Survey Identifies Health Issues in Six Chicago Communities, Leads to Targeted Interventions
From January 2002 through May 2004, a team of researchers led by Steven Whitman, Ph.D., of Mount Sinai Hospital Medical Center of Chicago, conducted a health assessment survey in six communities of Chicago in order to establish an evidence base from which health improvement strategies can be developed and targeted most effectively.
Researchers interviewed a total of 1,699 adults, along with primary caretakers for 811 children. The interviews covered five major topics: health conditions, health behaviors and attitudes, health care access, quality of life and other social or environmental factors.
Among the key findings of the survey:
- Almost two out of every three children (ranging from 58 to 68 percent) in the five heavily minority communities were either overweight or obese, compared with 26 percent of children nationally and 23 percent in the predominately white community.
- Approximately one quarter of children in four of the six communities were likely to have asthma, compared with a national average of 12 percent.
- In four mostly minority communities, high proportions of adults smoked (ranging from 32 to 39 percent), compared with a national average of 23 percent.
Since the close of the grant, the project team has been working with three task forces it established to find solutions to some of the health problems delineated in the survey.
The Robert Wood Johnson Foundation (RWJF) supported this project with an unsolicited grant of $747,427. In-kind contributions from Mount Sinai Hospital Medical Center totaled $145,000.
One of the key challenges to improving the health of local communities is that policy-makers and providers lack the kind of information at the community level that is necessary to design health promotion strategies and effectively target resources.
Current data sources provide information on birth outcomes, causes of death and a few communicable diseases. Data on many other health indicators such as smoking, diet, access to care and the prevalence of various diseases are generally not available at the community level. In addition, large urban areas in the United States have vast health disparities across their communities that are often masked by county- or city-level information. For example, life expectancy in Chicago is 70 years, but there is a difference of almost 22 years in life expectancy in different communities in the city.
In 2001, RJWF established a fourth goal health and well-being: to promote healthy communities and lifestyles to address those factors outside medical care that have an important influence on health. Under this new goal, one of RWJF's targeted areas involves projects that promote healthy communities and lifestyles or build a stronger knowledge base from which to promote them.
For this project, researchers at Sinai Urban Health Institute of the Mount Sinai Hospital Medical Center of Chicago conducted a health assessment survey called the Improving Community Health Survey in six of the 77 Chicago community areas: North Lawndale, South Lawndale, Humboldt Park, West Town, Roseland and Norwood Park. The goal was to establish an evidence base from which health improvement strategies can be developed and targeted most effectively.
To oversee the project, staff appointed a survey design committee consisting of 21 community members affiliated with social service agencies, government and educational programs, and other local community-based organizations, as well as staff from Sinai Health System. (For a list of committee members, see Appendix 1.) The committee, which met bi-weekly for three months, selected 27 topics on which the survey would focus. They fell into the following five categories:
- Health conditions.
- Health behaviors and attitudes.
- Health care access.
- Quality of life.
- Other social or environmental factors.
For a complete list of topics in these categories, see Appendix 2. The survey included 469 questions in the adult module and 144 questions in the child module. To ensure that their survey findings would be comparable with city, state and national data, the researchers adopted questions from existing surveys whenever possible. These included the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System and National Health Interview Survey.
Mount Sinai Hospital Medical Center subcontracted with the Survey Research Laboratory at the University of Illinois at Chicago to select the survey households, train the interviewers and conduct the survey. The research team fielded the survey in English and Spanish in six Chicago communities between September 2002 and April 2003. Of the 1,953 eligible adults contacted, 1,699 (87 percent) completed the interview; in addition, primary caretakers for 811 children completed separate interviews on their children's health status. Respondents received $40 for completing the adult portion of the survey and $20 for the child portion. As part of their participation, respondents also received brochures on a variety of health topics, as well as feedback on the results of the adult portion of the survey.
The project team disseminated project findings through articles, reports, conferences and presentations. (See Communications for details.) They had originally proposed to form three policy councils to address issues revealed by the survey data. However, the team found it more effective to work through the advisory council of the Sinai Urban Health Institute, selected community-based organizations and task forces established for specific health conditions covered in the survey. See After the Grant for details.
To the RWJF grant of $747,427, Mount Sinai Hospital Medical Center of Chicago added an in-kind contribution of $145,000.
The research team reported the following findings each regarding a specific topic covered in the survey in its report Sinai Health System's Improving Community Health Survey: Report 1 (2004). The team will release reports on other survey topics as data analysis is completed.
- Racial and ethnic disparities: Disparities exist across Chicago communities and racial groups. Norwood Park, the predominately white middle-class community area in the survey, scored overwhelmingly the best on the health measures examined in the survey, whereas Humboldt Park and North Lawndale, the two poorest, predominately minority community areas in the survey, almost always scored the worst. In addition, 4 percent of whites in the survey reported having been diagnosed with diabetes compared with 13 percent of African Americans. Some 34 percent of Puerto Rican children and 25 percent of African-American children likely have asthma compared with 20 percent of white children. Adults in North Lawndale, a predominantly black community area, were six times more likely to be uninsured compared with an adult in Norwood Park. Researchers note that Norwood Park is not nearly the richest community in the city and North Lawndale is not nearly the poorest, leading them to write: "If we had selected community areas at the extremes, the disparities almost certainly would have been far more severe."
- Insurance status and access to care: The proportion of residents with any form of health care coverage (either private or public) was substantially lower than the national average in five of the six communities studied, even when adjusted for race and ethnicity. For example, only 44 percent of adults 18 to 64 years old in South Lawndale, a mostly Mexican-American community, reported currently having any type of health insurance. In Humboldt Park, a community area that is half black, a quarter Mexican and a quarter Puerto Rican; and North Lawndale, a predominately black community area, 60 percent reported having some health coverage. This is well below national proportions of about 85 to 90 percent. In predominantly white Norwood Park, in contrast to the other Chicago communities, 93 percent of residents have some form of health insurance.
- Diabetes: The prevalence of diagnosed diabetes in two of the six communities was elevated compared with national and Chicago-wide levels. Rates at which people reported having been diagnosed with diabetes in Humboldt Park and Roseland were both 14 percent, compared with a national level of 7 percent and a Chicago level of five percent. In South Lawndale, an alarming contrast existed between the prevalence of diagnosed diabetes (three percent) and the diabetes mortality rate (40 per 100,000 people, compared with 31 per 100,000 in Chicago as a whole and 25 per 100,000 nationally.)
- Smoking: Four communities had high levels of current smokers some on the order of twice as high as national and Chicago averages. Survey respondents who reported being current smokers reached 39 percent in North Lawndale, 35 percent in Humboldt Park, 33 percent in Roseland and 32 percent in West Town. These are the same rates observed nationally nearly 30 years ago, compared to the current national average of 23 percent, and the Chicago average of 21 percent.
- Adult asthma: The prevalence of diagnosed asthma was almost twice the national average of 11 percent in three communities: Humboldt Park (18 percent), West Town (19 percent) and North Lawndale (18 percent). In addition, when people whose asthma was currently active were asked if they had ever received an "action plan" to manage their asthma, the proportion in each sampled community with such a plan was low: 18 percent for Roseland and 39 percent for Humboldt Park, for example.
- Pediatric asthma: High proportions of children in several of the communities have asthma. Compared with a national average of 12 percent, rates of children likely to have asthma reached 28 percent in Humboldt Park and West Town, and 23 percent in North Lawndale and Roseland. Puerto Rican children had the highest estimated pediatric asthma rate (34 percent). These are very likely the highest rates of pediatric asthma ever recorded, the researchers write.
- Depression: One-third (32 percent) of respondents "had either prior or current experience with depression," the researchers write. Specifically, 7 percent had been diagnosed with depression but did not screen positive for depression based on their answers to survey questions; 16 percent screened positive for depression, but had never been diagnosed; and 9 percent had been diagnosed and also screened positive for depression. Well over half of all people who screened positive for depression had never received a diagnosis for depression. According to the principal investigator, "This is a dreadful under-diagnosis of a very serious condition, which can often be successfully treated if detected."
- Adult obesity: The proportion of people who are obese was high in the mostly minority communities of North Lawndale (41 percent), Roseland (38 percent) and Humboldt Park (35 percent). These figures compared with 24 percent for the nation and 25 percent for Chicago. In addition, 25 percent of those who were overweight and 44 percent of those who were obese had high blood pressure, compared with 14 percent who were not overweight. In general, overweight and obese adults were more like to have been diagnosed with high blood pressure, diabetes, arthritis and depression.
- Pediatric obesity: Almost two thirds of children (ranging from 58 to 68 percent) age 2 to 12 years in the five heavily minority community areas were either overweight or obese, compared with only 26 percent of children nationally and 23 percent of children in Norwood Park, a predominately white community.
- HIV/AIDS: A substantial proportion of people reported having been tested for HIV for example, 75 percent in North Lawndale, 58 percent in Humboldt Park, 44 percent in Norwood Park and 40 percent in South Lawndale. These figures are consistent with communities hardest hit by the epidemic, the investigators say. Nationally, 46 percent of people have been tested, and in Chicago, 53 percent have been tested. Nearly all of the survey respondents favored distribution of information about HIV/AIDS and sexually transmitted diseases in schools. More than 90 percent favored distribution of this information in elementary schools, and a similarly high proportion supported the distribution of condoms in high schools. Support for a needle-exchange program ranged from 58 percent in North Lawndale to a high of 74 percent in West Town.
- Health-related quality of life: There were wide variations from community to community on self-reported health. Most significantly, people living in South Lawndale were seven times as likely to report fair or poor health as those in Norwood Park (51 percent versus 7 percent, respectively). For all communities, there was a strong relationship between "self-reported health-related quality of life" and "unhealthy days" during a month. In turn, both of these measures of perceived well-being were related to several health conditions, including diabetes, asthma, obesity and depression.
The research team offered the following recommendations in the report Sinai Health System's Improving Community Health Survey: Report 1 (2004).
- Insurance status and access to care: A universal health care plan should be adopted in the United States. The United States is the only industrialized country in the world without universal coverage. Illinois legislators can also establish universal coverage within the state.
- Diabetes: A comprehensive outreach program to screen and treat people for diabetes is necessary. Diabetes rates in some Chicago communities suggest the need for access to quality medical care, sound protocols for detecting and treating diabetes and good follow-up, including insurance-supported education and behavioral intervention.
- Smoking: More of the funds awarded to Illinois in the master settlement of the multi-state suit against tobacco companies should actually be spent on smoking prevention or, at the very least, on the resulting ill health. These funds (about $9 billion over about 30 years) should be targeted to those communities in greatest need. In addition, targeted and effective counseling and behavioral interventions should be made reimbursable by health insurance.
- Adult asthma: There should be a citywide campaign to educate physicians on the importance of asthma action plans, and an effort by insurers to promulgate existing protocols of successful care. Clinicians treating people for their asthma should also deliver asthma education.
- Pediatric asthma: Every family with a child who has asthma should have an asthma action plan, receive comprehensive education about how to use asthma medications, have appropriate case management and be able to contact a clinician 24 hours a day. In addition, a major targeted education campaign should be initiated throughout the city to explain and emphasize the damage done to children with asthma by secondhand smoke.
- Depression: Depression should be addressed like other illnesses, and suitable reimbursement should be provided for all those diagnosed with the disease. Primary care providers should be properly trained to screen for mental illness as part of an overall physical. Physicians must know when and where to appropriately refer people for further care. Programs that provide individual and family counseling at alternative venues (e.g., community centers, religious centers) can be important tools for both improving outreach and confronting stigma.
- Adult obesity: More opportunities for exercise should be provided, including safer parks and streets, more bicycle paths and more workplace exercise options. Appropriate food portion size should be encouraged in restaurants. Doctors should be encouraged to learn more about nutrition and exercise and to teach patients about such matters.
- Pediatric obesity: Interventions that will help children in Chicago to adopt a holistically better lifestyle one with more physical activity, less time in front of televisions and computers, and better access to healthy foods should be encouraged. Chicago public schools should serve more nutritious meals, and withdraw unhealthy snacks and drinks from vending machines and replace them with healthier foods and beverages. Public programs should be created to help parents to educate themselves about the issue of pediatric obesity and to assist their children with issues that lead to overweight and obesity.
- HIV/AIDS: Condoms should be made readily available in high schools. Policy-makers and school officials should note that while virtually all survey respondents favor the distribution of condoms in high schools, not a single school in Chicago distributed condoms. In addition, given the support from the community and the strong indication that needle-exchange programs can help suppress the HIV epidemic, policy-makers should support new and existing needle-exchange programs.
- Health-related quality of life: Questions concerning self-reported health-related quality of life should be used to screen patients in clinical situations. This measure may be a more effective tool to capture the burden of under-diagnosed and under-reported health conditions in a community.
The research team listed the following overarching policy implications in Sinai Health System's Improving Community Health Survey: Report 1 (2004).
- National, state and local governments should conduct local area surveys like this one on a regular basis.
- Chicago (and, indeed, the country) should turn its attention and resources toward prevention and screening measures rather than concentrating overwhelmingly on treatment.
- Investments should be made in educating professionals and the public in improving lifestyle.
- Initiatives should be created to ensure access to excellent health care for all children in Chicago.
- Universal access to quality health care should be established.
- Racial and other societal disparities in health should be recognized and eliminated.
- Although issues such as racism and poverty are responsible for many of the negative findings in this study, it is inadvisable to wait until these broader issues are solved before acting on the health issues. Action should be taken on health issues one at a time, at the local level, beginning now, regardless of how daunting the task may seem.
The project team published articles on the project in the Journal of Health Systems and the American Journal of Public Health. The report, entitled Sinai Health System's Improving Community Health Survey: Report 1, provides an overview of methodology, findings and recommendations for 10 of the topics covered by the survey. A second report, Sinai Health System's Improving Community Health Survey: Report 2, was released in September 2005 with information on 10 additional topics from Sinai's Community Survey. They include high blood pressure, arthritis, adult and child physical activity, food shopping, healthy eating, binge drinking and cancer screening. It is available online. A report entitled A Participatory Approach to Designing a Community Health Survey describes how the survey was designed and conducted.
In April 2004, the research team sponsored a conference the Sinai Health System Obesity Summit that brought together 60 participants representing 25 organizations from the Chicago area to examine the survey's findings concerning obesity, and to consider possible ways to address the problem. The project team gave some 70 presentations to community and professional groups, including the American Public Health Association. In addition, the project drew coverage from local media, with articles appearing in the Chicago Tribune and Chicago Sun-Times. The project Web site included publications and an overview of the project. See Bibliography for details. These communications efforts are examples of how these data have been used to inspire many efforts to improve health in these communities.
- Local level data can be enormously effective in attracting interest and mobilizing stakeholders to act. The principal investigator reports being "stunned" at the amount of interest that has been generated by the study. Attendance by health care professionals at the noon seminars at the Mount Sinai Hospital Medical Center is usually 20; this figure rose to 100 for noon seminars at which this project was discussed. The project also generated widespread interest from the media. (Principal Investigator)
- Researchers planning local level surveys should be prepared for a long, painstaking design process. According to the principal investigator, discussions with community members could have continued for months. The health concerns were vast, and it was difficult to capture all the risk factors associated with community health conditions in one single survey. (Principal Investigator)
- Though it cost time and money, hiring community members, offering substantial incentives and handing out health brochures, made a difference, not only to the quality of the data collected, but also to the health and well-being of the residents of the communities involved. (Principal Investigator)
- Researchers should be prepared for the challenges of translating research into action or policy initiatives. As for many public health problems, the solutions may seem simple and straightforward, but making them happen can be difficult. (Principal Investigator)
AFTER THE GRANT
In 2004, the project team received a three-year grant from the Chicago Community Trust to continue data analysis and dissemination of findings and to develop effective interventions and policies to address the health problems delineated in the survey. In April 2007, researchers published, Translating Sinai Health System's Improving Community Health Survey into Action, detailing the results of this work.
Between 2004 and 2007, investigators gave over 150 presentations to local community groups and hospitals. These presentations were designed to help local organizations implement more effective programs for improving the state of community health in the city. For example, with assistance from the project team:
- The Jewish Federation of Metropolitan Chicago conducted a health survey of the local Jewish population and used the results to implement a school-based childhood obesity prevention initiative.
- The Asian Health Coalition of Illinois conducted a health survey of the Chinatown population and used the results to expand community public health services.
As of July 2008, the project team was continuing its work to increase awareness of health disparities in Chicago, guide foundations and community groups in combating local health problems, and advocate for more effective city health education campaigns and policies.
GRANT DETAILS & CONTACT INFORMATION
Conducting a Health Assessment Survey to Improve Health Outcomes in Chicago Communities
Mount Sinai Hospital Medical Center of Chicago (Chicago, IL)
Dates: January 2002 to May 2004
Steven Whitman, Ph.D.
Survey Design Committee Members
David Ansell, M.D., M.P.H.
Department of Medicine
Mount Sinai Hospital
Joe Ann Bradley
Community Action Group
El Hogar del Nino
Jade Dell, M.A.
Sinai Urban Health Institute
Community Outreach Intervention Program
School of Public Health
University of Illinois at Chicago
Angela Ellison, M.A.
Manager of Training
Sinai Community Institute
Jocelyn Hirschman, M.P.H.
Sinai Urban Health Institute
Linda Miller, M.Ed.
Sinai Health System
Behavioral Health Department
Chicago Department of Public Health
Ed Rafalski, M.P.H.
Mount Sinai Hospital
Sinai Health System
Cassandra Robinson, M.S.
Social Service Worker
Chicago Youth Centers
Xochitl Salvador, M.P.H.
Public Health Administrator
Chicago Department of Health &
Sinai Community Institute
Ami Shah, M.P.H.
Sinai Urban Health Institute
Maurice Schwartz, M.D.
Mount Sinai Hospital
Mount Sinai Hospital
Abigail Silva, M.P.H.
Sinai Urban Health Institute
Big Brothers Big Sisters
Feliz Villafane de Palacios
Block Club Federation
Steven Whitman, Ph.D.
Sinai Urban Health Institute
Cynthia Williams, M.S.
Sinai Community Institute
Cook County Community Health Council
Main Topics for the Sinai Health System's Improving Community Health Survey
Health Behaviors and Attitudes
Health Care Access
Quality of Life
Health-Related Quality of Life
Other Social and Environmental Factors
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Whitman S, Silva A, Shah AM and Ansell D. "Diversity and Disparity: GIS and Small Area Analysis in Six Chicago Neighborhoods." Journal of Health Systems, 28(4): 397411, 2004. Cited online.
Dell J, Whitman S, Shah AM and Silva A. "Smoking in Six Diverse Chicago Communities A Population Study." American Journal of Public Health, 95(6): 10361042, 2005.
Shah AM, Whitman S, Silva A. "Geographic Variation in the Health of Six Chicago Community Areas: A Case for Local Level Data." American Journal of Public Health. Accepted for publication, August 2006.
Shah AM, Williams C, Delgado J and Whitman S. A Participatory Approach to Designing a Community Health Survey. Chicago: Sinai Health System, 2003.
Whitman S, Williams C and Shah AM. Sinai Health System's Improving Community Health Survey: Report 1. Chicago: Sinai Health System, 2004.
Shah AM and Whitman S. Sinai Health System's Improving Community Health Survey: Report 2. Chicago: Sinai Health System, 2004.
"Improving Community Health Survey in Six Community Areas: Adult and Child Modules." Survey Research Laboratory, fielded September 2002April 2003.
World Wide Web Sites
www.sinai.org/urban/originalresearch/rwj (no longer available). Web site created to facilitate public access to information about the Improving Community Survey Results. Chicago: Sinai Health System, 2002.
Presentations and Testimony
American Public Health Association 2003, available online
- Local Data Reveals Greater Racial and Ethnic Disparities: Results From a Community Health Survey
- Variations in the Prevalence of Obesity in Racially and Ethnically Diverse Communities in Chicago
- Disparities in Depressive Symptoms and Utilization of Mental Health Services: Results From Six Racial/Ethnically Diverse Communities in Chicago
- Insurance Coverage and Health: Greater Disparities Found in a Community Health Survey
- Disparities in the Prevalence, Severity and Management of Asthma Among Chicago Children
- Incorporating a Community's Voice in Research: A Strategy to Eliminate Racial and Ethnic Health Disparities
American Public Health Association, 2004, available online
- Mid-Year Progress Toward Healthy People 2010 Cancer Screening Goals in Six Racially/Ethnically Diverse Communities in Chicago
- Local Survey Data Tell More About Diabetes and Its Associated Risk Factors in Six Racially/Ethnically Diverse Communities in Chicago
- Measuring Health-Related Quality of Life in Six Racially/Ethnically Diverse Communities in Chicago as a Tool to Uncover Disparities and Guide Planning
National HIV Prevention Conference, 2005, abstract available online
- HIV Testing Practices and Attitudes on Prevention Efforts in Six Racially and Ethnically Diverse Community Areas
American Public Health Association, 2005, available online
- Sinai's Improving Community Health Survey Reveals Local Area Health Disparities
- Levels of Physical Activity in Six Diverse Communities in Chicago
- Overweight Children in Diverse Chicago Communities: Results From a Community Health Survey
Report prepared by: Robert Crum
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Carol S. Chang