The Community Alliance for Research & Engagement (CARE) at the Yale School of Public Health was established in 2007 to identify solutions to health challenges in New Haven through community action research. CARE has developed unique collaborations between Yale and the New Haven community, including neighborhood and non-profit associations, hospitals and health centers, city government and public schools, business community as well as faith, arts and cultural institutions.
Tracking Health: New Haven Community Health Needs and Assets
New Haven is a diverse, mid-size city that experiences substantial socioeconomic and health inequities. The population is predominantly racial/ethnic minority subgroups: 35 percent Black/African American and 27 percent Hispanic/ Latino. Median household income is well below national and statewide averages. Among the 20 neighborhoods that comprise New Haven, six experience the highest levels of morbidity and premature mortality as well as the highest rates of food insecurity, poor housing, violence and crime. In 2012, we documented that obesity prevalence (43 percent) was 2.5 times higher than nearby towns. Consequently, we note disparities in disease. For example, age-adjusted mortality for diabetes ranges from 51 per 100,000 in the wealthiest suburbs to 80 per 100,000 in New Haven. More striking are disparities within the city, where the mortality rate is only 48 per 100,000 in our high-income neighborhoods and is 87 per 100,000 in our low-income neighborhoods.
CARE has been closely involved in collaborative coalitions investing resources to improve health in New Haven. One of CARE’s biggest contributions has been conducting community health assessments in 2009, 2012 and 2015. Using a neighborhood-stratified, population-based randomized design in our six lowest income neighborhoods, the purpose is to understand and document health status, behavior, and perceptions of social and built environments.
Recognizing the importance of this work and motivated by requirements of the Affordable Care Act, Yale-New Haven Hospital (fifth largest US hospital system) partnered with CARE to support the 2012 and 2015 surveys. At each timepoint, 20 community residents were hired and trained to conduct interviews, with 1,200-1,300 collected triennially in <10 weeks (70 percent response rate), and with preliminary results released shortly thereafter. CARE is committed to rapidly disseminating data back to the community – with the intention of helping communities utilize these data to create change. In addition to releasing written reports and social media, community forums were organized in each neighborhood, where staff – including community surveyors – participated and presented data directly back to residents. Action planning focused on interpreting results, generating ideas for interventions, and integrating city and neighborhood efforts. Data also are shared with elected officials and other city leadership; we work continuously with the health department, other municipal entities and various health coalitions across the city and state.
Organizing for Action
Since CARE’s initial health assessment in 2009, we have worked within the six neighborhoods – organizing with residents to make their neighborhoods healthier places in which to live and work. Communities most at-risk for obesity, diabetes and other chronic diseases also experience structural barriers within the built environment that prevent people from engaging in healthy behaviors – unsafe streets for walking/biking; lack of access to affordable, healthy foods; limited recreational resources, etc. CARE uses its data to inform, develop and build community support for neighborhood-focused, resident-led chronic disease prevention. CARE hired a team of community organizers to work with these neighborhoods to strengthen local capacity, ownership and sustainability around health. Most importantly, CARE is guided by community organizing principles to train and mobilize residents around health-related issues important to their neighborhoods. Organizers guide groups to identify health priorities, access resources, implement activities and track results. Neighborhood groups meet monthly with up to 60 residents engaged per neighborhood. Collectively, we have:
CARE also has supported traditional public health projects targeting individual behavioral change, including the YMCA’s Diabetes Prevention Program, cooking classes, walking groups, organized sports and exercise.
Strengthening Citywide Coalitions
CARE works closely with the Partnership for a Healthier New Haven, a coalition co-led by the New Haven Community Services Administration (which oversees the Health Department) and Yale-New Haven Hospital. Recognizing the potential power of the city’s robust networks – including health service, research and policy organizations – the Partnership convened stakeholders in 2010 to systematically assess and strategize to improve health. CARE engages with municipal leaders and others to develop a local approach to utilize survey findings to inform strategic planning and to develop a community health improvement plan.
The New Haven Food Policy Council (directed by CARE’s Alycia Santilli), a city commission that advises the Mayor, develops strategies to effectively address food access, hunger, obesity and food-related diseases, community and economic development, urban agriculture, nutrition and food education. In 2013, the Food Policy Council’s Food Action Plan was adopted by the Board of Alders to establish formal food policy goals and priorities for the City. The Council successfully secured funding for a citywide Food System Director and expanded the reach of New Haven Public School’s Summer Meals Program to feed hungry children by 25 percent.
Improved Population Health
This work – coupled with other health initiatives implemented across New Haven – is resulting in improved population health in New Haven’s low-income neighborhoods. Preliminary data from the December 2015 document improvements in several health-related indicators. Most notably, there was a 7 percent reduction in obesity, decreasing from 43 percent in 2012 to 40 percent in 2015. Food insecurity decreased, from 41 percent in 2012 to 32 percent in 2015. Forty-three percent of residents reported improvements in their neighborhood over the past three years that make it easier to lead a healthy lifestyle. Residents also feel safer: in 2012, 33 percent felt unsafe walking in their neighborhood during the day, and 67 percent felt unsafe walking at night; these rates dropped to 15 percent and 53 percent, respectively.
We also note improvements in healthcare: 95 percent of respondents have health insurance, up from 88 percent in 2012. In turn, residents report improved access in 2015: 87 percent have a primary care physician; 84 percent did not delay seeking care due to cost; 81 percent could purchase needed medicines. However, these New Haven neighborhoods are still lagging in terms of healthy diet and physical activity. Only 14 percent of residents meet minimal fruit/vegetable consumption guidelines (5/day) and only 54 percent of residents meet physical activity recommendations (150 minutes/week).
Innovative collaborations are still needed to address community health among our most vulnerable populations. Through the first part of 2016, as in other years, we will be disseminating our results directly back to the community at neighborhood meetings and will host a community forum in the spring. We will collaborate directly with residents to utilize these data to improve health in our community.
CARE’s community organizing approach to health and its contributions to local coalitions, combined with rigorous survey methodology, is a unique and effective way to catalyze and sustain engagement, especially in low-resource neighborhoods. This approach can be a model for other collaborative, community-level obesity and chronic disease prevention efforts.
CARE is directed by Dr. Jeannette Ickovics, professor of chronic disease epidemiology at the Yale School of Public Health.