In the world of community development, the fact that ZIP code often trumps genetic code in determining a person's overall health has become conventional wisdom. If families live in well-maintained housing, if they're able to buy fresh food at a nearby supermarket, if their children can walk to school in safety, they are more likely to be healthy -- in both body and mind.
But community developers and their funders are grappling with how exactly to gauge the concrete connection between wide-ranging investments in a neighborhood and improvement in the health of the people who live there. Increasingly, they are seeking out hard data to evaluate the success of their work and to drive decision making about future projects.
That kind of measurement poses challenges, say practitioners, which include the subtleties of teasing out cause and effect, and the time required to quantify health outcomes that often take years or even generations to emerge. Yet despite the complexity of this analysis, researchers are using new tools and approaches to collect data which, in turn, are guiding the work of community revitalization.
"You can't draw a straight line from investments in struggling communities to reduced BMI and blood pressure rates," says Amy Gillman, a program director at Local Initiatives Support Corporation, the largest community development nonprofit in the country. "But we can measure changes in a neighborhood's environment and related behavior -- like eating better or getting more exercise or going to the doctor -- which show things are moving in the right direction."
Researchers employ a variety of methods to assess these kinds of changes over time, such as a tool known as a proxy, which puts a dollar value on the social impact of certain investments based on existing research, or health impact studies, that look at possible outcomes from a given development project. With a health impact study, for example, analysts might predict how access to healthy food, physical activity, social capital and many other related factors might be improved in a given housing project as a result of investments.
While these measuring tools don't tell a complete story on their own, they're an important component of identifying the links between community investment and health statistics. "The more resources we put into evaluations, the more confident we can be that we are moving closer to the truth," said Nicholas Freudenberg, a professor of public health at the City University of New York.
Capturing specific, local data presents a particular challenge. "Sometimes the best measures are not readily available at a small enough level," said Paul Mattessich, executive director of the non-profit Wilder Research. A meaningful picture of quality of life comes from city and even neighborhood statistics, he said, but often data are collected only at the state and county level.
Mattessich leads the Metrics for Health Communities Survey, a joint initiative by the Federal Reserve Bank of Minneapolis, Wilder Research and the Robert Wood Johnson Foundation. The results of the survey, sent out to a variety of organizations, including those that work on public health, community development, early childhood development, housing and transportation, will help shape effective strategies going forward.
Chris Walker, director of research and assessment at LISC, has been parsing what local information exists for the organization's Building Sustainable Communities program. For the past seven years, LISC and its partners have been investing steadily in targeted neighborhoods in areas ranging from housing and education to employment and commercial revitalization. The upshot, a new report shows, is markedly reduced poverty and increased income and levels of employment compared to neighborhoods with no such investments. And the higher the investment, the higher the neighborhood's relative performance on jobs and income changes.
LISC has relied primarily on federal data, bolstered with some statistics gathered locally, to get at how its programs are enhancing community wellbeing as part of their impact studies. "Police make available statistics on crime at the neighborhood level," says Walker. "And there can be local information in health areas, such as lead paint exposure and teen pregnancy." But such metrics are often inconsistently recorded, and many more are needed for an accurate portrait of a community's evolution.
In spite of these limits, calculating health outcomes is becoming easier and more refined than in the past, says Julie Willems Van Dijk, deputy director of the County Health Rankings & Roadmaps, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. "We have smarter and better ways of using what's already been collected and also better ways of thinking of ways to collect," said Van Dijk.
A straightforward solution for data collection, for example, is calling cell phones, not only landlines, when conducting surveys and interviews. That's because most Americans, particularly younger ones, use cell phones exclusively. Moreover, the widespread conversion from paper to electronic health records since the passage of the Affordable Care Act will enrich and streamline the gathering and analysis of information, Van Dijk noted.
One challenge of impact assessments of community development policy and health outcomes is that those outcomes often can only be seen over the course of years. "Diabetes, cancer and heart disease take decades to develop," said Freudenberg. "Few agencies have resources to follow people over that period of time."
But some short-term health benefits can be statistically noteworthy. Donald F. Schwarz, who directs a program called Catalyzing Demand for Healthy Places and Practices for the Robert Wood Johnson Foundation, noted that, for example, "We know that if we put people with serious mental illness in stable housing, the use of expensive health services goes down." Another known benefit, explains Schwarz, a former Philadelphia deputy mayor and health commissioner, is how removing asthma triggers by getting rid of allergens and mold in houses almost immediately lowers a community's rate of asthma attacks and ER visits.
Last year, LISC set up a broad-based initiative that includes increasing access to and education about affordable fresh food, nutrition and gardening in four New York City neighborhoods. One end goal of the project, called Communities for Healthy Food NYC, is a formal evaluation of changes in perception and behavior toward healthy food. Using resident surveys and focus groups, observations of local food environments and the initiative's events and activities, along with interviews with stakeholder groups, researchers will capture a before-and-after picture.
The initiative itself employs a slew of strategies that integrate healthy food access at every level, from nutrition education and cooking classes for residents to creating new food venues in vacant or underused commercial or community space.
"From a public health point of view, it's multiple interventions that make a difference," said Freudenberg, who is working as an evaluator for the healthy food initiative. In the battle against smoking, for example, it took education about the health effects of smoking and higher cigarette taxes, alongside growing public disapproval of smoking, to significantly lower rates. LISC hopes that a similarly multi-pronged campaign will eventually change eating habits in the initiative's target neighborhoods and, by extension, physical health and wellbeing.
Teasing out the connection between community development and health will reveal more and more about the symbiosis between economic recovery, health and quality of life. But ultimately, as long as neighborhoods and their residents are flourishing, is it really important to spend a lot of time figuring out what, precisely, helped? For LISC's Amy Gillman, the answer is a resounding "yes." "Now that we know community development is linked to good health, we can work toward that goal with greater intention and purpose."