Health Impact Collaborative of Cook County

Community Health Needs Assessment South Region

healthimpactcc.org/reports2016

June 2016

» Advocate Children’s Hospital » Advocate Christ Medical Center » Advocate South Suburban Hospital » Advocate Trinity Hospital » Chicago Department of Public Health » Cook County Department of Public Health » Illinois Public Health Institute

Participating hospitals and health departments:

» Mercy Hospital and Medical Center » Provident Hospital – Cook County Health and

Hospital System» Roseland Community Hospital » Park Forest Health Department » South Shore Hospital» Stickney Public Health District

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Table of Contents Table of Contents ……………………………………………………………………………………………………………. 1

Executive Summary – South Region ………………………………………………………………………………… 4

Community description for the South region of the Health Impact Collaborative of ………….. 5

Collaborative structure …………………………………………………………………………………………………………. 5

Stakeholder engagement ……………………………………………………………………………………………………. 5

Mission, vision, and values …………………………………………………………………………………………………….. 6

Assessment framework and methodology …………………………………………………………………………… 7

Significant health needs ……………………………………………………………………………………………………….. 8

Key assessment findings ……………………………………………………………………………………………………….. 9

Introduction …………………………………………………………………………………………………………………… 13

Collaborative Infrastructure for Community Health Needs Assessment (CHNA) in Chicago and Cook County ……………………………………………………………………………………………………………….. 13

Community and stakeholder engagement ……………………………………………………………………….. 15

Formation of the South Stakeholder Advisory Team …………………………………………………………… 17

South Leadership Team ………………………………………………………………………………………………………. 18

Steering Committee ……………………………………………………………………………………………………………. 18

Mission, vision, and values …………………………………………………………………………………………………… 19

Collaborative CHNA – Assessment Model and Process ………………………………………………… 20

Community Description for the South Region ……………………………………………………………….. 21

Overview of Collaborative Assessment Methodology ………………………………………………….. 25

Methods – Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA) …………………………………………………………………………………………………………….. 25

Methods – Community Health Status Assessment ………………………………………………………………. 26

Methods – Community Themes and Strengths Assessment ………………………………………………… 28

Community Survey – methods and description of respondents in South region ……………… 29

Focus Groups – methods and description of participants in South region ………………………. 30

Prioritization process, significant health needs, and Collaborative focus areas …………… 32

Health Equity and Social, Economic, and Structural Determinants of Health ………………. 37

Health inequities …………………………………………………………………………………………………………………. 37

Economic inequities ……………………………………………………………………………………………………………. 39

Education inequities ……………………………………………………………………………………………………………. 39

Inequities in the built environment ………………………………………………………………………………………. 39

Inequities in community safety and violence ……………………………………………………………………… 39

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Structural racism …………………………………………………………………………………………………………………. 40

The importance of upstream approaches …………………………………………………………………………. 40

Key Findings: Social, Economic, and Structural Determinants of Health ………………………. 41

Social Vulnerability Index and Child Opportunity Index ……………………………………………………… 41

Social Vulnerability Index …………………………………………………………………………………………………. 41

Childhood Opportunity Index ………………………………………………………………………………………….. 42

Poverty, Economic, and Education Inequity ………………………………………………………………………. 43

Poverty …………………………………………………………………………………………………………………………….. 43

Unemployment………………………………………………………………………………………………………………… 47

Education ………………………………………………………………………………………………………………………… 49

Built environment: Housing, infrastructure, transportation, safety, and food access—Social, economic, and structural determinants of health ……………………………………………………………… 52

Housing and Transportation …………………………………………………………………………………………….. 52

Food access and food security……………………………………………………………………………………….. 53

Environmental concerns ………………………………………………………………………………………………….. 53

Safety and Violence—Social, economic, and structural determinants of health ………………. 56

Structural racism and systems-level policy change—Social, economic, and structural determinants of health ……………………………………………………………………………………………………….. 57

Health Impacts—Social, economic, and structural determinants of health ………………………. 58

Key Findings: Mental Health and Substance Use ………………………………………………………….. 61

Overview …………………………………………………………………………………………………………………………….. 61

Scope of the issue – Mental health and substance use ……………………………………………………… 63

Mental health ………………………………………………………………………………………………………………….. 63

Substance use …………………………………………………………………………………………………………………. 66

Youth substance use ……………………………………………………………………………………………………….. 67

Community input on mental health and substance use …………………………………………………. 72

Key Findings: Chronic Disease……………………………………………………………………………………….. 73

Overview …………………………………………………………………………………………………………………………….. 73

Mortality related to chronic disease …………………………………………………………………………………… 75

Obesity and diabetes …………………………………………………………………………………………………………. 77

Asthma ……………………………………………………………………………………………………………………………….. 78

Health behaviors …………………………………………………………………………………………………………………. 79

Persons living with HIV/AIDS ………………………………………………………………………………………………… 80

Community input on chronic disease prevention ………………………………………………………………. 81

Key Findings: Access to Care and Community Resources ……………………………………………. 82

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Overview …………………………………………………………………………………………………………………………….. 82

Insurance coverage …………………………………………………………………………………………………………… 84

Self-reported use of preventative care ………………………………………………………………………………. 84

Provider availability …………………………………………………………………………………………………………….. 85

Prenatal care ……………………………………………………………………………………………………………………… 87

Cultural competency and cultural humility ………………………………………………………………………… 87

Conclusion – Reflections on Collaborative CHNA ………………………………………………………… 88

*Appendices are included as a separate document

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Executive Summary – South Region The Health Impact Collaborative of Cook County is a partnership of hospitals, health departments, and community organizations working to assess community health needs and assets, and to implement a shared plan to maximize health equity and wellness in Chicago and Cook County. The Health Impact Collaborative was developed so that participating organizations can efficiently share resources and work together on Community Health Needs Assessment (CHNA) and implementation planning to address community health needs – activities that every nonprofit hospital is now required to conduct under the Affordable Care Act (ACA). Currently, 26 hospitals, seven health departments, and nearly 100 community organizations across Chicago and Cook County are partners in the Health Impact Collaborative. The Illinois Public Health Institute (IPHI) is serving as the process facilitator and backbone organization for the collaborative CHNA and implementation planning processes. A CHNA summarizes the health needs and issues facing the communities that hospitals, health departments, and community organizations serve. Implementation plans and strategies serve as a roadmap for how the community health issues identified in the CHNA are addressed. Given the large geography and population of Cook County, the Collaborative partners decided to conduct three regional CHNAs. Each of the three regions, North, Central, and South, include both Chicago community areas and suburban municipalities. IPHI and the Collaborative partners are working together to design a shared leadership model and collaborative infrastructure to support community-engaged planning, partnerships, and strategic alignment of implementation, which will facilitate more effective and sustainable community health improvement in the future.

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Community description for the South region of the Health Impact Collaborative of Cook County

This CHNA report is for the South region of the Health Impact Collaborative of Cook County. As of the 2010 census, the South region had 2,081,036 residents which represents a 5% decrease in total population from the year 2000. Non-Hispanic whites and non-Hispanic blacks experienced the largest population decreases. Between 2000 and 2010 the non-Hispanic white population decreased by 163,693 residents and the non-Hispanic black population decreased by 65,704 residents. Despite an overall population decrease in the South region from 2000 to 2010, the Hispanic/Latino and Asian populations increased by 86,747 and 15,846 residents, respectively, during the same time period. Children and adolescents represent more than a quarter (26%) of the population in the South region. The majority of the population is between ages 18 and 64 and approximately 12% of the population is older adults aged 65 and over. Overall, the South region is extremely diverse and several priority groups were identified during the assessment process. Collaborative structure Six nonprofit hospitals, one public hospital, four health departments, and approximately 30 stakeholders partnered on the CHNA for the South region. The participating hospitals are Advocate Christ Medical Center and Children’s Hospital, Advocate South Suburban Hospital, Advocate Trinity Hospital, Mercy Hospital and Medical Center, Provident Hospital of Cook County, and Roseland Community Hospital. Health departments are key partners in leading the Health Impact Collaborative and conducting the CHNA. The participating health departments in the South region are Chicago Department of Public Health, Cook County Department of Public Health, Park Forest Health Department, and Stickney Health Department. The leadership structure of the Health Impact Collaborative includes a Steering Committee, Regional Leadership Teams, and Stakeholder Advisory Teams. Collectively, the hospitals and health departments serve as the Regional Leadership Team. Stakeholder engagement The Health Impact Collaborative of Cook County is focused on community-engaged assessment, planning, and implementation. Stakeholders and community partners have been involved in multiple ways throughout this assessment process, both in terms of community input data and as decision-making partners. To ensure meaningful ongoing

Priority populations identified during the assessment process include: • Children and youth • Diverse racial and ethnic communities • Homeless individuals and families • Incarcerated and formerly incarcerated • Immigrants and refugees, particularly

undocumented immigrants • Individuals living with mental health

conditions • LGBQIA and transgender individuals • Older adults and caregivers • People living with disabilities • Unemployed • Uninsured and underinsured • Veterans and former military

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involvement, each region’s Stakeholder Advisory Team has met monthly during the assessment phase to provide input at every stage and to engage in consensus-based decision making. Additional opportunities for stakeholder engagement during assessment have included participation in hospitals’ community advisory groups, community input through surveys and focus groups, and there will be many additional opportunities for engagement as action planning begins in the summer of 2016. The Stakeholder Advisory Team members bring diverse perspectives and expertise, and represent populations affected by health inequities including diverse racial and ethnic groups, immigrants and refugees, older adults, youth, homeless individuals, unemployed, uninsured, and veterans. Mission, vision, and values IPHI facilitated a three-month process that involved the participating hospitals, health departments, and diverse community stakeholders to develop a collaborative-wide mission, vision, and values to guide the CHNA and implementation work. The mission, vision, and values have been at the forefront of all discussion and decision making for assessment and will continue to guide action planning and implementation.

Mission: The Health Impact Collaborative of Cook County will work collaboratively with communities to assess community health needs and assets and implement a shared plan to maximize health equity and wellness. Vision: Improved health equity, wellness, and quality of life across Chicago and Cook County

Values: 1) We believe the highest level of health for all people can only be achieved through the

pursuit of social justice and elimination of health disparities and inequities. 2) We value having a shared vision and goals with alignment of strategies to achieve

greater collective impact while addressing the unique needs of our individual communities.

3) Honoring the diversity of our communities, we value and will strive to include all voices through meaningful community engagement and participatory action.

4) We are committed to emphasizing assets and strengths and ensuring a process that identifies and builds on existing community capacity and resources.

5) We are committed to data-driven decision making through implementation of evidence-based practices, measurement and evaluation, and using findings to inform resource allocation and quality improvement.

6) We are committed to building trust and transparency through fostering an atmosphere of open dialogue, compromise, and decision making.

7) We are committed to high quality work to achieve the greatest impact possible.

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Assessment framework and methodology The Collaborative used the MAPP Assessment framework. The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, shared resources, shared values, and the dynamic interplay of factors and forces within the public health system. The four MAPP assessments are:

• Community Health Status Assessment (CHSA)

• Community Themes and Strengths Assessment (CTSA)

• Forces of Change Assessment (FOCA)

• Local Public Health System Assessment (LPHSA) The Health Impact Collaborative of Cook County chose this community-driven assessment model to ensure that the assessment and identification of priority health issues was informed by the direct participation of stakeholders and community residents. The four MAPP assessments were conducted in partnership with Collaborative members and the results were analyzed and discussed in monthly Stakeholder Advisory Team meetings. Community Health Status Assessment (CHSA). IPHI worked with the Chicago Department of Public Health and Cook County Department of Public Health to develop the Community Health Status Assessment. This Health Impact Collaborative CHNA process provided an opportunity to look at data across Chicago and suburban jurisdictions and to share data across health departments in new ways. The Collaborative partners selected approximately 60 indicators across seven major categories for the Community Health Status Assessment.1 In keeping with the mission, vision, and values of the Collaborative, equity was a focus of the Community Health Status Assessment. Community Themes and Strengths Assessment (CTSA). The Community Themes and Strengths Assessment included both focus groups and community resident surveys. Approximately 5,200 surveys were collected from community residents through targeted outreach to communities affected by health disparities across the city and county between October 2015 and January 2016. About 2,250 of the surveys were collected from residents in the South region. The survey was disseminated in four languages and was available in paper and online formats. Between October 2015 and March 2016, IPHI conducted eight focus groups in the South region. Focus group participants were recruited from populations that are typically underrepresented in community health assessments including diverse racial and ethno-cultural groups; immigrants; limited English speakers; families with children; older adults; lesbian, gay, bisexual, queer, intersex, and asexual (LGBQIA) individuals; transgender individuals; formerly incarcerated adults; individuals living with mental illness; and veterans and former military. 1 The seven data indicator categories—demographics, socioeconomic factors, health behaviors, physical environment, healthcare and clinical care, mental health, and health outcomes—were adapted from the County Health Rankings model.

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Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA). The Chicago and Cook County Departments of Public Health each conducted a Forces of Change Assessment and a Local Public Health System Assessment in 2015, so the Collaborative was able to leverage and build off of that data. IPHI facilitated interactive discussions at the August and October 2015 Stakeholder Advisory Team meetings to reflect on the findings, gather input on new or additional information, and prioritize key findings impacting the region. Significant health needs Stakeholder Advisory Teams in collaboration with hospitals and health departments prioritized the strategic issues that arose during the CHNA. The guiding principles and criteria for the selection of priority issues were rooted in data-driven decision making and based on the Collaborative’s mission, vision, and values. In addition, partners were encouraged to prioritize issues that will require a collaborative approach in order to make an impact. Very similar priority issues rose to the top through consensus decision making in the South, Central, and North regions of Chicago and Cook County.

Based on community stakeholder and resident input throughout the assessment process, the Collaborative’s Steering Committee made the decision to establish Social, Economic and Structural Determinants of Health as a collaborative-wide priority. Regional and collaborative-wide planning will start in summer 2016 based on alignment of hospital-specific priorities.

Through collaborative prioritization processes involving hospitals, health departments, and Stakeholder Advisory Teams, the Health Impact Collaborative of Cook County identified four focus areas as significant health needs:

• Improving social, economic, and structural determinants of health while reducing social and economic inequities. *

• Improving mental health and decreasing substance abuse. • Preventing and reducing chronic disease, with a focus on risk factors –

nutrition, physical activity, and tobacco. • Increasing access to care and community resources.

* All hospitals within the Collaborative will include the first focus area – Improving social, economic, and structural determinants of health – as a priority in their CHNA and implementation plan. Each hospital will also select at least one of the other focus areas as a priority.

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Key assessment findings

1. Improving social, economic, and structural determinants of health while reducing social and economic inequities.

The social and structural determinants of health such as poverty, unequal access to healthcare, lack of education, structural racism, and environmental conditions, are underlying root causes of health inequities.2 Additionally, social determinants of health often vary by geography, gender, sexual orientation, age, race, disability, and ethnicity.2 The strong connections between social, economic, and environmental factors and health are apparent in Chicago and suburban Cook County, with health inequities being even more pronounced than most of the national trends. Figure 1.1. Summary of key assessment findings related to the social, economic, and structural determinants of health

2 Centers for Disease Control and Prevention. (2013). CDC Health Disparities and Inequalities Report. Morbidity and Mortality Weekly Report, 62(3)

Social, Economic, and Structural Determinants of Health Poverty and economic equity. African Americans, Hispanic/Latinos, and Asians have higher rates of poverty than non-Hispanic whites and lower annual household incomes. More than half (54%) of children and adolescents in the South region live at or below the 200% Federal Poverty Level. In Chicago and suburban Cook County, residents in communities with high economic hardship have life spans that are five years shorter on average compared to other areas of the county. Unemployment. The unemployment rate in the South region from 2009 to 2013 was 17% compared to 9.2% overall in the U.S. African American/blacks in Chicago and suburban Cook County have an unemployment rate that is three times higher (22.5%) than the rate for whites (7.5%) and Asians (7.1%). Education. The rate of poverty is higher among those without a high school education, and those without a high school education are more likely to develop chronic illnesses. The overall high school graduation rates in the South region (83%) are only slightly lower than the state and national averages of 85% and 84%, respectively. However, the high school graduation rates for the South region (83%) are substantially lower than those in neighboring DuPage (94%) and Will (91%) counties. Housing and transportation. Many residents indicated poor housing conditions in the South region and a lack of quality affordable housing that leads to cost-burdened households, crowded housing, and homelessness. There are inequities in access to public transportation options and transportation services for multiple communities in the city and suburbs of the South region. Environmental concerns. Climate change, poor air quality, changes in water quality, radon, and lead exposure are environmental factors that were identified as having the potential to affect the health of residents in the South region. The South region is particularly vulnerable to natural and manmade disasters and disease outbreaks due to its areas of high economic hardship and low economic opportunity. In addition, vacant or foreclosed housing has contributed to the long-term economic decline and divestment in the South region and has caused a noticeable increase in crime. Safety and Violence. Firearm-related and homicide mortality are highest among Hispanic/Latinos and African American/blacks in the South region. Police violence, gang activity, drug use/drug trafficking, intimate partner violence, child abuse, and robbery were some of the safety concerns identified by residents in the South region. The South and Central regions of the collaborative are disproportionately affected by trauma, safety issues, and community violence.

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Disparities related to socioeconomic status, built environment, safety and violence, policies, and structural racism were identified in the South region as being key drivers of community health and individual health outcomes. 2. Improving mental health and decreasing substance abuse.

Mental health and substance use arose as key issues in each of the four assessment processes in the South region. Community mental health issues are exacerbated by long-standing inadequate funding as well as recent cuts to social services, healthcare, and public health. The World Health Organization (WHO) emphasizes the need for a network of community-based mental health services.3 The WHO has found that the closure of mental health hospitals and facilities is often not accompanied by the development of community-based services and this leads to a service vacuum.3 In addition, research indicates that better integration of behavioral health services, including substance use treatment into the healthcare continuum, can have a positive impact on overall health outcomes.4 Figure 1.2. Summary of key assessment findings related to mental health and substance use

Mental Health and Substance Use

Community-based mental health care and funding. Community mental health issues are being exacerbated by long-standing inadequacies in funding as well as recent cuts to social services, healthcare, and public health. Socioeconomic inequities, disparities in healthcare access, housing issues, racism, discrimination, stigma, mass incarceration of individuals with mental illness, community safety issues, violence, and trauma are all negatively impacting the mental health of residents in the South region.

There are several communities that have high Emergency Department visit rates for mental health, intentional injury/suicide, substance use, and heavy drinking in the South region. Focus group participants and survey respondents in the South region reported stigma, cost or lack of insurance, lack of knowledge about where to get services, and wait times for treatment as barriers to accessing needed mental health treatment. Community survey respondents from the South region indicated that financial strain and debt were the biggest factors contributing to feelings of stress in their daily lives.

Substance use. The lack of effective substance use prevention, easy access to alcohol and other drugs, the use of substances to self-medicate in lieu of access to mental health services and the criminalization of addiction are factors and trends affecting community health and the local public health system in the South region. There are several barriers to accessing mental health and substance use treatment and services including social stigma, continued funding cuts, and mental health/substance use provider shortages. The need for policy changes that decriminalize substance use and connect individuals with treatment and services were identified as needs in the South region.

3. Preventing and reducing chronic disease, with a focus on risk factors – nutrition,

physical activity, and tobacco. Chronic disease prevention was another strategic issue that arose in all the assessments. The number of individuals in the U.S. who are living with a chronic disease is projected to

3 World Health Organization. (2007). http://www.who.int/mediacentre/news/notes/2007/np25/en/ 4 American Hospital Association. (2012). Bringing behavioral health into the care continuum: opportunities to improve quality, costs, and outcomes. http://www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf

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continue increasing well into the future.5 In addition, chronic diseases accounted for approximately 64% of deaths in Chicago in 2014.6 As a result, it will be increasingly important for the healthcare system to focus on prevention of chronic disease and the provision of ongoing care management.5

Figure 1.3. Summary of key assessment findings related to chronic disease

Chronic Disease Policy, systems, and environment Findings from community focus groups, the Forces of Change Assessment (FOCA), and the Local Public Health System Assessment (LPHSA) emphasized the important role of health environments and policies supporting healthy eating and active living. Nearly half (47%) of community survey respondents in the South region indicated challenges in availability of healthy foods in their community. Nearly a third (30%) of survey respondents reported few parks and recreation facilities in their communities, and 47% of survey respondents rated the quality and convenience of bike lanes in their community to be “fair,” “poor”, or “very poor.”

Health Behaviors. The majority of adults in suburban Cook County (84.9%) and Chicago (70.8%) self-report eating less than five daily servings of fruits and vegetables a day. In addition, more than a quarter of adults in suburban Cook County (28%) and Chicago (29%) report not engaging in physical activity during leisure times. Approximately 14% of youth in suburban Cook County and 22% of youth in Chicago report not engaging in physical activity during leisure time. Poor diet and a lack of physical activity are two of the major predictors for obesity and diabetes. A significant percentage of youth and adults report engaging in other health behaviors such as smoking and heavy drinking that are also risk factors for chronic illnesses. Low consumption of healthy foods may also be an indicator of inequities in food access.

Mortality related to chronic disease. The top three leading causes of death in the South region are heart disease, cancer, and stroke. There are stark disparities in chronic-disease related mortality in the South region, both in terms of geography and in terms of race and ethnicity.

4. Increasing access to care and community resources.

Healthy People 2020 states that access to comprehensive healthcare services is important for achieving health equity and improving quality of life for everyone.6 Disparities in access to care and community resources were identified as underlying root causes of many of the health inequities experienced by residents in the South region. Access is a complex and multi-faceted concept that includes dimensions of proximity; affordability; availability, convenience, accommodation, and reliability; quality and acceptability; openness, cultural competency, appropriateness and approachability.

5 Anderson, G. & Horvath, J. (2004). The growing burden of chronic disease in America. Public Health Reports, 119, 263-270. 6 Healthy People 2020. (2016). Access to Health Services. https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

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Figure 1.4. Summary of key assessment findings related to access to care and community resources

Access to care and community resources Cultural and linguistic competence and humility. Focus group participants in the South region and Stakeholder Advisory Team members emphasized that cultural and linguistic competence and humility are key aspects of access to quality healthcare and community services. Participants in six of eight focus groups in the South region cited lack of sensitivity to cultural difference as a significant issue impacting health of diverse racial and ethnic groups in the South region.

Insurance coverage. Aggregated rates from 2009 to 2013, show that 23% of the adult population age 18-64 in the South region reported being uninsured, compared to 19% in Illinois and 21% in the U.S. Men in Cook County are more likely to be uninsured (18%) compared to women (14%). In addition, ethnic and racial minorities are much more likely to be uninsured compared to non-Hispanic whites. In 2014, nearly a quarter of immigrants (23%) and 40% of undocumented immigrants are uninsured compared to 10% of U.S. born and naturalized citizens.

Use of preventive care and health literacy. Overall rates of self-reported cancer screenings vary greatly across Chicago and suburban Cook County compared to the rates for Illinois and the U.S. This could represent differences in access to preventative services or in knowledge about the need for preventative screenings. Approximately one-third of Chicago residents aged 65 or older reported that they had not received a pneumococcal vaccination in 2014. Health education about routine preventative care was mentioned by multiple residents as a need in their communities. Provider availability. Nearly 20% of adults in Chicago report that they do not have at least one person that they consider to be their personal doctor or healthcare provider. In addition, LGBQIA and transgender youth and adults are less likely to report having a regular place to go for medical care. There are several communities in the South region that are classified by the Health Resources and Services Administration as areas having shortages of primary care, dental care, or mental health providers. Use of prenatal care. Nearly 20% of women in Illinois and suburban Cook County do not receive prenatal care prior to the third month of pregnancy or receive no prenatal care.

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Introduction Collaborative Infrastructure for Community Health Needs Assessment (CHNA) in Chicago and Cook County In addition to providing health coverage for millions of uninsured people in the U.S., the Affordable Care Act includes a number of components designed to strengthen the healthcare delivery system’s focus on prevention and keeping people healthy rather than simply treating people who are ill. One component is the requirement that nonprofit hospitals work with public health and community partners every three years to conduct a Community Health Needs Assessment (CHNA), identify community health priorities, and develop implementation strategies for those priorities. The CHNA summarizes community health needs and issues facing the communities that hospitals serve, and the implementation strategies provide a roadmap for addressing them. After separately developing CHNAs in 2012-2013, hospitals in Chicago and suburban Cook County joined together to create the Health Impact Collaborative of Cook County (“Collaborative”) for the 2015-2016 CHNA process. This unprecedented collaborative effort enabled the members to efficiently share resources and foster collaboration that will help them achieve deep strategic alignment and more effective and sustainable community health improvement. Local health departments across Cook County have also been key partners in developing this collaborative approach to CHNA to bring public health expertise to the process and to ensure that the assessment, planning, and implementation are aligned with the health departments’ community health assessments and community health improvement plans.7 As of March 2016, the Collaborative includes 26 hospitals serving Chicago and Cook County, seven local health departments, and approximately 100 community partners participating on three regional Stakeholder Advisory Teams. (Appendices A and B list the full set of partners collaborating across the three regions.) The Illinois Public Health Institute (IPHI) serves as the “backbone organization,” convening and facilitating the Collaborative. The Collaborative operates with a shared leadership model as shown in Figure 2.2. Given the large geography and population in Cook County, the Collaborative partners decided to conduct three regional CHNAs within Cook County. The three regions each include Chicago community areas as well as suburban cities and towns. Figure 2.1 shows a map of the three CHNA regions – North, Central, and South. This report is for the South region. Similar reports will be available for the North and Central regions of the county at www.healthimpactcc.org/reports2016 by summer 2016.

7 Certified local health departments in Illinois have been required by state code to conduct “IPLAN” community health assessments on a five-year cycle since 1992.

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Figure 2.1. Map of the three CHNA regions in Cook County, Illinois

*Advocate Lutheran General Hospital and Advocate Children’s Hospital – Park Ridge are located at the same address and represented by a single icon **Northshore University HealthSystem Highland Park Hospital is participating in the collaborative although it is located outside Cook County Seven nonprofit hospitals, one public hospital, four health departments, and approximately 30 stakeholders are collaborating partners on the South region CHNA for Chicago and suburban Cook County. The participating hospitals are Advocate Christ Medical Center and Advocate Children’s Hospital, Advocate South Suburban Medical Center, Advocate Trinity Hospital, Mercy Hospital and Medical Center, Provident Hospital of Cook County, Roseland Community Hospital, and South Shore Hospital. Health departments are key partners in leading the Health Impact Collaborative and conducting the CHNA. The participating health departments in the South region are Chicago Department of Public Health, Cook County Department of Public Health, Park Forest Health Department, and Stickney Health Department.

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Figure 2.2. Structure of the Health Impact Collaborative of Cook County

Community and stakeholder engagement The hospitals and health systems involved in the Health Impact Collaborative of Cook County recognize that engagement of community members and stakeholders is invaluable in the assessment and implementation phases of this CHNA. Stakeholders and community partners have been involved in multiple ways throughout the assessment process, both in terms of providing community input data and as decision-making partners. Avenues for engagement in the South region CHNA include:

• Stakeholder Advisory Team

• Hospitals’ community advisory groups

• Data collection – community input through surveys and focus groups

• Action planning for strategic priorities (to begin summer 2016) The South Stakeholder Advisory Team includes representatives of diverse community organizations from across the South Side of Chicago and South Cook suburbs. Members of the Stakeholder Advisory Team are important partners in the CHNA and implementation planning process, contributing in the following ways:

1. Participating in a series of 8-10 meetings between May 2015 and August 2016. 2. Contributing to development of the Collaborative’s mission, vision, and values. 3. Providing input on assessment design, including data indicators, surveys, focus groups,

and asset mapping.

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4. Sharing data that is relevant and/or facilitating the participation of community members to provide input through surveys and focus groups.

5. Reviewing assessment data and assisting with developing findings and identifying priority strategic issues.

6. Will participate in action planning to develop goals, objectives, and strategies for improving community health and quality of life.

7. Will join an action team to help shape implementation strategies.

The organizations represented on the South Stakeholder Advisory Team are listed in Figure 2.3. Figure 2.3. South Stakeholder Advisory Team as of March 2016 South Region Stakeholder Team Members AERO Special Education Cooperative Arab American Family Services Aunt Martha’s Calumet Area Industrial Commission Cancer Support Center Chicago Hispanic Health Coalition Chinese American Service League Christian Community Health Center Claretian Associates Consortium to Lower Obesity in Chicago Children (CLOCC) Crossroads Coalition Cure Violence / CeaseFire Family Christian Health Center Healthcare Consortium of Illinois Health Care Rotary / Oak Lawn Healthy Schools Campaign Human Resources Development Institute (HRDI) Illinois Caucus for Adolescent Health Metropolitan Tenants Organization National Alliance on Mental Illness (NAMI) South Suburban PLOWS Council for Aging Salvation Army Kroc Center Southland Chamber of Commerce – Healthcare Committee Southland Hispanic Leadership Council South Suburban College South Suburban PADS South Suburban Mayors and Managers Association

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Formation of the South Stakeholder Advisory Team

Between March and May 2016, the Illinois Public Health Institute (IPHI) worked with the participating hospitals and health departments in the South region of Cook County (i.e., South Leadership Team) to identify and invite community stakeholders to participate as members of the Stakeholder Advisory Team. All participating stakeholders work with or represent communities that are underserved or affected by health disparities. The Stakeholder Advisory Team members represent many constituent populations including populations affected by health inequities; diverse racial and ethnic groups including Hispanic/Latinos, African Americans, Asians, and Eastern Europeans; youth; older adults; homeless individuals; individuals with mental illness; unemployed; and veterans and former military. To ensure a diversity of perspectives and expertise on the Stakeholder Advisory Team, IPHI provided a Stakeholder Wheel tool (shown in Figure 2.4) to identify stakeholders representing a variety of community sectors. The South Leadership Team gave special consideration to geographic distribution of stakeholder invitees and representation of unique population groups in the region. Stakeholders showed a high level of interest, with approximately 25 of 30 community stakeholders accepting the initial invite. Given the large geography and population in the area, honing in on advisory team members was an iterative process, and the Stakeholder Advisory Team has been open to adding members throughout the process when specific expertise was needed or key partners expressed interest in joining. The South Stakeholder Advisory Team provided input at every stage of the assessment and was instrumental in shaping the assessment findings and priorities issues that are presented in this report. The South Stakeholder Advisory Team met with the participating hospitals and health departments (i.e., South Leadership Team) seven times between May 2015 and March 2016. IPHI designed and facilitated these meetings to solicit input, make recommendations, identify assets, and work collaboratively with hospitals and health systems to identify priority health needs. Figure 2.4. Stakeholder Wheel

Adapted from Connecticut Department of Public Health and Health Resources in Action (HRiA)

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South Leadership Team Each region of the Health Impact Collaborative of Cook County has a leadership team consisting of the hospitals and health departments participating in the collaborative in the defined regional geography. The charge of the South Leadership Team is to:

• Work together with IPHI and community stakeholders to design and implement the CHNA process;

• Work together with IPHI on data analysis; and • Liaise with other hospital staff and with

community partners. During the assessment process, the South Leadership Team held monthly planning calls with IPHI and monthly in-person meetings with stakeholders. The South region lead is the Lead Community Health Consultant from Advocate Health Care.

Steering Committee The Steering Committee helps to determine the overall course of action for the assessment and planning activities so that all teams and activities remain in alignment with the mission, vision, and values. The Steering Committee makes all decisions by consensus on monthly calls, designation of ad hoc subcommittees as needed, and through email communications. The Steering Committee is made up of regional leads from the three regions, representatives from three large health systems, the Illinois Hospital Association, IPHI, and the Chicago and Cook County Departments of Public Health. Members of the South Leadership Team and the Collaborative-wide Steering Committee are named in Appendix B.

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Mission, vision, and values

Over a three-month period between May and July 2015, the diverse partners involved in the Health Impact Collaborative of Cook County worked together to develop a collaborative-wide mission, vision, and values to guide the CHNA and implementation work. The mission, vision, and values reflect input from 26 hospitals, seven health departments, and nearly 100 community partners from across Chicago and suburban Cook County. To collaboratively develop the mission, vision, and values, IPHI facilitated three in-person workshop sessions, including one with the South Stakeholder Advisory Team. IPHI coordinated follow-up edits and vetting of final drafts over email to ensure the values represented the input of diverse partners across the collaborative. The Collaborative’s mission, vision, and values are presented in Figure 2.5. Figure 2.5. Health Impact Collaborative of Cook County Collaborative Mission, Vision, Values

the pursuit of social justice and elimination of health disparities and inequities. 2) We value having a shared vision and goals with alignment of strategies to achieve

greater collective impact while addressing the unique needs of our individual communities.

3) Honoring the diversity of our communities, we value and will strive to include all voices through meaningful community engagement and participatory action.

4) We are committed to emphasizing assets and strengths and ensuring a process that identifies and builds on existing community capacity and resources.

6) We are committed to building trust and transparency through fostering an atmosphere of open dialogue, compromise, and decision making.

7) We are committed to high quality work to achieve the greatest impact possible.

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Collaborative CHNA – Assessment Model and Process The Health Impact Collaborative of Cook County conducted a collaborative CHNA between February 2015 and June 2016. IPHI designed and facilitated a collaborative, community-engaged assessment based on the Mobilizing for Action through Planning and Partnerships (MAPP) framework. MAPP is a community-driven strategic planning framework that was developed by the National Association for County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). Both the Chicago and Cook County Departments of Public Health use the MAPP framework for community health assessment and planning. The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, and the dynamic interplay of factors and forces within the public health system. The Health Impact Collaborative of Cook County chose this inclusive, community-driven process so that the assessment and identification of priority health issues would be informed by the direct participation of stakeholders and community residents. The MAPP framework emphasizes partnerships and collaboration to underscore the critical importance of shared resources and responsibility to make the vision for a healthy future a reality.

Figure 3.1. MAPP Framework

The Key Findings sections of this report highlight key assessment data and findings from the four MAPP assessments. As part of continuing efforts to align and integrate community health assessment across Chicago and Cook County, the Health Impact Collaborative leveraged recent assessment data from local health departments where possible for this CHNA. Both the Chicago and Cook County Departments of Public Health completed community health assessments using the MAPP model between 2014 and 2015. As a result, IPHI was able to compile data from the two health departments’ respective Forces of Change and Local Public Health System Assessments for discussion with the South Stakeholder Advisory Team, and data from the Community Health Status Assessments was also incorporated into the data presentation for this CHNA. See pages 26-32 for description of the assessment methodologies used in this CHNA.

The key phases of the MAPP process include: • Organizing for Success and Developing

Partnerships • Visioning • Conducting the Four MAPP Assessments • Identifying Strategic Issues • Formulating Goals and Strategies • Taking Action – Planning, Implementing,

Evaluating

The four MAPP assessments are: • Community Health Status Assessment (CHSA) • Community Themes and Strengths

Assessment (CTSA) • Forces of Change Assessment (FOCA) • Local Public Health System Assessment

(LPHSA)

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Community Description for the South Region The South region of the Health Impact Collaborative of Cook County includes approximately 30 community areas in Chicago and 50 municipalities in suburban Cook County. In the 2010 census, the South region had 2,081,036 compared to 2,213,031 residents in the 2000 census. The total land areas encompassed by the South region is roughly 495 square miles and the population density in the region is approximately 4,471 residents per square mile based on the 2010 census data.8 Non-Hispanic African American/blacks make up the largest racial or ethnic group in the South region, representing 43% of the population. Compared to the North and Central regions, the South region has the highest percentage of African American/black individuals. Approximately 29.5% of individuals in the South region identify as white and 24.0% as Hispanic/Latino. A relatively small percentage of the South region’s population is Asian (2.7% as of 2010). However, the Asian population is experiencing significant growth with an increase of 15,846 Asian residents (32% increase) between 2000 and 2010 in the South region. The Hispanic/Latino population is also experiencing significant growth with a 21% increase (86,747 residents) in population size between 2000 and 2010. Figure 4.1. Regional race and ethnicity

Data Source: Cook County Department of Public Health, U.S. Census Bureau 2010 Census Although African American/blacks are the largest population group in the South region, they are experiencing large population decreases (See Figures 4.2) across Chicago and suburban Cook County. In the South region, the African American population decreased by 7% (65,704 individuals) from 2000 to 2010. Figure 4.2. Population change in race/ethnicity between 2000 and 2010, South region

Race/Ethnicity 2010

Population 2000

Population Change in Population

Percent Change in Population

African American/black (non-Hispanic)

872,226 937,930 -65,704 -7%

White (non-Hispanic) 619,507 783,200 -163,693 -21% Hispanic/Latino 498,264 411,517 + 86,747 21% Asian (non-Hispanic) 66,146 50,300 + 15,846 32%

Data Source: U.S. Census Bureau 2010 Census

8 2010 Decennial Census and American Communities Survey, 2010-2014.

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Two important metrics provide a picture of recent immigrant populations that speak languages other than English: percent of the population who report limited English proficiency and linguistically isolated households. Within the South region, there are geographic variations in the percentages of the population with limited English proficiency as shown in Figure 4.4. Approximately 8% of all households in Chicago and suburban Cook County are linguistically isolated, defined by the Census as households where “all members 14 years old and over have at least some difficulty with English.” Figure 4.4. Limited English Proficiency, 2009-2013

Data Source: American Communities Survey, 2009-2013

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Children and adolescents under 18 represent more than a quarter (26.2%) of the population in the South region. Approximately 62% of the population is 18 to 64 years old and about 12% are older adults age 65 and over. Figure 4.5. Age distribution of residents, by region, Chicago and suburban Cook County, 2010

Data Source: U.S. Census Bureau 2010 Census The overall population aged 65 and older remained approximately the same between 2000 and 2010. However, several communities in the South region experienced a growth in their older adult population (Figure 4.6.). More assessment data about the community health implications of a growing older adult population can be found on page 47 of this report. Figure 4.6. Change in population aged 65 or older in Chicago and Cook County, 2000-2010

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Census data show that the population of males and females in Chicago and suburban Cook County is approximately equal. While data on transgender individuals is very limited, a 2015 study by the U.S. Census Bureau estimates that there are approximately 3.4 to 4.7 individuals per 100,000 residents in Illinois that are transgender.9 It is estimated that approximately 5.7% of Chicago residents identify as lesbian, gay, or bisexual.10 There are disparities in many health indicators such as access to clinical care, health behaviors such as smoking and heavy drinking, and self-reported health status for LGBQIA and transgender populations.11 The demographic characteristics of additional priority population groups are shown in Figure 4.7. Figure 4.7. Demographic characteristics of key populations in the South region Key Population Demographic Characteristics Data Sources

Formerly Incarcerated

40%-50% of people released from Illinois prisons return to the City of Chicago. In 2013, that represented 12,000 individuals re-entering the community in Chicago over the course of the year.

City of Chicago. (2016). Ex-offender re-entry initiatives. http://www.cityofchicago.org/city/en/depts/mayor/supp_info/ex-offender_re-entryinitiatives.html)

Homeless An estimated 125,848 people were homeless in Chicago in 2015, and children and teens represent 35% (43,958) of the homeless population. In 2015, 2,025 homeless individuals were accessing shelter services in suburban Cook County.

Chicago Coalition for the Homeless. (2016). http://www.chicagohomeless.org/faq-studies/); Alliance to End Homelessness in Suburban Cook County. (2015). http://www.suburbancook.org/counts

People living with mental health conditions

11% of adults in Illinois reported living with a mental or emotional illness in 2012.

Behavioral Risk Factor Surveillance System

People with disabilities

Approximately 12% of the population in the South region lives with a disability.

American Communities Survey, 2010-2014

Undocumented immigrants

Approximately 308,000 undocumented immigrants live in Cook County (183,000 in Chicago and 125,000 in suburban Cook County), accounting for approximately 6% of the County’s population.

Tsao, F. & Paral, R. (2014). Illinois’ Undocumented Immigrant Population: A Summary of Recent Research by Rob Paral and Associates. http://icirr.org/sites/default/files/Illinois%20undocumented%20report_0.pdf

Veterans and former military

Overall, approximately 202,886 veterans live in Chicago and suburban Cook County. In the South region, approximately 100,453 individuals (6% of the population) are classified as veterans.

American Communities Survey, 2010-2014

9 Harris, B.C. (2015). Likely transgender individuals in U.S. Federal Administration Records and the 2010 Census. U.S. Census Bureau. http://www.census.gov/srd/carra/15_03_Likely_Transgender_Individuals_in_ARs_and_2010Census.pdf 10 Gates, G.J. (2006). Same-sex Couples and the Gay, Lesbian, Bisexual Population: New Estimates from the American Community Survey. The Williams Institute on Sexual Orientation Law and Public Policy, UCLA School of Law. http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-Same-Sex-Couples-GLB-Pop-ACS-Oct-2006.pdf 11 B.W. Ward et al. (2014). Sexual Orientation and Health among U.S. Adults: National Health Interview Survey, 2013. National Center for Health Statistics, Centers for Disease Control and Prevention.

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Overview of Collaborative Assessment Methodology12 The Health Impact Collaborative of Cook County employed a mixed-methods approach to assessment, utilizing the four MAPP assessments13 to analyze and consider data from diverse sources to identify significant community health needs for the South region of Cook County.

Methods – Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA) The Chicago and Cook County Departments of Public Health each conducted a Forces of Change Assessment and a Local Public Health System Assessment in 2015, so the Collaborative was able to leverage and build on that data.

The LPHSA assessments conducted in Chicago and Cook County in 2015 were led by the respective health departments, and each engaged nearly 100 local representatives of various sectors of the public health system including clinical, social services, policy makers, law enforcement, faith-based groups, coalitions, schools and universities, local planning groups, and many others. 12 Note: Some hospitals and health systems conducted additional assessment activities and data analyses that are presented in the hospital-specific CHNA report components. 13 The MAPP Assessment framework is presented in more detail on page 21 of this report. The four MAPP assessments are: Community Health Status Assessment (CHSA), Community Themes and Strengths Assessment (CTSA), Forces of Change Assessment (FOCA), and Local Public Health System Assessment (LPHSA).

What are the FOCA and the LPHSA? The Forces of Change Assessment (FOCA) seeks to identify answers to the questions: 1. What is occurring or might occur that affects the health of our community or the local public

health system? 2. What specific threats or opportunities are generated by these occurrences? • For the FOCA, local community leaders and public health system leaders engage in

forecasting, brainstorming, and in some cases prioritization. • Participants are encouraged to think about forces in several common categories of change

including: economic, environmental, ethical, health equity, legal, political, scientific, social, and technological.

• Once all potential forces are identified, groups discuss the potential impacts in terms of threats and opportunities for the health of the community and the public health system.

The Local Public Health System Assessment (LPHSA) is a standardized tool that seeks to answer: 1. What are the components, activities, competencies, and capacities of our local public

health system and how are the 10 Essential Public Health Services (see Figure 5.1) being provided to our community?

2. How effective is our combined work toward health equity? • For the LPHSA, the local public health system is defined as all entities that contribute to

the delivery of public health services within a community. • Local community leaders and public health system leaders assess the strengths and

weaknesses of the local public health system. • Participants review and score combined local efforts to address the 10 Essential Public

Health Services and efforts to work toward health equity. • Along with scoring, participants identify strengths and opportunities for short- and long-

term improvements.

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IPHI worked with both the Chicago and Cook County Departments of Public Health to plan, facilitate, and document the LPHSAs. Many members of the Health Impact Collaborative of Cook County participated in one or both of the LPHSAs and found the events to be a great opportunity to increase communication across the local public health system, increase knowledge of the interconnectedness of activities to improve population health, understand performance baselines and benchmarks for meeting public health performance standards, and identify timely opportunities to improve collaborative community health work. IPHI created combined summaries of the city and suburban data for both the FOCA and the LPHSA (see Appendices E and F), which were shared with the South Leadership Team and Stakeholder Advisory Team. IPHI facilitated interactive discussion at in-person meetings in August and October 2015 to reflect on the FOCA and LPHSA findings, gather input on new or additional information, and prioritize key findings impacting the region. Methods – Community Health Status Assessment Epidemiologists from the Cook County Department of Public Health and Chicago Department of Public Health have been invaluable partners on the Community Health Status Assessment (CHSA). This CHNA presented an opportunity for health departments to share data across Chicago and suburban jurisdictions, laying the groundwork for future data collaboration. The health departments and IPHI worked with hospitals and stakeholders to identify a common set of indicators, based on the County Health Rankings model (see Figure 5.2). In addition to the major categories of indicators in the County Health Rankings model, this CHNA also includes an indicator category for Mental Health. Therefore, the CHSA indicators fall into seven major categories:

 Demographics

 Socioeconomic Factors

 Health Behaviors

 Physical Environment

 Health Care and Clinical Care

 Mental Health

 Health Outcomes (Birth Outcomes, Morbidity, Mortality)

Figure 5.1. The 10 Essential Public Health Services

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Figure 5.2. County Health Rankings model

Data were compiled from a range of sources, including:

• Seven local health departments: Chicago Department of Public Health, Cook County Department of Public Health, Evanston Health & Human Services Department, Oak Park Health Department, Park Forest Health Department, Stickney Public Health District, and Village of Skokie Health Department

• Additional local data sources including: Cook County Housing Authority, Illinois Lead Program, Chicago Metropolitan Agency for Planning (CMAP), Illinois EPA, State/Local Police

• Hospitalization and ED data: Advocate Health Care through its contract with the Healthy Communities Institute made available averaged, age adjusted hospitalization and Emergency Department statistics for four time periods based on data provided by the Healthy Communities Institute and Illinois Hospital Association (COMPdata)

• State agency data sources: Illinois Department of Public Health (IDPH), Illinois Department of Healthcare and Family Services (HFS) Illinois Department of Human Services (DHS), Illinois State Board of Education (ISBE)

• Federal data sources: Decennial Census and American Communities Survey via two web platforms-American FactFinder and Missouri Census Data Center, Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), Dartmouth Atlas of Health Care, Feeding America, Health Resources and Services Administration (HRSA), United States Department of Agriculture (USDA), National Institutes of Health (NIH) National Cancer Institute, and the Community Commons / CHNA.org website

The Health Impact Collaborative of Cook County used the County Health Rankings model to guide selection of assessment indicators. IPHI worked with the health departments, hospitals, and community stakeholders to identify available data related to Health Outcomes, Health Behaviors, Clinical Care, Physical Environment, and Social and Economic Factors. The Collaborative decided to add Mental Health as an additional category of data indicators, and IPHI and Collaborative members also worked hard to incorporate and analyze diverse data related to social and economic factors.

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Cook County Department of Public Health, Chicago Department of Public Health, and IPHI used the following software tools for data analysis and presentation:

• Census Bureau American FactFinder website, CDC Wonder website, Community Commons / CHNA.org website, Microsoft Excel, SAS, Maptitude, and ArcGIS.

The mission, vision, and values of the Collaborative have a strong focus on improved health equity in Chicago and suburban Cook County. As a result, the Collaborative utilized the CHSA process to identify inequities in social, economic, healthcare, and health outcomes in addition to describing the health status and community conditions in the South region. Many of the health disparities vary by geography, gender, sexual orientation, age, race, and ethnicity. For several health indicators, geospatial data was used to create maps showing the geographic distribution of health issues. The maps were used to determine the communities of highest need in each of the three regions. For this CHNA, communities with rates for negative health issues that were above the statistical mean were considered to be high need. Methods – Community Themes and Strengths Assessment The Community Themes and Strengths Assessment included both focus groups and community resident surveys. The purpose of collecting this community input data was to identify issues of importance to community residents, gather feedback on quality of life in the community and identify community assets that can be used to improve communities.

Data Limitations The Health Impact Collaborative of Cook County made substantial efforts to be comprehensive in data collection and analysis for this CHNA; however, there are a few data limitations to keep in mind when reviewing the findings:

• Population health and demographic data often lag by several years, so data is presented for the most recent years available for any given data source.

• Data is reported and presented at the most localized geographic level available – ranging from census tract for American Communities Survey data to county-level for Behavioral Risk Factor Surveillance System (BRFSS) data. Some data indicators are only available at the county or City of Chicago level, particularly self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System (YRBS).

• Some community health issues have less robust data available, especially at the local community level. In particular, there is limited local data that is available consistently across the county about mental health and substance use, environmental factors, and education outcomes.

• The data analysis for these regional CHNAs represents a new set of data-sharing activities between the Chicago and Cook County Departments of Public Health. Each health department compiles and analyzes data for the communities within their respective jurisdictions, so the availability of data for countywide analysis and the systems for performing that analysis are in developmental phases.

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Community Survey – methods and description of respondents in South region By leveraging its partners and networks, the Collaborative collected approximately 5,200 resident surveys between October 2015 and January 2016, including 2,288 in the South region. The survey was available on paper and online and was disseminated in five languages – English, Spanish, Polish, Korean, and Arabic.14 The majority of the responses were paper-based (about 75%) and about a quarter were submitted online. The community resident survey was a convenience sample survey, distributed by hospitals and community-based organizations through targeted outreach to diverse communities in Chicago and Cook County, with a particular interest in reaching low income communities and diverse racial and ethnic groups to hear their input into this Community Health Needs Assessment. The community resident survey was intended to complement existing community health surveys that are conducted by local health departments for their IPLAN community health assessment processes. IPHI reviewed approximately 12 existing surveys to identify possible questions, and worked iteratively with hospitals, health departments, and stakeholders from the 3 regions to hone in on the most important survey questions. IPHI consulted with the UIC Survey Research Laboratory to refine the survey design. The data from paper surveys was entered into the online SurveyMonkey system so that electronic and paper survey data could be analyzed together. Survey data analysis was conducted using SAS statistical analysis software, and Microsoft Excel was used to create survey data tables and charts. The majority of survey respondents from the South region identified as heterosexual (91%, n=2146) and African American/black (57%, n=2146). Twenty-seven percent (27%) of survey respondents identified as white, 2% Asian/Pacific Islander, and 2% Native American/American Indian.1 Approximately 25% (n=1651) of survey respondents in the South region identified as Hispanic/Latino and approximately 10% identified as Middle Eastern (n=1651).1 Two-percent of survey respondents from the South region indicated that they were living in a shelter and 1% indicated that they were homeless (n=2257). The South region had the highest percentage of individuals with less than a high school education (12%, n=2027) compared to the North and Central regions of Cook County, and the majority of respondents from the South region (68%, n=1824) reported an annual household income of less than $40,000.

14 Written surveys were available in English, Spanish, Polish and Korean; all surveys with Arabic speakers were conducted with the English version of the survey along with interpretation by staff from a community-based organization that works with Arab-American communities.

Community Resident Survey Topics  Adult Education and Job Training  Barriers to Mental Health Treatment  Childcare, Schools, and Programs for

Youth  Community Resources and Assets  Discrimination/Unfair Treatment  Food Security and Food Access  Health Insurance Coverage  Health Status  Housing, Transportation, Parks &

Recreation  Personal Safety  Stress

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Focus Groups – methods and description of participants in South region IPHI conducted eight focus groups in the South region between October 2015 and March 2016. The collaborative ensured that the focus groups included populations who are typically underrepresented in community health assessments, including racial and ethno-cultural groups, immigrants, limited English speakers, low-income communities, families with children, LGBQIA and transgender individuals and service providers, individuals with disabilities and their family members, individuals with mental health issues, formerly incarcerated individuals, veterans, seniors, and young adults. The main goals of the focus groups were:

1. Understand needs, assets, and potential resources in the different communities of Chicago and suburban Cook County

2. Start to gather ideas about how hospitals can partner with communities to improve health.

Each of the focus groups was hosted by a hospital or community-based organization, and the host organization recruited participants. IPHI facilitated the focus groups, most of which were implemented in 90-minute sessions with approximately 8 to10 participants. IPHI adjusted the length of some sessions to be as short as 45 minutes and as long as two hours to accommodate the needs of the participants, and some groups included as many as 25 participants. A description of the focus group participants from the South region is presented in Figure 5.3.

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Figure 5.3. Focus groups conducted in the South region.

There were residents from the South region that participated in focus groups that were conducted in other regions. A focus group in the Austin community area (in the Central region) that was conducted with formerly incarcerated individuals and hosted by the National Alliance for the Empowerment of the Formerly Incarcerated included participants who were residents in the South region. A focus group in the Lakeview community area (in the North region) that was conducted with LGBQIA and transgender individuals and hosted by Howard Brown Health Center also included several participants who were residents in the South region.

Focus Groups Location and Date Arab American Family Services Participants in the focus group at Arab American Family Services were residents in the South region and staff at the organization. Their clients include Arab American immigrants and families.

Bridgeview, Illinois (12/4/2015)

Chinese American Service League Participants in the focus group at the Chinese American Service League were residents of the Chinatown neighborhood in Chicago and staff at the organization. Their clients include multiple immigrant groups, children, older adults, disabled individuals, and families.

Chinatown, Chicago, Illinois (1/19/2016)

Human Resources Development Institute (HRDI) Participants were clients in HRDI’s day programs on the South Side of Chicago. Individuals in the focus group had experienced mental illness at some point in the past and some had previous interactions with the criminal justice system.

West Roseland, Chicago, Illinois (12/15/2015)

National Alliance on Mental Illness (NAMI) South Suburban Participants included the parents, families, and caregivers of adults with mental illness living in South suburban Cook County.

Hazel Crest, Illinois (1/21/2016)

Park Forest Village Hall Community residents, health department staff, service providers, and local government representatives in the South Cook suburbs.

Park Forest, Illinois (11/12/2015)

Sexual Assault Nurse Examiners (SANE) SANE providers serving the South side of Chicago and South suburbs at Advocate South Suburban Hospital.

Hazel Crest, Illinois (12/17/2015)

Stickney Senior Center Participants were older adults participating in the services provided at a senior center in the South Cook suburbs.

Burbank, Illinois (12/3/2015)

Veterans of Foreign Wars (VFW) Post 311 Participants included veterans, retired military, and former military living in the South Cook suburbs.

Richton Park, Illinois (1/28/2016)

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Prioritization process, significant health needs, and Collaborative focus areas IPHI facilitated a collaborative prioritization process that took place in multiple steps. In the South region, the participating hospitals, health departments, and Stakeholder Advisory Team worked together through February and March 2016 to prioritize the health issues and needs that arose from the CHNA. Figure 6.1 shows the criteria used to prioritize significant health needs and focus areas for the three regions of Chicago and Cook County. Figure 6.1. Prioritization criteria

Collaborative participants identified and discussed key assessment findings throughout the collaborative assessment process from May 2015 to February 2016. IPHI worked with the Collaborative partners to summarize key findings from all four MAPP assessments between December 2015 and February 2016. Once the key findings were summarized, IPHI vetted the list of significant health needs and strategic issues with the Steering Committee in February 2016 and they agreed that those issues represented a summary of key assessment findings. Following the meeting with the Steering Committee, the Stakeholder Advisory Teams and hospitals and health departments participated in an online poll to provide their initial input on priority issues to inform discussion at the March 2016 regional meetings. During the South region Stakeholder Advisory Team meeting conducted in March 2016, team members reviewed summaries of assessment findings, the prioritization criteria, the mission, vision, and values, and poll results. The meeting began with individual reflection, with each participant writing a list of the top five issues for the Collaborative to address. Following individual reflection, representatives from hospitals, health departments, and community stakeholders worked together in small groups to discuss their individual lists of five priorities. IPHI instructed the small groups to work toward consensus on the top two to three issues that the collaborative should address collectively for meaningful impact. The small groups then reported back, and IPHI facilitated a full group discussion and consensus building process to hone in on the top five priorities for the region.

The guiding principles for prioritization were: The Health Impact Collaborative’s mission, vision, and values; alignment with local health department priorities; and data-driven decision making.

The Collaborative used the following criteria when selecting strategic issues as focus areas and priorities:

• Health equity. Addressing the issue can improve health equity and address disparities

• Root cause/Social determinant. Solutions to addressing the issue could impact multiple problems

• Community input. Identified as an important issue or priority in community input data

• Availability of resources/feasibility. Resources (funding and human capital, existing programs and assets), Feasibility (likelihood of being able to do something collaborative and make an impact)

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Priority issues identified in the South region at the March 2016 stakeholder meetings were:

• Social and structural determinants of health o With an emphasis on economic inequities, educational inequities, and

structural racism • Healthy environment

o Including built environment and transportation, environmental contamination, and related health issues

• Mental health and substance use o With an emphasis on the connections between mental health and issues

related to trauma, community safety, and violence prevention • Chronic disease prevention

o With a focus on health equity, prevention, and the connections between chronic disease and built environment and social determinants of health

• Access to care and community resources o Including addressing barriers to access for low income households, improving

health literacy, improving cultural and linguistic competence, and supporting linkages between healthcare and community-based organizations for prevention

Following the South region prioritization meeting, the Health Impact Collaborative Steering Committee met and reviewed the top issues that emerged in all three regions (summarized in Figure 6.2). The priorities identified across the three regions were very similar so the Health Impact Collaborative of Cook County was able to identify Collaborative-wide focus areas, which are shown in Figure 6.3. Healthy Environment came up as a key issue in all three regions, although it was classified differently during prioritization in the different regions. Because of the close connections between Healthy Environment and two of the other top issues – Social Determinants of Health and Chronic Disease – Healthy Environment is included as a topic within both of those broad issues, as shown in Figure 6.3. Based on input from the South and Central Stakeholder Advisory Teams, Community Safety and Violence Prevention is included as a topic under both Social Determinants of Health and Mental Health and Substance Use.

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Figure 6.2. Summary of priorities identified during March 2016 stakeholder meetings, by region

Social and Structural

Determinants Healthy

Environment

Mental Health and Substance Use

(Behavioral Health) Chronic Disease Access to Care and

Community Resources

North 

Under social determinants and chronic disease   

Emphasized connections between healthy environment and chronic disease

Central 

Under social determinants and chronic disease   

Emphasized connections between healthy environment, safety, and socioeconomic factors

Emphasized connections between healthy environment and chronic disease

South     

Emphasized connections between community safety, trauma, and mental health

Emphasized connections between healthy environment and chronic disease

Note: Policy, Advocacy, Funding and Data Systems Issues were also priority topics of discussion in all 3 regional discussions, and they were all identified as areas for improvement in the Local Public Health System Assessment (LPHSA). These are strategies that should be applied across all priorities.

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Figure 6.3. The Four Focus Areas for the Health Impact Collaborative of Cook County

Policy, Advocacy, Funding, and Data Systems are strategies that should be applied across all priorities.

Key Community Health Needs for Each of the Collaborative Focus Areas: Social, economic and structural determinants

of health

Mental health and substance abuse

(Behavioral health)

Chronic disease prevention

Access to care and community resources

• Economic

inequities and poverty

• Education inequities

• Structural racism

• Housing and transportation

• Healthy environment

• Safety and violence

• Overall access

to services and funding

• Violence and trauma, and its ties to mental health

• Focus on risk

factors – nutrition, physical activity, tobacco

• Healthy environment

• Cultural & linguistic

competency/ humility

• Health literacy

• Access to healthcare and social services, particularly for uninsured and underinsured

• Navigating complex healthcare system and insurance

• Linkages between heathcare providers and community-based organizations for prevention

Through the Collaborative prioritization process involving hospitals, health departments, and Stakeholder Advisory Teams, the Health Impact Collaborative of Cook County identified four “focus areas” as significant health needs:

1. Improving social, economic, and structural determinants of health while reducing social and economic inequities. *

2. Improving mental health and decreasing substance abuse.

3. Preventing and reducing chronic disease, with a focus on risk factors – nutrition, physical activity, and tobacco).

4. Increasing access to care and community resources.

* All hospitals within the Collaborative will include the first focus area—Improving social, economic, and structural determinants of health—as a priority in their CHNA and implementation plan. Each hospital will also select at least one of the other focus areas as a priority.

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The regional discussions highlighted the relationship between healthy environment, chronic disease, and social and structural determinants of health. As a result, healthy environment is listed under both chronic disease and determinants of health. Participants emphasized the connections between community safety, trauma, and mental health during the regional meetings, particularly in the South region. As a result, safety and violence is listed as both a social determinant and a behavioral health determinant. All three regional discussions also identified policy, advocacy, funding, and data systems as key strategies and approaches that should be applied across all of the focus areas. All hospitals within the Collaborative will include the first focus area—Improving social, economic, and structural determinants of health—as a priority in their CHNA report. Each hospital will then select at least one additional focus area as a priority. Based on alignment of the hospital-specific priorities, regional and Collaborative-wide planning will start in summer 2016.

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Health Equity and Social, Economic, and Structural Determinants of Health A key part of the mission of the Health Impact Collaborative is to work collaboratively with communities to implement a shared plan to maximize health equity and wellness. In addition, one of the core values of the Collaborative is the belief that the highest level of health for all people can only be achieved through the pursuit of social justice and the elimination of health disparities and inequities. The values of the Collaborative are echoed by both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), which state that addressing the social determinants of health is the core approach to achieving health equity.15, 16 In addition, the CDC encourages health organizations, institutions, and education programs to look beyond behavioral factors and address the underlying factors related to social determinants of health.15 Health inequities The social determinants of health such as poverty, unequal access to healthcare, lack of education, stigma, and racism are underlying contributing factors to health inequities.15 Additionally, social determinants of health often vary by geography, gender, sexual orientation, age, race, disability, and ethnicity.17 Nationwide some of the most prominent health disparities include the following:

• Cardiovascular disease is the leading cause of death in the U.S. and non-Hispanic blacks are at least 50% more likely to die of heart disease or stroke prematurely than their non-Hispanic white counterparts.

• The prevalence of adult diabetes is higher among Hispanics, non-Hispanic blacks, and those of other mixed races than among Asians and non-Hispanic whites.

• Diabetes prevalence is higher among adults without college degrees and those with lower household incomes.

• The infant mortality rate for non-Hispanic blacks is more than double the rate for non-Hispanic whites. There are higher rates of infant mortality in the Midwest and South than in other parts of the country.

15 Centers for Disease Control and Prevention. (2014). NCHHSTP Social Determinants of Health. http://www.cdc.gov/nchhstp/socialdeterminants/faq.html 16 World Health Organization. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. http://www.who.int/social_determinants/thecommission/finalreport/en/ 17 Centers for Disease Control and Prevention. (2013). CDC Health Disparities and Inequalities Report. Morbidity and Mortality Weekly Report, 62(3)

Figure 7.1. Health equity

Source: Saskatoon Health Region, https://www.communityview.ca/infographic_SHR_health_equity.html

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• Suicide rates are highest among American Indians/Alaskan Natives and non-Hispanic whites for both men and women.17

• Discrimination against LGBQIA and transgender community members has been linked with high rates of psychiatric disorders, substance use, and suicide.18

• Nearly a quarter of immigrants (23%) and 40% of undocumented immigrants are uninsured compared to 10% of U.S. born and naturalized citizens.19

The strong connections between social and economic factors and health are also apparent in Chicago and suburban Cook County, with health inequities being even more extreme than many of the national trends. Some of the major health inequities present in Chicago and suburban Cook County are listed below.

In all of the assessments, the social and structural determinants of health were identified as underlying root causes of the health inequities experienced by communities in Chicago and suburban Cook County. Disparities related to socioeconomic status, built environment, safety and violence, policies, and structural racism were highlighted in the South region as being key drivers of health outcomes.

18 Healthy People 2020. (2016). Lesbian, Gay, Bisexual, and Transgender Health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health 19 The Henry J. Kaiser Family Foundation. (2016). Health coverage and care for immigrants. http://kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/

Health inequities in Chicago and suburban Cook County

• African Americans experienced an overall increase in mortality from cardiovascular disease between 2000-2002 and 2005-2007 in suburban Cook County while whites experienced an overall decrease in cardiovascular disease-related mortality during the same time period.

• In the South region, African Americans have the highest mortality rates for cardiovascular disease, diabetes-related conditions, stroke, and cancer compared to other race/ethnic groups in the region.

• Hispanic and African American teens have much higher birth rates compared to white teens in Chicago and suburban Cook County.

• African American infants are more than four times as likely as white infants to die before their first birthday in Chicago and suburban Cook County.

• Homicide and firearm-related mortality are highest among African Americans and Hispanics.

• In 2012, the firearm-related mortality rate in the South region (20.4 deaths per 100,000) was more than four times higher than the rate for the North region (4.6 deaths per 100,000). In 2012, the homicide mortality rate in the South region (19.8 deaths per 100,000) was more than six times higher than the rate for the North region (3.1 deaths per 100,000).

• There are significant gaps in housing equity for African American/blacks and Hispanic/Latinos compared to whites and Asians.

• The life expectancy for Chicagoans living in areas of high economic hardship is five years lower than those living in better economic conditions.

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Economic inequities Socioeconomic factors are the largest determinants of health status and health outcomes.20 Poverty can create barriers to accessing quality health services, healthy food, and other necessities needed for good health status. 21 Poverty also largely impacts housing status, educational opportunities, the physical environment that a person works and lives in, and health behaviors.20 Asians, Hispanic/Latinos, and African American/blacks have higher rates of poverty compared to non-Hispanic whites as well as lower annual household incomes. In addition, approximately 32% of children and adolescents live below 100% of the federal poverty level and more than half (57%) of children below 200% of the federal poverty level in the South region. Of the three regions, the South has the highest rates of childhood poverty. Unemployment can create financial instability and as result can create barriers to accessing healthcare services, insurance, healthy foods, and other basic needs.21 The unemployment rate in the South region is higher (17.0%) compared to the Central (12.1%) and North (8.2%) regions. The unemployment rate in the South region also exceeds the rates for Illinois (10.5%) and the U.S. (9.2%). In the South region and across Chicago and Cook County, African Americans/blacks have a much higher rate of unemployment compared to whites and Asians. Education inequities Community residents in the South region often described their local school systems as poorly performing, underfunded, and substandard. Education is an important social determinant of health, because the rate of poverty is higher among those without a high school diploma. In addition, those without a high school education are at a higher risk of developing certain chronic illnesses.5 Inequities in the built environment Community input data indicates that residents in the South region are concerned about abandoned buildings in their communities, potential lead exposure in homes, and the possibility of poor water and air quality. Nearly half (44%) of residents surveyed in the South region indicated one or more problems in their current homes that could have a negative impact on health. Residents also indicated that there is a lack of quality affordable housing in the South region, contributing to homelessness in their communities. Participants also highlighted inequities in access to transportation and access to health foods in the South region. Inequities in community safety and violence Violent crime disproportionately affects residents living in communities of color in Chicago and suburban Cook County.22 In addition, homicide and firearm-related mortality is highest in the South and Central regions and in African American and Hispanic/Latino communities. Community residents in the South region indicated that a lack of positive community policing, gang activity, drug use/drug trafficking, the presence of guns, domestic violence,

20 Centers for Disease Control and Prevention. (2014). Social Determinants of Health. http://www.cdc.gov/nchhstp/socialdeterminants/faq.html. 21 American Community Survey, 2010-2014; CommunityCommons.org CHNA Data (2015). 22 Data Sources for Violent Crime: CDPH 2014, CCDPH 2009-2013, IDPH 2012

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child abuse, human trafficking, property crimes (home break-ins, theft, muggings), and poorly maintained foreclosed or vacant properties were some of the primary reasons that they felt unsafe in their communities. Exposure to violence not only causes physical injuries and death, but it also has been linked to negative psychological effects such as depression, stress, and anxiety, as well as self-harm and suicide attempts.23 Structural racism Policies that reinforce or promote structural racism have detrimental effects on community health. Not only do communities of color experience higher rates of morbidity and mortality, but individuals who report experiencing racism exhibit worse health than individuals that do not experience it.24 Community input indicates that many residents consider the ongoing long-term divestment in the South region, particularly in communities of color, a serious problem. Community residents stated that people belonging to diverse racial and ethnic groups were more likely to live in low-income neighborhoods with fewer job opportunities and many indicated that they had experienced discrimination in their day-to-day lives. The importance of upstream approaches As shown in figure 7.2, health is determined in large part by the social determinants of health including economic resources, built environment, community safety, and policy. As a result, an upstream approach that addresses the social determinants of health has the greatest impact on health outcomes. Figure 7.2. Centers for Disease Control and Prevention, Health Impact Pyramid

Source: Freiden, T. Centers for Disease Control and Prevention. 2010. A framework for public health action: The health impact pyramid. American Journal of Public Health. 100(4): 590-595. (6p). 23 Mayor, S. (2002). WHO report shows public health impact of violence. The BMJ, 325(7367). 24 Williams, D., Costa, M., Odunlami, A., Mohammed, S. (2012). Moving Upstream: How Interventions that Address the Social Determinants of Health Can Improve Health and Reduce Disparities. Journal of Public Health Management and Practice, 14(Suppl) S8-17.

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Key Findings: Social, Economic, and Structural Determinants of Health Social Vulnerability Index and Child Opportunity Index

Social Vulnerability Index The Social Vulnerability Index is an aggregate measure of the capacity of communities to prepare for and respond to external stressors on human health such as natural or human-caused disasters, or disease outbreaks. The Social Vulnerability Index ranks each census tract on 14 social factors, including poverty, lack of vehicle access, and crowded housing. Communities with high Social Vulnerability Index scores have less capacity to deal with or prepare for external stressors and as a result are more vulnerable to threats on human health. Figure 7.3. Social Vulnerability Index by Census Tract, 2010 25

25 Agency for Toxic Substances and Disease Registry. (2014). The Social Vulnerability Index. http://svi.cdc.gov/

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Childhood Opportunity Index The Childhood Opportunity Index is based on several indicators in each of the following categories: demographics and diversity; early childhood education; residential and school segregation; maternal and child health; neighborhood characteristics of children; and child poverty. Children that live in areas of low opportunity have an increased risk for a variety of negative health indicators such as premature mortality, are more likely to be exposed to serious psychological distress, and are more likely to have poor school performance.26 Figure 7.4. Childhood Opportunity Index by Census Tract, 2007-2013

26 Ferguson, H., Bovaird, S., Mueller, M. (2007). Pediatrics and Child Health, 12(8), 701-706.

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Poverty, Economic, and Education Inequity

Poverty Poverty can create barriers to accessing health services, healthy food, and other necessities needed for good health status.21 It can also affect housing status, educational opportunities, an individual’s physical environment, and health behaviors.21 The Federal Poverty Guidelines define poverty based on household size, ranging from $11,880 for a one-person household to $24,300 for a four-person household and $40,890 for an eight-person household.27

The FOCA results were echoed in the eight focus groups conducted in the South region. Focus group participants identified poor economic growth and unemployment, long-term divestment in the South region, lack of vocational education opportunities, and a lack of job and workforce development as some of the major economic issues facing their communities. The Community Health Status Assessment (CHSA) highlighted many of the economic disparities in Chicago and suburban Cook County. As shown in Figure 7.8, the mean per capita income for Asians, African Americans, and Hispanic/Latinos is lower than it is for non-Hispanic whites. In addition, those same racial and ethnic groups are more likely to live at or below 100% and 200% of the federal poverty level (FPL). Overall, the percentages of the population living at or below 100% and 200% FPL are higher in Chicago and suburban Cook County than the rates for Illinois and the U.S. 27 U.S. Department of Health and Human Services. (2016). Poverty Guidelines. https://aspe.hhs.gov/poverty-guidelines.

Forces of Change Assessment (FOCA) findings related to Poverty and Economic Inequity

Several trends and factors were identified related to poverty and economic equity including:

• increasing poverty and wealth disparities; • lack of livable wage jobs; • high student loan debt; and • interconnections among economics, housing, transportation, and workforce issues.

The potential threats to community health that these factors pose include:

• poverty and its relationship to poor health; • the increasing need for social services as economic security declines; • the risk of homelessness; and • reduced power of labor unions, which can affect job security and wages.

Opportunities to address the economic stability issues and economic inequities threatening health include:

• living wage legislation; • school-based job training; • promoting lower-cost/debt-free higher education; and • leveraging the case management aspects of healthcare transformation to assist

individuals with housing, food, and other social determinants of health.

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Figure 7.5. Map of poverty rates in Cook County – population living below 100% of the Federal Poverty Level (FLP), 2009-2013

Data Source: American Communities Survey, 2009-2013

20% of the population in the South region lives below 100% of the Federal Poverty Level (FPL).

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Figure 7.6. Map of poverty rates in Cook County – population living below 200% of the Federal Poverty Level (FLP), 2009-2013

Data Source: American Communities Survey, 2009-2013

43% of the population in the South region lives below 200% of the Federal Poverty Level (FPL).

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Figure 7.7. Percentage of the population living at or below 100% of the poverty level by race and ethnicity, 2009-2013

Data Source: American Communities Survey, 2009-2013 Figure 7.8. Per capita income28, by race and ethnicity, 2009-2013

Data Source: American Communities Survey, 2009-2013 Nearly half of all children living in Chicago and Cook County live at or below 200% of the federal poverty level. The percentage of children in poverty is higher for Cook County than it is for Illinois and the U.S., and African American and Latino children have much higher poverty rates than non-Hispanic white children. Although the number of children living in poverty decreased overall in Chicago between 2009 and 2013, the number of children living in poverty doubled in suburban Cook County. As shown in the map of the Childhood Opportunity Index in Figure 7.4, there are large inequities in childhood opportunity across Chicago and suburban Cook County with the majority of communities in the South region having low or very low economic opportunity.

28 Per capita income is defined as the mean income per person for a specific subgroup of the population.

Nearly half of all children living in Chicago and Cook County live at or below 200% of the federal poverty level.

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Individuals aged 65 or older account for 12% of those living in poverty in Chicago and suburban Cook County as of 2013. The population of older adults is projected to at least double in the U.S. between 2012 and 2050.29 The growing population of older adults was identified as a significant trend that impacts community health in a variety of ways. The FOCA identified a number of potential community health impacts of a rapidly growing older adult population including:

• Decreased tax base and increased number of retirees and pensioners • Increased costs associated with long-term care and a growing burden of age-related

chronic disease • Increased need for caregivers

Opportunities to address these potential issues in Chicago and suburban Cook County include creating age-friendly cities and communities.

Unemployment Unemployment can create financial instability, and, as a result, can create barriers to accessing healthcare services, insurance, healthy foods, and other basic needs. Trends and factors related to employment identified in the FOCA included the outsourcing of jobs from the U.S. A lack of jobs threatens community health through increasing social and

community breakdown. The unemployment rate in the South region is high (17.0%) compared to the Central (12.1%) and North (8.2%) regions. The unemployment rate in the South region also exceeds the rates for Illinois (10.5%) and the U.S. (9.2%). Only 7% of respondents to the community resident survey from the South region reported that there were “a lot” or “a great deal” of good jobs in their communities. In addition, 24% respondents indicated that job training and adult education in their communities were inadequate.

Figure 7.9. Unemployment disparities by race and ethnicity, 2009-2013African American/blacks have the highest rates of unemployment in Chicago and suburban Cook County

Data Source: American Communities Survey, 2009-2013

29 U.S. Census Bureau. (2014). An aging nation: The older population in the United States. https://www.census.gov/prod/2014pubs/p25-1140.pdf

The population of older adults is projected to at least double in the U.S. between 2012 and 2050.

The unemployment rate in Chicago increased by 69% between 2000 and 2009-2013 and increased in suburban Cook County by 133% during the same time period. In addition, unemployment disparities persist in Chicago and suburban Cook County with African Americans and Hispanic/Latinos having higher unemployment rates than non-Hispanic whites.

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Figure 7.10. Map of unemployment rates, population over age 16, 2009-2013

Data Source: American Communities Survey, 2009-2013

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Education Education is an important social determinant of health, because the rate of poverty is higher among those without a high school diploma or GED. In addition, as previously mentioned, those without a high school education are at a higher risk of developing certain chronic illnesses, such as diabetes.5 The FOCA identified multiple trends and factors influencing educational attainment in Chicago and suburban Cook County including inequities in school quality and early childhood education, school closings in Chicago, and unequal application of discipline policies for black and Hispanic/Latino youth. These factors and trends produce threats to health such as lack of job- and college-readiness as well as an increased risk of becoming chronically involved with the criminal justice system as an adult. Opportunities to address education issues include efforts to apply evidence-based school improvement programs, vocational learning opportunities, advocacy, and using maternal/child health funding to improve early childhood outcomes. Figure 7.11. High school graduation rates in Chicago and Suburban Cook County, 2011-2012

Data Source: U.S. Department of Education, EDFacts, 2011-2012

The high school graduation rates in the South region (83%) are approximately the same as the state and national averages of 85% and 84%, respectively. However, the high school graduation rates for the South region (83%) are substantially lower than those in neighboring DuPage (94%) and Will (91%)

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Figure 7.12. Map of population over age 25 without a high school education, 2009-2013

Approximately 19% of adults over age 25 in Chicago and 12% of adults over 25 in suburban Cook County did not have a high school diploma or equivalent, as of 2009-2013.

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Figure 7.13. The relationship between education and poverty in Chicago and suburban Cook County

Data Source: American Communities Survey, 2010-2014 Seven out of the eight focus groups in the South region mentioned schools and education as a major component of health in their communities. Participants in four of the focus groups described their public school district as substandard. Approximately 59% of Community Resident Survey respondents from the South region indicated that the schools in their community were less than good.

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Built environment: Housing, infrastructure, transportation, safety, and food access—Social, economic, and structural determinants of health

Housing and Transportation The FOCA identified lack of affordable housing and transportation especially for vulnerable populations as significant forces affecting health in Chicago and suburban Cook County. Homelessness, gentrification, and transit inequalities were seen as threats to health. Building on current efforts to improve physical infrastructure like sidewalks, bike lanes, and outdoor recreation space, initiatives to rehab vacant housing, policies to support affordable housing, and creating jobs through housing initiatives were identified as opportunities. The percentage of the population that utilizes public transportation as their primary means of commute to work is high in the South region and Cook County compared to Illinois and the U.S.

Geography Percent of population using public transit to commute to work South Region 16.1% Cook County 18.1%

Illinois 8.9% United States 5.1%

Data Source: American Communities Survey, 2010-2014 The percentage of households with no motor vehicle is higher in the South region and Cook County compared to Illinois and the U.S., and could indicate a need for transportation alternatives.

Geography Percentage of Households with no motor vehicle South Region 18.1% Cook County 17.8%

Illinois 10.8% United States 9.1%

Data Source: American Communities Survey, 2010-2014 Transportation was a major issue discussed by focus group participants in the South region. Transportation services for seniors and disabled individuals have been discontinued or are extremely limited. As a result, it is difficult to use public transportation to go to clinics and medical appointments and pick-up prescriptions. Several residents in the South region mentioned the need to expand public transit routes and/or hours. Approximately 21% of survey respondents from the South region rated the convenience of timing and stops for public transit as “poor” or “very poor.” Quality affordable housing was another major issue identified by focus group participants. In addition, several focus group participants mentioned the need to address homelessness in their communities. Approximately 23% of survey respondents from the South region reported that housing in their communities was not affordable. In addition, as previously stated, 44% of survey respondents in the South region described poor housing conditions in their current homes.

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Food access and food security Food insecurity is the household-level economic and social condition of limited or uncertain access to adequate food.30 Factors and trends related to food and systems that were identified in the FOCA include lack of healthy food access, unhealthy food environments driven by federal food policies and food marketing, and increasing community gardens/urban agriculture. Threats to health related to the forces of change include increasing obesity and chronic disease and lowered school performance. Numerous opportunities were identified to address food systems in Chicago and suburban Cook County, including SNAP double bucks programs, incentivizing grocery store and community gardens, using hospital campuses/land as places for gardens, increasing the number of farmers markets and grocery stores, and the workforce development prospects for urban agriculture.

Approximately 15% of the population in Chicago and suburban Cook County have experienced food insecurity in the report year (2013). According to the USDA in 2014, all households with children, single-parent households, non-Hispanic black households, Hispanic/Latino households, and low-income households below 185% of the poverty threshold had higher food insecurity rates compared to other populations in the U.S.30

Residents in the South region highlighted inequities in access to healthy foods. Focus group participants reported that many communities in the South region do not have access to markets with fresh produce. Seniors were described as having more difficulty accessing healthy food due to high costs and lack of senior transportation services. Approximately 55% of survey respondents from the South region indicated that they or their

families have had to worry about whether or not their food would run out before they had the money to buy more. Over 75% of enrolled schoolchildren in the South region of Chicago and Suburban Cook County are eligible for free or reduced price lunch. In addition, 21% of all households in the South region are receiving SNAP benefits, the highest percentage of all the regions. Environmental concerns Climate change, air quality, radon, lead, and water quality were identified as forces of change that present direct threats to health. Federal action on climate change and multi-sector healthy housing initiatives are potential opportunities to improve health. The use of lead paint in homes was stopped in 1979. Most homes (79%) in Chicago and suburban Cook County were built before 1979, indicating an increased risk of lead paint being present in the home. Exposure to lead paint particles through ingestion, absorption, and inhalation can cause numerous adverse health issues including gastrointestinal problems, fatigue, neurological problems, muscle weakness and pain, as well as developmental delays in children.31 Lead exposure is particularly dangerous to children 30 USDA. (2014). http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx#insecure 31 Centers for Disease Control and Prevention. (2013). Health problems caused by lead. http://www.cdc.gov/niosh/topics/lead/health.html

Over 75% of enrolled school children in the South region are eligible for free or reduced price lunches

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because their bodies absorb more lead than adults and their brains and nervous systems are more sensitive to the damaging effects of lead.32 If pregnant women are exposed to lead paint particles, there is a risk of exposure to their developing baby.32 Environmental concerns mentioned by focus group participants included lead exposure and water and air quality. Forty-four percent of survey respondents from the South region indicated one or more problems with their current homes that could have a negative impact on health. Figure 7.16. Map of homes built before 1979 (lead paint risk) Data Source: American Community Survey, 2009-2013

32 U.S. Environmental Protection Agency (2015). https://www.epa.gov/lead/learn-about-lead

Approximately 79% of the homes in Chicago and suburban Cook County were built before 1979.

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Figure 7.17. Housing conditions identified by community residents in the South region, Health Impact Collaborative Community Survey, 2015 Which of the following describes your current home? Check all that apply. (n=2142)

Nearly a quarter of survey respondents from the South region reported outside air leaking through windows, doors, and crevices. The next most frequent home maintenance concern reported was peeling paint, which was cited by about 18% of respondents. Approximately 13% of respondents reported water leaks over the past 12 months and 10.6% of respondents reported mold/mildew being present in their homes. The World Health Organization (WHO) has identified air particles with a diameter of 10 microns or less, which can penetrate and lodge deeply inside the lungs, as the most damaging to human health.33 This form of particle pollution is known as particulate matter or PM. Chronic exposure to these particles contributes to the risk of developing cardiovascular problems, respiratory diseases, and lung cancer. The percentage of days with PM 2.5 levels exceeding the National Ambient Air Quality Standard (35 micrograms per cubic meter per year) is higher than the rate for Illinois and the U.S. Figure 7.18. Percentage of days exceeding the National Ambient Air Quality Standard for PM 2.5, 2008

Geography Percentage of days exceeding the National Ambient Air Quality Standard (35 micrograms per cubic meter) –

Population Adjusted Average South Region 1.8% Cook County 1.6%

Illinois 1.1% United States 1.2%

Data Source: CDC, National Environmental Public Health Tracking Network, 2008.

33 World Health Organization. (2014). Ambient (outdoor) air quality and health. http://www.who.int/mediacentre/factsheets/fs313/en/

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Safety and Violence—Social, economic, and structural determinants of health Although violent crime occurs in all communities, violent crime disproportionately affects communities of color in Chicago and suburban Cook County.34 In addition, there are multiple negative health outcomes associated with exposure to violence and trauma.34 Factors and trends in safety and violence identified in the FOCA include gun violence, intimate partner violence, police violence, and bullying. The threats to health from these forces include the links between community violence, chronic disease, and mental health problems, plus the impact of fear and stress on health and well-being. Opportunities to address safety and violence issues in Chicago and suburban Cook County include supporting the role of schools in violence prevention and services for families, and increasing communication between communities and police. Concerns about safety and violence were echoed in the focus group results. Participants in six out of the eight focus groups in the South region mentioned safety concerns in their communities. Safety issues highlighted by participants in the South region include lack of positive community policing, gang activity, and drug use/drug trafficking, domestic violence, child abuse, robbery, and personal safety. Residents who live in the South Cook suburbs described how the foreclosure crisis has led to many abandoned properties and that those properties have become hubs of drug activity and other illegal activities in their communities. The focus group results align with the results of the Community Resident Survey where respondents from the South region indicated that gang activity (33%), drug use/drug dealing (28%), presence of guns in the neighborhood (23%), and property/homes not maintained (18%) as the top four reasons that they felt unsafe in the last 12 months. Homicide and firearm mortality were highest in the South region of Chicago and suburban Cook County. Figure 7.19. Homicide and firearm-related mortality by region, 2012

Data Source: Illinois Department of Public Health, 2012

34 Chicago Department of Public Health. (2016). Health Chicago 2.0.

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Figure 7.20. Communities in the South region with the highest violent crime rates, 2014

Structural racism and systems-level policy change—Social, economic, and structural determinants of health The WHO has found that structural racism is a direct cause of health inequities.2 The FOCA identified many factors and trends related to racism, discrimination, and stigma including the ongoing existence of implicit bias; mass incarceration affecting communities of color; and unequal quality of education across racial, ethnic, and class categories. These forces present threats to overall health outcomes and increased health disparities. The FOCA identified some opportunities to address issues related to racism and discrimination in Chicago and suburban Cook County including public education campaigns, embedding equity into organizational values, implementing collective impact and community organizing, and promoting social movements. Community members in the South region focus groups indicated that communities of color have a disproportionate burden of health problems. The ongoing long-term divestment in the South region was considered a serious problem by several residents. Participants stated that African Americans, Latinos and immigrants were more likely to live in low-income neighborhoods with fewer job opportunities. Residents emphasized the need to give locally owned businesses incentives to establish in low-income neighborhoods. School districts in low-income communities of color were often described as substandard. In addition, many of the survey respondents from the South region indicated that they had experienced discrimination in their daily lives (Figure 7.21).

Chicago community areas and suburban cities in the South region with the highest violent crime rates

Chicago Communities Suburban Cities and Towns West Englewood Harvey Washington Park Sauk Village

Greater Grand Crossing Robbins Englewood Phoenix Riverdale Chicago Heights

Auburn Gresham Burnham Data Source: UCR Crime Data, U.S. Federal Bureau of Investigation, 2014

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Figure 7.21. Discrimination in the daily lives of community survey respondents, Health Impact Collaborative Community Survey, 2015 In your day to day life, how often have any of the following things happened to you? (n=2120)

The Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA) identified that policy and advocacy to address inequities are essential to an upstream approach to addressing the social determinants of health. The FOCA and LPHSA discussions also emphasized that communities being affected by inequities should be involved in leading policy change efforts and that there needs to be changes to state and local politics in order to achieve the systems changes that are needed to address inequities. Additional systems level issues identified by focus group participants include treatment for mental illness and substance use in lieu of incarceration, outreach and advocacy to veterans and former military, advocacy and support for older adults and caregivers, advocacy for the rights and fair treatment of immigrants and refugees, and sustainable funding alternatives for community based organizations. Health Impacts—Social, economic, and structural determinants of health As summarized on pages 37-40 of this report, there are many health disparities that relate to racial inequities and income inequities. These societal inequities have profound effects on life expectancy. In both Chicago and suburban Cook County, life expectancy varies widely between communities with high economic opportunities and communities with low economic opportunities. In suburban Cook County, average life expectancy is approximately 79.7 years, whereas life expectancy for residents in Chicago is 77.8 years. Overall in Chicago, life expectancy for people in areas of high economic hardship is five years lower than those living in communities with better economic conditions.35 Years of potential life lost is the average number of years a person might have lived if they had not died prematurely. It can also be used as an indicator of health disparities. The Chicago community areas and suburban municipalities in the South region with the highest and lowest life expectancies, natality, and years of potential life lost by region are presented in Figures 7.22a. – 7.22.c. 35 Healthy Chicago 2.0. (2016).

Health Impact Collaborative of Cook County

South Region CHNA 59

Figure 7.22a. Communities in the South region with the lowest and highest life expectancies Lowest life expectancies:

Chicago Life expectancy

(Years) Suburban Cook

County Life expectancy

(Years) Fuller Park 67.1 Steger 71.4 Englewood 70.3 Robbins 72.0 Burnside 70.4 Riverdale 72.3

Highest life expectancies:

Chicago Life expectancy

(Years) Suburban Cook

County Life expectancy

(Years) McKinley Park 82.3 Orland Park 81.2 Hyde Park 82.4 Orland Hills 81.3 Armour Square 83.9 Willow Springs 81.8

Data Source: Illinois Department of Public Health, 2008-2012 7.22b. Natality (Number of deaths of infants less than one-year-old) per 1,000 live births, by region, 2012

Data Source: Illinois Department of Public Health, 2008-2012

Health Impact Collaborative of Cook County

South Region CHNA 60

Figure 7.22c. Years of Potential Life Lost (YPLL), comparison of communities in the South region

Data Source: Illinois Department of Public Health, 2008-2012

Health Impact Collaborative of Cook County

South Region CHNA 61

Key Findings: Mental Health and Substance Use Overview This section summarizes needs and issues related to mental health and substance use, referred to jointly as “behavioral health”. The South region CHNA found that mental health and substance use are issues that are in need of collaborative action to improve systems and support better health status and health outcomes in communities. In particular, the CHNA found that funding and systems are inadequate across the board to support behavioral health needs in Chicago and Cook County. Stigma and lack of open conversation about behavioral health are also factors that contribute to community mental health and substance use issues in youth and adults. The Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA) findings emphasized that current community mental health and substance use issues are the result of long-standing inadequate funding that has been exacerbated by recent cuts to social services, healthcare, and public health. The findings from the FOCA and community focus groups emphasized that behavioral health is an issue that affects population groups across income levels and race and ethnic groups in the South region. However, inequities related to the social and structural determinants of health have profound impacts on who is most impacted by the shortage of facilities and services. The following groups were identified as being at increased risk to be affected by cuts to community-based mental health and substance use services and facilities, shortages of mental and behavioral health professionals, and lack of trauma-informed care:

• Children and adolescents • Family caregivers • Homeless individuals • Incarcerated and formerly

incarcerated individuals • Individuals with a history of mental

illness and/or substance use

• LGBQIA individuals and transgender individuals

• Residents in long-term care facilities • Uninsured and underinsured • Veterans and former military

Mental health and substance use were two of the most discussed issues in the FOCA. The FOCA findings emphasized that social and structural determinants have substantial impacts on mental health. In particular, the following factors were identified as impacting mental health in communities: socioeconomic inequities; inadequate healthcare access; lack of affordable and safe housing; racism, discrimination, and stigma; and lack of safety or perceived safety, violence, and trauma. In terms of the connections between trauma and mental health, substantial evidence has emerged over the past decade that adverse childhood experiences (ACEs) strongly relate to a wide range of physical and mental health issues throughout a person’s lifespan. ACEs include physical and emotional abuse and neglect, observing violence against relatives or friends, substance misuse within the household, mental illness in the household, and forced separation from a parent or close family member through incarceration or other means.36

36 http://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences

Health Impact Collaborative of Cook County

South Region CHNA 62

The FOCA discussions identified some opportunities to address behavioral health access issues such as training first responders and implementing new prevention and community-based care models. The Behavioral Health Continuum of Care Model (Figure 8.1) includes Promotion, Prevention, Treatment, and Recovery. The World Health Organization (WHO) emphasizes the need for a network of community-based mental health services.37 The WHO has found that the closure of mental health hospitals and facilities is often not accompanied by the development of community-based services and this leads to a service vacuum.37 In addition, research indicates that better integration of behavioral health services, including substance abuse treatment into the healthcare continuum, can have a positive impact on overall health outcomes.38 The Substance Abuse and Mental Health Services Administration (SAMHSA) emphasizes the importance of promotion to create environments and conditions that support mental and emotional well-being and the ability of individuals to withstand challenges and prevention and early intervention to reduce the burden of mental health and substance use in communities.

Communities in the South region that have high rates of emergency department (ED) visits for behavioral health

Chicago Suburban Cook County • Auburn Gresham • Chicago Lawn • East Side • Englewood • Gage Park • Greater Grand Crossing • Hegewisch • New City • Riverdale • Roseland • South Chicago • South Deering • South Lawndale • South Shore • Summit • Washington Park • West Elsdon • West Englewood • West Pullman • Woodlawn

• Bloom Township • Burnham • Calumet City • Calumet Park • Calumet Township • Chicago Heights • Dixmor • Dolton • East Hazel Crest • Ford Heights • Glenwood • Harvey • Hazel Crest • Midlothian • Phoenix • Riverdale • Robbins • Sauk Village • South Chicago Heights

37 World Health Organization. (2007). http://www.who.int/mediacentre/news/notes/2007/np25/en/ 38 American Hospital Association. (2012). Bringing behavioral health into the care continuum: opportunities to improve quality, costs, and outcomes. http://www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf

Figure 8.1. Behavioral Health Continuum of Care Model

Health Impact Collaborative of Cook County

South Region CHNA 63

Scope of the issue – Mental health and substance use Data availability is a challenge for assessing mental health and substance use within the Community Health Status Assessment. The Health Impact Collaborative of Cook County made efforts to include as much mental health-related data as possible in this CHNA. The Community Health Status Assessment indicators included in the CHNA are:

• Self-reported mental health status

• Emergency department (ED) visits for mental health, intentional injury and suicide, substance use, and alcohol abuse

• Healthcare provider shortage areas for mental health Mental health The Behavioral Risk Factor Surveillance System (BRFSS) and Healthy Chicago Survey found that approximately 34%-44% of adults in Chicago and suburban Cook County report not having enough social or emotional support (Figure 8.2). These rates are higher than the rates for Illinois (20%) and the United States (23%). Figure 8.2. Self-reported emotional and mental health indicators Self-reported emotional and mental health indicators Suburban Cook

County (2012) Chicago

(2014) Illinois (2013)

United States (2013)

Percentage of adults that lack social or emotional support

34% 44% 20% 23%

Average number of days (in previous month) that adults report their mental health as not good

3.2 3.1 3.3 3.4

Data Source: Behavioral Risk Factor Surveillance System (BRFSS) (2013) and Healthy Chicago Survey (2014)

Cook County Jail is currently one of the largest facilities for people with mental illness and substance use issues in the U.S.

On any given day, at least one-quarter of the inmates at Cook County Jail are people with mental illness.

http://www.npr.org/2011/09/04/140167676/nations-jails-struggle-with-mentally-ill-prisoners http://www.cookcountysheriff.com/MentalHealth/MentalHealth_main.html

Health Impact Collaborative of Cook County

South Region CHNA 64

High rates of Emergency Department (ED) visits for mental health and substance use may indicate a lack of community-based treatment options, services, and facilities. Figure 8.3. Emergency Department (ED) visits for mental health in Cook County, by zip code (age-adjusted rate per 10,000)

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014

Health Impact Collaborative of Cook County

South Region CHNA 65

Figure 8.4. Emergency Department (ED) visits for intentional injury and suicide in Cook County, by zip code (age-adjusted rate per 10,000)

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014

Health Impact Collaborative of Cook County

South Region CHNA 66

Substance use According to the Substance Abuse and Mental Health Services Administration (SAMHSA), many factors influence a person’s chance of developing a mental and/or substance use disorder. From a community health perspective, the “variable risk factors” and substance use issues are particularly important as potential intervention points for prevention. The variable risk factors for substance use align with work on the social determinants of health; SAMHSA identifies income level, employment status, peer groups, and adverse childhood experiences (ACEs) as key variable risk factors. Protective factors include positive relationships, availability of community-based resources and activities, and civil rights and anti-hate crime laws and policies limiting access to substances. There is a high prevalence of co-morbidity between mental illness and drug use.39 Figure 8.6 shows the communities in the South region where high ED visit rates for mental illness overlap with high ED visit rates for substance use. Overall, the CHNA findings point to a number of societal trends related to mental health and substance use that are negatively affecting community health and the local public health system. The lack of effective substance use prevention, easy access to alcohol and other drugs, the use of these substances to self-medicate, and the criminalization of addiction in lieu of access to mental health services are seen to have profound impacts on community health in the South region of the Health Impact Collaborative and across Chicago and Cook County. Barriers to accessing mental health and substance use treatment and services include social stigma, lack of accessible and affordable mental health services due to continued funding cuts, low reimbursement rates for mental health services, and low salaries for mental health professionals (all of which have led to provider shortages). Opportunities to address behavioral health access issues include training first responders and implementing new community health models. The Community Health status assessment revealed some geographic disparities in the ED visit rates for heavy drinking and substance use, as shown in Figures 8.7 and 8.5. Additionally, 9% of Chicago adults report heavy drinking in the past month, which is substantially higher than the U.S. overall (6%).

39 National Institutes of Health – National Institute on Drug Use. (2010). https://www.drugabuse.gov/publications/comorbidity-addiction-other-mental-illnesses/why-do-drug-use-disorders-often-co-occur-other-mental-illnesses

The U.S. Department of Justice estimates: 61% of individuals in state prisons and 44% of individuals in local jails with current or past violent offenses and three or more past incarcerations have a mental health issue.

63% of incarcerated individuals who had used drugs in the month before their arrest had mental health problems.

U.S. Department of Justice – Office of Justice Programs. (2006). Bureau of Justice Statistics Special Report: Mental Health Problems of Prison and Jail Inmates. http://www.bjs.gov/content/pub/pdf/mhppji.pdf

Health Impact Collaborative of Cook County

South Region CHNA 67

Youth substance use Drug use in adolescent and teen years may be part of a pattern of risky behavior which could include unsafe sex, driving while intoxicated, and other unsafe activities.40 Drug use in adolescent or teenage years can result in multiple negative outcomes including school failure, problems with relationships, loss of interest in normal healthy activities, impaired memory, increased risk for infectious disease, mental health issues, and overdose death.40 As a result, preventive measures to prevent or reduce drug use among adolescents and teens are important.40

40 National Institute on Drug Abuse. (2014). Principles of adolescent substance use disorder treatment: A research-based guide.

Substance use among youth in suburban Cook County

Illinois Youth Survey, comparing 2010 and 2014 survey results

• In 2014, 52% of 12th graders reported drinking alcohol in the past month, 41% reported marijuana use, 9% reported using prescription drugs to get high, and 7% reported MDMA/ecstasy use.

• The number of 12th graders in Cook County that reported drinking alcohol in the past year (52%) is lower than the state average (63%). All other self-reported rates for drug use among students in Cook County are approximately the same as those for the state of Illinois.

• Alcohol use reported among middle school and high school students decreased slightly from 2010 to 2014. This follows a national trend of decreases in adolescent and teenage alcohol use that has been occurring over the last 15 years.

• 12th graders’ reporting heavy drinking decreased from 33% in 2010 to 28% in 2014.

• Rates of self-reported cocaine/crack use among 12th graders decreased by 3%, and self-reported marijuana and MDMA/ecstasy use both increased by 2%.

• Self-reported use of inhalants, hallucinogens/LSD, methamphetamine, and heroin did not change between 2010 and 2014.

24% (67) of eligible elementary/middle schools and 48% (35) of eligible high schools in suburban Cook County participated in the 2014 Illinois Youth Survey.

Health Impact Collaborative of Cook County

South Region CHNA 68

Figure 8.5. Emergency Department (ED) visits for substance abuse in Cook County, by zip code (age-adjusted rate per 10,000)

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014

Health Impact Collaborative of Cook County

South Region CHNA 69

Figure 8.6. Emergency Department (ED) visits for mental health and substance abuse in Cook County, by zip code (age-adjusted rates per 10,000)

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014

Health Impact Collaborative of Cook County

South Region CHNA 70

Figure 8.7 shows ED visit rates for alcohol abuse. Several communities in the South region of Chicago and suburban Cook County have ED visit rates of 54.91 per 10,000 or greater for alcohol abuse. Nationwide, ED visits for alcohol abuse have been on an upward trajectory. Between 2001 and 2010, the rate of ED visits for alcohol-related diagnoses for males and females increased 38%. The nationwide rate for males as of 2010 is 94 per 10,000 and the rate for females is 36 per 10,000.41 Figure 8.7. Emergency Department (ED) visits for alcohol abuse in Cook County, by zip code age-adjusted rate per 10,000)

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014 There are several communities in the South region that are designated as mental health professional shortage areas, as shown in Figure 8.8. Mental Health Professional Shortage

41 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a9.htm

Health Impact Collaborative of Cook County

South Region CHNA 71

Areas are designated by the Health Resources and Services Administration (HRSA) as areas having shortages of mental health providers. Each shortage area is assigned a score (1-22) based on a variety of different factors including geographic area (a county or service area), population (e.g., low income or Medicaid eligible), or the presence of different types of facilities (e.g., federally qualified health centers, or state or federal prisons).42 The higher a score is for an area, the greater the need for mental health professionals, services, or facilities. The majority of communities in the South region are designated as mental health professional shortage areas. Figure 8.8. Map of mental health professional shortage areas in the South region, 2015

Data Source: U.S. Department of Health and Human Services Administration – Health Resources and Services Administration, 2016

42 U.S. Department of Health and Human Services Administration – Health Resources and Services Administration. (2016). http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx

Health Impact Collaborative of Cook County

South Region CHNA 72

Community input on mental health and substance use Closing of mental health facilities and discontinuation of services has led to an increased burden on communities and community-based organizations. Focus groups in the South region discussed how the lack of mental health services has led to a number of problems, including increased hospitalization, more expensive care, high incarceration, homelessness, substance use, suicide, and overburdening of existing programs or facilities. Community members also emphasized that there is a lack of sensitivity for patients in crisis and their families in both first responders and medical professionals. Community input highlighted the need for sensitivity training for healthcare staff to improve their interaction with both patients and their families. The stigma related to mental illness was stated to be a major barrier to accessing care for many residents in the South region. Community members indicated a need for community outreach to increase mental health awareness and decrease stigma.

Community resident survey – mental health

15% of community survey respondents in the South region indicated that they or a family member did not seek needed mental health treatment because of cost or a lack of insurance coverage.

15% of respondents indicated that they or their family members did not seek mental health treatment due to a lack of knowledge about where to get services.

9% indicated that wait times for treatment or counseling appointments were a barrier to accessing needed care.

Approximately half (51%) of survey respondents from the South region indicated that their financial situation or financial strain contributed most to feelings of stress in their day-to-day lives.

Nearly a third of respondents (30%) indicated that the health of family members contributed to feelings of stress in their daily lives and 28% indicated that time pressure or constraints contributed the most to feelings of stress.

Health Impact Collaborative of Cook County

South Region CHNA 73

Key Findings: Chronic Disease Overview This section summarizes needs and issues related to chronic disease. Chronic disease conditions—including type 2 diabetes, obesity, heart disease, stroke, cancer, arthritis, and HIV/AIDS—are among the most common and preventable of all health issues, and chronic disease is also extremely costly to individuals and to society.43 The South region CHNA findings emphasize that preventing chronic disease requires a focus on risk factors such as nutrition and healthy eating, physical activity and active living, and tobacco use. The findings across all four assessments emphasized that chronic disease is an issue that affects population groups across income levels and race and ethnic groups in the South region. However, social and economic inequities have profound impacts on which individuals and communities are most affected by chronic disease. Priority populations to consider in terms of chronic disease prevention include: children and adolescents, low-income families, immigrants, diverse racial and ethnic groups, older adults and caregivers, uninsured individuals, and those insured through Medicaid, individuals living with mental illness, individuals living in residential facilities, and incarcerated or formerly incarcerated individuals.

Many of the assessment findings in the social determinants of health section of this report are connected to chronic disease prevention. Assessment findings related to food access, food security, and built environment are included in the social determinants section starting on page 53.

43 Ward B.W., Schiller J.S., Goodman R.A. (2014). Multiple chronic conditions among U.S. adults: a 2012 update. Preventing Chronic Disease.

The CHNA findings highlighted that chronic disease prevention requires multifaceted approaches including: • Addressing social determinants of health and underlying socioeconomic and racial

inequities • Improving the built environment to facilitate active living and access to healthy affordable

food • Addressing both food access and food insecurity in communities • Improving access to primary and specialty care, with an emphasis on preventive care

• Improving access to affordable insurance and medications • Facilitating multi-sector partnerships for chronic disease prevention (including community-

based organizations, social service providers, healthcare providers and health plans, transportation, economic development, food entrepreneurs, etc.)

• Collaborating on policies related to healthy eating and active living, and related to overall funding for healthcare, public health, and community-based services

• Improving data systems to understand how chronic disease is affecting diverse communities and to measure the impact of collaborative interventions

Health Impact Collaborative of Cook County

South Region CHNA 74

In order to reduce chronic disease-related mortality and address inequities in mortality and disease burden, a focus on chronic disease prevention is critical. The CDC has identified four domains for chronic disease prevention. Data presented in this section and throughout the CHNA report provides information about current chronic disease burden and health behaviors, built environment and community conditions, and community input about opportunities to create healthier communities and address chronic disease risk factors.

Communities in the South region with a high burden of chronic disease across multiple indicators*

* Indicators included here are mortality (heart disease, cancer, stroke, diabetes) and hospitalization data (asthma and diabetes).

CDC’s Four Domains for Chronic Disease Prevention 1. Epidemiology and surveillance: to

monitor trends and track progress.

2. Environmental approaches: to promote health and support healthy behaviors.

3. Healthcare system interventions: to improve the effective delivery and use of clinical and other high-value preventive services.

4. Community programs linked to clinical services

Health Impact Collaborative of Cook County

South Region CHNA 75

Mortality related to chronic disease The Healthy Chicago 2.0 Assessment found that chronic diseases accounted for approximately 64% of deaths in Chicago in 2014.34 The top three leading causes of death across Chicago and suburban Cook County are heart disease, cancer, and stroke (Figure 9.1). Figure 9.1. Leading causes of death, Chicago and Cook County

Chicago (2012) Cook County (2012) Illinois (2014) United States (2014) • Heart Disease • Cancer • Stroke and

Cerebrovascular Diseases

• Chronic Lower Respiratory Diseases

• Accidents

• Heart Disease • Cancer • Stroke and

Cerebrovascular Disease

• Chronic Lower Respiratory Diseases

• Accidents

• Heart Disease • Cancer • Chronic Lower

Respiratory Disease

• Stroke and Cerebrovascular Diseases

• Accidents

• Heart Disease • Cancer • Chronic Lower

Respiratory Disease

• Accidents • Stroke and

Cerebrovascular Diseases

Racial and ethnic disparities in mortality rates persist in the South region of Chicago and Cook County, as shown in Figures 9.2 and 9.5. And, there are major variations in chronic disease-related mortality rates across both the Chicago community areas and Cook County suburbs, as shown in Figure 9.3. Figure 9.2. Chronic disease-related mortality (per 100,000) for the South region in 2012, by race and ethnicity

Data Source: Illinois Department of Public Health, 2012

Health Impact Collaborative of Cook County

South Region CHNA 76

Figure 9.3. Chronic disease-related mortality (per 100,000), age adjusted rates, 2008-2012

Heart Disease Mortality Cancer Mortality Stroke Mortality

Data Source: Illinois Department of Public Health, 2008-2012

The coronary heart disease mortality rate in the South region was 120.4 deaths per 100,000 population in 2012. The Healthy People 2020 target is 103.4 per 100,000 population.

The cancer mortality rate in the South region was 205.8 deaths per 100,000 population in 2012. The Healthy People 2020 target is 161.4 per 100,000 population.

The stroke mortality rate in the South region was 40.1 deaths per 100,000 population in 2012. The Healthy People 2020 target is 34.8 per 100,000 population.

Health Impact Collaborative of Cook County

South Region CHNA 77

Obesity and diabetes Hospitalization and emergency department (ED) visits are indicative of poorly controlled chronic diseases such as diabetes and a lack of access to routine preventive care. Poorly controlled diabetes can lead to severe or life-threatening complications such as heart and blood vessel disease, nerve damage, kidney damage, eye damage and blindness, foot damage and lower extremity amputation, hearing impairment, skin conditions, and Alzheimer’s disease.44 Non-Hispanic African American/blacks in the South region have the highest rates of diabetes-related mortality. Figure 9.4. Diabetes-related hospitalization rate (per 10,000) in the South region, 2012-2014

Data Source: Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014 Figure 9.5. Diabetes-related mortality in South region, by race and ethnicity (age-adjusted rates per 100,000), 2012

Data Source: Illinois Department of Public Health, 2012

44 Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/dxc-20169861

Health Impact Collaborative of Cook County

South Region CHNA 78

Asthma Figures 9.6 and 9.7 show the geographic distributions of emergency department (ED) visits due to adult and pediatric asthma. Communities on the South Side of Chicago and South Cook suburbs have disproportionately high rates of ED visits for asthma. ED visits are indicative of increased exposure to environmental contaminants that can trigger asthma as well as poorly managed asthma. Figure 9.6. Emergency Department (ED) visits in the South region due to adult asthma (age-adjusted rates per 10,000), 2012-2014

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014 Figure 9.7. Emergency Department (ED) visits in the South region due to pediatric asthma (age-adjusted rates per 10,000), 2012-2014

Data Source: Healthy Communities Institute, Illinois Hospital Association COMPdata, 2012-2014

Health Impact Collaborative of Cook County

South Region CHNA 79

Health behaviors Poor diet and a lack of physical activity are two of the major predictors for obesity and diabetes. Low consumption of healthy foods may also be an indicator of inequities in food access. More than 75% of enrolled schoolchildren in the South region of Chicago and suburban Cook County are eligible for free or reduced price lunch, and 21% of all households in the South region report receiving SNAP benefits. More data and information about food access is included on page 53 of this report.

Figure 9.8. Self-reported behaviors in adults and youth

Self-reported health behaviors, Adults Suburban

Cook County (2012)

Chicago (2014)

Illinois (2013)

United States (2013)

Adults Eating LESS than Five Daily Servings of Fruits and Vegetables

85% 71% 78% 77%

Heavy Drinking in the Previous month N/A 9% 7% 6%

Current Smokers 14% 18% 18% 19% No Leisure-Time Physical Activity 26% 29% 25% 25%

Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey

Self-reported health behaviors, Youth Suburban Cook

County (2012) Chicago

(2014) Illinois (2013)

United States (2013)

Current Smokers (high school students) 12% 11% 18% 16%

No Leisure-Time Physical Activity 16% 22% 13% 15%

Data Source: Youth Risk Behavior Surveillance System

• The majority of adults in suburban Cook County (85%) and Chicago (71%) report eating less than five daily servings of fruits and vegetables a day.

• More than a quarter of adults in suburban Cook County (26%) and Chicago (29%) report not engaging in physical activity during leisure time.

• Approximately 16% of youth in suburban Cook County and 22% of youth in Chicago report not engaging in physical activity during leisure time.

Health Impact Collaborative of Cook County

South Region CHNA 80

Persons living with HIV/AIDS Because of antiretroviral therapy, individuals with HIV are now living longer lives with better quality of life. Consistent use of antiretroviral therapy along with regular clinical care slows the progression of HIV, keeps individuals with HIV healthier, and greatly reduces their risk of transmitting HIV.45 As the population of Persons Living with HIV/AIDS (PLWHA) grows, it is important to have systems in place for their continuity of care.46 In suburban Cook County, the number of PLWHAs increased 87% from 2,500 in 2004 to 4,683 in 2013.47 In 2012, there were 22,346 PLWHAs in Chicago, which is a 12% increase from 2005 (19,892 PLWHAs).48,49 The communities with the largest numbers of PLWHA are shown in Figure 9.9. In addition to geographic disparities in PLWHAs, there are also disparities related to gender, age, race/ethnicity, and sexual orientation. African American/black men who are young and have sex with men are most seriously affected by HIV.50 Overall, African American/blacks have the most severe burden of HIV compared to all other racial and ethnic groups.50 Additional data on sexually transmitted infections (STIs) is included in Appendix D. Figure 9.9. Communities in the South region with the highest percentages of Persons Living with HIV/AIDS (PLWHA), per 100,000 population

Communities in the South region with the highest percentages of persons living with HIV/AIDS

Chicago Suburban Cook County • Auburn Gresham • Avalon Park • Burnside • Calumet Heights • Chatham • Chicago Lawn • Douglas • Englewood • Fuller Park • Grand Boulevard • Greater Grand

Crossing • Hyde Park • Kenwood

• Morgan Park • Near South Side • New City • Oakland • Pullman • Riverdale • Roseland • South Chicago • South Deering • South Lawndale • South Shore • Washington

Heights • Washington Park

• West Englewood

• West Pullman • Woodlawn

• Burnham • Calumet Park • Calumet Township • Dolton • Harvey • Hazel Crest • Markham • Phoenix

45 Centers for Disease Control and Prevention. (2016). Living with HIV. http://www.cdc.gov/hiv/basics/livingwithhiv/index.html 46 Chicago Department of Public Health – HIV/STI Bureau. (2016). Chicago EMA HIV/AIDS Profile. 47 Cook County Department of Public Health. (2013). Sexually Transmitted Infections Surveillance Report, 2013. http://cookcountypublichealth.org/files/pdf/publications/hiv-surv-report-2013-final-copy.pdf 48 Chicago Department of Public Health. (Winter 2005-2006). STD/HIV/AIDS Chicago, Winter 2005-2006. http://www.aidschicago.org/resources/legacy/pdf/2006/fact_cdph_winter.pdf 49 Chicago Department of Public Health. (2014). HIV/STI Surveillance Report, 2014. http://www.cityofchicago.org/content/dam/city/depts/cdph/HIV_STI/2014HIVSTISurveillanceReport.pdf 50 Centers for Disease Control and Prevention. (2015). HIV in the United States: At a glance. http://www.cdc.gov/hiv/statistics/overview/ataglance.html

Health Impact Collaborative of Cook County

South Region CHNA 81

Community input on chronic disease prevention Focus group participants in the South region identified several factors that influence chronic disease in their communities including:

• need for non-emergency preventative care and linkage to care following hospitalization;

• inequities in access to healthcare services; • a lack of youth-friendly providers, services, and facilities; • the built environment and transportation systems needed to support healthy eating

and active living; and • healthy food access.

Community input on the connections between chronic disease and built environment is included in the social determinants of health section starting on page 37. Residents in the South region discussed inequities in access to healthy foods. Focus group participants reported that many communities in the South region, particularly communities on the South Side of Chicago have limited access to healthy fresh foods and grocery stores.

Community survey data – Healthy eating and active living • Food insecurity. Approximately 55% of survey respondents from the South region

indicated that they or their families have had to worry about whether or not their food would run out before they had the money to buy more.

• Healthy food availability. The South region had the lowest percentage of respondents (53%) indicating that healthy foods, including fresh fruit and vegetables, are available in their communities.

• Parks and recreation. Nearly a third of respondents (30%) from the South region indicated that there are few or no parks and recreation facilities available in their communities.

• Reliability of public transportation. Approximately 34% of respondents found the reliability of public transportation to be fair and 18% of respondents rated it as poor. These were the lowest ratings of the three regions.

• Quality and convenience of bike lanes. About 30% of respondents rated the quality and convenience of bike lanes in their communities as fair, while 16.8% rated them as poor or very poor.

Health Impact Collaborative of Cook County

South Region CHNA 82

Key Findings: Access to Care and Community Resources Overview Findings from the CHNA data clearly point to interrelated access issues, with similar communities facing challenges in terms of access to healthcare and access to community-based social services and access to community resources for wellness such as accessible and affordable parks and recreation and healthy food access. These are many of the same communities that are also being most impacted by social, economic, and environmental inequities, so lack of access to education, housing, transportation, and jobs are also underlying root causes of inequities that affect access to care and community resources.51 Some specific priority needs related to access that were emphasized in the CHNA findings are:

• Inadequate access to healthcare, mental health services, and social services, particularly for the uninsured and underinsured

• Opportunities to coordinate and link access to healthcare and social services • Need to improve cultural and linguistic competency and humility • Need to improve health literacy • Navigating complex healthcare systems and insurance continues to be a

challenge in the post Affordable Care Act environment Several priority populations were identified through the community focus groups and Forces of Change Assessment (FOCA) as being more likely to experience inequities in access to care and community resources including low income households, diverse racial and ethnic groups, immigrants and refugees, older adults, children and adolescents, LGBQIA individuals, transgender individuals, people living with physical or intellectual disabilities, individuals living with mental illness, individuals living in residential facilities, those currently or formerly incarcerated, single parents, homeless individuals, veterans and former military, and people who are uninsured. 51 Levesque, J.F., Harris, M.F. & Russell, G. (2013). Patient-centered access to health care: conceptualising access at the interface of health systems and populations. International Journal of Equity in Health, 12(1), 18.

Access is a complex and multifaceted concept that includes dimensions of proximity; affordability; availability, convenience, accommodation, and reliability; quality and acceptability; openness, cultural competency, appropriateness and approachability.

Forces of Change Assessment – Healthcare System Trends The following forces were identified as trends that are or may have an impact on health and the public health system in Cook County: • Ongoing implementation of the Affordable Care Act

(ACA) and healthcare transformation • Transition of healthcare systems from acute care to

preventative care • Inadequate funding, services, and systems for mental

health and substance use • Increasing availability of health-related data • Changing role of health departments from providers to

coordinators • Racism, discrimination, and stigma based on

demographic characteristics and/or health conditions • Demographic shifts – Aging population as well as

increases in Latino and Asian populations in the South region

• Desire for cross-generational and family-oriented programs and services

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The FOCA and LPHSA identified a number of challenges that could threaten the success of population health approaches including:

• competition among healthcare providers;

• decreasing viability of small and trusted community groups as a result of consolidation and integration of healthcare systems;

• continuing barriers to providing mental health services;

• complex insurance and reimbursement poses challenges for providers and consumers;

• inequities in the distribution of medical services;

• lack of providers accepting Medicaid;

• funding cuts to social services; and

• barriers to developing systems and capacity in hospitals and health departments to address the social determinants of health because social determinants may be seen as political or outside the realm of health.

The Community Health Status Assessment data includes multiple factors that influence access to care including poverty, insurance coverage, self-reported use of preventative care, hospitalization statistics, provider availability, and use of prenatal care. The connection between poverty and health is explored in detail in the social determinants of health section of this report beginning on page 37. Several communities in the South region have high rates of negative health indicators and poor health outcomes, which indicates a lack of access to healthcare and community resources.

Opportunities – Access to Care and Community Resources Forces of Change Assessment and Community Focus Groups

• Community health workers fostering trusted relationships with community members and increasing community health literacy

• Increasing collaborative policy development and advocacy – hospitals, providers, health departments, and community organizations

• Healthcare workforce pipelines

• Collaborating to improve mental health and substance use treatment and prevention

• Technology and social media provide opportunities to promote access and knowledge of services

• Strengthening the roles of health departments and community-based organizations to promote healthy communities, wellness, and chronic disease prevention through system and environmental changes

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Communities in the South region have rates of negative health indicators and poor health outcomes

Chicago Suburban Cook County • Auburn Gresham • Chicago Lawn • East Side • Englewood • Greater Grand Crossing • Gage Park • Hegewisch • New City • Riverdale • Roseland • South Chicago • South Deering • South Lawndale • South Shore • Summit • Washington Park • West Elsdon • West Englewood • West Pullman • Woodlawn

Insurance coverage Lack of insurance is a major barrier to accessing primary care, specialty care, and other health services. In the post-Affordable Care Act landscape, the size and makeup of the uninsured population is shifting rapidly. Aggregated rates from 2009-2013 show that approximately 23% of the adult population age 18-64 in the South region reported being uninsured, compared to 18.8% in Illinois and 20.6% in the U.S. Men in Cook County are more likely to be uninsured (18.2%) compared to women (13.8%). In addition, African Americans, Latinos, and diverse immigrants are much more likely to be uninsured compared to non-Hispanic whites. It is estimated that 40% of undocumented immigrants are uninsured compared to 10% of U.S.-born and naturalized citizens. High insurance costs and lack of insurance were identified as barriers to accessing healthcare in multiple focus groups in the South region. Self-reported use of preventative care Lack of insurance may impact access to lifesaving cancer screenings, immunizations, and other preventive care. Routine cancer screenings may help prevent premature death from cancer and it may reduce cancer morbidity since treatment for earlier-stage cancers is often less aggressive than treatment for more advanced-stage cancers.52 Overall rates of self-reported cancer screenings vary greatly across Chicago and suburban Cook County compared to the rates for Illinois and the U.S. This could represent differences in access to preventative services or difference in knowledge about the need for preventative screenings.

52 National Institutes of Health – National Cancer Institute. (2016). Cancer Screening Overview. http://www.cancer.gov/about-cancer/screening/hp-screening-overview-pdq

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Figure 10.1. Self-reported use of preventive care Self-reported lack of preventive care Suburban Cook

County (2012) Chicago

(2014) Illinois (2013)

United States (2013)

Cervical Cancer Screening 16% 20% 23% 22%

Colorectal Cancer Screening 46% 53% 24% N/A

Breast Cancer Screening 42% 29% 27% 27%

Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey Vaccination is another important preventive measure. The CDC recommends that all adults aged 65 or older receive the pneumococcal vaccine. Approximately one-third (30%) of Chicago residents aged 65 or older reported that they had not received a pneumococcal vaccination in 2014. Figure 10.2. Self-reported pneumococcal vaccination among 65+ Self-reported lack of preventive care Suburban Cook

County (2012) Chicago (2014)

Illinois (2013)

United States (2013)

Lack of Pneumococcal Vaccination (65+)

N/A 30% 31% 53%

Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey Health education about routine preventive care was specifically mentioned in three of the focus groups as a need in their communities. Parents, youth, and immigrants were identified as populations that are more likely to not have information about how and where to seek out preventive services. Provider availability A large percentage of adults reported that they do not have at least one person that they consider to be their personal doctor or healthcare provider. In the U.S., LGBQIA and transgender youth and adults are less likely to report having a regular place to go for medical care. Regular visits with a primary care provider improves chronic disease management and reduces illness and death.53 As a result, it is an important form of prevention. 53 National Institutes of Health. (2005). Contribution of Primary Care to Health Systems and Health. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/

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Figure 10.3. Self-reported lack of primary care

Health Professional Shortage Areas are designated by the Health Resources and Services Administration (HRSA) as areas having shortages of primary care, dental care, or mental health providers. Each shortage area is assigned a score based on factors such as geography (a county or service area), population characteristics (e.g., low-income or Medicaid eligible), or the presence of different types of facilities (e.g., federally qualified health centers, or state or federal prisons).54 The shortage areas with the highest scores are the ones with the greatest need for health professionals, services, or facilities. There are several communities in the South region that are designated as primary care health professional shortage areas as shown in Figure 10.4. Shortages of mental health professionals is also a critical aspect of access to healthcare. Figure 10.4. Map of primary care provider shortage areas in the South region, 2015

Data Source: Health Resources and Services Administration, Health Professional Shortage Area Database, 2015 Multiple focus groups in the South region mentioned that continued funding cuts and the current State budget crisis are further reducing much needed community-based health resources. Participants stated that individuals with mental illness, individuals living with

54 U.S. Department of Health and Human Services Administration – Health Resources and Services Administration. (2016). http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx

Self-reported lack of a consistent source of primary care, 2013

Suburban Cook County (2012)

Chicago (2014)

Illinois (2013)

United States (2013)

Lack of consistent source of primary care 13% 19% 12% 23%

Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey

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intellectual disabilities, formerly incarcerated individuals, diverse racial and ethnic groups, and immigrants have the least amount of access to healthcare resources. Prenatal care Access to prenatal care is an important preventative measure to reduce the risk of pregnancy complications, reduce the infant’s risk for complications, reduce the risk for neural tube defects, and help ensure that the medications women take during pregnancy are safe.55 Nearly 20% of women in Illinois and suburban Cook County do not receive prenatal care prior to the third month of pregnancy or receive no prenatal care. (Recent comparable data for the City of Chicago was not available at the time this report was produced.) Figure 10.5. Prenatal care Number of births to mothers with inadequate prenatal care (per 100 live births), 2008-2012

Suburban Cook County Illinois United States Number of births to mothers that lacked prenatal care (per 100 live births)

18.6 19.0 19.3

Data Source: Illinois Department of Public Health, 2008-2012 Cultural competency and cultural humility As detailed in the Community Description on pages 22-25 of this report, the South region of the Health Impact Collaborative of Cook County is home to diverse racial and ethnic populations including many immigrants and limited English speaking populations. Focus group participants in the South region observed that immigrants are at increased risk for health issues related to isolation, behavioral health, and discrimination and have less access to quality medical care. The importance of culturally and linguistically competent providers across the spectrum of care and prevention programs was mentioned by several groups. Although language interpretation services are available at hospitals, a few groups cited long wait times for interpreters and incorrect interpretations of medical terminology as barriers to utilizing those services. In addition, participants indicated that more services are needed to help immigrants and refugees navigate the complex U.S. healthcare system. Multiple groups explained the need for more health-related data collection and research for certain racial and ethnic groups, so that their needs and any access issues can be adequately assessed. Access to quality home healthcare services was identified as an important need for individuals and families that choose to age in place. Multiple focus group participants indicated that oversight of home healthcare agencies, integration of the different home healthcare services, and standardization of home healthcare training would improve the quality and safety of the services that are provided.

55 National Institute of Child Health and Human Development. (2013). https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/pages/prenatal-care.aspx

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Conclusion – Reflections on Collaborative CHNA

The members of the Health Impact Collaborative of Cook County have worked together to accomplish many things over the past 18 months. In the second largest county in the country with a population of over 5 million, 26 hospitals, 7 health departments, and more than 100 community partners came together for a comprehensive community health needs assessment in Chicago and Cook County. Using the MAPP model for the CHNA proved to yield robust data from various perspectives including health status and health behaviors, forces of change, public health system strengths and weaknesses, and perceptions and experiences from diverse and often underserved community populations. A focus on health equity, community input, stakeholder engagement, and collaborative leadership and decision making have been some of the hallmarks of this process thus far. The CHNA process presented an exciting opportunity to engage diverse groups of community residents and stakeholders. The input from those community partners has been invaluable in helping to identify and understand the priority community health issues that we need to address collectively for meaningful impact. All of the issues prioritized by the Health Impact Collaborative of Cook County are issues that cannot be addressed by any one organization alone. Leveraging the continued participation of community stakeholders invested in health equity and wellness, including actively identifying and engaging new partners, will continue to be essential for developing and deploying aligned strategic plans for community health improvement in any of the following priority areas:

1. Improving social, economic, and structural determinants of health while reducing social and economic inequities.

2. Improving mental health and deceasing substance abuse. 3. Preventing and reducing chronic disease (focused on risk factors – nutrition, physical

activity, and tobacco). 4. Increasing access to care and community resources.

To be successful, the Health Impact Collaborative will continue to partner with health departments across Chicago and Cook County to adopt shared and complimentary strategies and leverage resources to improve efficiencies and increase effectiveness for overall improvement. Data sharing across the health departments was instrumental in developing this CHNA and will continue to be an important tool for establishing, measuring and monitoring outcome objectives. Further, the shared leadership model driving the CHNA will be essential to continue to balance the voice of all partners in the process including the hospitals, health department, stakeholders, and community members. Driven by a shared mission and a set of collective values that have guided the CHNA process and decision making, the Health Impact Collaborative will work together to develop implementation plans and collaborative action targeted to achieving the shared vision of Improved health equity, wellness, and quality of life across Chicago and Cook County. Engaging in this collaborative CHNA process has developed a solid foundation and opened the door for many opportunities moving forward. Participating in developmental evaluation, funded by the Robert Wood Johnson Foundation, is helping to document process strengths

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and improvement opportunities as well as understand and measure specific foundational elements necessary to develop a strong collective impact initiative. The Regional Leadership Teams and Stakeholder Advisory Teams look forward to building on the momentum, working in partnership with diverse community stakeholders at regional and local levels to address health inequities and improve community health in communities across Chicago and Cook County.

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HICCC CHNA cover page Updated for South Shore
FINAL_South Region Report_v3_20December2016
- Table of Contents
- Executive Summary – South Region
  - Collaborative structure
  - Stakeholder engagement
  - Mission, vision, and values
  - Assessment framework and methodology
  - Significant health needs
  - Key assessment findings
- Introduction
  - Collaborative Infrastructure for Community Health Needs Assessment (CHNA) in Chicago and Cook County
  - Community and stakeholder engagement
  - Formation of the South Stakeholder Advisory Team
  - South Leadership Team
  - Steering Committee
  - Mission, vision, and values
- Collaborative CHNA – Assessment Model and Process
- Community Description for the South Region
- Overview of Collaborative Assessment Methodology11F
  - Methods – Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA)
  - Methods – Community Health Status Assessment
  - Methods – Community Themes and Strengths Assessment
    - Community Survey – methods and description of respondents in South region
    - Focus Groups – methods and description of participants in South region
- Prioritization process, significant health needs, and Collaborative focus areas
- Health Equity and Social, Economic, and Structural Determinants of Health
  - Health inequities
  - Economic inequities
  - Education inequities
  - Inequities in the built environment
  - Inequities in community safety and violence
  - Structural racism
  - The importance of upstream approaches
- Key Findings: Social, Economic, and Structural Determinants of Health
  - Social Vulnerability Index and Child Opportunity Index
    - Social Vulnerability Index
    - Childhood Opportunity Index
  - Poverty, Economic, and Education Inequity
    - Poverty
    - Unemployment
    - Education
  - Built environment: Housing, infrastructure, transportation, safety, and food access—Social, economic, and structural determinants of health
    - Housing and Transportation
    - Food access and food security
    - Environmental concerns
  - Safety and Violence—Social, economic, and structural determinants of health
  - Structural racism and systems-level policy change—Social, economic, and structural determinants of health
  - Health Impacts—Social, economic, and structural determinants of health
- Key Findings: Mental Health and Substance Use
  - Overview
  - Scope of the issue – Mental health and substance use
    - Mental health
    - Substance use
    - Youth substance use
    - Community input on mental health and substance use
- Key Findings: Chronic Disease
  - Overview
  - Mortality related to chronic disease
  - Obesity and diabetes
  - Asthma
  - Health behaviors
  - Persons living with HIV/AIDS
  - Community input on chronic disease prevention
- Key Findings: Access to Care and Community Resources
  - Overview
  - Insurance coverage
  - Self-reported use of preventative care
  - Provider availability
  - Prenatal care
  - Cultural competency and cultural humility
- Conclusion – Reflections on Collaborative CHNA

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