BUILDING BRIDGES Community-University Partnerships for Health - - PowerPoint PPT Presentation

BUILDING BRIDGES

Community-University Partnerships for Health

OBJECTIVES

• 1. Provide overview of CARE: Community

Alliance for Research and Engagement at Yale, and our flagship initiative, Community Interventions for Health.

• Global health initiative with focus on

chronic disease

• 2. Document current health status of New

Haven children and adults based on >2400 surveys conducted this fall, including mental and physical health.

• 3. Invite collaborative research.

CARE Mission

To improve the health of New Haven residents through visionary leadership, community engagement, collaborative community-based research, and dissemination of findings.

Yale Center for Clinical Investigation Schools of Public Health, Medicine, Nursing

CARE‟S UNIQUE STRENGTHS

COMMUNITY ALLIANCE RESEARCH ENGAGEMENT

CARE‟S UNIQUE STRENGTHS

COMMUNITY

New Haven

• Rich historical and cultural traditions
• Vital to economy of south central CT
• Ideal population size (130,000 people):

– small enough to create close partnerships – Large and diverse enough for robust engagement, research, and action

COMMUNITY

New Haven: Community Challenges

• Wealth disparity

– CT is one of the richest states – New Haven is one of poorest US cities

• Food insecurity: 163 of 169 towns/cities in CT
• Economic insecurity: 78% NHPS eligible for free/reduced

price meals

• Health disparity

– From birth to death, New Haven residents face risk of illness and disability 1.5 to 7 times higher than others in the state

OUR RESPONSE

• Unacceptable poor health status in

New Haven

• We can prevent or reduce many

adverse health outcomes

• Revitalize our community by

promoting health of our citizens

CARE‟S UNIQUE STRENGTHS

ALLIANCE

CREATE/STRENGTHEN PARTNERSHIPS

• Take action with many partners to

improve health in New Haven

• Create programs and policies to

prevent disease and promote health

• Evaluate impact

.

ALLIANCE

DIVERSE CITYWIDE COALITION

• Residents and grass roots coalitions
• City of New Haven officials
• New Haven Public Schools
• Health centers/health providers
• Business community
• Leadership of community-based organizations
• Faith-based communities
• Organized philanthropy
• Senior leadership and faculty across Yale

.

ALLIANCE

CARE’S UNIQUE STRENGTHS

RESEARCH

COMMUNITY INTERVENTIONS FOR HEALTH

• International collaborative to prevent

chronic disease

• New Haven is first US city to participate

http://www.3four50.com/cih/

RESEARCH

Knowledge = Power

• Identify and document community issues
• Learn about experiences, priorities, and

concerns of community members

• Mobilize community members and leaders
• Identify areas for improvement and solutions
• Determine whether solutions have worked
• Convince funders to provide resources
• Persuade policymakers to support needed

programs and services

CARE’S UNIQUE STRENGTHS

ENGAGEMENT

Build trust, visibility, integrity, leadership

2007

• Future Search Consensus Conference
• Diabetes Awareness Day

2008

• Heart Health
• Childhood Obesity Summit
• Sexual Health: Real Life, Real Talk
• 6 Community forums on Public Health & Health Disparities

2009

• Arts and Ideas Festival – CIH LAUNCH
• Conference /Workshops on Ethics, Dissemination, &Translation
• Community Forum on Health Equity

2010

• Community conversations
• Active work with neighborhood groups

ENGAGEMENT

CARE‟S UNIQUE STRENGTHS

COMMUNITY ALLIANCE RESEARCH ENGAGEMENT

Community Interventions for Health Prevent chronic disease

Risk Factors – 3 Four 70

Lack of exercise Unhealthy Diet Tobacco Use

Mokdad et al. JAMA. 2004;291:1238-45

Why Chronic Disease?

It‟s costly! It‟s preventable!

75% of the nation’s $2.5 trillion health care expenditures

Chronic Disease in the US

• Prevalence: 133 million, 50% >1 chronic condition
• Mortality: 70% of all deaths
• Premature Mortality: 33% yrs life lost before age 65
• Costs: >75% of the nation‟s $2.5 trillion annually

(direct + indirect, 2005) – Smoking: $193 billion – Obesity: $117 billion – Heart disease & stroke: $448 billion – Diabetes: $174 billion – Cancer: $89 billion

http://www.cdc.gov/NCCdphp/overview

Preventable Hospitalizations, CT 2008

>47,000 preventable hospitalizations accounting for 255,000 patient days and $1.2 billion in charges

– These patients utilized more health care resources in hospital and post-discharge – New Haven County - highest per capita rates for 12 of 19 conditions (e.g., asthma, CHF, COPD, diabetes-related, LBW babies) – Reflect gaps in primary care, disease management, access to health services that lead to increased disease severity and hospitalization

(CT Office of Health Care Access, 2010)

CT Cost: “Preventable” Hospitalizations

Ambulatory Care Sensitive Conditions, linked to Chronic Disease

611,000,000 893,000,000 1,160,000,000 $0 $500,000,000 $1,000,000,000 $1,500,000,000 2000 2004 2008 (CT Office of Health Care Access, 2010)

Prevention is Cost-Effective

• Clinical smoking cessation interventions

cost an estimated $2,587 for each year of life saved, the most cost-effective of all clinical preventative services.

• $1 spent on preconception care

programs for women with diabetes, can reduce health costs by up to $5.19, by preventing complications for both mothers and babies.

http://www.cdc.gov/NCCdphp/overview

• Time and monetary constraints for

engaging in healthy behaviors

• Accessibility/availability of healthy
• ptions
• Lack of knowledge and risk perception
• Institutional awareness of evidence-

based practices to prevent chronic disease

• Community Interventions for Health (CIH)

is a solution Barriers

Action: Intervention Programs

Framework for effective intervention strategies to promote healthy lifestyles and healthy communities: programs and policies that address health and social indicators.

Evidence: Research Study

Large multinational cohort study to identify best practice approaches in chronic disease prevention; comparative analyses.

CIH: A Solution

• New Haven is first US city in CIH collaborative.

Long Empirical Tradition

Surveillance

MONICA EPIC

Interventions

Comprehensive Cardiovascular Community Control Program CINDI CARMEN

Region/Country Specific:

AGITA(Brazil) Stanford 5(USA) Minnesota Heart Healthy (USA) Pawtucket (US) Isfahan(Iran) North Karelia (Finland) German CVD Prevention Study Finnmark Study (Norway) Tromsø (Norway) Finbalt Study MRFIT (USA)

Setting Specific:

CATCH (school) Wisewomen (HC) Sorenson Well- Work Study (W) Glasglow Take Heart(W)

CIH: Comprehensive Community Interventions CIH focuses on developing populations using structural interventions at the ground level AND includes a strong evaluation component Case control Biomarker Specific:

Interheart Risk Factor CARMELA

Cohorts:

Brazil 1982 Cohort Pelotas British Cohort 1970 (BCS70) DONALD Study Germany 1985 Danish National Birth Cohort 1996 Framingham USA Bogalusa Heart Study for Children (USA)

• 1. Strengthen broad collaborative

partnerships to improve individual and community health, reduce disparities.

• 2. Develop and implement targeted

program and policy interventions.

• 3. Evaluate impact of interventions

through rigorous assessment over time; ensure effectiveness and sustainability.

CIH: Strategies for Change

• Neighborhoods

– Safe routes for walking and bicycling – Affordable/accessible fruit carts or farmers markets

• Schools/Worksite

– Healthy food/drink in cafeteria and vending machines – Advertisement-free schools – Incentives for participation in on-site and off-site physical activity – Before and after school programs:

• students, teachers, staff, families
• Health care settings

– Smoke-free hospitals with healthy food options – Incentives and training for providers to screen for and prevent chronic disease

Examples of Structural Interventions

• Comprehensive community interventions rare.

Most studies target single setting populations with mixed success and challenges regarding sustainable change.

• Structural interventions work. Systemic changes are

cost-effective and sustainable given focus on policy, environmental and economic change rather than isolated individual behavioral change.

• CIH includes an extensive evaluation that include

both process and outcome/impact evaluation.

• Urgent need to understand evidence based

programs/policies to prevent chronic disease, preserve

quality of life, strengthen neighborhoods, and reduce costs.

Importance of CIH

• Improve community health and reduce health disparities

– with an eye to become our nation‟s healthiest city.

• Visible collaboration between City and Yale through

expansion of community/university partnership; leverage world-class health research; first/only US site of large international collaborative to improve health.

• Improve Wellness Programs for City and University

employees to reduce absenteeism, increase productivity, save money.

• Increase financial resources for neighborhoods, schools,

health centers, and worksites, with oversight to ensure new initiatives follow a best practice „road map‟.

• Strengthen network of collaborations for more robust

translation of research into practice as well as active dissemination of important research findings

Benefits to New Haven and to Yale

Framework to translate/evaluate interventions

• Environmental Scan/Neighborhood Asset Mapping
• Large prospective cohort (N≈4000)

– Neighborhoods, schools, worksites, health centers

– Repeated measures, biennially

• Biomarkers for subset

General Methodological Approach

• Prevalence

– D Behavioral risk factors

• e.g. consumption, exercise patterns

– D Biometric measures

• e.g. BMI, blood pressure
• Program/policy implementation
• Cost-benefit

Evaluation Indicators

Accelerated Timeline 2009-2010

Aug: Asset Map Sept: Hire/Train Oct/Nov: Surveys Dec: Preliminary Reports Feb-Apr: Reports & Community Dialogues

Focus on Six Neighborhoods

Dixwell Fair Haven Hill North Newhallville West River/Dwight West Rock

Documenting New Haven‟s Health CARE‟s Neighborhood Mapping

CARE‟s Neighborhood Mapping

MAJOR PARTNERS

Neighborhoods of Choice

The Community Foundation For Greater New Haven

“Asset” Mapping

• Inventory of community assets
• Describe assets visibly on a map
• Focus on assets rather than needs
• Tool for raising awareness

How Is Asset Mapping Done?

1) Walk neighborhood streets 2) Find, collect and map information 3) Enter info into handheld computers

What CARE Mapped: STORES

• Healthy and

unhealthy foods

• Fresh produce
• Junk food
• Tobacco products

What CARE Mapped: RESTAURANTS

• Sit down/fast food
• Availability of

healthy foods

• Nutrition

information posted

What CARE Mapped

Parks Gardens Recreation

Neighborhood Health Surveys

Community-Level Surveys

• October-November 2009, we

conducted community-level surveys to get a real-time snapshot of health in New Haven

– 1205 randomly selected residents (adults) in 6 high-need neighborhoods – 1175 5th and 6th grade students from 12 randomly selected schools

• >85% participation across both

Neighborhood Survey Demographics (N=1205)

• 61% women
• Mean age = 40 years (range18-64)
• Race/Ethnicity

– African American/Black: 64% – Latino/Hispanic: 21% – White: 15% – Other: 4%

• Foreign born: 17%

Survey Findings

• New Haven residents report

poorer health than U.S. average

Self-Rated Health

Health Insurance

Health Conditions

5 10 15 20 25 30 35 40 Heart Disease/Attack Diabetes Asthma Obesity High Blood Pressure High Cholesterol Rate Reported (%)

All New Haven Participants National Average*

*Behavioral Risk Factor Surveillance System, 2008 (Centers for Disease Control)

Nutrition

• 38% eat fruit

7 days/week

• 48% eat vegetables

7 days/week

• Most had just 1-2 servings, compared to

recommended 5/day

Nutrition

53% drink soda daily; 76% >2 sodas/day 32% eat sweets daily

Food Insecurity

18 11 2 4 6 8 10 12 14 16 18 20

Food Insecurity

Chart Title

All New Haven Participants National Average*

US Dept of Agrilculture, 2009

Exercise

• 53% report no vigorous exercise
• 38% report doing no moderate exercise

Exercise Feelings of safety limit exercise

• 65% “strongly agree” or

“somewhat agree” that it is unsafe to go for walks in their neighborhood at night

Daily Smoking

Smoking

• Most smokers said they would be

motivated to quit by saving the money they spend on cigarettes

Stress and Depression

• 28% feel down,

depressed or hopeless

• 24% report moderate

to extreme stress

Mental & Physical Health

STRESS DEPRESSION Self-rated Health *** *** Obesity * *** Heart Disease *** *** High Blood Pressure *

NS

Diabetes

NS

** Lung Disease ** ** Asthma **

NS

Food Insecurity * * Use ER for Care *** *** * p < 0.05; ** p < 0.01; *** p < 0.001

SUMMARY NEW HAVEN NEIGHBORHOODS

– Lack healthy options in stores/restaurants – Parks and gardens – an asset – Lower self-rated health and insurance – More health damaging behaviors – More chronic conditions – High levels of stress and depression, which are related to adverse physical health outcomes

New Haven Public Schools

• Working in close collaboration with

Board of Education leadership

• 12 randomly selected K-8 schools
• 5th and 6th graders
• N=1,175, 88% participation rate

– 2% parental “non-consent” – 10% absent

New Haven Public Schools

Surveys Physical Measures Blood pressure

Survey Data: General Health

• Self-report Health
• 35% excellent
• 30% very good
• 28% good
• 7% fair/poor
• 68% report having regular doctor
• 14% illness/injury restricts activity
• 18% used ER since beginning of

school because sick or hurt

Exercise & Limitations

• 56% exercise >30 minutes 5-7

days/week

• 46% don‟t feel safe in their

neighborhood

• 27% report limitations to physical

activity because of fears of safety

Meals

• 39% family meals 3+ times/week
• 26% fast food 3+ days/week
• 12% food insecurity

Screens

• 82% have TV in bedroom
• 3+ hours of screen time

– Per school day: 41% – Per week-end day: 62%

Daily Food/Beverage Consumption: Students

BMI Category, School Surveys

2 49 19 31 4 49 19 28 10 20 30 40 50 Boys (n=529) Girls (n=612) Underweight Healthy weight Overweight Obese

Blood Pressure Category, School Surveys

90.5 4.9 4.6 91.8 3.1 5.1 20 40 60 80 100 Boys (n=525) Girls (n=609) Normal BP Pre-HTN HTN

PLUS SELF-REPORT

• 24.0% asthma (20.0% US)
• 3.5% diabetes (0.2% US)

Integrating Health and School Reform (1 of 2)

• Vision: best urban district in US.

– healthy children ready, willing, and able to learn

• Collective Investment:

– Mobilize students, families, teachers, staff and community for student success

• “Wrap around” services:

– Community partnerships/programs to support student achievement and promote health in and after school, in the community, and at home

Integrating Health and School Reform (2 of 2)

• Sound and Effective Infrastructure:

– data systems, curriculum and data teams, school evaluation, physical infrastructure, and tradition of collaboration

• Goals:

– eliminate achievement gap, health inequities, and provide all students with opportunities and necessary support to succeed.

Planned Analyses (examples)

• Hierarchical modeling to examine neighborhood

environment and chronic disease risk, including geo-coded maps, census and crime data, behavioral survey

• Relative impact of school vs neighborhood environment on

children‟s health

– Protective factors

• Health, social, environmental factors that influence

academic performance

• Chronic stress and health: “Urban Miasma”

NEW HAVEN COMMUNITY INTERVENTIONS FOR HEALTH

Intervention Phase Knowledge to Action

Without knowledge action is useless and knowledge without action is futile (Abu Bakr, c.573–674)