Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods

  • Date: Nov 01 2016
  • Policy Number: 20166

Key Words: Access To Health Care, Health Disparities, Poverty, Health Services

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:

  • APHA Policy Statement 201514: Building Environments and a Public Health Workforce to Support Physical Activity Among Older Adults
  • APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
  • APHA Policy Statement 20137: Improving Health and Wellness through Access to Nature
  • APHA Policy Statement 201210: Promoting Health Impact Assessment to Achieve Health in All Policies
  • APHA Policy Statement 20099: Improving Health Through Transportation and Land-Use Policies 
  • APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States 
  • APHA Policy Statement 20101: Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities
  • APHA Policy Statement 200914: Building Public Health Infrastructure for Youth Violence Prevention
  • APHA Policy Statement 200027: Encourage Healthy Behavior by Adolescents
  • APHA Policy Statement 9718(PP): Supporting A National Priority To Eliminate Homelessness
  • APHA Policy Statement 9521(PP): The Role of Public Health in Ensuring Healthy Communities
  • APHA Policy Statement 9511: The Environment and Children’s Health
  • APHA Policy Statement 9301: Environmental Tobacco Smoke

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 building that fosters integration of economically, racially, and culturally diverse residents and strengthens civic engagement among low-income residents who may previously have been or felt disenfranchised.[25,43,44]

Research on gentrification points to policies and practices that can support revitalizing neighborhoods in ways that bring health and other benefits to existing residents. Inclusive redevelopment approaches engage and partner with existing community residents and community organizations from early in the planning process and provide residents with assistance so that they can stay in neighborhoods that are reaping the benefits of community development.[43,44,48,49] Improving educational quality for children and youths and offering adult education, job training, support for existing small businesses, entrepreneurship support, and financial services can help low-income residents thrive as their neighborhood revitalizes. Effective resident involvement can also help ensure that neighborhood revitalization builds on the existing culture and assets of the neighborhood.[20,43,44]

Maintaining housing affordability is essential in preventing displacement. And yet the second major criticism frequently leveled at community development projects comes from critics of affordable and supportive housing, the very projects that could help low-income residents remain in a revitalizing area. Critics argue that such housing will reduce property values, increase crime, or erode the character of a neighborhood. However, research shows that when new, high-quality affordable housing is added in low-income communities, quite the opposite occurs: property values increase, crime decreases, and neighborhoods improve their income and racial diversity.[50] While affordable housing introduced in high-income neighborhoods can have the opposite effects, attention to the siting, scale, and quality of such projects, together with public education, can avoid these issues.[50,51]

Action Steps

Therefore, APHA:

  1. Calls upon public health, health care, and community development agencies, organizations, professionals, and researchers to collaborate in order to leverage the combined expertise and resources of these sectors in catalyzing revitalization efforts in high-poverty neighborhoods that maximize improvements in social determinants of health and population health outcomes and promote health equity and social justice. Also, these groups and individuals should work together to develop health-oriented standards and best practices for community development projects.
  2. Calls upon public health agencies and researchers to pursue research designed to provide a better understanding of causalities and to evaluate health outcomes resulting from community development collaborations that integrate health.
  3. Urges community developers, hospital and health systems, public health practitioners, and other cross-sector partners to include early, ongoing, and meaningful partnerships with community residents and community organizations in the planning and implementation of community revitalization efforts and to support and strengthen the capacity of community organizations to engage in these types of partnerships.
  4. Urges public health agencies to solicit input from and the involvement of CDCs and CDFIs in public health department community health assessments and community health improvement plans.
  5. Urges hospitals and other community health systems to invest in community development projects that address fundamental social determinants of health and urges hospital systems to solicit the input and involvement of community development practitioners in CHNAs to inform hospital and community population health investments.
  6. Recommends that more universities and schools of public health incorporate study of the community development sector's role in addressing neighborhood conditions into their curricula so that graduates are prepared to partner with community development organizations in designing, implementing, and evaluating neighborhood interventions. These institutions should consider including individuals with a community development background on their faculties. Also, public health agencies, organizations, and leaders should increase their understanding of the role of community development in addressing the effects of neighborhoods on health through continuing education and discussions.
  7. Encourages public health institutes, agencies, and organizations (a) to convene leaders from the health and community development sectors to explore opportunities for these sectors to partner in improving neighborhood health; (b) to convene leaders from the health and community development sectors to advocate for equitable development with city, county, state, and federal agencies and elected officials; and (c) to include community development professionals on their staffs.
  8. Calls upon the Centers for Disease Control and Prevention to incorporate information and recommendations about community development into its programmatic activities and policies.
  9. Urges philanthropic organizations, CDFIs, public agencies, and private investors to develop flexible funding to incentivize holistic community revitalization and innovative initiatives linking community development and health interventions.
  10. Urges the US Treasury Community Development Financial Institutions Fund, the Opportunity Finance Network, NeighborWorks America, the National Alliance of Community Economic Development Associations, and other national organizations that work with local, regional, and national CDFIs and CDCs to (a) educate all CDFIs and CDCs about public health’s assets and expertise and about the CHNA process required of hospital systems under the ACA; (b) encourage CDFIs and CDCs to seek out and participate in CHNA processes and reach out to public health institutions, especially for aid in health-related decision making and evaluation; and (c) encourage CDFIs and CDCs to review CHNAs so as to align community development investments with community health needs.

References

1. Kawachi I, Berkman LF, eds. Neighborhoods and Health. New York, NY: Oxford University Press; 2003.
2. Robert Wood Johnson Foundation Commission to Build a Healthier America. Time to act: investing in the health of our children and communities. Available at: http://www.rwjf.org/en/library/research/2014/01/recommendations-from-the-rwjf-commission-to-build-a-healthier-am.html. Accessed January 4, 2017.
3. US Department of Health and Human Services. Social determinants of health. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health. Accessed January 4, 2017.
4. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–258.
5. Erickson D, Andrews N. Partnerships among community development, public health, and health care could improve the well-being of low-income people. Health Aff (Millwood). 2011;30:2056–2063.
6. Martin AB, Hartman M, Benson J, Catlin A. National health spending in 2014: faster growth driven by coverage expansion and prescription drug spending. Health Aff (Millwood). 2016;35:150–160.
7. Somerville MH, Seeff L, Hale D, O’Brien DJ. Hospitals, collaboration, and community health improvement. J Law Med Ethics. 2015;43:56–59.
8. Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2013. Available at: http://www.cdc.gov/mmwr/pdf/other/su6203.pdf. Accessed January 4, 2017.
9. Joint Center for Political and Economic Studies. Place matters: ensuring opportunities for good health for all. Available at: http://jointcenter.org/research/place-matters-ensuring-opportunities-good-health-all. Accessed January 4, 2017.
10. Bishaw A. Changes in areas with concentrated poverty: 2000 to 2010. Available at: https://www.census.gov/content/dam/Census/library/publications/2014/acs/acs-27.pdf. Accessed January 4, 2017.
11. Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci. 2010;1186:125–145.
12. Feldman PJ, Steptoe A. How neighborhoods and physical functioning are related: the roles of neighborhood socioeconomic status, perceived neighborhood strain, and individual health risk factors. Ann Behav Med. 2004;27:91–99.
13. Brookings Institution. The enduring challenge of concentrated poverty in America: case studies from communities across the U.S. Available at: https://www.brookings.edu/wp-content/uploads/2016/06/1024_concentrated_poverty.pdf. Accessed January 4, 2017.
14. Ellen IG, Mijanovich T, Dillman K-N. Neighborhood effects on health: exploring the links and assessing the evidence. J Urban Aff. 2001;23:391–408.
15. Berkman LF, Kawachi I, Glymour M, eds. Social Epidemiology. 2nd ed. Oxford, England: Oxford University Press; 2014.
16. Cubbin C, Sundquist K, Ahlén H, Johansson S-E, Winkleby MA, Sundquist J. Neighborhood deprivation and cardiovascular disease risk factors: protective and harmful effects. Scand J Public Health. 2006;34:228–237.
17. Jutte DP, Miller JL, Erickson DJ. Neighborhood adversity, child health, and the role for community development. Pediatrics. 2015;135(suppl 2):S48–S57.
18. Taylor SE, Repetti RL, Seeman T. Health psychology: what is an unhealthy environment and how does it get under the skin? Annu Rev Psychol. 1997;48:411–447.
19. Evans GW, Schamberg MA. Childhood poverty, chronic stress, and adult working memory. Proc Natl Acad Sci U S A. 2009;106:6545–6549.
20. Andrews NO, Erickson DJ, eds. Investing in What Works for America’s Communities: Essays on People, Place & Purpose. San Francisco, CA: Federal Reserve Bank of San Francisco; 2012.
21. Gostin LO, Powers M. What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Aff (Millwood). 2006;25:1053–1060.
22. Federal Financial Institutions Examination Council. Findings from analysis of nationwide summary statistics for 2009 Community Reinvestment Act. Available at: http://www.ffiec.gov/hmcrpr/cra_fs09.htm. Accessed January 4, 2017.
23. Erickson DJ. The Housing Policy Revolution: Networks and Neighborhoods. Washington, DC: Urban Institute; 2009.
24. Center for Social Disparities in Health, Build Healthy Places Network, Robert Wood Johnson Foundation. Making the case for linking community development and health. Available at: http://www.buildhealthyplaces.org/content/uploads/2015/10/making_the_case_090115.pdf. Accessed January 4, 2017.
25. Miller J. Build Healthy Places Community Close Ups. San Francisco, CA: Public Health Institute; 2015.
26. Pastor M, Morello-Frosch R. Integrating public health and community development to tackle neighborhood distress and promote well-being. Health Aff (Millwood). 2014;33:1890–1896.
27. Trowbridge MJ, Pickell SG, Pyke CR, Jutte DP. Building healthy communities: establishing health and wellness metrics for use within the real estate industry. Health Aff (Millwood). 2014;33:1923–1929.
28. Schuchter J, Jutte DP. A framework to extend community development measurement to health and well-being. Health Aff (Millwood). 2014;33:1930–1938.
29. Ollove M. States freed to use Medicaid money for housing. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/11/20/states-freed-to-use-medicaid-money-for-housing. Accessed January 4, 2017.
30. Mattessich P, Rausch E. Collaboration to Build Healthier Communities. Minneapolis, MN: Wilder Research and Federal Reserve Bank of Minneapolis; 2013.
31. Erickson J, Branscomb J, Milstein B. Multi-Sector Partnerships for Health: 2014 Pulse Check Findings. Cambridge, MA: ReThink Health; 2015.
32. Zuckerman D. Hospitals Building Healthier Communities: Embracing the Anchor Mission. Takoma Park, MD: Democracy Collaborative, University of Maryland; 2013.
33. Active Living by Design. Clinical-community collaboration around social determinants of health. Available at: http://activelivingbydesign.org/resources/clinical-community-collaboration-case-examples/. Accessed January 4, 2017.
34. Jutte DP, LeWinn KZ, Hutson MA, Dare R, Falk J. Bringing researchers and community developers together to revitalize a public housing project and improve health. Health Aff (Millwood). 2011;30:2072–2078.
35. Walker C. Building Sustainable Communities: Initial Research Results. New York, NY: Local Initiatives Support Corporation; 2014.
36. Center for Promise, Tufts University School of Arts and Sciences. Transforming East Lake: Systematic Intentionality in Atlanta. Washington, DC: America’s Promise Alliance; 2015.
37. HOPE SF Learning Center. Trauma Informed Community Building Evaluation. San Francisco, CA: Health Equity Institute for Research, Practice & Policy, San Francisco State University; 2015.
38. Lubell J, Crain R, Cohen R. Framing the issues: the positive impacts of affordable housing on health. Available at: http://www.housingpartners.com/assets/creating_change/http___app.bronto3.pdf. Accessed January 4, 2017.
39. Sandel M, Cook J, Poblacion A, et al. Housing as a health care investment: affordable housing supports children’s health. Available at: http://www.childrenshealthwatch.org/wp-content/uploads/Housing-as-a-Health-Care-Investment.pdf. Accessed January 4, 2017.
40. Center for Outcomes Research and Education. Health in housing: exploring the intersection between housing and health care. Available at: https://www.enterprisecommunity.org/resources/health-housing-exploring-intersection-between-housing-and-health-care-recommendations-and. Accessed January 4, 2017.
41. Dubowitz T, Ghosh-Dastidar M, Cohen DA, et al. Diet and perceptions change with supermarket introduction in a food desert, but not because of supermarket use. Health Aff (Millwood). 2015;34:1858–1868.
42. Build Healthy Places Network home page. Available at: http://www.buildhealthyplaces.org/. Accessed January 4, 2017.
43. Glanville J. Taking the sting out of gentrification. Planning. 2013;79:12–15.
44. Chaskin RJ, Joseph ML. Integrating the Inner City: The Promise and Perils of Mixed-Income Public Housing Transformation. Chicago, IL: University of Chicago Press; 2015.
45. Lees L, Slater T, Wyly E. Gentrification. New York, NY: Routledge; 2013.
46. Goetz EG. From breaking down barriers to breaking up communities. Urban Aff Rev. 2015;51:820–842.
47. Ferreira R. “Bushwick was mine,” “Bushwick es mio”: gentrification and the emotional displacement of Latinas. Available at: http://digitalcommons.bard.edu/cgi/viewcontent.cgi?article=1311&context=senproj_s2014. Accessed January 4, 2017.
48. PolicyLink. Equitable development toolkit. Available at: http://www.policylink.org/equity-tools/equitable-development-toolkit/about-toolkit. Accessed January 4, 2017.
49. Uitermark J, Nicholls W. Planning for social justice: strategies, dilemmas, tradeoffs. Available at: http://journals.sagepub.com/doi/pdf/10.1177/1473095215599027. Accessed January 4, 2017.
50. Diamond R, McQuade T. Who Wants Affordable Housing in Their Backyard? An Equilibrium Analysis of Low Income Property Development. Cambridge, MA: National Bureau of Economic Research; 2016.
51. Galster G, Pettit K, Santiago A, Tatian P. The impact of supportive housing on neighborhood crime rates. J Urban Aff. 2002;24:289–315.