Abstract
Evidence for the role of place in health outcomes has been growing. Significant disparities in health outcomes between neighborhoods reflect place-based inequities in the physical, social, and economic assets needed by residents to live productive and healthy lives. The community development sector invests in revitalizing disadvantaged low-income communities through financing and development of affordable housing, businesses, community centers, health clinics, and programs and services, while the public health sector has increasingly recognized the importance of social determinants of health in shaping health outcomes and the health care sector has been tasked with increasing its focus on prevention and population health. To date, however, there has been limited collaboration among these sectors. With 77 million people in the United States living in high-poverty neighborhoods, there is an urgency to advance such collaboration to reduce health inequities. Integration of these sectors is needed to ensure that significant public and private investments in neighborhood revitalization maximize opportunities for health improvement, public health expertise informs the development of tools and techniques to guide health-related project decision making and to measure health outcomes, and increasing investments by the health care sector in prevention and population health are coordinated and leveraged with community development sector investments. Innovative collaborations involving the community development sector show promise in mitigating place-based disadvantage and improving the social determinants of health.
Relationship to Existing APHA Policy Statements
This policy statement is consistent with earlier APHA policy statements that address related issues such as toxic stress, youth development, aging, criminal justice, economic status, neighborhood environments, access to nature, and healthy housing. Examples include the following:
This policy statement is also consistent with APHA policy statements that reference the Patient Protection and Affordable Care Act (e.g., 201515, 201316, and 201312).
Problem Statement
Evidence for the role of place in shaping health outcomes continues to grow.[1] According to the Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier America, “people can make healthier choices if they live in neighborhoods that are safe, free from violence, and designed to promote health.”[2] In Healthy People 2020, the US Department of Health and Human Services (DHHS) highlights the importance of social determinants of health in shaping health outcomes.[3] Neighborhood conditions have been found to influence health outcomes ranging from infectious diseases, infant health, and asthma to cardiovascular disease, obesity, and depression.[1,4] However, low-income neighborhoods frequently lack the assets and conditions needed to support good health, resulting in significant place-based inequities with profound social, economic, and health consequences. The largely nonprofit community development sector is a $200 billion industry with the mission and resources to revitalize neighborhoods.[5] However, addressing health is far from standard practice in community development, and community development projects have had limited involvement from or collaboration with public health and health care organizations and practitioners.[5]
With the passage of the Patient Protection and Affordable Care Act (ACA), the $3 trillion[6] US health care system is moving to meet provisions of the legislation that require an increased emphasis on prevention and population health.[7] Cross-sector collaboration is needed to sharpen the focus on health in community development; to bring health care, public health, community development, and other sector resources together to achieve greater health improvements for communities; to ensure protection for low-income and diverse residents of revitalizing neighborhoods; and to build the needed evidence base and tools to support such efforts. The RWJF Commission recommends that the United States “fundamentally change how we revitalize neighborhoods, fully integrating health into community development.”[2] APHA hereby recognizes a need for cross-sector collaboration to integrate health into community development in order to address the significant role of place-based disadvantage in persistent health inequities and social injustice in the United States.
The United States suffers from stark inequities in health outcomes,[8] and significant disparities in life expectancy have been found in neighborhoods in the same city just a few miles apart; for example, life expectancy differs by more than 25 years between neighborhoods in New Orleans and by nearly 30 years in Baltimore and Albuquerque.[9] Since 2000, the number of people in the United States living in high-poverty neighborhoods has continued to increase, with 77 million people, or over one fourth of US residents, living in neighborhoods where more than 20% of the population is below the federal poverty line.[10] Fifty-one percent of people residing in high-poverty areas live in central cities, 28% live in suburbs, and 20% live in nonmetropolitan and rural areas.[10] Persistent racial segregation, driven by policies such as redlining, ensures that a greater proportion of people of color live in high-poverty neighborhoods; one fourth of African Americans, one sixth of Hispanic Americans, and one eighth of American Indians in urban areas live in high-poverty neighborhoods, as compared with only one in 25 non-Hispanic Whites.[9] One fifth of elders 65 years and older live in high-poverty areas; more than one in five children in the United States live in poverty, including one in three Latino and African American children; and more than half of people who are themselves in poverty live in high-poverty areas.[9,10]
Residents of disadvantaged neighborhoods experience reduced access to jobs, poorer quality schools, higher crime, greater environmental exposures such as lead and tobacco, less opportunity to build financial assets, and erosion of social cohesion, and neighborhood deprivation is linked to an increased risk of all-cause mortality.[1,11–13] While personal behaviors contribute to health outcomes, health behaviors such as physical activity, smoking, alcohol use, drug use, and dietary habits are themselves influenced by neighborhood conditions (independent of individual socioeconomic status).[1,2,14–16]
Both physical pathways (e.g., lead exposure, air quality, access to healthy foods) and psychosocial pathways are at play. While networks and social ties may be strong despite neighborhood disadvantage, these networks often fail to link residents to social and economic opportunities because the neighborhoods themselves offer limited access to needed services and because social ties are to others who similarly lack access to opportunities.[1] In addition, external stressors and social adversity, when perceived as overwhelming and experienced repeatedly, produce a physiological stress response that can trigger disease.[15] The impact of neighborhood disadvantage is particularly profound during childhood, with effects through adulthood and into late life.[15,17] Adverse childhood experiences rooted in neighborhood exposures may become “biologically embedded” and have lifelong effects on health,[15,18] such as reducing adult working memory and increasing the incidence of cardiovascular disease.[15,19] Ensuring healthy child development requires reducing children’s exposure to neighborhood stressors, increasing supportive factors, and nurturing good family and caregiving functioning.[17,20] Meanwhile, stress exposure can be cumulative and can produce premature aging, sometimes called “weathering,” while neighborhood context late in life may have a protective or aggravating influence on elder health. Little is currently known about the potential for reversing toxic stress in adulthood once health impacts have occurred.[15]
According to the DHHS, addressing social determinants of health—the conditions in which people live, including factors such as education, economic stability, built environment, and social context—is critical in reducing health disparities and remediating health inequities.[3] Recognizing social justice as a core public health value highlights the importance of addressing these determinants. This in turn requires public health organizations to partner and work with other sectors that have the expertise and resources needed to improve essential determinants that reside beyond public health’s scope of practice and to inform policy and public decision making that shape the social determinants of health at the local, state, and national levels. A social justice orientation also requires protecting the needs of disadvantaged communities and vulnerable populations and collaborating with the sectors already working in these communities and with these populations. The burdens and demonstrated negative health effects of living in distressed high-poverty neighborhoods are sufficiently significant that remediating conditions in these neighborhoods represents a significant social justice issue.[21]
Since the start of the war on poverty in the 1960s, the community development sector has been working in high-poverty neighborhoods.[2] Community developers invest in revitalizing disadvantaged low- and moderate-income areas by financing and developing affordable housing, businesses, community centers, health clinics, early childhood centers, and programs and services to support individuals, children, and families.[22] The community development sector involves a range of fields such as real estate, city planning, social work, affordable housing, and finance and includes public, private, and nonprofit entities, with leadership from nonprofit community development corporations (CDCs), nonprofit community development finance institutions (CDFIs), and the US Department of Housing and Urban Development (HUD). As of 2012, approximately 1,000 CDFIs and several thousand CDCs were operating in urban, rural, and tribal areas of the United States.[20] Public financing via tax credits, subsidies, grants, and loans, alongside philanthropic grants and loans, capital made available through regulatory requirements for private banks, and commercial investments, provides the funds for community development projects.[5,20,23,24] Loans and investments are repaid from project income (e.g., rent and housing subsidies collected from mixed-income housing and commercial properties) or income related to provision of services such as early childhood education.[25] Currently, the majority of such investments do not include a focus on improving health, nor do public health and health care organizations regularly partner in community development projects.[2,7,26]
With its focus on eliminating health inequities and its commitment to social justice, the public health sector has long worked with low-income communities, increasingly pursuing place-based interventions and addressing social determinants of health. Meanwhile, innovative community developers have recognized that education, health and health care, safety, housing stability, and social cohesion all influence economic mobility. They have begun more comprehensively to address these needs in holistic, cross-sectoral neighborhood revitalization efforts that are both people and place based, improving social determinants of health and, in some instances, intentionally including health-promoting features.[20,26] Such projects are building service-rich, mixed-income neighborhoods and bringing much-needed resources and amenities to historically disinvested, and often historically segregated, communities. However, these types of approaches remain rare. Moreover, the health outcomes of these holistic neighborhood revitalization projects are only beginning to be studied, and there are limited tools to guide community development practitioners as to the most effective, and most cost-effective, health elements to incorporate to improve outcomes for low-income residents.[20,24,27,28]
Concurrently, with the passage of the ACA, health care systems are in transition, changing their policies and practices to meet the act’s requirements. Recognizing the role that nonmedical factors play in health outcomes, the ACA includes provisions designed to increase attention to prevention and population health. Among these provisions, the ACA requires that all nonprofit hospitals conduct community health needs assessments (CHNAs) every 3 years and develop implementation plans to address identified needs. The Internal Revenue Service recognition of “community health improvement services” as reportable community benefit expenditures (also required of nonprofit hospitals) also encourages hospitals to address nonmedical determinants of health. To date, however, a mere 5% of community benefit expenditures have been directed toward community health improvement services, and there has been limited collaboration between hospitals and community developers.[7]
There is, in addition, exploration under way of the role that Medicaid funding may be able to play in community development. The ACA extended Medicaid eligibility. At the state level, New York is experimenting with using state-only Medicaid funding to finance the construction of supportive housing. At the federal level, the Centers for Medicare and Medicaid Services announced that Medicaid funds could be used to cover “housing-related activities and services” for elderly, mentally ill, disabled, and, more recently, chronically homeless Medicaid recipients. Federal Medicaid dollars can be used to pay for a range services that help recipients transition into and remain in community-based housing, as well as for services offered within supportive housing. This could free up funding previously used to cover supportive services (e.g., from HUD and private sources), potentially making it available to support development or renovation of housing. At present, however, federal Medicaid funding cannot itself be used to build or renovate housing or to pay room and board or rent, limiting the role it can play in expanding the availability of housing.[29]
Thus, substantial public and private dollars are being invested in projects that could, but do not, optimize their potential to improve health and reduce health and social inequities in low-income communities. If community development is to be truly equitable, sustainable, and supportive of community health and well-being, it must take a holistic approach. Metrics for success must not be solely economic but must center on human well-being, measuring health determinants and physical and mental health outcomes with attention to social justice, community engagement, and health needs throughout the life course. Public health and health care professionals can bring valuable insight and experience to the field, resulting in benefits for more stakeholders and, most important, community residents.
Evidence-Based Interventions and Strategies
The evidence base for the capacity of thoughtful, cross-sector community development interventions to improve neighborhood conditions in high-poverty areas—and thereby to improve the health of low-income residents—is growing rapidly and strongly supports greater collaboration. At the same time, more research is needed into how community development investments improve health, which approaches are most effective, and where risks may arise. Public health, in particular, can play a key role by utilizing the “natural experiments” represented by community development efforts to expand the evidence base to guide work at this nexus.[17,20,28]
Evidence of cross-sector collaboration to address health in community development: Cross-sector collaboration that integrates health and community development is occurring across the United States.[30–32] Community developers have modeled cross-sector collaboration with partners including but not limited to public health, health care, social services, education, financial services, and youth development, as well as with community residents and resident organizations, to improve social determinants of health and the well-being of residents in high-poverty areas.[17,24–26,30] The financial, community development, public, and philanthropic sectors have collaborated to create funds, grants, and financing mechanisms that incentivize and support incorporating health components into community development projects.[24] At the federal level, collaborations among HUD, the Department of Transportation, the Environmental Protection Agency, DHHS, and the Centers for Disease Control and Prevention and between these agencies and other entities support local efforts to improve health, economic well-being, and sustainability through community development.[24] Hospitals and health care systems, serving as “anchor institutions,” have collaborated to invest in affordable housing, local food sourcing, sustainability, creation of green space, and support for youth and workforce development in low-income communities.[25,32] In the public health sector, a wide variety of collaborations have been undertaken to improve community environments.[24,30]
Studies of cross-sector collaboration integrating health and community development have documented collaborations among community developers, city planners, urban designers, public health departments, hospitals, health care systems and community health clinics, school districts, colleges and universities, philanthropic organizations, housing agencies, local businesses, food marketers, banks and financial service providers, health and social service providers, community residents, and child, youth, and senior services organizations.[25,30,32,33]
Lessons for effective cross-sector collaboration in community development and health are emerging. Successful collaboration is supported by strong leadership, trust among partners, and development of a shared vision, while barriers occur when these elements are lacking.[30] Differing timelines, goals, and metrics of success and different languages between sectors prove challenging. Lack of financing or resources to support collaboration has been identified by practitioners as a major barrier.[24,30,31,34] Studies emphasize the importance of broad, multistakeholder engagement of community residents and community organizations to ensure that revitalization meets community needs, to support civic participation and the building of social capital, and to build or repair trust.[25,26,30,33,34] While new partnerships, projects, and initiatives continue to provide lessons to the field and new approaches continue to emerge, studies to date demonstrate the feasibility of cross-sector collaboration integrating health and community development.
Evidence of improved social determinants of health: The evidence linking socioeconomic factors to health outcomes argues for the importance of such cross-sector collaboration.[3] Holistic community development and health projects have demonstrated improvements in community conditions and improved social determinants outcomes for residents.
Community revitalization projects have improved access to determinants of health such as supportive and affordable housing; high-quality early childhood, K–12, college, and adult education; healthy food; physical activity amenities, parks, and active transportation infrastructure; economic revitalization, support for small businesses and entrepreneurship, and access to employment; financial services; social services; and community building.[24–26,30,33]
Community revitalization projects have also demonstrated improvements in resident outcomes related to social determinants of health. For example, an evaluation of investments in the Local Initiatives Support Corporation’s “Building Sustainable Communities” initiative showed 9% greater growth in jobs and incomes than in comparable communities not receiving such investments.[35] Also, Atlanta’s Villages of East Lake, launched in 1995, replaced a distressed public housing project with new, high-quality mixed-income housing, early-childhood and K–12 educational facilities, social services, healthy food access, and physical activity amenities. Public housing residents partnered with the community development team throughout the planning of the project. Measured improvements in key social determinants of health include a 90% reduction in violent crime and a high school graduation rate of nearly 80% (as compared with 50% across the Atlanta public school system). Also, 100% of nonelderly, nondisabled subsidized housing residents are employed or in job training (up from 13%), and 98% of students in grades 3–8 now meet or exceed state standards in core subjects.[36]
In Dorchester, Massachusetts, cross-sector collaboration initiated by the Codman Square Health Center includes new affordable housing for low-income residents, a farmers’ market, and a new charter school. In 2014 the charter school recorded a 97% attendance rate, and 100% of graduating seniors were accepted into college. Sixty-eight percent of Codman Academy alumni either have graduated from or are currently enrolled in college.[33] In addition, BRIDGE Housing, through a process it calls “trauma-informed community building,” has increased social capital, community engagement, and perceived safety among residents of the Potrero Terrace and Annex public housing projects in San Francisco in advance of comprehensive, mixed-income neighborhood redevelopment.[37]
Evidence to date suggests the importance of combining people- and place-based strategies and indicates that access to education, economic and employment opportunities, safe and affordable housing and infrastructure, and health and community-based services and programs is central in community development investments designed to improve health.[20] While holistic interventions that simultaneously address multiple social determinants appear to be particularly effective, more research is needed.[5,24]
Evidence of improved health outcomes and reduced health care costs: The evidence base demonstrating that community development efforts lead to improved health outcomes and reduced health care costs is still evolving. There is growing evidence that high-quality, stable, supportive, and affordable housing can enhance health outcomes and decrease care costs.
A 2007 review of the literature, while noting the need for additional research to establish causal pathways, revealed numerous health benefits associated with affordable housing. Stable housing, through housing vouchers or public housing, was shown to result in greater household spending on food and health care, reduced child malnutrition, and reduced stress and mental health problems relative to insecure housing. Home ownership exhibited links to improved physical and mental health as well as improved respiratory functioning. Also, high-quality housing reduced lead exposures, asthma, and household injuries. In the case of individuals with HIV/AIDS, the rate of all-cause mortality among those with housing was one fifth the rate among those who were homeless.[38]
A study of more than 2,000 low-income, food-insecure households with infants revealed that the one quarter that received housing assistance during the prenatal period experienced 43% fewer infant hospitalizations.[39] In San Francisco, comparisons between children living in HOPE VI redeveloped public housing and children living in non-redeveloped housing showed a 39% greater likelihood of new-issue acute health care visits in the latter group.[24]
Another study examined the link between housing and health care usage and costs among residents in family housing, permanent supportive housing, and housing for seniors and people with disabilities. The results showed reduced Medicaid expenditures, decreased emergency care usage, and increased preventive care usage among residents in these types of housing; also, residents reported improved access to care and quality of care.[40] Mission Creek Apartments in San Francisco is a Mercy Housing development that incorporates health services, adult day care, and other services and amenities. A program that placed 50 homeless seniors with high health care needs who were in a city-run skilled nursing facility into permanent supportive housing at Mission Creek saved the city $1.45 million per year in health care costs.[5]
Few studies to date have robustly assessed health outcomes of community revitalization efforts beyond housing. Early findings are suggestive and sometimes surprising. Interventions such as improved street design, introduction of light rail, and access to recreational facilities have been associated with increased physical activity and reduced body mass indexes. Also, traffic safety measures have reduced injury risks, and early childhood development programs have been shown to improve cognitive development.[5,24]
A recent study of the impact of a new grocery store in a low-income food desert in Pittsburgh, Pennsylvania, revealed dietary improvements in terms of reduced consumption of calories, salt, sugar, and alcohol; improved satisfaction with the study neighborhood; and improved reported access to fresh foods. Surprisingly, however, there was no measurable increase in consumption of fresh produce or whole grains, and paradoxically the dietary improvements found were independent of whether residents shopped at the new store.[41] The mechanisms by which health behaviors are improved through such an intervention are not yet well understood, but they hint at the relevance of “ecological-level exposures.”[15] A vital role for public health is to undertake the research needed to provide a better understanding of causal mechanisms and assess the health outcomes of community development efforts,[34] as well as to determine when and where there is a need to integrate such upstream interventions with traditional public health interventions.
Gaps in research and practice: The feasibility of cross-sector collaboration to integrate health into community development has been modeled, its ability to improve social determinants of health (both access and outcomes) in high-poverty neighborhoods is being demonstrated, and there is early evidence suggesting improved health outcomes from such efforts. Evidence supports increasing cross-sector collaboration that integrates health into community development; however, significant gaps remain in both practice and the evidence base.
In practice, although the community development sector continues to invest billions of dollars each year in low-income communities, explicitly incorporating health goals into redevelopment projects is not the norm.[2,17,20] Similarly, health care systems play vital roles in their communities and regions, representing substantial economic activity (more than $780 billion per year, including major construction projects) and investment portfolios (approximately $500 billion), but only a few to date have directed these resources toward improving community and population health in the regions they serve.[32]
On the research front, as discussed above, the evidence base for the health impact of cross-sector collaboration to integrate health and community development is still evolving. Community revitalization projects afford opportunities to deepen our understanding of the role of neighborhoods in supporting health. Further study of the long-term outcomes of such interventions with respect to social determinants of health and health disparities is needed, as is research designed to provide a better understanding of what works and how it works.[28] Research into collaboration itself among community development, health, and other sectors is also needed to identify the most effective strategies for aligning efforts (e.g., by examining approaches such as collective impact and the community quarterback model).[20,24] In addition, tools are needed to guide practitioners in community development and related professions as to how to incorporate health into community development. Researchers have articulated a framework for outcomes research, while organizations in the field are developing tools that will allow practitioners to incorporate important health determinants into their projects and to measure and document health outcomes.[27,42]
Opposing Arguments
Critics of publicly funded revitalization of high-poverty neighborhoods voice concerns that community development investments that stimulate economic activity, reduce crime, and improve neighborhood amenities will displace low-income residents, who are unable to meet rising housing and other costs.[43] Such displacement raises troubling social justice concerns, doubly so when public policy allows or encourages investments that displace communities whose neighborhoods have become segregated and disinvested as a result of earlier public policies.[9,44] Gentrification poses risks not only of physical displacement of low-income residents, disabled residents, and other vulnerable communities but of “emotional displacement,” as when affordable housing enables low-income residents to remain in a gentrifying neighborhood but familiar businesses and needed services have been driven out, friends move away, and the remaining low-income residents experience conflict and culture clashes with new, higher-income residents.[44–47]
Failure to invest in underserved neighborhoods, however, is not an effective response to these concerns, as it does not address existing place-based inequities that substantially shape health disparities. Indeed, opposing public investment and health sector collaboration in community development efforts in low-income, disinvested communities risks two different, but equally problematic, potential harms. Disadvantaged communities may continue to experience exposure to harmful neighborhood and community conditions, or, alternatively, poorly guided or market-driven investment may gentrify such communities without protections for low-income residents (e.g., affordable housing and needed programs and amenities) and without proactive community buil
