS SELF-REPORT 24.0% asthma (20.0% US) 3.5% diabetes (0.2% US)
Integrating Health and School Reform (1 of 2) Vision: best urban district in US. healthy children ready, willing, and able to learn Collective Investment: Mobilize students, families, teachers, staff and community for student success Wrap around services: Community partnerships/programs to support student achievement and promote health in and after school, in the community, and at home
Integrating Health and School Reform (2 of 2) Sound and Effective Infrastructure: data systems, curriculum and data teams, school evaluation, physical infrastructure, and tradition of collaboration Goals: eliminate achievement gap, health inequities, and provide all students with opportunities and necessary support to succeed.
Planned Analyses (examples) Hierarchical modeling to examine neighborhood environment and chronic disease risk, including geo-coded maps, census and crime data, behavioral survey Relative impact of school vs neighborhood environment on children s health Protective factors Health, social, environmental factors that influence academic performance Chronic stress and health: Urban Miasma
NEW HAVEN COMMUNITY INTERVENTIONS FOR HEALTH Intervention Phase Knowledge to Action Without knowledge action is useless and knowledge without action is futile (Abu Bakr, c.573 674)