Executive summary of a health needs assessment

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Scenario

The scarcity of health resources continues to negatively affect communities across the country. Deciding how to allocate scarce resources creates significant ethical challenges for local policymakers and other stakeholders within the community.

You represent a local non-profit community health organization in Chicago. Your organization is compiling data to conduct a needs assessment in order to determine the feasibility of a new community-based mobile health clinic. You have been asked to review the most recent strategic plan for the city of Chicago.

The mobile clinic would offer free preventive care, urgent care, and chronic disease management services to vulnerable citizens of Chicago, who may not otherwise have the financial resources to access quality healthcare services. Your executive summary will be used in the development of a needs assessment for the project.

Your targeted population is an urban, low income community disenfranchised by current health reform policies, high unemployment, a shortage of primary care physicians, and divisive partisan attitudes regarding entitlement programs. The goal of the community-based clinic is to work collaboratively with local health facilities to reduce costs, improve access, and to enhance the quality of care for underserved communities.

Instructions

Review the community health needs assessment linked here that was conducted by the Health Impact Collaborative of Cook County:

POST-South-Report.pdf

Pages 37 – 49 of the report highlight challenges facing the city with respect to costs, access, and quality of care issues. Write an executive summary addressing the following questions:

What are some of socio-economic factors that affect access to care based on the findings in the report?

What are the critical focus areas identified in the report?

Based on the report’s content, how might the use of a mobile health clinic address the critical focus areas?

What are some of the potential barriers to success for a mobile health clinic?

Health Impact Collaborative
of Cook County

Community Health Needs Assessment
South Region

healthimpactcc.org/reports2016

June 2016

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

Participating hospitals and health departments:

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

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

Health Impact Collaborative of Cook County

South Region CHNA 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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South Region CHNA 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*Appendices are included as a separate document

Health Impact Collaborative of Cook County

South Region CHNA 4

Executive Summary – South Region
The Health Impact Collaborative of Cook County
is a partnership of hospitals, health departments,
and community organizations working to assess
community health needs and assets, and to
implement a shared plan to maximize health
equity and wellness in Chicago and Cook County.
The Health Impact Collaborative was developed
so that participating organizations can efficiently
share resources and work together on Community
Health Needs Assessment (CHNA) and
implementation planning to address community
health needs – activities that every nonprofit
hospital is now required to conduct under the
Affordable Care Act (ACA). Currently, 26 hospitals,
seven health departments, and nearly 100
community organizations across Chicago and
Cook County are partners in the Health Impact
Collaborative. The Illinois Public Health Institute
(IPHI) is serving as the process facilitator and
backbone organization for the collaborative
CHNA and implementation planning processes.

A CHNA summarizes the health needs and issues facing the communities that hospitals,
health departments, and community organizations serve. Implementation plans and
strategies serve as a roadmap for how the community health issues identified in the CHNA
are addressed. Given the large geography and population of Cook County, the
Collaborative partners decided to conduct three regional CHNAs. Each of the three regions,
North, Central, and South, include both Chicago community areas and suburban
municipalities.

IPHI and the Collaborative partners are working together to design a shared leadership
model and collaborative infrastructure to support community-engaged planning,
partnerships, and strategic alignment of implementation, which will facilitate more effective
and sustainable community health improvement in the future.

Health Impact Collaborative of Cook County

South Region CHNA 5

Community description for the South region of the Health Impact
Collaborative of Cook County
This CHNA report is for the South region of the Health Impact Collaborative of Cook County.
As of the 2010 census, the South region had 2,081,036 residents which represents a 5%
decrease in total population from the year 2000. Non-Hispanic whites and non-Hispanic
blacks experienced the largest population decreases. Between 2000 and 2010 the non-
Hispanic white population decreased by 163,693 residents and the non-Hispanic black
population decreased by 65,704 residents. Despite an overall population decrease in the
South region from 2000 to 2010, the
Hispanic/Latino and Asian populations
increased by 86,747 and 15,846 residents,
respectively, during the same time period.
Children and adolescents represent more
than a quarter (26%) of the population in
the South region. The majority of the
population is between ages 18 and 64 and
approximately 12% of the population is
older adults aged 65 and over. Overall, the
South region is extremely diverse and
several priority groups were identified
during the assessment process.

Collaborative structure
Six nonprofit hospitals, one public hospital, four health departments, and approximately 30
stakeholders partnered on the CHNA for the South region. The participating hospitals are
Advocate Christ Medical Center and Children’s Hospital, Advocate South Suburban Hospital,
Advocate Trinity Hospital, Mercy Hospital and Medical Center, Provident Hospital of Cook
County, and Roseland Community Hospital. Health departments are key partners in leading
the Health Impact Collaborative and conducting the CHNA. The participating health
departments in the South region are Chicago Department of Public Health, Cook County
Department of Public Health, Park Forest Health Department, and Stickney Health
Department.

The leadership structure of the Health Impact Collaborative includes a Steering Committee,
Regional Leadership Teams, and Stakeholder Advisory Teams. Collectively, the hospitals and
health departments serve as the Regional Leadership Team.

Stakeholder engagement
The Health Impact Collaborative of Cook County is focused on community-engaged
assessment, planning, and implementation. Stakeholders and community partners have
been involved in multiple ways throughout this assessment process, both in terms of
community input data and as decision-making partners. To ensure meaningful ongoing

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

undocumented immigrants
• Individuals living with mental health

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

Health Impact Collaborative of Cook County

South Region CHNA 6

involvement, each region’s Stakeholder Advisory Team has met monthly during the
assessment phase to provide input at every stage and to engage in consensus-based
decision making. Additional opportunities for stakeholder engagement during assessment
have included participation in hospitals’ community advisory groups, community input
through surveys and focus groups, and there will be many additional opportunities for
engagement as action planning begins in the summer of 2016. The Stakeholder Advisory
Team members bring diverse perspectives and expertise, and represent populations
affected by health inequities including diverse racial and ethnic groups, immigrants and
refugees, older adults, youth, homeless individuals, unemployed, uninsured, and veterans.

Mission, vision, and values
IPHI facilitated a three-month process that involved the participating hospitals, health
departments, and diverse community stakeholders to develop a collaborative-wide mission,
vision, and values to guide the CHNA and implementation work. The mission, vision, and
values have been at the forefront of all discussion and decision making for assessment and
will continue to guide action planning and implementation.

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

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

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

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 7

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

• Community Health Status Assessment (CHSA)

• Community Themes and Strengths Assessment (CTSA)

• Forces of Change Assessment (FOCA)

• Local Public Health System Assessment (LPHSA)

The Health Impact Collaborative of Cook County chose this community-driven assessment
model to ensure that the assessment and identification of priority health issues was informed
by the direct participation of stakeholders and community residents.

The four MAPP assessments were conducted in partnership with Collaborative members and
the results were analyzed and discussed in monthly Stakeholder Advisory Team meetings.

Community Health Status Assessment (CHSA). IPHI worked with the Chicago Department of
Public Health and Cook County Department of Public Health to develop the Community
Health Status Assessment. This Health Impact Collaborative CHNA process provided an
opportunity to look at data across Chicago and suburban jurisdictions and to share data
across health departments in new ways. The Collaborative partners selected approximately
60 indicators across seven major categories for the Community Health Status Assessment.1 In
keeping with the mission, vision, and values of the Collaborative, equity was a focus of the
Community Health Status Assessment.

Community Themes and Strengths Assessment (CTSA). The Community Themes and Strengths
Assessment included both focus groups and community resident surveys. Approximately
5,200 surveys were collected from community residents through targeted outreach to
communities affected by health disparities across the city and county between October
2015 and January 2016. About 2,250 of the surveys were collected from residents in the South
region. The survey was disseminated in four languages and was available in paper and
online formats. Between October 2015 and March 2016, IPHI conducted eight focus groups
in the South region. Focus group participants were recruited from populations that are
typically underrepresented in community health assessments including diverse racial and
ethno-cultural groups; immigrants; limited English speakers; families with children; older adults;
lesbian, gay, bisexual, queer, intersex, and asexual (LGBQIA) individuals; transgender
individuals; formerly incarcerated adults; individuals living with mental illness; and veterans
and former military.

1 The seven data indicator categories—demographics, socioeconomic factors, health behaviors, physical
environment, healthcare and clinical care, mental health, and health outcomes—were adapted from the
County Health Rankings model.

Health Impact Collaborative of Cook County

South Region CHNA 8

Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA).
The Chicago and Cook County Departments of Public Health each conducted a Forces of
Change Assessment and a Local Public Health System Assessment in 2015, so the
Collaborative was able to leverage and build off of that data. IPHI facilitated interactive
discussions at the August and October 2015 Stakeholder Advisory Team meetings to reflect
on the findings, gather input on new or additional information, and prioritize key findings
impacting the region.

Significant health needs
Stakeholder Advisory Teams in collaboration with hospitals and health departments prioritized
the strategic issues that arose during the CHNA. The guiding principles and criteria for the
selection of priority issues were rooted in data-driven decision making and based on the
Collaborative’s mission, vision, and values. In addition, partners were encouraged to prioritize
issues that will require a collaborative approach in order to make an impact. Very similar
priority issues rose to the top through consensus decision making in the South, Central, and
North regions of Chicago and Cook County.

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 9

Key assessment findings

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

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

Figure 1.1. Summary of key assessment findings related to the social, economic, and
structural determinants of health

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

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

Health Impact Collaborative of Cook County

South Region CHNA 10

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

2. Improving mental health and decreasing substance abuse.

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

Figure 1.2. Summary of key assessment findings related to mental health and substance use

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 11

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

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

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

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

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

4. Increasing access to care and community resources.

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

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

Health Impact Collaborative of Cook County

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

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

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

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

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South Region CHNA 13

Introduction
Collaborative Infrastructure for Community Health Needs Assessment (CHNA)
in Chicago and Cook County
In addition to providing health coverage for millions of uninsured people in the U.S., the
Affordable Care Act includes a number of components designed to strengthen the
healthcare delivery system’s focus on prevention and keeping people healthy rather than
simply treating people who are ill. One component is the requirement that nonprofit hospitals
work with public health and community partners every three years to conduct a Community
Health Needs Assessment (CHNA), identify community health priorities, and develop
implementation strategies for those priorities. The CHNA summarizes community health needs
and issues facing the communities that hospitals serve, and the implementation strategies
provide a roadmap for addressing them.

After separately developing CHNAs in 2012-2013, hospitals in Chicago and suburban Cook
County joined together to create the Health Impact Collaborative of Cook County
(“Collaborative”) for the 2015-2016 CHNA process. This unprecedented collaborative effort
enabled the members to efficiently share resources and foster collaboration that will help
them achieve deep strategic alignment and more effective and sustainable community
health improvement. Local health departments across Cook County have also been key
partners in developing this collaborative approach to CHNA to bring public health expertise
to the process and to ensure that the assessment, planning, and implementation are aligned
with the health departments’ community health assessments and community health
improvement plans.7 As of March 2016, the Collaborative includes 26 hospitals serving
Chicago and Cook County, seven local health departments, and approximately 100
community partners participating on three regional Stakeholder Advisory Teams.
(Appendices A and B list the full set of partners collaborating across the three regions.) The
Illinois Public Health Institute (IPHI) serves as the “backbone organization,” convening and
facilitating the Collaborative. The Collaborative operates with a shared leadership model as
shown in Figure 2.2.

Given the large geography and population in Cook County, the Collaborative partners
decided to conduct three regional CHNAs within Cook County. The three regions each
include Chicago community areas as well as suburban cities and towns. Figure 2.1 shows a
map of the three CHNA regions – North, Central, and South. This report is for the South region.
Similar reports will be available for the North and Central regions of the county at
www.healthimpactcc.org/reports2016 by summer 2016.

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

Health Impact Collaborative of Cook County

South Region CHNA 14

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

*Advocate Lutheran General Hospital and Advocate Children’s Hospital – Park Ridge are located at the same
address and represented by a single icon

**Northshore University HealthSystem Highland Park Hospital is participating in the collaborative although it is
located outside Cook County

Seven nonprofit hospitals, one public hospital, four health departments, and approximately
30 stakeholders are collaborating partners on the South region CHNA for Chicago and
suburban Cook County. The participating hospitals are Advocate Christ Medical Center and
Advocate Children’s Hospital, Advocate South Suburban Medical Center, Advocate Trinity
Hospital, Mercy Hospital and Medical Center, Provident Hospital of Cook County, Roseland
Community Hospital, and South Shore Hospital. Health departments are key partners in
leading the Health Impact Collaborative and conducting the CHNA. The participating health
departments in the South region are Chicago Department of Public Health, Cook County
Department of Public Health, Park Forest Health Department, and Stickney Health
Department.

Health Impact Collaborative of Cook County

South Region CHNA 15

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

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

• Stakeholder Advisory Team

• Hospitals’ community advisory groups

• Data collection – community input through surveys and focus groups

• Action planning for strategic priorities (to begin summer 2016)

The South Stakeholder Advisory Team includes representatives of diverse community
organizations from across the South Side of Chicago and South Cook suburbs. Members of
the Stakeholder Advisory Team are important partners in the CHNA and implementation
planning process, contributing in the following ways:

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

and asset mapping.

Health Impact Collaborative of Cook County

South Region CHNA 16

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

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

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

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

The organizations represented on the South Stakeholder Advisory Team are listed in Figure 2.3.

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

Health Impact Collaborative of Cook County

South Region CHNA 17

Formation of the South Stakeholder Advisory Team
Between March and May 2016, the Illinois Public Health Institute (IPHI) worked with the
participating hospitals and health departments in the South region of Cook County (i.e.,
South Leadership Team) to identify and invite community stakeholders to participate as
members of the Stakeholder Advisory Team.

All participating stakeholders work with or represent communities that are underserved or
affected by health disparities. The Stakeholder Advisory Team members represent
many constituent populations including populations affected by health inequities; diverse racial
and ethnic groups including Hispanic/Latinos, African Americans, Asians, and Eastern Europeans;
youth; older adults; homeless individuals; individuals with mental illness; unemployed; and
veterans and former military. To ensure a diversity of perspectives and expertise on the
Stakeholder Advisory Team, IPHI provided a Stakeholder Wheel tool (shown in Figure 2.4) to
identify stakeholders representing a variety of community sectors. The South Leadership Team
gave special consideration to geographic distribution of stakeholder invitees and representation
of unique population groups in the region. Stakeholders showed a high level of interest, with
approximately 25 of 30 community stakeholders accepting the initial invite. Given the large
geography and population in the area, honing in on advisory team members was an iterative
process, and the Stakeholder Advisory Team has been open to adding members throughout the
process when specific expertise was needed or key partners expressed interest in joining.

The South Stakeholder Advisory Team provided input at every stage of the assessment and
was instrumental in shaping the assessment findings and priorities issues that are presented in
this report. The South Stakeholder Advisory Team met with the participating hospitals and
health departments (i.e., South Leadership Team) seven times between May 2015 and March
2016. IPHI designed and facilitated these meetings to solicit input, make recommendations,
identify assets, and work collaboratively with hospitals and health systems to identify priority
health needs.

Figure 2.4. Stakeholder Wheel

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

Health Impact Collaborative of Cook County

South Region CHNA 18

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

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

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

community partners.

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

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

Health Impact Collaborative of Cook County

South Region CHNA 19

Mission, vision, and values

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

Figure 2.5. Health Impact Collaborative of Cook County Collaborative Mission, Vision, Values

Mission:
The Health Impact Collaborative of Cook County will work collaboratively with
communities to assess community health needs and assets and implement a shared
plan to maximize health equity and wellness.
Vision:
Improved health equity, wellness, and quality of life across Chicago and Cook County
Values:
1) We believe the highest level of health for all people can only be achieved through

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

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 20

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

Figure 3.1. MAPP Framework

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

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

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

Evaluating

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

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

(LPHSA)

Health Impact Collaborative of Cook County

South Region CHNA 21

Community Description for the South Region
The South region of the Health Impact Collaborative of Cook County includes approximately
30 community areas in Chicago and 50 municipalities in suburban Cook County. In the 2010
census, the South region had 2,081,036 compared to 2,213,031 residents in the 2000 census.
The total land areas encompassed by the South region is roughly 495 square miles and the
population density in the region is approximately 4,471 residents per square mile based on
the 2010 census data.8

Non-Hispanic African American/blacks make up the largest racial or ethnic group in the
South region, representing 43% of the population. Compared to the North and Central
regions, the South region has the highest percentage of African American/black individuals.
Approximately 29.5% of individuals in the South region identify as white and 24.0% as
Hispanic/Latino. A relatively small percentage of the South region’s population is Asian (2.7%
as of 2010). However, the Asian population is experiencing significant growth with an
increase of 15,846 Asian residents (32% increase) between 2000 and 2010 in the South region.
The Hispanic/Latino population is also experiencing significant growth with a 21% increase
(86,747 residents) in population size between 2000 and 2010.

Figure 4.1. Regional race and ethnicity

Data Source: Cook County Department of Public Health, U.S. Census Bureau 2010 Census

Although African American/blacks are the largest population group in the South region, they
are experiencing large population decreases (See Figures 4.2) across Chicago and suburban
Cook County. In the South region, the African American population decreased by 7% (65,704
individuals) from 2000 to 2010.

Figure 4.2. Population change in race/ethnicity between 2000 and 2010, South region

Race/Ethnicity
2010

Population
2000

Population
Change in
Population

Percent Change in
Population

African American/black
(non-Hispanic)

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

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

Data Source: U.S. Census Bureau 2010 Census

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

Health Impact Collaborative of Cook County

South Region CHNA 22

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

Figure 4.4. Limited English Proficiency, 2009-2013

Data Source: American Communities Survey, 2009-2013

Health Impact Collaborative of Cook County

South Region CHNA 23

Children and adolescents under 18 represent more than a quarter (26.2%) of the population
in the South region. Approximately 62% of the population is 18 to 64 years old and about 12%
are older adults age 65 and over.

Figure 4.5. Age distribution of residents, by region, Chicago and suburban Cook County, 2010

Data Source: U.S. Census Bureau 2010 Census

The overall population aged 65 and older remained approximately the same between 2000
and 2010. However, several communities in the South region experienced a growth in their
older adult population (Figure 4.6.). More assessment data about the community health
implications of a growing older adult population can be found on page 47 of this report.

Figure 4.6. Change in population aged 65 or older in Chicago and Cook County, 2000-2010

Health Impact Collaborative of Cook County

South Region CHNA 24

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

Figure 4.7. Demographic characteristics of key populations in the South region
Key Population Demographic Characteristics Data Sources

Formerly
Incarcerated

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

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

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

Chicago Coalition for the Homeless.
(2016).
http://www.chicagohomeless.org/faq
-studies/);

Alliance to End Homelessness in
Suburban Cook County. (2015).
http://www.suburbancook.org/counts

People living with
mental health
conditions

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

Behavioral Risk Factor Surveillance
System

People with
disabilities

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

American Communities Survey, 2010-
2014

Undocumented
immigrants

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

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

Veterans and
former military

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

American Communities Survey, 2010-
2014

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

Health Impact Collaborative of Cook County

South Region CHNA 25

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

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

The LPHSA assessments conducted in Chicago and Cook County in 2015 were led by the
respective health departments, and each engaged nearly 100 local representatives of
various sectors of the public health system including clinical, social services, policy makers,
law enforcement, faith-based groups, coalitions, schools and universities, local planning
groups, and many others.

12 Note: Some hospitals and health systems conducted additional assessment activities and data analyses that
are presented in the hospital-specific CHNA report components.

13 The MAPP Assessment framework is presented in more detail on page 21 of this report. The four MAPP
assessments are: Community Health Status Assessment (CHSA), Community Themes and Strengths Assessment
(CTSA), Forces of Change Assessment (FOCA), and Local Public Health System Assessment (LPHSA).

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

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

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

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

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

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

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

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

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

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

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

term improvements.

Health Impact Collaborative of Cook County

South Region CHNA 26

IPHI worked with both the Chicago and Cook County
Departments of Public Health to plan, facilitate, and
document the LPHSAs. Many members of the Health
Impact Collaborative of Cook County participated in
one or both of the LPHSAs and found the events to be a
great opportunity to increase communication across the
local public health system, increase knowledge of the
interconnectedness of activities to improve population
health, understand performance baselines and
benchmarks for meeting public health performance
standards, and identify timely opportunities to improve
collaborative community health work.

IPHI created combined summaries of the city and
suburban data for both the FOCA and the LPHSA (see
Appendices E and F), which were shared with the South Leadership Team and Stakeholder
Advisory Team. IPHI facilitated interactive discussion at in-person meetings in August and
October 2015 to reflect on the FOCA and LPHSA findings, gather input on new or additional
information, and prioritize key findings impacting the region.

Methods – Community Health Status Assessment
Epidemiologists from the Cook County Department of Public Health and Chicago
Department of Public Health have been invaluable partners on the Community Health Status
Assessment (CHSA). This CHNA presented an opportunity for health departments to share
data across Chicago and suburban jurisdictions, laying the groundwork for future data
collaboration. The health departments and IPHI worked with hospitals and stakeholders to
identify a common set of indicators, based on the County Health Rankings model (see Figure
5.2). In addition to the major categories of indicators in the County Health Rankings model,
this CHNA also includes an indicator category for Mental Health. Therefore, the CHSA
indicators fall into seven major categories:

 Demographics

 Socioeconomic Factors

 Health Behaviors

 Physical Environment

 Health Care and Clinical Care

 Mental Health

 Health Outcomes (Birth Outcomes, Morbidity, Mortality)

Figure 5.1. The 10 Essential
Public Health Services

Health Impact Collaborative of Cook County

South Region CHNA 27

Figure 5.2. County Health Rankings model

Data were compiled from a range of sources, including:

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 28

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

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

The mission, vision, and values of the Collaborative have a strong focus on improved health
equity in Chicago and suburban Cook County. As a result, the Collaborative utilized the
CHSA process to identify inequities in social, economic, healthcare, and health outcomes in
addition to describing the health status and community conditions in the South region. Many
of the health disparities vary by geography, gender, sexual orientation, age, race, and
ethnicity.

For several health indicators, geospatial data was used to create maps showing the
geographic distribution of health issues. The maps were used to determine the communities
of highest need in each of the three regions. For this CHNA, communities with rates for
negative health issues that were above the statistical mean were considered to be high
need.

Methods – Community Themes and Strengths Assessment
The Community Themes and Strengths Assessment included both focus groups and
community resident surveys. The purpose of collecting this community input data was to
identify issues of importance to community residents, gather feedback on quality of life in the
community and identify community assets that can be used to improve communities.

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 29

Community Survey – methods and description of respondents in South region
By leveraging its partners and networks, the Collaborative collected approximately 5,200
resident surveys between October 2015 and January 2016, including 2,288 in the South
region. The survey was available on paper and online and was disseminated in five
languages – English, Spanish, Polish, Korean, and Arabic.14 The majority of the responses
were paper-based (about 75%) and about a quarter were submitted online.

The community resident survey was a
convenience sample survey, distributed by
hospitals and community-based organizations
through targeted outreach to diverse
communities in Chicago and Cook County,
with a particular interest in reaching low
income communities and diverse racial and
ethnic groups to hear their input into this
Community Health Needs Assessment. The
community resident survey was intended to
complement existing community health
surveys that are conducted by local health
departments for their IPLAN community
health assessment processes. IPHI reviewed
approximately 12 existing surveys to identify possible questions, and worked iteratively with
hospitals, health departments, and stakeholders from the 3 regions to hone in on the most
important survey questions. IPHI consulted with the UIC Survey Research Laboratory to refine
the survey design. The data from paper surveys was entered into the online SurveyMonkey
system so that electronic and paper survey data could be analyzed together. Survey data
analysis was conducted using SAS statistical analysis software, and Microsoft Excel was used
to create survey data tables and charts.

The majority of survey respondents from the South region identified as heterosexual (91%,
n=2146) and African American/black (57%, n=2146). Twenty-seven percent (27%) of survey
respondents identified as white, 2% Asian/Pacific Islander, and 2% Native
American/American Indian.1 Approximately 25% (n=1651) of survey respondents in the South
region identified as Hispanic/Latino and approximately 10% identified as Middle Eastern
(n=1651).1 Two-percent of survey respondents from the South region indicated that they were
living in a shelter and 1% indicated that they were homeless (n=2257). The South region had
the highest percentage of individuals with less than a high school education (12%, n=2027)
compared to the North and Central regions of Cook County, and the majority of
respondents from the South region (68%, n=1824) reported an annual household income of
less than $40,000.

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

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

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

Recreation
 Personal Safety
 Stress

Health Impact Collaborative of Cook County

South Region CHNA 30

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 31

Figure 5.3. Focus groups conducted in the South region.

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

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

Bridgeview, Illinois
(12/4/2015)

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

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

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

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

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

Hazel Crest, Illinois
(1/21/2016)

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

Park Forest, Illinois
(11/12/2015)

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

Hazel Crest, Illinois
(12/17/2015)

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

Burbank, Illinois
(12/3/2015)

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

Richton Park, Illinois
(1/28/2016)

Health Impact Collaborative of Cook County

South Region CHNA 32

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

Figure 6.1. Prioritization criteria

Collaborative participants identified and discussed key assessment findings throughout the
collaborative assessment process from May 2015 to February 2016. IPHI worked with the
Collaborative partners to summarize key findings from all four MAPP assessments between
December 2015 and February 2016. Once the key findings were summarized, IPHI vetted the
list of significant health needs and strategic issues with the Steering Committee in February
2016 and they agreed that those issues represented a summary of key assessment findings.
Following the meeting with the Steering Committee, the Stakeholder Advisory Teams and
hospitals and health departments participated in an online poll to provide their initial input
on priority issues to inform discussion at the March 2016 regional meetings.

During the South region Stakeholder Advisory Team meeting conducted in March 2016, team
members reviewed summaries of assessment findings, the prioritization criteria, the mission,
vision, and values, and poll results. The meeting began with individual reflection, with each
participant writing a list of the top five issues for the Collaborative to address. Following
individual reflection, representatives from hospitals, health departments, and community
stakeholders worked together in small groups to discuss their individual lists of five priorities.
IPHI instructed the small groups to work toward consensus on the top two to three issues that
the collaborative should address collectively for meaningful impact. The small groups then
reported back, and IPHI facilitated a full group discussion and consensus building process to
hone in on the top five priorities for the region.

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 33

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

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

structural racism
• Healthy environment

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

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

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

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

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

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

Following the South region prioritization meeting, the Health Impact Collaborative Steering
Committee met and reviewed the top issues that emerged in all three regions (summarized in
Figure 6.2).

The priorities identified across the three regions were very similar so the Health Impact
Collaborative of Cook County was able to identify Collaborative-wide focus areas, which are
shown in Figure 6.3.

Healthy Environment came up as a key issue in all three regions, although it was classified
differently during prioritization in the different regions. Because of the close connections
between Healthy Environment and two of the other top issues – Social Determinants of
Health and Chronic Disease – Healthy Environment is included as a topic within both of those
broad issues, as shown in Figure 6.3.

Based on input from the South and Central Stakeholder Advisory Teams, Community Safety
and Violence Prevention is included as a topic under both Social Determinants of Health and
Mental Health and Substance Use.

Health Impact Collaborative of Cook County

South Region CHNA 34

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

Social and Structural

Determinants
Healthy

Environment

Mental Health and
Substance Use

(Behavioral Health)
Chronic Disease

Access to Care and
Community Resources

North 

Under social
determinants and
chronic disease   

Emphasized
connections between
healthy environment
and chronic disease

Central 

Under social
determinants and
chronic disease   

Emphasized
connections
between healthy
environment, safety,
and socioeconomic
factors

Emphasized
connections between
healthy environment
and chronic disease

South     

Emphasized connections
between community
safety, trauma, and
mental health

Emphasized
connections between
healthy environment
and chronic disease

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

Health Impact Collaborative of Cook County

South Region CHNA 35

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

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

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

of health

Mental health and
substance abuse

(Behavioral health)

Chronic disease
prevention

Access to care and
community resources

• Economic

inequities and
poverty

• Education
inequities

• Structural racism

• Housing and
transportation

• Healthy
environment

• Safety and
violence

• Overall access

to services and
funding

• Violence and
trauma, and its
ties to mental
health

• Focus on risk

factors –
nutrition,
physical activity,
tobacco

• Healthy
environment

• Cultural & linguistic

competency/
humility

• Health literacy

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

• Navigating complex
healthcare system
and insurance

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

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

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

2. Improving mental health and decreasing substance abuse.

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

4. Increasing access to care and community resources.

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

Health Impact Collaborative of Cook County

South Region CHNA 36

The regional discussions highlighted the relationship between healthy environment, chronic
disease, and social and structural determinants of health. As a result, healthy environment is
listed under both chronic disease and determinants of health. Participants emphasized the
connections between community safety, trauma, and mental health during the regional
meetings, particularly in the South region. As a result, safety and violence is listed as both a
social determinant and a behavioral health determinant. All three regional discussions also
identified policy, advocacy, funding, and data systems as key strategies and approaches
that should be applied across all of the focus areas.

All hospitals within the Collaborative will include the first focus area—Improving social,
economic, and structural determinants of health—as a priority in their CHNA report. Each
hospital will then select at least one additional focus area as a priority. Based on alignment of
the hospital-specific priorities, regional and Collaborative-wide planning will start in summer
2016.

Health Impact Collaborative of Cook County

South Region CHNA 37

Health Equity and Social, Economic, and Structural Determinants
of Health

A key part of the mission of the Health Impact
Collaborative is to work collaboratively with
communities to implement a shared plan to
maximize health equity and wellness. In
addition, one of the core values of the
Collaborative is the belief that the highest
level of health for all people can only be
achieved through the pursuit of social justice
and the elimination of health disparities and
inequities. The values of the Collaborative are
echoed by both the Centers for Disease
Control and Prevention (CDC) and the World
Health Organization (WHO), which state that
addressing the social determinants of health is
the core approach to achieving health
equity.15, 16 In addition, the CDC encourages
health organizations, institutions, and education programs to look beyond behavioral factors
and address the underlying factors related to social determinants of health.15

Health inequities
The social determinants of health such as poverty, unequal access to healthcare, lack of
education, stigma, and racism are underlying contributing factors to health inequities.15
Additionally, social determinants of health often vary by geography, gender, sexual
orientation, age, race, disability, and ethnicity.17 Nationwide some of the most prominent
health disparities include the following:

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

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

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

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

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

Figure 7.1. Health equity

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

Health Impact Collaborative of Cook County

South Region CHNA 38

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

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

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

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

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

18 Healthy People 2020. (2016). Lesbian, Gay, Bisexual, and Transgender Health.
https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

19 The Henry J. Kaiser Family Foundation. (2016). Health coverage and care for immigrants.
http://kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/

Health inequities in Chicago and suburban Cook County

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

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

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 39

Economic inequities
Socioeconomic factors are the largest determinants of health status and health outcomes.20
Poverty can create barriers to accessing quality health services, healthy food, and other
necessities needed for good health status. 21 Poverty also largely impacts housing status,
educational opportunities, the physical environment that a person works and lives in, and
health behaviors.20 Asians, Hispanic/Latinos, and African American/blacks have higher rates
of poverty compared to non-Hispanic whites as well as lower annual household incomes. In
addition, approximately 32% of children and adolescents live below 100% of the federal
poverty level and more than half (57%) of children below 200% of the federal poverty level in
the South region. Of the three regions, the South has the highest rates of childhood poverty.
Unemployment can create financial instability and as result can create barriers to accessing
healthcare services, insurance, healthy foods, and other basic needs.21 The unemployment
rate in the South region is higher (17.0%) compared to the Central (12.1%) and North (8.2%)
regions. The unemployment rate in the South region also exceeds the rates for Illinois (10.5%)
and the U.S. (9.2%). In the South region and across Chicago and Cook County, African
Americans/blacks have a much higher rate of unemployment compared to whites and
Asians.

Education inequities
Community residents in the South region often described their local school systems as poorly
performing, underfunded, and substandard. Education is an important social determinant of
health, because the rate of poverty is higher among those without a high school diploma. In
addition, those without a high school education are at a higher risk of developing certain
chronic illnesses.5

Inequities in the built environment
Community input data indicates that residents in the South region are concerned about
abandoned buildings in their communities, potential lead exposure in homes, and the
possibility of poor water and air quality. Nearly half (44%) of residents surveyed in the South
region indicated one or more problems in their current homes that could have a negative
impact on health. Residents also indicated that there is a lack of quality affordable housing
in the South region, contributing to homelessness in their communities. Participants also
highlighted inequities in access to transportation and access to health foods in the South
region.

Inequities in community safety and violence
Violent crime disproportionately affects residents living in communities of color in Chicago
and suburban Cook County.22 In addition, homicide and firearm-related mortality is highest in
the South and Central regions and in African American and Hispanic/Latino communities.
Community residents in the South region indicated that a lack of positive community
policing, gang activity, drug use/drug trafficking, the presence of guns, domestic violence,

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

Health Impact Collaborative of Cook County

South Region CHNA 40

child abuse, human trafficking, property crimes (home break-ins, theft, muggings), and
poorly maintained foreclosed or vacant properties were some of the primary reasons that
they felt unsafe in their communities. Exposure to violence not only causes physical injuries
and death, but it also has been linked to negative psychological effects such as depression,
stress, and anxiety, as well as self-harm and suicide attempts.23

Structural racism
Policies that reinforce or promote structural racism have detrimental effects on community
health. Not only do communities of color experience higher rates of morbidity and mortality,
but individuals who report experiencing racism exhibit worse health than individuals that do
not experience it.24 Community input indicates that many residents consider the ongoing
long-term divestment in the South region, particularly in communities of color, a serious
problem. Community residents stated that people belonging to diverse racial and ethnic
groups were more likely to live in low-income neighborhoods with fewer job opportunities
and many indicated that they had experienced discrimination in their day-to-day lives.

The importance of upstream approaches
As shown in figure 7.2, health is determined in large part by the social determinants of health
including economic resources, built environment, community safety, and policy. As a result,
an upstream approach that addresses the social determinants of health has the greatest
impact on health outcomes.

Figure 7.2. Centers for Disease Control and Prevention, Health Impact Pyramid

Source: Freiden, T. Centers for Disease Control and Prevention. 2010. A framework for public health action: The
health impact pyramid. American Journal of Public Health. 100(4): 590-595. (6p).

23 Mayor, S. (2002). WHO report shows public health impact of violence. The BMJ, 325(7367).
24 Williams, D., Costa, M., Odunlami, A., Mohammed, S. (2012). Moving Upstream: How Interventions that Address
the Social Determinants of Health Can Improve Health and Reduce Disparities. Journal of Public Health
Management and Practice, 14(Suppl) S8-17.

Health Impact Collaborative of Cook County

South Region CHNA 41

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

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

Figure 7.3. Social Vulnerability Index by Census Tract, 2010 25

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

Health Impact Collaborative of Cook County

South Region CHNA 42

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

Figure 7.4. Childhood Opportunity Index by Census Tract, 2007-2013

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

Health Impact Collaborative of Cook County

South Region CHNA 43

Poverty, Economic, and Education Inequity

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

The FOCA results were echoed in the eight focus groups conducted in the South region.
Focus group participants identified poor economic growth and unemployment, long-term
divestment in the South region, lack of vocational education opportunities, and a lack of job
and workforce development as some of the major economic issues facing their communities.

The Community Health Status Assessment (CHSA) highlighted many of the economic
disparities in Chicago and suburban Cook County. As shown in Figure 7.8, the mean per
capita income for Asians, African Americans, and Hispanic/Latinos is lower than it is for non-
Hispanic whites. In addition, those same racial and ethnic groups are more likely to live at or
below 100% and 200% of the federal poverty level (FPL). Overall, the percentages of the
population living at or below 100% and 200% FPL are higher in Chicago and suburban Cook
County than the rates for Illinois and the U.S.

27 U.S. Department of Health and Human Services. (2016). Poverty Guidelines. https://aspe.hhs.gov/poverty-
guidelines.

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

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

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 44

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

Data Source: American Communities Survey, 2009-2013

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

Health Impact Collaborative of Cook County

South Region CHNA 45

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

Data Source: American Communities Survey, 2009-2013

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

Health Impact Collaborative of Cook County

South Region CHNA 46

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

Data Source: American Communities Survey, 2009-2013

Figure 7.8. Per capita income28, by race and ethnicity, 2009-2013

Data Source: American Communities Survey, 2009-2013

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 47

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

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

chronic disease
• Increased need for caregivers

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

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

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

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

Data Source: American Communities Survey, 2009-2013

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 48

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

Data Source: American Communities Survey, 2009-2013

Health Impact Collaborative of Cook County

South Region CHNA 49

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

Figure 7.11. High school graduation rates in Chicago and Suburban Cook County, 2011-2012

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

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

i

Health Impact Collaborative of Cook County

South Region CHNA 50

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

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

Health Impact Collaborative of Cook County

South Region CHNA 51

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

Data Source: American Communities Survey, 2010-2014

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

Health Impact Collaborative of Cook County

South Region CHNA 52

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

Housing and Transportation
The FOCA identified lack of affordable housing and transportation especially for vulnerable
populations as significant forces affecting health in Chicago and suburban Cook County.
Homelessness, gentrification, and transit inequalities were seen as threats to health. Building
on current efforts to improve physical infrastructure like sidewalks, bike lanes, and outdoor
recreation space, initiatives to rehab vacant housing, policies to support affordable housing,
and creating jobs through housing initiatives were identified as opportunities.

The percentage of the population that utilizes public transportation as their primary means of
commute to work is high in the South region and Cook County compared to Illinois and the
U.S.

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

Illinois 8.9%
United States 5.1%

Data Source: American Communities Survey, 2010-2014

The percentage of households with no motor vehicle is higher in the South region and Cook
County compared to Illinois and the U.S., and could indicate a need for transportation
alternatives.

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

Illinois 10.8%
United States 9.1%

Data Source: American Communities Survey, 2010-2014

Transportation was a major issue discussed by focus group participants in the South region.
Transportation services for seniors and disabled individuals have been discontinued or are
extremely limited. As a result, it is difficult to use public transportation to go to clinics and
medical appointments and pick-up prescriptions. Several residents in the South region
mentioned the need to expand public transit routes and/or hours. Approximately 21% of
survey respondents from the South region rated the convenience of timing and stops for
public transit as “poor” or “very poor.”

Quality affordable housing was another major issue identified by focus group participants. In
addition, several focus group participants mentioned the need to address homelessness in
their communities. Approximately 23% of survey respondents from the South region reported
that housing in their communities was not affordable. In addition, as previously stated, 44% of
survey respondents in the South region described poor housing conditions in their current
homes.

Health Impact Collaborative of Cook County

South Region CHNA 53

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

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

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

families have had to worry about whether or not their food would run out before they had
the money to buy more. Over 75% of enrolled schoolchildren in the South region of Chicago
and Suburban Cook County are eligible for free or reduced price lunch. In addition, 21% of
all households in the South region are receiving SNAP benefits, the highest percentage of all
the regions.

Environmental concerns
Climate change, air quality, radon, lead, and water quality were identified as forces of
change that present direct threats to health. Federal action on climate change and multi-
sector healthy housing initiatives are potential opportunities to improve health.

The use of lead paint in homes was stopped in 1979. Most homes (79%) in Chicago and
suburban Cook County were built before 1979, indicating an increased risk of lead paint
being present in the home. Exposure to lead paint particles through ingestion, absorption,
and inhalation can cause numerous adverse health issues including gastrointestinal
problems, fatigue, neurological problems, muscle weakness and pain, as well as
developmental delays in children.31 Lead exposure is particularly dangerous to children

30 USDA. (2014). http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-
graphics.aspx#insecure
31 Centers for Disease Control and Prevention. (2013). Health problems caused by lead.
http://www.cdc.gov/niosh/topics/lead/health.html

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

Health Impact Collaborative of Cook County

South Region CHNA 54

because their bodies absorb more lead than adults and their brains and nervous systems are
more sensitive to the damaging effects of lead.32 If pregnant women are exposed to lead
paint particles, there is a risk of exposure to their developing baby.32

Environmental concerns mentioned by focus group participants included lead exposure and
water and air quality. Forty-four percent of survey respondents from the South region
indicated one or more problems with their current homes that could have a negative impact
on health.

Figure 7.16. Map of homes built before 1979 (lead paint risk)

Data Source: American Community Survey, 2009-2013

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

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

Health Impact Collaborative of Cook County

South Region CHNA 55

Figure 7.17. Housing conditions identified by community residents in the South region, Health
Impact Collaborative Community Survey, 2015

Which of the following describes your current home? Check all that apply. (n=2142)

Nearly a quarter of survey respondents from the South region reported outside air leaking
through windows, doors, and crevices. The next most frequent home maintenance concern
reported was peeling paint, which was cited by about 18% of respondents. Approximately
13% of respondents reported water leaks over the past 12 months and 10.6% of respondents
reported mold/mildew being present in their homes.

The World Health Organization (WHO) has identified air particles with a diameter of 10
microns or less, which can penetrate and lodge deeply inside the lungs, as the most
damaging to human health.33 This form of particle pollution is known as particulate matter or
PM. Chronic exposure to these particles contributes to the risk of developing cardiovascular
problems, respiratory diseases, and lung cancer. The percentage of days with PM 2.5 levels
exceeding the National Ambient Air Quality Standard (35 micrograms per cubic meter per
year) is higher than the rate for Illinois and the U.S.

Figure 7.18. Percentage of days exceeding the National Ambient Air Quality Standard for PM
2.5, 2008

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

Population Adjusted Average
South Region 1.8%
Cook County 1.6%

Illinois 1.1%
United States 1.2%

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

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

Health Impact Collaborative of Cook County

South Region CHNA 56

Safety and Violence—Social, economic, and structural determinants of health
Although violent crime occurs in all communities, violent crime disproportionately affects
communities of color in Chicago and suburban Cook County.34 In addition, there are
multiple negative health outcomes associated with exposure to violence and trauma.34
Factors and trends in safety and violence identified in the FOCA include gun violence,
intimate partner violence, police violence, and bullying. The threats to health from these
forces include the links between community violence, chronic disease, and mental health
problems, plus the impact of fear and stress on health and well-being. Opportunities to
address safety and violence issues in Chicago and suburban Cook County include
supporting the role of schools in violence prevention and services for families, and increasing
communication between communities and police.

Concerns about safety and violence were echoed in the focus group results. Participants in
six out of the eight focus groups in the South region mentioned safety concerns in their
communities. Safety issues highlighted by participants in the South region include lack of
positive community policing, gang activity, and drug use/drug trafficking, domestic violence,
child abuse, robbery, and personal safety. Residents who live in the South Cook suburbs
described how the foreclosure crisis has led to many abandoned properties and that those
properties have become hubs of drug activity and other illegal activities in their communities.
The focus group results align with the results of the Community Resident Survey where
respondents from the South region indicated that gang activity (33%), drug use/drug dealing
(28%), presence of guns in the neighborhood (23%), and property/homes not maintained
(18%) as the top four reasons that they felt unsafe in the last 12 months. Homicide and firearm
mortality were highest in the South region of Chicago and suburban Cook County.

Figure 7.19. Homicide and firearm-related mortality by region, 2012

Data Source: Illinois Department of Public Health, 2012

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

Health Impact Collaborative of Cook County

South Region CHNA 57

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

Structural racism and systems-level policy change—Social, economic, and
structural determinants of health
The WHO has found that structural racism is a direct cause of health inequities.2 The FOCA
identified many factors and trends related to racism, discrimination, and stigma including the
ongoing existence of implicit bias; mass incarceration affecting communities of color; and
unequal quality of education across racial, ethnic, and class categories. These forces present
threats to overall health outcomes and increased health disparities. The FOCA identified
some opportunities to address issues related to racism and discrimination in Chicago and
suburban Cook County including public education campaigns, embedding equity into
organizational values, implementing collective impact and community organizing, and
promoting social movements.

Community members in the South region focus groups indicated that communities of color
have a disproportionate burden of health problems. The ongoing long-term divestment in the
South region was considered a serious problem by several residents. Participants stated that
African Americans, Latinos and immigrants were more likely to live in low-income
neighborhoods with fewer job opportunities. Residents emphasized the need to give locally
owned businesses incentives to establish in low-income neighborhoods. School districts in
low-income communities of color were often described as substandard. In addition, many of
the survey respondents from the South region indicated that they had experienced
discrimination in their daily lives (Figure 7.21).

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

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

Greater Grand Crossing Robbins
Englewood Phoenix
Riverdale Chicago Heights

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

Health Impact Collaborative of Cook County

South Region CHNA 58

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

The Forces of Change Assessment (FOCA) and Local Public Health System Assessment
(LPHSA) identified that policy and advocacy to address inequities are essential to an
upstream approach to addressing the social determinants of health. The FOCA and LPHSA
discussions also emphasized that communities being affected by inequities should be
involved in leading policy change efforts and that there needs to be changes to state and
local politics in order to achieve the systems changes that are needed to address inequities.
Additional systems level issues identified by focus group participants include treatment for
mental illness and substance use in lieu of incarceration, outreach and advocacy to
veterans and former military, advocacy and support for older adults and caregivers,
advocacy for the rights and fair treatment of immigrants and refugees, and sustainable
funding alternatives for community based organizations.

Health Impacts—Social, economic, and structural determinants of health
As summarized on pages 37-40 of this report, there are many health disparities that relate to
racial inequities and income inequities. These societal inequities have profound effects on life
expectancy. In both Chicago and suburban Cook County, life expectancy varies widely
between communities with high economic opportunities and communities with low
economic opportunities.

In suburban Cook County, average life expectancy is approximately 79.7 years, whereas life
expectancy for residents in Chicago is 77.8 years. Overall in Chicago, life expectancy for
people in areas of high economic hardship is five years lower than those living in
communities with better economic conditions.35 Years of potential life lost is the average
number of years a person might have lived if they had not died prematurely. It can also be
used as an indicator of health disparities. The Chicago community areas and suburban
municipalities in the South region with the highest and lowest life expectancies, natality, and
years of potential life lost by region are presented in Figures 7.22a. – 7.22.c.

35 Healthy Chicago 2.0. (2016).

Health Impact Collaborative of Cook County

South Region CHNA 59

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

Chicago
Life expectancy

(Years)
Suburban Cook

County
Life expectancy

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

Highest life expectancies:

Chicago
Life expectancy

(Years)
Suburban Cook

County
Life expectancy

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

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

7.22b. Natality (Number of deaths of infants less than one-year-old) per 1,000 live births, by
region, 2012

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

Health Impact Collaborative of Cook County

South Region CHNA 60

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

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

Health Impact Collaborative of Cook County

South Region CHNA 61

Key Findings: Mental Health and Substance Use
Overview
This section summarizes needs and issues related to mental health and substance use,
referred to jointly as “behavioral health”. The South region CHNA found that mental health
and substance use are issues that are in need of collaborative action to improve systems
and support better health status and health outcomes in communities. In particular, the
CHNA found that funding and systems are inadequate across the board to support
behavioral health needs in Chicago and Cook County. Stigma and lack of open
conversation about behavioral health are also factors that contribute to community mental
health and substance use issues in youth and adults.

The Forces of Change Assessment (FOCA) and Local Public Health System Assessment
(LPHSA) findings emphasized that current community mental health and substance use issues
are the result of long-standing inadequate funding that has been exacerbated by recent
cuts to social services, healthcare, and public health.

The findings from the FOCA and community focus groups emphasized that behavioral health
is an issue that affects population groups across income levels and race and ethnic groups in
the South region. However, inequities related to the social and structural determinants of
health have profound impacts on who is most impacted by the shortage of facilities and
services. The following groups were identified as being at increased risk to be affected by
cuts to community-based mental health and substance use services and facilities, shortages
of mental and behavioral health professionals, and lack of trauma-informed care:

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

incarcerated individuals
• Individuals with a history of mental

illness and/or substance use

• LGBQIA individuals and transgender
individuals

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

Mental health and substance use were two of the most discussed issues in the FOCA. The
FOCA findings emphasized that social and structural determinants have substantial impacts
on mental health. In particular, the following factors were identified as impacting mental
health in communities: socioeconomic inequities; inadequate healthcare access; lack of
affordable and safe housing; racism, discrimination, and stigma; and lack of safety or
perceived safety, violence, and trauma.

In terms of the connections between trauma and mental health, substantial evidence has
emerged over the past decade that adverse childhood experiences (ACEs) strongly relate
to a wide range of physical and mental health issues throughout a person’s lifespan. ACEs
include physical and emotional abuse and neglect, observing violence against relatives or
friends, substance misuse within the household, mental illness in the household, and forced
separation from a parent or close family member through incarceration or other means.36

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

Health Impact Collaborative of Cook County

South Region CHNA 62

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

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

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

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

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

Figure 8.1. Behavioral Health Continuum of Care Model

Health Impact Collaborative of Cook County

South Region CHNA 63

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

• Self-reported mental health status

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

• Healthcare provider shortage areas for mental health

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

Figure 8.2. Self-reported emotional and mental health indicators
Self-reported emotional and mental health indicators
Suburban Cook

County (2012)
Chicago

(2014)
Illinois
(2013)

United States
(2013)

Percentage of adults that
lack social or emotional
support

34% 44% 20% 23%

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

3.2 3.1 3.3 3.4

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 64

High rates of Emergency Department (ED) visits for mental health and substance use may
indicate a lack of community-based treatment options, services, and facilities.

Figure 8.3. Emergency Department (ED) visits for mental health in Cook County, by zip code
(age-adjusted rate per 10,000)

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

Health Impact Collaborative of Cook County

South Region CHNA 65

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

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

Health Impact Collaborative of Cook County

South Region CHNA 66

Substance use
According to the Substance Abuse and Mental Health Services Administration (SAMHSA),
many factors influence a person’s chance of developing a mental and/or substance use
disorder. From a community health perspective, the “variable risk factors” and substance use
issues are particularly important as potential intervention points for prevention. The variable
risk factors for substance use align with work on the social determinants of health; SAMHSA
identifies income level, employment status, peer groups, and adverse childhood experiences
(ACEs) as key variable risk factors. Protective factors include positive relationships, availability
of community-based resources and activities, and civil rights and anti-hate crime laws and
policies limiting access to substances.

There is a high prevalence of co-morbidity
between mental illness and drug use.39 Figure
8.6 shows the communities in the South
region where high ED visit rates for mental
illness overlap with high ED visit rates for
substance use. Overall, the CHNA findings
point to a number of societal trends related
to mental health and substance use that are
negatively affecting community health and
the local public health system. The lack of
effective substance use prevention, easy
access to alcohol and other drugs, the use of
these substances to self-medicate, and the
criminalization of addiction in lieu of access
to mental health services are seen to have
profound impacts on community health in the South region of the Health Impact
Collaborative and across Chicago and Cook County.

Barriers to accessing mental health and substance use treatment and services include social
stigma, lack of accessible and affordable mental health services due to continued funding
cuts, low reimbursement rates for mental health services, and low salaries for mental health
professionals (all of which have led to provider shortages). Opportunities to address
behavioral health access issues include training first responders and implementing new
community health models. The Community Health status assessment revealed some
geographic disparities in the ED visit rates for heavy drinking and substance use, as shown in
Figures 8.7 and 8.5. Additionally, 9% of Chicago adults report heavy drinking in the past
month, which is substantially higher than the U.S. overall (6%).

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 67

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

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

Substance use among youth in suburban Cook County

Illinois Youth Survey, comparing 2010 and 2014 survey results

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

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 68

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

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

Health Impact Collaborative of Cook County

South Region CHNA 69

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

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

Health Impact Collaborative of Cook County

South Region CHNA 70

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

Figure 8.7. Emergency Department (ED) visits for alcohol abuse in Cook County, by zip code
age-adjusted rate per 10,000)

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

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

Health Impact Collaborative of Cook County

South Region CHNA 71

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

Figure 8.8. Map of mental health professional shortage areas in the South region, 2015

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

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

Health Impact Collaborative of Cook County

South Region CHNA 72

Community input on mental health and substance use
Closing of mental health facilities and discontinuation of services has led to an increased
burden on communities and community-based organizations. Focus groups in the South
region discussed how the lack of mental health services has led to a number of problems,
including increased hospitalization, more expensive care, high incarceration, homelessness,
substance use, suicide, and overburdening of existing programs or facilities.

Community members also emphasized that there is a lack of sensitivity for patients in crisis
and their families in both first responders and medical professionals. Community input
highlighted the need for sensitivity training for healthcare staff to improve their interaction
with both patients and their families.

The stigma related to mental illness was stated to be a major barrier to accessing care for
many residents in the South region. Community members indicated a need for community
outreach to increase mental health awareness and decrease stigma.

Community resident survey – mental health

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 73

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

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

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

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

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

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 74

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

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

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

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

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

CDC’s Four Domains for Chronic Disease
Prevention

1. Epidemiology and surveillance: to

monitor trends and track progress.

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

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

4. Community programs linked to clinical
services

Health Impact Collaborative of Cook County

South Region CHNA 75

Mortality related to chronic disease

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

Figure 9.1. Leading causes of death, Chicago and Cook County

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

Cerebrovascular
Diseases

• Chronic Lower
Respiratory
Diseases

• Accidents

• Heart Disease
• Cancer
• Stroke and

Cerebrovascular
Disease

• Chronic Lower
Respiratory
Diseases

• Accidents

• Heart Disease
• Cancer
• Chronic Lower

Respiratory
Disease

• Stroke and
Cerebrovascular
Diseases

• Accidents

• Heart Disease
• Cancer
• Chronic Lower

Respiratory
Disease

• Accidents
• Stroke and

Cerebrovascular
Diseases

Racial and ethnic disparities in mortality rates persist in the South region of Chicago and
Cook County, as shown in Figures 9.2 and 9.5. And, there are major variations in chronic
disease-related mortality rates across both the Chicago community areas and Cook County
suburbs, as shown in Figure 9.3.

Figure 9.2. Chronic disease-related mortality (per 100,000) for the South region in 2012, by
race and ethnicity

Data Source: Illinois Department of Public Health, 2012

Health Impact Collaborative of Cook County

South Region CHNA 76

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

Heart Disease Mortality Cancer Mortality Stroke Mortality

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 77

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

Figure 9.4. Diabetes-related hospitalization rate (per 10,000) in the South region, 2012-2014

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

Figure 9.5. Diabetes-related mortality in South region, by race and ethnicity (age-adjusted
rates per 100,000), 2012

Data Source: Illinois Department of Public Health, 2012

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

Health Impact Collaborative of Cook County

South Region CHNA 78

Asthma
Figures 9.6 and 9.7 show the geographic distributions of emergency department (ED) visits
due to adult and pediatric asthma. Communities on the South Side of Chicago and South
Cook suburbs have disproportionately high rates of ED visits for asthma. ED visits are indicative
of increased exposure to environmental contaminants that can trigger asthma as well as
poorly managed asthma.

Figure 9.6. Emergency Department (ED) visits in the South region due to adult asthma (age-
adjusted rates per 10,000), 2012-2014

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

Figure 9.7. Emergency Department (ED) visits in the South region due to pediatric asthma
(age-adjusted rates per 10,000), 2012-2014

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

Health Impact Collaborative of Cook County

South Region CHNA 79

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

Figure 9.8. Self-reported behaviors in adults and youth

Self-reported health behaviors, Adults
Suburban

Cook County
(2012)

Chicago
(2014)

Illinois
(2013)

United States
(2013)

Adults Eating LESS than
Five Daily Servings of
Fruits and Vegetables

85% 71% 78% 77%

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

Current Smokers 14% 18% 18% 19%
No Leisure-Time
Physical Activity 26% 29% 25% 25%
Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey

Self-reported health behaviors, Youth
Suburban Cook

County (2012)
Chicago

(2014)
Illinois
(2013)

United States
(2013)

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

No Leisure-Time
Physical Activity 16% 22% 13% 15%
Data Source: Youth Risk Behavior Surveillance System

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 80

Persons living with HIV/AIDS
Because of antiretroviral therapy, individuals with HIV are now living longer lives with better
quality of life. Consistent use of antiretroviral therapy along with regular clinical care slows the
progression of HIV, keeps individuals with HIV healthier, and greatly reduces their risk of
transmitting HIV.45 As the population of Persons Living with HIV/AIDS (PLWHA) grows, it is
important to have systems in place for their continuity of care.46

In suburban Cook County, the number of PLWHAs increased 87% from 2,500 in 2004 to 4,683
in 2013.47 In 2012, there were 22,346 PLWHAs in Chicago, which is a 12% increase from 2005
(19,892 PLWHAs).48,49 The communities with the largest numbers of PLWHA are shown in Figure
9.9.

In addition to geographic disparities in PLWHAs, there are also disparities related to gender,
age, race/ethnicity, and sexual orientation. African American/black men who are young
and have sex with men are most seriously affected by HIV.50 Overall, African
American/blacks have the most severe burden of HIV compared to all other racial and
ethnic groups.50 Additional data on sexually transmitted infections (STIs) is included in
Appendix D.

Figure 9.9. Communities in the South region with the highest percentages of Persons Living
with HIV/AIDS (PLWHA), per 100,000 population

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

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

Crossing
• Hyde Park
• Kenwood

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

Heights
• Washington Park

• West
Englewood

• West Pullman
• Woodlawn

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

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

Health Impact Collaborative of Cook County

South Region CHNA 81

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

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

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

and active living; and
• healthy food access.

Community input on the connections between chronic disease and built environment is
included in the social determinants of health section starting on page 37.

Residents in the South region discussed inequities in access to healthy foods. Focus group
participants reported that many communities in the South region, particularly communities
on the South Side of Chicago have limited access to healthy fresh foods and grocery stores.

Community survey data – Healthy eating and active living

• Food insecurity. Approximately 55% of survey respondents from the South region

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

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

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 82

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

Some specific priority needs related to access that were emphasized in the CHNA findings
are:

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

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

challenge in the post Affordable Care Act environment

Several priority populations were
identified through the community
focus groups and Forces of Change
Assessment (FOCA) as being more
likely to experience inequities in
access to care and community
resources including low income
households, diverse racial and ethnic
groups, immigrants and refugees,
older adults, children and adolescents,
LGBQIA individuals, transgender
individuals, people living with physical
or intellectual disabilities, individuals
living with mental illness, individuals
living in residential facilities, those
currently or formerly incarcerated,
single parents, homeless individuals,
veterans and former military, and
people who are uninsured.

51 Levesque, J.F., Harris, M.F. & Russell, G. (2013). Patient-centered access to health care: conceptualising access
at the interface of health systems and populations. International Journal of Equity in Health, 12(1), 18.

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

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

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

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

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

coordinators
• Racism, discrimination, and stigma based on

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

increases in Latino and Asian populations in the South
region

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

Health Impact Collaborative of Cook County

South Region CHNA 83

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

• competition among healthcare providers;

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

• continuing barriers to providing mental health services;

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

• inequities in the distribution of medical services;

• lack of providers accepting Medicaid;

• funding cuts to social services; and

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

The Community Health Status Assessment data includes multiple factors that influence
access to care including poverty, insurance coverage, self-reported use of preventative
care, hospitalization statistics, provider availability, and use of prenatal care. The connection
between poverty and health is explored in detail in the social determinants of health section
of this report beginning on page 37.

Several communities in the South region have high rates of negative health indicators and
poor health outcomes, which indicates a lack of access to healthcare and community
resources.

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

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

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

• Healthcare workforce pipelines

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

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

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

Health Impact Collaborative of Cook County

South Region CHNA 84

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

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

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

Insurance coverage
Lack of insurance is a major barrier to accessing primary care, specialty care, and other
health services. In the post-Affordable Care Act landscape, the size and makeup of the
uninsured population is shifting rapidly. Aggregated rates from 2009-2013 show that
approximately 23% of the adult population age 18-64 in the South region reported being
uninsured, compared to 18.8% in Illinois and 20.6% in the U.S. Men in Cook County are more
likely to be uninsured (18.2%) compared to women (13.8%). In addition, African Americans,
Latinos, and diverse immigrants are much more likely to be uninsured compared to non-
Hispanic whites. It is estimated that 40% of undocumented immigrants are uninsured
compared to 10% of U.S.-born and naturalized citizens.

High insurance costs and lack of insurance were identified as barriers to accessing
healthcare in multiple focus groups in the South region.

Self-reported use of preventative care
Lack of insurance may impact access to lifesaving cancer screenings, immunizations, and
other preventive care. Routine cancer screenings may help prevent premature death from
cancer and it may reduce cancer morbidity since treatment for earlier-stage cancers is
often less aggressive than treatment for more advanced-stage cancers.52 Overall rates of
self-reported cancer screenings vary greatly across Chicago and suburban Cook County
compared to the rates for Illinois and the U.S. This could represent differences in access to
preventative services or difference in knowledge about the need for preventative
screenings.

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

Health Impact Collaborative of Cook County

South Region CHNA 85

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

County (2012)
Chicago

(2014)
Illinois
(2013)

United States
(2013)

Cervical Cancer
Screening 16% 20% 23% 22%

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

Breast Cancer
Screening 42% 29% 27% 27%
Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey

Vaccination is another important preventive measure. The CDC recommends that all adults
aged 65 or older receive the pneumococcal vaccine. Approximately one-third (30%) of
Chicago residents aged 65 or older reported that they had not received a pneumococcal
vaccination in 2014.

Figure 10.2. Self-reported pneumococcal vaccination among 65+
Self-reported lack of preventive care
Suburban Cook

County (2012)
Chicago
(2014)

Illinois
(2013)

United States
(2013)

Lack of
Pneumococcal
Vaccination
(65+)

N/A 30% 31% 53%

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

Health education about routine preventive care was specifically mentioned in three of the
focus groups as a need in their communities. Parents, youth, and immigrants were identified
as populations that are more likely to not have information about how and where to seek out
preventive services.

Provider availability
A large percentage of adults reported that they do not have at least one person that they
consider to be their personal doctor or healthcare provider. In the U.S., LGBQIA and
transgender youth and adults are less likely to report having a regular place to go for
medical care. Regular visits with a primary care provider improves chronic disease
management and reduces illness and death.53 As a result, it is an important form of
prevention.

53 National Institutes of Health. (2005). Contribution of Primary Care to Health Systems and Health.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/

Health Impact Collaborative of Cook County

South Region CHNA 86

Figure 10.3. Self-reported lack of primary care

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

Figure 10.4. Map of primary care provider shortage areas in the South region, 2015

Data Source: Health Resources and Services Administration, Health Professional Shortage Area Database, 2015

Multiple focus groups in the South region mentioned that continued funding cuts and the
current State budget crisis are further reducing much needed community-based health
resources. Participants stated that individuals with mental illness, individuals living with

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

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

Suburban Cook
County (2012)

Chicago
(2014)

Illinois
(2013)

United States
(2013)

Lack of consistent
source of primary care 13% 19% 12% 23%
Data Source: Behavioral Risk Factor Surveillance System and Healthy Chicago Survey

Health Impact Collaborative of Cook County

South Region CHNA 87

intellectual disabilities, formerly incarcerated individuals, diverse racial and ethnic groups,
and immigrants have the least amount of access to healthcare resources.

Prenatal care
Access to prenatal care is an important preventative measure to reduce the risk of
pregnancy complications, reduce the infant’s risk for complications, reduce the risk for neural
tube defects, and help ensure that the medications women take during pregnancy are
safe.55 Nearly 20% of women in Illinois and suburban Cook County do not receive prenatal
care prior to the third month of pregnancy or receive no prenatal care. (Recent comparable
data for the City of Chicago was not available at the time this report was produced.)

Figure 10.5. Prenatal care
Number of births to mothers with inadequate prenatal care (per 100 live births),
2008-2012

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

18.6 19.0 19.3

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

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

Access to quality home healthcare services was identified as an important need for
individuals and families that choose to age in place. Multiple focus group participants
indicated that oversight of home healthcare agencies, integration of the different home
healthcare services, and standardization of home healthcare training would improve the
quality and safety of the services that are provided.

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

Health Impact Collaborative of Cook County

South Region CHNA 88

Conclusion – Reflections on Collaborative CHNA

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

Leveraging the continued participation of community stakeholders invested in health equity
and wellness, including actively identifying and engaging new partners, will continue to be
essential for developing and deploying aligned strategic plans for community health
improvement in any of the following priority areas:

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

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

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

To be successful, the Health Impact Collaborative will continue to partner with health
departments across Chicago and Cook County to adopt shared and complimentary
strategies and leverage resources to improve efficiencies and increase effectiveness for
overall improvement. Data sharing across the health departments was instrumental in
developing this CHNA and will continue to be an important tool for establishing, measuring
and monitoring outcome objectives. Further, the shared leadership model driving the CHNA
will be essential to continue to balance the voice of all partners in the process including the
hospitals, health department, stakeholders, and community members.

Driven by a shared mission and a set of collective values that have guided the CHNA
process and decision making, the Health Impact Collaborative will work together to develop
implementation plans and collaborative action targeted to achieving the shared vision of
Improved health equity, wellness, and quality of life across Chicago and Cook County.
Engaging in this collaborative CHNA process has developed a solid foundation and opened
the door for many opportunities moving forward. Participating in developmental evaluation,
funded by the Robert Wood Johnson Foundation, is helping to document process strengths

Health Impact Collaborative of Cook County

South Region CHNA 89

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

Health Impact Collaborative of Cook County

South Region CHNA 90

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