why places matter building a movement for healthy communities - pl tce usa - 2007

8/14/2019 Why Places Matter Building a Movement for Healthy Communities - PL TCE USA - 2007

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Building a Movement for Healthy Communities

Why Place Matters:


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PolicyLink is a national research and action instituteadvancing economic and social equity byLifting Up What Works.

Design by: Leslie Yang

COVER PHOTOS COURTESY OF (from left to right, top to bottom): iStockphoto.com (Danny Warren), iStockphoto.com (kon-stantin32), iStockphoto.com (Thania Navarro), Harlem Childrens Zone, iStockphoto.com (Christopher Hudson), iStockphoto.com (Justin Horrocks), p.37: iStockphoto.com (kajetan), iStockphoto.com (Inger Anne Hulbkdal), Youth UpRising.

PHOTOS COURTESY OF: p.16: Harlem Childrens Zone; p.26: iStockphoto.com (Justin Horrocks); p.27: iStockphoto.com (kon-stantin32); p.28: iStockphoto.com (Kerry Muzzey); p.29: iStockphoto.com (Tomas Levstek); p.32: Blue Cross & Blue Shield ofMinnesota Foundation; p.33: iStockphoto.com (Hannamariah photography); p.34: Youth UpRising; p.37: iStockphoto.com(kajetan); p.38: iStockphoto.com (Thania Navarro); p.39: iStockphoto.com (Danny Warren); p.41: iStockphoto.com (DanielRodriguez), p.42: iStockphoto.com (Cameron Whitman); p.45: iStockphoto.com (Christopher Hudson); p.46: iStockphoto.com (Inger Anne Hulbkdal); p.47: iStockphoto.com (Brandon Laufenberg); p.48: iStockphoto.com (Michael Braun); p.57:iStockphoto.com (Pathathai Chungyam); p.58 iStockphoto (Bonnie Jacobs).


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Judith BellPresident

Victor RubinVice President for Research

Building a Movement for Healthy Communities

Why Place Matters:

All Rights Reserved.Copyright 2007.


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Why Place Matters: Building a Movement for Healthy Communities2

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Table of Contents

Case Studies 4

Preface 5

Executive Summary 6

Introduction 13

I. Class, Race, Ethnicity, and Health 18

a. Socioeconomic Status (SES) and Health 18

b. Race, Ethnicity, and Health 19

c. The Health of Immigrants 20

II. A Framework for Healthy Communities 22a. Economic Environment 24

b. Social Environment 30

c. Physical Environment 36

d. Service Environment 44

III. Themes from the Case Studies: Lessons Learned 49

IV. Recommendations: Moving Into the Future 51

Notes 62


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Case Studies

Harlem Childrens Zone: Focusing on 100 Blocks and One Child at a Time 16

Moving to Opportunity 25

Health Impact Assessment in San Francisco: A Tool to Build Healthier Communities 26

Metro Denver Health and Wellness Commission: A Broad Coalition to Address Healthin Schools, Worksites, and Communities 27

Using Food Stamps to Buy Fresh Produce at a Local Flea Market 28

Fresno Works for Better Health: A Partnership to Improve Health Through Economicand Leadership Development 29

Kids Make A Stand in Shasta County 32

The Blue Cross and Blue Shield of Minnesota Foundation: Grantmaking to AddressCommunity Conditions That Impact Health 33

Youth UpRising: A Center for Youth Leadership and Community Transformation 34

Looking at Transportation Planning Through a Health Lens 37

The Greening of Los Angeles: Improving Health Through a Movement for Urban Parks 38

Keeping Housing Away from Freeways and Toxic Polluters 39

City of Richmond: Considering Health in the General Plan 41

Improving Health by Improving Homes: Research and Advocacy in Three Cities 42

Kaiser Permanente: A Health System Looking Beyond Health Care 45

Colonias in Californias Central Valley: Working for Basic Infrastructure 46

Data + Community Collaboration = Policy Change 47

Community Coalition: Promoting Healthy NeighborhoodsThrough Leadership Development and Community Involvement 48

Unnatural Causes 53

Moving the Golden State towards Health: The Governors (and Advocates)Vision for a Healthy California 55

The Bay Area Regional Health Inequities Initiative (BARHII) 57

Reading, Writing, Arithmetic, and Health: Lessons Learned from

School Efforts to Combat Obesity 58


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PolicyLink and The California Endowment havelong recognized that place matters. Our workis informed and driven by the recognition thatneighborhood environmental factorsfrom localeconomic opportunities, to social interactions withneighbors, to the physical environment, to servicessuch as local grocery stores where people canbuy nutritious foodall affect individual health.

Were extremely enthusiastic about the growingmovement thats developing place-based solutionsto place-based problems.

We know that residents of low-income communitiesand communities of color suffer disproportionatelyfrom negative environmental factors: poor air qualityas a result of over-exposure to toxins such as dieselexhaust from highways and bus depots, poorlymaintained homes with mold, lack of healthy foodoptions, and the lack of clean, safe open spacessuch as parks and playgrounds. Social, economicand service componentslack of access to good

jobs, inadequate healthcare and other crucialservices, and fractured social networksalso presentobstacles. As detrimental as these are, we knowthat, unfortunately, they represent only a few of thefactors that cripple far too many neighborhoods andthe people who live in them. Understandably, theresmuch work to be done.

We believe that an equitable approach to buildinghealthy communities requires a number of diversetactics from multiple stakeholders. Collaborationacross a broad range of sectors and groups, includingthe private sector, is necessary to create the typeof healthy communities we want for ourselves andour neighbors. And the experience and voices ofcommunity membersparticularly people of color

must be an integral part of discussions and strategicthinking around sustainable change.

Were not alone in our belief. The organizationsand coalitions profiled in this reportmany led byvisionary leadersdemonstrate that environmentalfactors, which strengthen and enliven communities,can be created and replicated to benefit everyone.No one approach works for all communities, each isparticular to the place and the people they are meantto serve, and the goals they want to achieve.

Why Place Matters offers examples of promisingpractices from across the country, with manyconcentrated in communities throughout California.Some groups are working with planners to developstrategies for improving residents transportationoptions; some are joining with city governmentsto create plans for neighborhood economicrevitalization; some are linking healthcare services to

prevention, and others are working with the privatesector to better serve their communities social andservice needs. We trust each of them will illuminatethe connection between people and place in newways, facilitate collaboration and the exchange ofideas, encourage cross-sector partnerships, andstimulate action.

We appreciate the participation of everyone whoshared with us those best practices that are workingwell in communities, near and far. It is our hopethat these successful strategies will be used byadvocates and policymakers, government andbusiness, researchers and educators, city planners andcommunity builders, and all others who want to be apart of the movement to build healthy communities.

This report benefited significantly from researchand writing by Diana Bianco, a health care policyconsultant. The PolicyLink Center for Health andPlace teamMildred Thompson, Rebecca Flournoy,Glenda Johnson, Mary Lee, Rajni Banthia, Iman Mills,and Erika Bernabeicontributed throughout, fromthe initial conceptualization to final editing. TheCalifornia Endowment was represented by MarionStandish who provided overall vision and oversight,and George Flores who added useful comments andediting suggestions. Paulette Robinson, consultant,provided excellent editing support. We thank them

all for their dedication and hard work.

PrefacePreface

Preface

Robert K. RossPresidentThe California Endowment

Angela Glover BlackwellFounder and CEOPolicyLink


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Driven by the knowledge that whereyou live determines how you live, a newmovement is building. It is spearheadedby local leaders and anchored by the beliefthat a broad array of communities andinterests must be engaged. Advocating forequitable policies and practices to establish

healthy communities, this movement drawsfrom a broad framework, incorporating acommunitys physical, social, economic, andservice environments. Traditional single-issueboundaries are being broken, forging newconnections and alliances across diversesectors. Efforts are underway to influence andchange environmental factors so communitiescan thrive.

The leadership of this movement isappearing in many parts of society. Publichealth officials, planning officials, and

educators are studying a neighborhoodsphysical or built environmentthe safetyof its streets and parks, the conditionof housing and schools, the location ofbusinesses, and patterns of regional growthand changeas indicators of residentshealth. Community leaders, electedofficials, and organizations are realizingthat a high degree of civic participationand strong social support systems informpeoples sense of safety and belongingand influences their health. Business andcommunity leaders and government officialsare linking a neighborhoods economichealthfor example, the presence of, orconnection to, jobs paying living wages,a thriving commercial sector that employslocal residents with neighborhood-servingbusinessesto individual health and well-being. Local organizations are linkingthe presence of culturally-grounded,neighborhood-level services to the

physical and emotional health of residents,understanding that every service from theeffective delivery of medical care to the use ofrecreational programs has health implications.

The framework described in this reportprovides a way to understand the relationship

between community conditions and health,analyzes the connections among all of theenvironmental factors that contribute toa healthy community, and identifies bothprotective and negative environmental effectson community health. Why Place Mattersbuilds on the growing movement to improvethe health of individuals through a focus oncommunity and illustrates how organizationsand groups are employing effective place-based strategies throughout California andthe country.

I. Class, Race, Ethnicity,and Health

American neighborhoods are oftensegregated by race and income.Communities of color and low-incomecommunities are plagued overwhelminglyby high crime rates, under-funded schools,insufficient services, poor transportationand housing options, and other harmfulattributes that compromise individual andcommunity health. Segregation limits

residents access to full-service grocerystores; safe, walkable streets; and a healthyenvironment. In fact, polluting businesses andfactories are located much more frequentlyin communities of color, which means aless healthy neighborhood with more airand soil contamination. Communities ofcolorAfrican Americans, Latinos, and someAsian Americanssuffer disproportionately

Executive Summary


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from certain health problemsdiabetes, highblood pressure, obesity, and asthma.

Since so many American communities areinformally but thoroughly segregated by raceas well as income, health disparities are botha health and a place-based issue, one whereimproving community conditions could makea real difference in health outcomes. Whenpolicies and practices are put into place thatimprove the physical, economic, social, andservice condition of communities, the lives ofthose within the communities also improve.

II. A Framework for Healthy

CommunitiesPlace matters.

Individual health is compromised whenresidents fear walking outdoors in theevening and wont allow their children to gooutside during the day, after school, or onweekends. A childs health suffers when heor she must sit in shoddy school buildingsin need of repair, without nutritiousmeals or an opportunity for physicalactivity. Childrens and families health are

impacted when their neighborhood lacksa decent grocery store with fresh fruitsand vegetables for sale. Families sufferwhen there is little access to economicopportunities. Residents suffer in high crimeareas because crime influences the qualityand availability of services and economicopportunities; it impacts whether businesseswill locate in the neighborhood, or whetherothers will come to the neighborhood topatronize local businesses or attend social orcultural events. Neighborhoods across thecountry are afflicted with risk factors that

have profound implications for communityand individual health.

By contrast, many protective factors helpbuild and sustain community and individualhealth. Safe, well-maintained parks canpromote physical activity and public spaces

for neighborhood gatherings. Access tohealthy food can reduce obesity and relateddiseases such as hypertension and heart

disease. Clean air quality can reduce asthmain adults and children. Reliable and safepublic transportation can provide residentswith the necessary mobility to get to jobsand schools. There are myriad ways that aneighborhoods protective factors positivelyimpact individual health.This reports case studies highlight examplesof groups working to increase and fortifyprotective factorsin economic, social,physical, and service environmentsthroughout California and the country. The

case studies show how the experience andvoice of community members are criticalfor successful place-based strategies. Manyof the efforts profiled represent innovativepartnerships and new alliances for change.These collaborations are influencingpolicymakersin the public, business, andnonprofit sectorsproducing real changein communities and states. Many of theefforts also involve people of color inleadership positions, building the capacityof local leaders to advocate for policychange, showcasing the need for a focus on

equitable outcomes.

The specific factors that are most importantand the strategic approaches for enablinghealthy communities vary, but there aresome time-tested truths that these casestudies confirm: local residents havesignificant insight into what problems aremost critical to address, what communitystrengths can be used to improve health andcommunity conditions, and what strategiesand solutions will be most effective. Localleaders, connected with those at the regionaland state levels, will create the power andmomentum to pull the ultimate levers forsustainable change at the local, state, andnational levels.


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A. Economic Environment

A solid economic environment entails

commercial investment, a focus on providingjobs that take people out of poverty,businesses that provide healthy food optionsto all residents, and a path that moves peopleto opportunity. The presence of thrivingdiverse businesses is a protective factor thathelps build financially secure and healthyneighborhoods. New business developmenttends to draw additional activity as othersseek to capitalize on existing economicvitality, providing an opportunity to hirelocal residents, creating increased individualincome and available disposable income.

Coalitions, such as Fresno Works for BetterHealth, have been creating innovativeprograms to improve job quality, in terms ofwages, benefits, and career ladders; to tailortraining to the needs of local residents; andto ensure that residents of one communitycan have practical access to jobs throughouttheir metropolitan area. Within theirneighborhoods retail sector, residents of low-income neighborhoods typically face a paucityof healthy food options. However, there arenow many examples of organizations and

coalitions working to improve healthy foodaccess. One is Kaiser Permanente, whichhas established farmers markets across thestate; another is Fresno Metro Ministry, whichworked with the California Departmentof Social Services, the U.S. Department ofAgriculture, and the California NutritionNetwork to ensure that low-income residentscould use their food stamps to buy nutritiousfood at a local flea market.

B. Social Environment

Strong social networks that bring neighborstogetherwhether to advocate for change,cultivate a community garden, or provideservicescan strengthen community tiesand empower individuals to be advocatesfor themselves and change agents for theirneighborhoods.

When diverse people come together fora common goal, it increases the potentialfor meeting their objectives and also offers

opportunity for bridging differences.Knowledge, skills, and connectionstojobs, services, and civic lifecan be shared,enabling individuals to build stronger tiesto a broader community. For example, theCity of Blackduck, Minnesota, and theHmong American Partnership are part of astatewide effortHealthy Together: CreatingCommunity with New Americansto reduceimmigrants health disparities by buildingsocial connections and relationships betweennewcomers and established communitymembers, providing mental health

services to new arrivals, and increasing theorganizational capacity of groups that serverefugees and immigrants.

Building leadership within a communityincreases the level of capacity for mobilization,civic engagement, and political power. Youthin Shasta County, participating in one site ofthe multiyear, multisite Healthy Eating, ActiveCommunities initiative came together toconvince a local Wal-Mart to stock healthieroptions at the checkout stands. Strongcommunity networks used their collective

power to change business practices to bemore supportive of healthy eating.

A community with strong social networkscan also determine which businesses receiveinvestment dollars and decide what thecommunitys physical spaces will look like;whether there is investment in parks andschool construction; they can present acollective voice as to where resources areallocated and public policy is implemented.When neighbors know each other andfeel invested in the betterment of theircommunity, they can create opportunities tocome together and make changes that betterall their lives.


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C. Physical Environment

Safe parks; full-service grocery stores and/or

farmers markets; safe, walkable streets;less truck and bus traffic; well-maintainedhousing; and open spaces that encouragecommunity gathering are all protective factorsthat contribute to the health of a communityand have a positive impact on the health ofresidents. Likewise, residents geographicaccess to opportunitiesconvenient locationto reliable transportation that allows peopleto get to jobs and schoolscontributes tohealthy people and a healthy neighborhood.

A diverse group of organizations in Los

Angeles County have come together toadvocate for new parks for Latino, Asian,and African American neighborhoodsthat lack them. They are lobbying politicalleaders, conducting research, organizingunderrepresented communities, andbrokering solutions to increase the numberof parks and open spaces in Los Angeles.And theyve succeeded. Major new parksin the past seven years include the LosAngeles State Historic Park at the Cornfield indowntown Los Angeles, Rio de Los AngelesState Park at Taylor Yard, the Baldwin Hills

Park, and the Ascot Hills Park. As part of amassive effort to revitalize the Los AngelesRiver, leaders have proposed the creation of80 new parks to create a continuous 51-milerecreational greenway.

The City of Richmond, California, recognizesthat the impact of a citys plans on healthneeds to be better understood and analyzed.It is updating its general plan with a healthpolicy element. The framework for theanalysis and recommendations cover 10areas: access to recreation and open space;access to healthy foods; access to healthservices; access to daily goods and services;access to public transit and safe activetransportation options; environmental quality;safe neighborhoods and public spaces; accessto affordable housing; access to economicopportunities; and green and sustainablebuilding practices.

Improving the physical environment alsoentails keeping housing away from freewaysand toxic polluters since polluting businesses

and highways are linked to higher rates ofasthma and other respiratory diseases forresidents. It means eradicating unhealthyhousing and the pernicious slum housingdisease, a term that describes a litany ofconditions such as lead poisoning; skinrashes and fungal infections; and ailmentsbrought on by peeling paint, mold, andcockroach infestations. It also meansestablishing new ways for local publichealth agencies to operate, using suchtechniques as the Healthy DevelopmentMonitoring Tool. Designed by the San

Francisco Department of Public Health andconcerned stakeholders, the tool providesthe health rationales for considering eachelement of community conditions andmoves through established standards,key indicators, development targets, andstrategic suggestions for policy and designaround eight elements: environmentalstewardship, sustainable transportation,public safety, public infrastructure, adequateand healthy housing, healthy economy,citizen participation, and access to goodsand services.

D. Service Environment

The equitable distribution of healthcareservices and other neighborhood-levelservices has a huge impact on the overallhealth of a community. Access to qualityhealthcare services, public safety, andcommunity support services are all necessaryfor a healthy community. Public services,such as adequate police and fire protection,water and sewer systems, healthcare

facilities that are accessible and staffed withpersonnel who understand cultural needs,and quality facilities for neighborhoodmeetings and cultural events, are necessaryfor a healthy community. Reliable andregular sanitation service; mass transit thatprovides clean, safe, and reliable service; andresponsive, caring public health providers allpositively affect a community.

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For several years, California Rural LegalAssistance (CRLA) has undertaken legaladvocacy to bring an equitable share of public

resources to some of Californias CentralValley, low-income Latino communities.Because these communities are plaguedby a lack of adequate water and sewersystems, quality housing, safe roads, noparks for children to play, and inadequateschool facilities, CRLA and PolicyLink areconducting research to assess the causes andconsequences to residents and to convenestakeholders in the region to identify newpolicy options.

Health systems are also recognizing that

healthy communities extend beyond peoplehaving access to health care. Since 2003,Kaiser Permanente, in collaboration withlocal health departments and community-based organizations, has established 25farmers markets outside hospitals and healthclinics in five states. Through its CommunityHealth Initiatives, Kaiser is improving healththrough an emphasis on policy change andimproving the community conditions thatinfluence health.

Kaiser Permanente is only one of many

community stakeholders whose emphasisis on improving the poor services andunacceptable conditions that createunhealthy communities. Youth UpRisingand The Community Coalition havecomprehensive, community-basedapproaches. Their constituents drive theirprograms and their advocacy. Both are alsofocused on developing the next generationof activists capable of leading their peers andimpacting public policy.

III. Themes from Case StudiesThe case studies profiled in this reportrepresent a variety of approaches toaddressing health disparities, based indifferent communities. Most of the casestudies involve people from the communitytaking action, rather than waiting for anexpert solution or a top-down government

or foundation program. The studies highlightnot only the factors that influence health,but also the actions that community leaders

are spearheading to improve their situations.Armed with data to inform their strategiesand build their cases, organizations andcoalitions are safeguarding victories throughnew laws, regulations, or practices; liftingup their best practices for replication;and working on leadership developmentto elevate the importance of healthycommunities. Whether their efforts arefocused on achieving improvements fortheir neighborhood, such as a grocery storeor a park, or improving air quality in theirregion by altering transportation plans, or

changing the statewide policies that shapemetropolitan development, theyalong withdiverse stakeholdersare acting on the basictruth that place matters.

IV. Recommendations:Moving Forward

Fourteen recommendations emerge fromresearch, practice, and efforts for policy change:

Capitalize on emerging opportunities

and prioritize needs: Because changesare needed in the physical, social,economic, and service environments,certain issues will take precedence atany given time; not all needed changescan be pushed simultaneously. Anunderstanding of the timeliness of issuesand the capacity of advocates is crucialfor success.

Promote a comprehensive approach:Comprehensiveness has multiplemeanings for groups focused on building

and sustaining healthy communities. It canmean that a single organization takes ona very broad array of issues and developsa multifaceted approach to serving, andworking with, children, families, andneighborhoods. It can also mean that anorganization takes on diverse areas ofpolicy change that cut across traditionalboundaries. A third approach emerges

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when organizations that work primarilyon one issue make stronger connectionsand alliances with others.

Maintain a focus on equity andeliminating health disparities:Thereis growing awareness of the importanceof certain issues. For instance, thehealth impacts from obesity, as wellas the consequences on climate fromautomobile-dependent development.The challenge to building healthycommunities is to capture the broadersense of urgency and concern, anduse it to strengthen a focus on theneeds of vulnerable populations andthe fundamental questions of race andclass that underlie current disparities.Advocates for the good health of low-income communities and communitiesof color need to be engaged indebates about the specific challengesconfronting their communities, theapproaches to address them, andbroader societal issues, to ensure thatnew policies and practices are equitableand overcome previous barriers to fullinclusion and participation.

Involve residents and leaders in

policy change efforts: Improving healththrough a focus on place is in largepart a process of community changeand development, and the participationof residents and community leadersis critical for successful programs andpolicy change. Community engagementis a prerequisite for place-basedstrategies and policymaking that isauthentic in its approach and meaningfulin terms of its impact.

Build the capacity to analyze and

solve community problems: Diverseleaders who reflect their communitiesare crucial to increasing the participationof people of color and low-incomeindividuals in the push for change.Community members need support togrow as leaders, and they need to beconnected to policy change efforts atthe local, state, and national levels. The

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organizations working to improve healthand involve residents also need capacityto be effective advocates for change.

Successful efforts for building healthycommunities require connections, skills,and relationships to be cultivated andstrategically applied.

Foster collaborations and alliances:Multi-sector approaches and new,unusual, and rekindled collaborationsand alliances must be encouragedand fostered. Specific avenues forcollaboration and coordinationneed to be identified and pursued.Collaborations and coalitions succeedbecause the mutual self-interests ofmember groups are well-served by their

joint goals and activities. To succeed,groups need to identify their areasof common interest, understand theconstraints that impact each other, andensure good and open communication.

Use local efforts as platforms forregional and state change: Developingapproaches to local challengespresents opportunities for risk-takingand experimentation. The voices oflocal advocates allow policymakers

to understand protective and riskfactors, from a community perspective.Successful approaches can become thebasis for regional or statewide agendasfor change.

Push local governments, particularlypublic health departments, toprioritize healthy communities:Community health can be recognizedas important by local officials, but toact effectively, cities and counties mustreorient their planning and operations,

establish new methods of collaboratingacross sectors, and focus much moreon prevention. Local governments havebegun to incorporate a broader vision ofhealth into their policymaking. More willbe needed to build healthy communities.

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Translate research to highlight thelink between community conditionsand individual health and to provide

insights about the effectiveness ofdifferent approaches: Public health,medical, and social scientific researchshould continue to establish thelink between health and communityconditions, assess the effectiveness ofexisting policies, and help identify thepriorities within and across communities.Research should be relevant tocommunity needs, support communitychange agendas, be designed todocument and better understand localissues, and provide diverse stakeholders

with information needed to bolsterefforts seeking policy change.

Create healthy environments tosupport healthy personal choices:Environments impact individuals andtheir ability to make healthy choices.Individuals do have choices, but theirchoices are dictated by where they liveand to which services they have access.Linking health objectives to place-based issues, as well as to the policiesand change strategies that will address

them, is crucial to creating healthycommunities. Healthy personal choicesneed to become the easy choice.

Document and disseminate successstories: The public needs a sense thatchange is possible. Stories about advocacyand policy change need to highlight howchange can happen and the ways it canmake a difference. The stories need toshine a light on the work of leaders inlow-income communities of colorhowthey are advocating for change that

makes their communities healthier.Help the media reframe stories:Stories about healthy communities musttake a new tack, moving away froma sole focus on portraying sad storiesabout individuals. Instead, stories mustbe about improving communities andpeople creating change. They musthighlight the connection betweenhealth and protective factors in the

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social, services, physical, and economicenvironments. These stories confirm thatchange is possible, provide possibilities

for replication, and attest that a broadermovement can be stitched together tomake a difference in communities acrossthe country.

Invest for the long-term:Demonstrating improvement in healthoutcomes takes time. A long-termcommitment is necessary to changethe conditions in underserved andunderprivileged communities. Investedstakeholdersfunders, policymakers,researchers, advocates, practitioners,and the communitymust understandthat time and money will be needed;the work will be stalled by failures butalso accelerated by successes. They mustkeep moving forward with the vision thathealthy communities and healthy peopleexistand thrivetogether.

Broaden the platform for change:The case studies in this report are thetip of the iceberg of what is happeningto advance a movement for healthycommunities. Many connectionsneed to be developed to build furthermomentum and to expand the impactof current efforts. Strategic newalliances, collaborations, and coalitionsmust continue to be developed tohelp move specific and broaderagendas. Exciting and inspiring effortsare drawing different constituenciestogether to create the connections thatwill expand and strengthen a movementfor healthy communities.

Healthy people and healthy places go

together. The growing movement for healthycommunitieswith its push for an array ofchanges in the physical, economic, social, andservice environmentsholds great promise.Engagement, leadership, and a commitmentto change will improve communities andallow people to live healthier lives.

Place matters.

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One number may determine how long you liveand how good you feel. Its not your weightor your cholesterol count. In fact, it may helpdetermine those, too. Its your address.

Live in a community with parks andplaygrounds, living wages, a good healthcare

delivery system, grocery stores sellingnutritious food, and neighbors who knowone another, and the odds are youre morelikely to thrive. Take away the ingredientsthat lead to healthy communities, and youremore likely to suffer one of the plaguesbesetting the United States right now:obesity, asthma, heart disease, and highblood pressure.

American communities are often segregatedby race and incomeand unfortunatelylow-income communities and communities

of color often have the worst communityconditions and, correspondingly, the highestlevels of many health problems. Thespecific factors that are most important fora particular communitys health will vary,but local residents will have significantinsight into what problems are most criticalto address, what community strengths canbe used to improve health and communityconditions, and what strategies and solutionswill be most effective.

Affordable and culturally appropriatehealthcare is critical to address disparities,and efforts to expand access are underway atthe local, state, and federal levels. Providingmore children and families with quality healthcare would make a significant differencein improving individual health. But accessalone will not solve our health crisislack ofaccess to care accounts for only 10 percent ofmortality in the United States.1

Resources continue to pour into thehealthcare system. In 2005, healthcarespending in the United States reached $2trillion, or $6,700 per person; It is projectedto double, to $4 trillion, by 2015.2 Despiteall of these resources, America still is not thehealthiest country in the world, nor has it

erased significant health disparities.

A range of issues must be addressed toimprove Americans health and reduceracial/ethnic and income-based disparitiesin health. People need doctors and nurseswho can speak their language, understandtheir culture, advise them on healthy livingand prevention, and prescribe the rightmedication and treatment.

In addition, practitioners, researchers,and policymakers are realizing that to

make people healthier, they have to makeneighborhoods and communities healthier.No doctor can undo the ill effects ofliving in a community with unsafe streetsand polluting businesses. Several studieshave tracked physicians prescriptionsfor patients to eat healthy foods andexercise regularly only to find that it wasvirtually impossible for residents of certaincommunities to fill that prescriptionbecause of limited access to the requisiteresources.3 Asking patients to exerciseregularly, when they live in a neighborhoodbeset with violence and without any greenspace, presents environmental barriers to theactive life prescribed for a healthy lifestyle.Similarly, a neighborhood without accessto healthy foods, including fresh fruits andvegetables, presents a barrier to having ahealthy diet.

Introduction

Introduction

The mosteffective means

of buildinghealthy and

economicallyrobust

communitiesis to develop

and harness theleadership of

young people tobecome agents

of positivechange.

Vision Statement,

Youth UpRising


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Individuals make decisions every day thatinfluence their health, and their options areheavily influenced by their surroundings.That is why an emphasis on improvingcommunities could result in better healthfor more people. Changes that affect thestructural and cultural components of aneighborhood can mean improvements fora generation, not just for an individual. Andcommunity conditions, norms, and supportscan make a difference both in preventingdisease and in managing health when oneis sick.

A simultaneous focus on individual behaviorand community conditions can be particularlypowerful. For example, a doctor can work

with a child and her family to manage herasthma using education, medication, andtreatment. If a community group succeedsin improving her substandard housing orrerouting truck and bus traffic away from herneighborhood to reduce harmful particulatesin the air, the number of attacks she haswill decrease and fewer of her friends willcontract asthma. Similarly, a man who isobese needs to work with his physician to

change his eating and exercise habits. Ifhe has options for physical activity close tohis home and a grocery store that stocksnutritious foods, his odds of losing weight arehigher, and his children might avoid obesity.A movement is building to act on theidea that communitythe place wherewe live and workmatters to health.Abundant research shows that there is arelationship between health disparities andcommunity factorsthe economic health ofa neighborhood, the existence of supportnetworks, the quality of the natural andbuilt environment, and the availabilityof culturally-appropriate health services.Inspired by the data and motivated by theseriousness of the problems they face daily,

local groupsespecially in low-incomecommunities and communities of coloraretrying place-based strategies to improvehealth: addressing air quality, economicopportunity, and substandard housing, allof which can directly affect health. They arealso tackling issues such as social supportsand access to stores with healthy food. Theyare organizing residents to press governmentfor services, advocating for policy change,

Measuring a Healthy Community

Community health indicators are essential tools for tracking progress towards developinghealthy communities. Data indicators monitor social, economic, and physical conditions thatimpact quality of life, health-promoting behaviors, social well-being, and health status over time.Community report cards also feature rankings, comparisons, ratings, performance measures, orgrades for various indicators and can be used to set minimum or baseline standards.

Comprehensive evaluations of community factors influencing health have recently beenreported.4,5 For example, Healthy People 2010, an indicators project initiated by the federalgovernment, is widely used by state, local, and community-based groups to track progresstowards the goal of eliminating disparities in health outcomes based on race and ethnicity.6The California Health Interview Survey includes ethnic- and race-focused data and facilitatesrobust analyses using other data sets, including the census. Information technology tools such aselectronic medical records and GIS mapping also help strengthen community epidemiology.

The documentation of community indicators has supported broad health agendas that reflectmultiple levels of influence (i.e., individual behavior, community or neighborhood characteristics,and policy change) and has supported calls for leaders outside the health services sector to beinvolved. Discussions about these indicators have helped expand the publics views about healthto include factors beyond access to care. Advocates have used the data and conclusions to spuraction by policymakers or by agencies responsible for oversight.


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and looking for opportunities to replicatesuccessful efforts. Such efforts to changepolicies seek greater equity for disadvantagedpopulations, and they are making a differencearound the country.

The examples of action range in scalefrom the city block to the metropolitanregion and reflect the diversity of citiesand regions. In Los Angeles, residentsare creating more parks in underservedneighborhoods. The Harlem ChildrensZone in New York City opened a charterschool that includes a free health clinicand a chef who prepares nutritious schoollunches. In rural communities in California,public health advocates have partnered withteens to increase the availability of healthyfood in grocery stores. A local communitycoalition convinced county commissionersin Washington state to create walking paths

and bike trails. And in the San Diego area,asthma sufferers are lobbying local legislatorsto stop a proposed housing development thatwould be in a largely industrial area near amajor highway that spews diesel pollutionand would be adjacent to an industrial area.

These efforts are focused on improvingindividual well-being and addressing healthdisparities through a focus on community.

Some are creating physical improvementsat the neighborhood level, some areestablishing new ways for local public healthagencies to operate, and still others aremaking changes to statewide policies. Eacheffort differs in emphasis and style, but theyare all contributing to a more comprehensiveapproach to health.

New, unusual, and rekindled alliances arehallmarks of this nascent movement. Publichealth advocates are collaborating with landuse planners. Businesses are partnering with

groups serving immigrants and refugees.Traditional environmental organizations,environmental justice groups, and healthcoalitions are working hand in hand.

This report seeks to build on this growingmovement to improve the health ofindividuals through a focus on community.It describes place-based strategieshighlighting change in a neighborhood,city, region, or statefrom around thecountry and presents research that supportsthese efforts. Why Place Matters offers a

framework for understanding the relationshipbetween communities and health andanalyzes the connections among the factorsthat contribute to a healthy community. Casestudies illustrate how communities havesuccessfully improved local environments andbuilt the knowledge and skill of communityresidents and leaders to guide future changes.

The framework, the case studies, and therecommendations for moving forward bearwitness to the emerging certainty that placedoes matter, that community residentsinsights and voice are critical, and that withthe support of a wide range of stakeholders,significant change can happen.

A range of tools is available to helpcommunity leaders target, structure,and fuel their change efforts. Individual

organizations, including the PreventionInstitute (www.preventioninstitute.org)and PolicyLink (www.policylink.org), haveonline resources and publications thatexplain and catalogue policies and casestudies that are useful for developingagendas for change. Both organizations,The California Endowment (www.calendow.org), and several other groups also provideinformation about and training on thegeneral tools for successful advocacyforming and maintaining coalitions,choosing the appropriate forum for change,

using research strategically, developinga successful campaign, and engaging inmedia and electronic advocacy.7

Introduction


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Harlem Childrens Zone:Focusing on 100 Blocks and One Child at a Time

Factors: Economic, socia , p ysica , service

he revitalization o Harlem occupies the minds and agendas o manypeople. While many focus solely on the economic aspectsdeveloping

uxury con ominiums an commercia rea estateot ers e ieve t at t e most va ua e aspectof Harlems revival is its human capital, particularly its children. Geoffrey Canada, presidentand CEO of Harlem Childrens Zone (HCZ), has adopted a 100-block area in Central Harlemin New York City and created a multifaceted approach to the healthy development of over7,400 children rom in ancy to adulthood. HCZs approach ocuses on strengthening amilies,providing opportunities for sustainable social and economic well-being, and creating physicalenvironments that foster learning and growth.

According to the 2000 U.S. Census, approximately 152,000 people, predominately AfricanAmerican, live in Central Harlem; 26 percent are children. In 2003, a study of health in theneighborhood found that residents disproportionately suffer from conditions such as heartdisease, stroke, and cancer and that rates of infant mortality are higher than in many other

sections of New York City. The report found that the asthma rate among children is four timeshigher than in other parts of the city, childhood obesity rates are rising, and theres a highprevalence of Type 2 diabetes among teenagers. The financial health of the neighborhoodmirrors its physical health: 61 percent of children live in poverty, and one in four black men inCentral Harlem is unemployed.

To make a positive impact on the neighborhood, the Harlem Childrens Zone Project is amultipronged, place-based approach to developing a healthy neighborhoodone child at atime. One of the HCZ Projects programs is the Baby College, which offers a nine-week series ofclasses on Saturdays to 60100 parents of children between the ages of zero and three. Topicsdiscussed include childhood nutrition, constructive ways to discipline children, and methodsfor educating toddlers. Since the programs inception seven years ago, outreach workers haveorganized monthly gatherings of the Baby College graduates to foster social networks that serveas support systems, providing emotional assistance in times o need. The monthly gatherings also

introduce parents to other programs within HCZ. One such program is Harlem Gems, a universalpre-kindergarten program for four-year-olds.

To address the communitys high asthma rate, HCZ launched its Asthma Initiativein partnershipwith Harlem Hospitals Department of Pediatrics, Columbia Universitys Mailman School of PublicHealth, and the NYC Department of Health and Mental Hygieneto screen all neighborhoodchildren for asthma and to combat the triggers that cause asthma attacks. Workers conducthome visits to survey families and provide services to asthma sufferers. In 2006, the HCZAsthma Initiative surveyed 5,793 students and found that over 30 percent had asthma. (Thenational rates are from 5 to 7 percent. HCZ has enrolled 756 children since the initiative began;outcomes s ow t at participants are oing etter since joining t e program: t e sc oo a senteerate related to asthma dropped from 24 percent to 7 percent, and emergency room visits alsoropped considerably. The organizational structure of HCZ contributes to the success of the

Asthma Initiative outreach: HCZ has developed trust with parents through its programs such asthe Baby College, Harlem Gems, and the Peacemaker program in the local elementary schools,

and information on healthy living is distributed through the wide variety of HCZs educationalan socia programs.

In January 2005, HCZ opened a six-story facility that houses part of the Promise Academy, acharter school that will ultimately educate up to 600 middle- and high-school students. Theschool includes a ree health clinic, the Harlem Childrens Health Project, operated by theChildrens Health Fund. It provides medical, dental, and mental health services andscreens children for asthma and other health issues such as obesity and diabetes.The HCZ Obesity Initiative works with children to help them obtain or maintain ahealthy body mass index. HCZ hired a chef who prepares nutritious

(continued on next page)


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foods in the cafeteriaa stark contrast to the fast-food spots, convenience stores, and donutshops that populate much of the neighborhood.

Another HCZ program that addresses healthy living is the TRUCE Fitness and Nutrition Center

(TRUCE is an acronym for the Renaissance University for Community Education). Through thecenter, middle-school students have conducted surveys to analyze the factors that lead to obesityand diabetes in Central Harlem. They found that very few neighborhood grocery stores stockedhealthy foods. To address this deficit, they created community gardens and donated the produceto food banks and sold it to local markets. Youth have become gardeners, learned about healthyeating, and developed their entrepreneurial skills.

TRUCE also offers a comprehensive youth development program for high-school studentsfocused on academic growth and career readiness through the use of the arts, media literacy,and multimedia technology. Youth publish a quarterly newspaper and produce an award-winningcable TV program. Both outlets allow HCZ to communicate messages about healthy living,encourage dialogue around community issues, and inform the community about HCZ programs.TRUCE teens have excelled academically.

A healthy community must be economically sound. Through a partnership with a local bank(Carver Bank) and the Corporation for Enterprise Development (CFED, an organization that seeksto expand economic opportunity), families in the Young Harlem Investors program open savingsaccounts for their children to encourage the pursuit of higher education. HCZ and CFED matchthe familys deposits by contributing when families meet certain milestones.

The Investment Camp teaches youth about financial literacy, including investing in the stockmarket. According to Canada, this programlaunched in partnership with Lehman Brothershas resulted in 75 youth earning $14,000. Lets say youre 14 and someone says to you, Hey,go and sell this package; if you get caught, you might go to jail or, worse, you might get killed.Were saying, Learn these stock names; youll make more money than youve ever imagined,much more than standing on that corner, says Canada. Our job is to tell kids that there arelots of opportunities out there that they dont know about.

HCZs impact extends further than the families it serves. The organization employs a number of

vehicles to push for policy change. Canada co-chairswith Richard Parsons, chairman and CEOof Time Warnerthe citys Commission on Economic Opportunity, established by Mayor MichaelBloomberg. The commission is charged with coming up with time-tested, results-driven policyrecommendations to reduce poverty. The initiative will focus on children younger than six, youngadults ages 1624, and the working poora parallel demographic to those enrolled in HCZscomprehensive programs. Based on recommendations, the city will devise a strategic plan, whichwill be monitored by advisors. Additionally, Canadawith Karen Schimke, president and CEO ofthe Schuyler Center for Analysis and Advocacyco-chairs the Childrens Cabinet Advisory Board,which advises Governor Eliot Spitzer on his Childrens Agenda announced in the spring of 2007.9

The Harlem Childrens Zone philosophy and approach embody the proverb, It takes a village toraise a child. Through its Practitioners Institute, the senior staff of HCZ plays a role in liftingup what works by citing best practices and successful approaches to programs. According tothe institutes director, Rasuli Lewis, participants get a surround-sound understanding of HCZs

conveyor belt of services, targeting those from zero to 24 years of age. . . . At the end of thevisit, practitioners understand that improving the childs health must be comprehensive. Heconcluded, You cant focus solely on one environment because oftentimes a child comes froma distressed home within a distressed neighborhood, so youve also got to provide services to thechild, family, and community.

For all its comprehensive services and all the implications for broader policymaking, the zoneremains at heart a neighborhood organizing strategy, one that emphasizes the power of adultsgetting involved and the need for mutual accountability for positive results among all parties,whether they be teachers, doctors, program managers, or parents. As Canada says, Peoplemust realize that if our children dont make it, neither will our country.

Introduction


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Developing strategies for healthiercommunities requires understanding bothpeople and the places where they live.A focus on equity requires understandingthe pervasive effects of class, race, andethnicity. Income, wealth, socioeconomicstatus, race, and ethnicity are all important

influences on individuals health and on theconditions in every community. They shapeaccess to insurance and health services, thecultural competence of health providers,the nature of job-related health and safetyissues, and even aspects of diet and lifestyle.These economic and social factors are alsocritical determinants of health outcomes.The neighborhood conditions that caneither promote or prevent healthy livingare not evenly distributed: they vary byincome and race. The social supports thatcan be conducive to health and safety vary

as well. In recent years, research has beenisolating the particular effects of class andrace on health; the findings add precision toour innate sense of just how, exactly, placematters. To understand that connection,we need to first examine the basic socialdeterminants of health.

a. Socioeconomic Status (SES)and Health

People with low socioeconomic status have

worse health outcomes than people withhigher socioeconomic status.10 The basicbottom-line finding holds for a wide rangeof indicators of income, wealth, occupation,or education. A variety of reasons for thispersistent disparity have been explored.

In the most direct sense, income allows formeeting health-related needs and enables

healthier choices. Regular and sufficientincome enables one to purchase neededgoods and services, such as health care, ahabitable residence, or a car to drive to work.A lack of money can prevent someone fromgetting regular health screenings, eatingnutritious foods, and exercising. And when

there isnt enough money for basic needs,health suffers. For example, if a person hashigh housing costs, he or she often spendsless on healthy foods and health care.11

Another important factor is ones abilityto use savings or other assets to coverexpenses related to an emergency or acatastrophic illness. Having a low incomeusually means little or no money in the bank.Without financial reserves, people with lowincomes can find themselves in a doublebind that leads to stress and related health

problems.12 For example, if someone is inbetween jobs, is too sick to work, or has afamily member who needs assistance, heor she has no financial cushion. With noor meager savings, placing a deposit on anew apartment or a down payment on ahome becomes impossible. The inability tomaintain a stable place to live has a directimpact on health; the resulting displacementand homelessness can lead to mental healthproblems, hypertension, and a higher rate ofear infections and asthma among children.13

Similarly, people in the lowest occupationalpositions are more likely to suffer fromdepression, diabetes, heart disease, arthritis,chronic pain, and tension headaches thanpeople with the highest occupationalpositions.14 Jobs that pay lower wages tendto result in more job-related injuries, bemore stressful, have greater turnover, andbe less stable. Thus, such occupations can

I. Class, Race, Ethnicity, and Health

In order to

have effectiveplace-basedefforts, we mustaddress theneeds of ruralcommunities...we need basicinfrastructure...

supermarkets,transportation,lights,

sidewalks, andreduced gangviolence...

this will buildcommunitycohesion.Veva Islas-Hooker,Central CaliforniaRegional ObesityPreventionProgram


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produce adverse effects on both physical andpsychological health.15

Education also influences health. Forexample, people who do not have a highschool diploma, a college education, ora graduate degree tend to be sicker thantheir better-educated counterparts.16Several reasons may explain the influenceof education. It influences peoples abilityto earn income and create wealth. It mayinfluence ones perceived social status andalso may improve ones occupational status,allowing a person to secure a job where he orshe may have greater control over decisionsand therefore less stress, or a job that has

fewer occupational hazards.17

A persons perception of his or her positionin society also makes a difference in healthoutcomes. People who feel they are on thebottom rung of the societal ladder arelikely to be sicker, independent of income.18However, having any status in the community,even if it is not financial, can help. Forexample, someone who works as a janitoralow-prestige, lower-income jobalso mighthold a high (unpaid) position at a churchand therefore have clout in his community.

Studies of subjective SES indicate that thisjanitor might be healthier than someoneof similar income who lacks such status inthe community. Better health is not just amatter of money and, in this case, couldbe attributed to the enhanced treatment,respect, control, and power received fromtheir community status.19

Yet this does not mean that everyone shouldsimply battle to get higher up on the ladder.In communities where the difference inaverage income between the highest andlowest earners is greatest, both groups haveworse health outcomes than people who livein communities where the gap is smaller.20

Individuals experience income and othermeasures of SES not just as members oftheir own family, but also as members ofa community, because neighborhoods aregenerally sorted by wealth, most basically

by the capacity to afford housing of similarcost. And the socioeconomic compositionof a neighborhood has important effects

on health apart from the SES of individualhouseholds. A variety of studies havefound that a neighborhoods overall SESinfluences a range of health behaviorssuch as likelihood of smoking and physicalactivity, as well as depression, hostility, andmortality risk.21 Other studies have shownimprovements in the health status of somechildren, particularly girls, who moved frompoor neighborhoods to those with moremixed incomes, even when their familyincomes did not change.22 The availability ofcommunity supports and resourcesservices,

social networks, and community-focusedinstitutionsand exposure to detrimentalfactors such as polluting freeways all affectthe health of individual community residents.

b. Race, Ethnicity, and Health

Race and ethnicity have implicationsfor health at the individual level, at thecommunity level, and at the level of broadersocietal norms and practices. As witheconomic factors, a growing body of researchhas evolved that sorts through the distinctinfluences of cultural and social factors at allthree levels.

The starting point for any such discussion isthe persistence of health disparities: racialand ethnic minorities are at greater riskof ill health than their nonminority peers,even when controlling for the effects ofSES.23 African Americans, Hispanics, NativeAmericans, and some groups of AsianAmericans suffer poorer health outcomesthan whites, regardless of socioeconomic

position, because of the stress associatedwith being a person of color.24 Experienceswith racism or discrimination in daily life aswell as institutional and internalized racismdirectly contribute to health disparities.25

Researchers have linked discriminationsuffered by Asian Americans to higher ratesof heart trouble and chronic pain.26 African

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Americans who experience discrimination feelless in control of their lives, experience moreanger, and have less emotional support. They

also report more tobacco use, more alcoholconsumption, and lifetime use of marijuanaor cocaine.27

Internalized racismwhere members of amarginalized group hold an oppressive viewof themselves or start to believe in negativestereotypes perpetrated by the dominantculturehas additional adverse effects onhealth. It can lead to depression amongwomen, violence and suicide among men,and substance abuse by both sexes.28 Onestudy found that internalized racism can lead

to more heart problems for people of color.29

Recent research also has shown that African-Caribbean women who report a high level ofinternalized racism are at increased risk forobesity and diabetes.30

Moreover, there are health consequencesfrom larger patterns of institutional racismexperienced in particular neighborhoodsand in other contexts. For instance,people of color may experience racism inthe educational system, the workforce,and housing. Persistent inequities limit

socioeconomic mobility and decrease accessto goods, services, and resourcesall ofwhich lead to poor living conditions thatadversely affect health.31

Because so many American communitiesare informally but thoroughly segregatedby race as well as by income, racial andethnic health disparities need to be seen asa place-based issue, one where improvingcommunity conditions could make a realdifference. Segregation and racial isolationlead to concentrated poverty, lower individualincomes, and poor air quality, as we willillustrate later in this report.32 Segregationlimits residents access to full-service grocerystores and safe, walkable streets, since theseresources are found less frequently in low-income communities of color.33

Physical environments are also affected.Polluting businesses and factories are located

much more frequently in communitiesof color, which means a less healthyneighborhood environment with more air and

soil contamination.34

c. The Health of Immigrants

Immigrants face unique challenges whenit comes to health: they must master anunfamiliar economic landscape and striveto find new social connections. Theyoften experience discrimination and alack of economic opportunityboth ofwhich can affect their health. A study ofmore than 5,000 immigrants from diverseethnic backgrounds found that the longer

they lived in the United States, the morelikely they were to be obese, to have highcholesterol, and to smoke.35 Immigrantsmay also face unsafe working conditions,and undocumented workers generally fearspeaking out against labor practices andmistreatment, given their tenuous standing.

Although many ethnic groups in the UnitedStates experience poor health, drawingbroad conclusions about the health statusof immigrants is difficult. For instance,most people with low incomes have poorerhealth than people with higher incomes, yetresearch shows that this pattern is not truefor all immigrants. First-generation Latinoimmigrants, for example, are healthier thanother ethnic groups of similar socioeconomicstatus, as well as some higher-incomeCaucasians.

This often translates into immigrantparents being healthier than their (second-generation) children.36 A recent study foundthat low-income, first-generation, and older

Latino immigrants were healthier than low-income, second-generation Latinos. There isevidence that a similar pattern exists in otherimmigrant communities as well.

Important lessons can be learned from theimmigrant experience. What aspects ofAmerican culture are harmful to health andshould be changed? What strengths do


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21I. Class, Race, Ethnicity, and Health

immigrants bring with them to this countrythat should be supported and maintainedrather than lost? Should they live in an ethnic

enclave or gateway community where theymay find a supportive community, strongerneighborhood cohesion, and more congruentsocial norms to protect their health? Previousfindings may be attributed to theoriesthat suggest that immigrants tend to behealthier than those who did not immigrate.Nonetheless, the immigration experience isimportant to explore to better understand theimpact of individual, community, and broadersocietal factors on health. For immigrants,as for Native-born Americans, health is

shaped by a complex mix of cultural, racial,

and economic factors at each level in whichthey experience life: as individuals, familymembers, and workers, as well as residentsof a community, city, and region, and as partof American society overall.

We can take this grounding in the basic socialdeterminants of health disparities and applyit specifically to a focus on communities.

This focus is not only on the factors thatinfluence health, but also on the actionsthat local leaders are taking to improvetheir circumstances. Whether their effortsare focused on achieving improvements fortheir neighborhood, such as a grocery storeor a park, or on improving air quality intheir region through altering transportationplans, or on changing the statewide policiesthat shape metropolitan development, theyare acting on the basic truth that placematters. Whether they take on one issueor, as in the case of the Harlem Childrens

Zone, are as comprehensive as possible, theyare equally committed to improving health byimproving their communities.


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Building a movement for healthycommunities requires a bold and broad-basedvision. It requires understanding the factorsthat improve health, as well as those thathave negative impacts. The framework thatfollows provides a common language and aplatform for promoting community health.37

Community EnvironmentalFactors:

This framework categorizes the numerousfactors that affect community health into fourcomponents: the economic, social, physical,and service environments. Following is adiscussion of each factor, with descriptions,explanations, and supporting research.While the factors are discussed separately,they do not exist independently; they

blend into and influence each other. Alsoincluded throughout this report are casestudies highlighting how community-basedorganizations and leaders are changing policyto improve health.

A factor may affect health in multiple ways,directly and indirectly. For example, crime mayhave direct effects on the physical and mental

health of victims. The indirect influenceson healthy behavior are just as important.Consider: in a crime-ridden neighborhood,residents will avoid walking outdoors in theevening; adults will not allow their children togo outside to play after school, on weekends,or during school breaks. Crime may alsoinfluence the quality and availability ofservices and economic opportunities in theneighborhood: businesses most likely maynot be willing to locate there; others outsideof the neighborhood will hesitate patronizinglocal businesses or attending social or culturalevents there.

Similarly, the factors in the frameworkcan have protective or negative effectson health. A community environmentwith more protective factors is a healthiercommunity. These factors influenceindividual behaviors, encouraging preventionand better management of disease, creating

II. A Framework for Healthy Communities

A way to starta movementon a statewidelevel is toget people

to move pastfocusing onlyon one issueand embrace acomprehensiveagenda and

strategyfor shared

prosperitycapitalism anda vigorousrole forgovernment.Furthermore,alignmenthas to comefrom engagedconstituencies.Thefoundationsandintermediariescant start amovement.It must becreated byconstituencies.Donald Cohen,

Center on PolicyInitiatives

The terms neighborhoods andcommunities are primarily geographicreferences. In this sense, neighborhoodis the relatively small area in whichpeople live. Community is defined morebroadly because where individuals and

families work and socialize often traversesneighborhoods, cities, or regions. Theterm community also may apply togroups of people who do not live inimmediate proximity to each other, butnonetheless come together and form ashared connection through an institution,such as a church or clinic.


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a healthier population.38 For example, safe,well-maintained parks can promote physicalactivity; conversely, a lack of accessible

places for children and adults to exercise cancontribute to higher rates of obesity.

The factors impact various constituencies andcommunity residents differently, dependingon geography, size, composition, andthe culture of a community. The projectsdescribed in this report demonstratethat including local leaders and involvingcommunity members in identifying problems

and developing solutions are critical toensuring that the approaches, and theirresults, are appropriate and effective. In

Shasta County, California, for example,middle-school students worked with a localWal-Mart to make healthy snacks morereadily available to shoppers. They identifiedand promoted this project that resonatednot only among themselves, but also withother community memberswith impressiveoutcomes (see the Kids Make A Stand casestudy later in this report).



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The economic environment of a community

has a critical impact on health. Jobopportunities, the presence of diversebusinessesgrocery stores, banks,restaurants and the amount of collectivewealthhomeownership and savingscaninfluence residents health.39 Without avibrant economic environment, residentsmust cope with joblessness or more tenuous

job security and the higher crime rates thatcan be fueled by joblessness.40 When thereare few local businesses, or local businessesare closing, there tends to be a spiralingeffect wherein new businesses do not

choose to locate in the area. In contrast,new business development tends to attractadditional activity as others try to capitalizeon existing economic vitality.

Independent of the impact of each

individuals income on his or her health, theeconomic environment of a neighborhoodhas its own impact. The economic healthof a community affects the physical andpsychological health of its residents.Longitudinal data from an Alameda County(California) study provided importantevidence for the association betweenpoverty areas and health: Residents in aneighborhood of concentrated poverty hadan increased risk of death (mortality) overa nine-year period. The increased risk wasassociated with living in the neighborhood

regardless of the income, age, gender,education, baseline health status, or race ofthe residents.41

Employment, income, wealth, and assets: The quality and quantity ofemployment opportunities available to residents and the amount of collective wealthand assets in the community can influence residents health.

Protective factors: Living-wage jobs with health benefits; safe workplaces.Savings, retirement, and homeownership provide economic stability.Risk factors: Large numbers of community residents with low-wage jobs with

no benefits and unsafe working conditions. Racial and economic segregation andconcentrated poverty lead to higher stress and premature mortality.

Neighborhood economic conditions: Presence of commercial services, includinggrocery stores, banks, and restaurants.

Protective factors: Attracts public and private investment in services andinfrastructure.Risk factors: Disinvestment leads to loss of jobs and businesses and a decline inproperty values.

Economic Environment

a. Economic Environment

When we havestatewideor nationalmeetings,we have areal sense ofcommunity andeverybody hasa critical role to

play. There areopportunitiesfor leaders to

talk expansivelyabout wherethey want themovement togo and inspire

people to bepart of a team.It is reallyvaluable tocome togetherand paint abroad pictureof the worldthat we all

are seeking tocreate.Marice Ashe,Public Health Lawand Policy


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Grocery stores, in particular, promoteeconomic growth and foster healthy eating

habits.43 The presence of a grocery storedraws foot and street traffic, becoming aneconomic anchor for other businesses. Low-income communities tend to have fewersupermarkets and more convenience storesand fast-food restaurants than wealthiercommunities.44 In addition to the economiclosses this represents, the lack of grocerystores contributes to residents eating morefoods high in fat, calories, and sugar becausethey are largely available at the moreprevalent convenience stores and fast-foodoutlets. The development of grocery storesor other healthy outlets in a communitycan improve the eating habits of residentsand attract complementary retail services.45This example of how one component of acommunity impacts the broader economicenvironment as well as individuals habits (inthis case, their eating habits) highlights whya focus on community factors is crucial tostrategies to improve health.

A recent study by the California Centerfor Public Health Advocacy found that the

ratio of fast-food venues to grocery storeswas over four to one in California.46 Areport published by La Salle Bank found farmore fast-food restaurants than grocerystores in lower-income neighborhoodsin Chicago.47 In predominately AfricanAmerican neighborhoods, the nearest grocerystore was twice the distance as the nearestfast-food restaurant. African Americanand lower-income neighborhoods reportedhigher rates of obesity, chronic illness (cancer,diabetes, and cardiovascular disease), diet-related deaths, and years of potential life lost

(relative to life expectancy). These findingspoint to a link among food availability, eatinghabits, and health outcomes. The absenceof supermarkets and the preponderance ofunhealthy food retailers directly correspondto health outcomes.

A healthy neighborhood or small-townretail environment means more than a goodgrocery store, of course. When residents ofdisinvested communities get a fair chance torevive their commercial areas, they generallyseek a mix of stores and services with good

selection, fair prices, and friendly service;in short, the qualities most middle-classcommunities take for granted. In SoutheastSan Diego, the Market Creek Plaza shoppingcenter, anchored by a supermarket, hasprospered through the active engagementof lower-income residents who have had avoice in all design and marketing decisions.48The mix of the centers half locally-ownedbusinesses and half leading national chains,with a strong emphasis on local hiring by allretailers, reflects the values of the residents;their cultures are represented and they haveeasy access to basic commercial services.

Residents of low-income neighborhoodsface fundamental economic challengesthat go well beyond the availability ofconsumer goods and commercial services.Without adequate education or training,their employment prospects have grownincreasingly bleak. Massive changes in


Moving to Opportunity

In its Moving to Opportunity (MTO)

project, the U.S. Department of Housingand Urban Development looked at howresidents of public housing fared whenthey were given assistance to move toless poor neighborhoods, compared withresidents who stayed.42 This includedstudying the effects of neighborhoodpoverty on health. Researchers examinedhow moving out of a depressed area affectshealth, educational achievement, and otheraspects of the lives of children, youth, andfamilies. Moving did have health benefits.Girls who left for better neighborhoods

had large improvements in mental health.(The same move showed no significantchange for boys.) While moving did notseem to diminish the incidence of asthma,high blood pressure, smoking, or drinkingalcohol for adults, those who left poorneighborhoods did have lower obesity ratesand a lower prevalence of psychological

distress and depression.


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the national economy have led to a loss ofmillions of blue-collar jobs with good wages,and in their place, many service-sector jobsoffer only lower wages, fewer benefits, and

little opportunity for advancement. Evenwhen parents are fully employed, if theirwages and benefits do not lift their familyout of poverty, they are at greater risk in tworespects: they can fall victim to financialdisaster because of uninsured healthcarecosts, and they will be at greater risk forchronic conditions, such as diabetes or heartdisease, because they reside in a community

that lacks the features of a healthyenvironment.

The shift to a service-focused, knowledge-

based economy, however, is a phenomenonto which advocates for change at thecommunity level are responding. AcrossCalifornia, regional coalitions have beencreating innovative programs to improve

job quality in terms of wages, benefits, andcareer ladders, to tailor training to the needsof local residents and to ensure that residentsof one community can have practical access

Health Impact Assessment in San Francisco:A Tool to Build Healthier Communities

Factors: Economic, physical, service

Health Impact Assessment (HIA) is an approach to examining the effects thatland use and development decisions could have on health in a particular geographic area. Themethodology has been applied in England, Australia, Canada, and several other countries, whilein the United States, the most comprehensive work has taken place in San Francisco.

For 18 months, beginning in November 2004, the San Francisco Department o Public Healthworked on the Eastern Neighborhoods Community Health Impact Assessment (ENCHIA) withstakeholders in a part of the city slated for intensive redevelopment. Out of this process camethe Healthy Development Measurement Tool (HDMT)a guide to the definition of issues, thecollection of data, and the assessment of options. The HDMT provides the health rationalesfor considering each element of community conditions and moves through the established

standards, key indicators, development targets, and strategic suggestions for policy and design.The eight elements include environmental stewardship, sustainable transportation, public safety,public infrastructure, access to goods and services, adequate and healthy housing, healthyeconomy, and citizen participation.

The process has proven useful to community-based organizations and has informed the debateover redevelopment policies in neighborhoods. Several groups that participated in ENCHIA,including the South of Market Community Action Network, are continuing to use the HIAframework as a basis for leadership development and assessing project proposals. This isan educational and a voluntary process, rather than a mandated review process such as anEnvironmental Impact Assessment, though there are some topics that overlap the two processes.

The San Francisco experience is being mirrored by a growing set of other HIA processes, many

of them driven by community coalitions. In Richmond and West Oakland, local groupsare using the HIA approach not only for analysis but also as an educational tool anda way to organize and increase the participation of residents of lower-incomecommunities. In this context, the HIA becomes part of a broader effort to holddecision makers and developers accountable for the costs and benefitso development.


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to jobs throughout their metropolitan area,(see the Fresno Works for Better Healthcase study.)

Another economic challenge for lower-income residents comes from the highcosts of housing, with the potential addedpressures of gentrification and displacementas some neighborhoods become moreappealing to those who can pay more. InSan Francisco and a number of other citieswhere this kind of dislocation is a persistentproblem, the consequences of neighborhood

change are being factored into theassessment of community health. The HealthyDevelopment MeasurementTool, designed

by the local public health department inconjunction with leaders of the EasternNeighborhoods, is now used to estimatethe health consequences of alternativeredevelopment plans, and the methodologyis also being explored in Richmond, Oakland,and several other California cities.49

Metro Denver Health and Wellness Commission:A Broad Coalition to Address Health in Schools, Worksites, andCommunities

Factors: Economic, socia , physica , service

he Metro Denver Health and Wellness Commission (MDHWC) wants to make metropolitanDenver the healthiest region in the nation. It seeks to boost economic growth by improvinghealth, lowering healthcare costs, and increasing productivity.

In its recently released strategic plan, the MDHWC suggests area schools offer physicaleducation/activities and nutrition classes and provide healthy ood to improve test scoresand concentration, reduce disruptive behavior and absenteeism, and lower depression. The

DHWC a so wants arge an sma emp oyers to start wor site we ness programs an provi ehealth insurance incentives to promote healthy li estyle choices. Their hope is that these e ortswill lower absenteeism, improve safety and morale, and decrease health costs. Finally, thecommission wants to see the development of a transportation system in metropolitan Denverthat supports physical activity and to improve access to parks, trails, and healthy foods. Thecommission hopes these projects will reach 425,000 young people, 1.3 million employees, and2.6 mi ion metro-area resi ents.

he commission is a coalition of over 80 community leaders from government, nonprofits,business, and education. Members of the MDHWC include local mayors, foundation andbusiness executives, school district employees, consumer health advocates, and groups thatserve low-income communities and communities of color. The commission is chaired byColorados lieutenant governor and co-chaired by the executive vice president of the MetroDenver Economic Development Corporation, the director of the Center for Human Nutrition at

the University of Colorado at Denver and Health Sciences Center, and the mayor ofBroomfield, Colorado.

In orming the commission, sta and the co-chairs worked hard to make sure they hadrepresentation from organizations across many sectors. They recognized that diversityof membership and the involvement of government, nonprofit, and business leaderscould uniquely situate the commission to make a real di erence in the health otheir community. The commission has begun implementation of the strategic planwith resources from local businesses and foundations committed to making thevision a rea ity.



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Using Food Stamps to Buy Fresh Produce at aLocal Flea Market

Factors: Economic, service

A flea market may not be the first place people think of when they want tobuy fresh fruits and vegetables. But after doing a community food assessment, Fresno MetroMinistry in California learned that many people in its community shopped for produce at theSelma Flea Market. Unfortunately, when California switched to Electronic Benefits Transfer (EBT)cards for food stamp recipients, low-income individuals and families were no longer able to useood stamps at the market. To process the EBT cards, merchants needed high-tech machinery

and a phone line. They had neither.

Fresno Metro Ministry worked with the California Department of Social Services, the U.S.Department of Agriculture, and the California Nutrition Network to change that. Now, marketstaff use a single wireless electronic device to swipe the EBT card and deduct an amount from

the participants food stamp account in exchange for tokens that they can then use to shop ateligible food vendors at the flea market.

Low-income amilies are now able to use their ood stamps to buy nutritious ood at a placein their community where they feel welcome and comfortable. Going to the flea market is aweekend social event, says Edie Jessup of Fresno Metro Ministry. For low-income families,farmers markets can be expensive and intimidatingthe EBT program at the Selma Flea Marketprovides a good alternative.

The EBT program has made a di erence, both or vendors at the market as well as orcommunity members, many of whom are farm workers. Vendors are regaining revenue theylost when the state switched to EBT from the previous coupon system. In 2006, they sold$38,000

why places matter building a movement for healthy communities - pl tce usa - 2007

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