East North Philadelphia Latino Community Health Needs Assessment

Acknowledgements

Benefactors The Philadelphia Collaborative for Health Equity was launched thanks to the philanthropic contributions to the 2017 Jefferson Gala and a lead contribution from the Lindy Family. We are especially grateful to the Lindy Family for their foresight and generosity. Their seed funding, given in honor of Drs. Zell and Emily Kravinsky, provided crucial infrastructure for P-CHE and established a community catalyst fund that will work directly with target communities to identify needs and advance initiatives at community-serving organizations that will address those needs.

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Author Caleb Dafilou, MPH, Research Fellow, Center for Urban Health, Philadelphia Collaborative for Health Equity

Editor Rickie Brawer, PhD, MPH, MCHES, Co- Director, Center for Urban Health, Thomas Jefferson University Hospital and Assistant Professor, Department of Family and Community Medicine, Jefferson University, Sidney Kimmel Medical College Research Team Jack Ludmir, MD, Executive Vice President for Equity, Executive Director Philadelphia Collaborative for Health Equity, Associate Provost Community Engagement, Enterprise Director Women and Children’s Service Line, Professor Obstetrics & Gynecology

Rickie Brawer, PhD, MPH, MCHES, Co- Director, Center for Urban Health, Thomas Jefferson University Hospital and Assistant Professor, Department of Family and Community Medicine, Jefferson University, Sidney Kimmel Medical College

Caleb Dafilou, MPH, Research Fellow, Center for Urban Health, Philadelphia Collaborative for Health Equity

Abby Cabrera, MPH, Community Benefit Coordinator, Center for Urban Health Susana Suarez, Health Educator, Center for Urban Health Felicia Rinier, MPP, Administrative Director, Philadelphia Collaborative for Health Equity Erin Morton, Associate Director of Corporate and Financial Relations, Office of Institutional Advancement

Maria Florencia Arisi, MD(c), Sidney Kimmel Medical College Martin Hehir, MD(c), Sidney Kimmel Medical College Crystal Lee, MPH, MD(c), Sidney Kimmel Medical College John Mckeegan, MD(c), Sidney Kimmel Medical College Vincent Pepe, MD(c), Sidney Kimmel Medical College Laura Barbour, Intern, Center for Urban Health Abdulai Saccoh, Intern, Center for Urban Health

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Community Benefit Acknowledgement Thank you the key community stakeholders who participated in conversations, interviews, and follow-up meetings to inform the findings of this report. Thank you to organizations who hosted focus groups and PhotoVoice projects, and to the community members who participated:  Ceiba  Casa del Carmen of Catholic Social Services  Esperanza, Inc.  HACE CDC  HUNE  Iglesia del Barrio  Impact Services  Mann Older Adult Center  Providence Center Thank you to community organizations who provided data and reports. Thank you to those who sit on the P-CHE Latino Community Advisory Group.

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Table of Contents Acknowledgements ...... 2 Introduction ...... 6 Methods ...... 7 Background ...... 9 Defining a Geographic Focal Region ...... 9 Demographic Comparison ...... 10 Neighborhood History ...... 13 Social Determinants of Health ...... 15 Education ...... 15 Employment and Financial Health ...... 20 Poverty ...... 22 Social and Political Context ...... 29 Environmental Factors ...... 33 Food Access ...... 33 Housing ...... 38 Environmental Health ...... 41 Built Environment ...... 50 Trauma, Safety, and Violence...... 55 Access to Care ...... 64 Health Status ...... 70 Morbidity and Mortality ...... 70 Mental Health...... 74 Health Behavior and Health Education ...... 83 Priorities ...... 89 References ...... 90

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Introduction Despite being home to some of the nation’s best academic and healthcare centers, Philadelphia is considered the poorest and unhealthiest big city in America. Jefferson is taking a leadership role in changing hat reputation with the launch of the Philadelphia Collaborative for Health Equity (P-CHE). This ambitious new program leverages the power of the collective impact to address health disparities head on, bringing together stakeholders throughout the city to identify the social and economic factors affecting community health. P-CHE is a bold solution to an increasingly complex problem – one that Jefferson cannot attack alone. In Philadelphia, your zip code is a better predictor of health than your genetic code. The life expectancy of a baby born in Center City is more than a 20 years longer than a baby born in North Philadelphia. Home to an extensive art and culture scene, a diverse population of 1.5 million, and the highest concentration of universities and academic medical centers per population – in many ways, Philadelphia has the indicators of a thriving, vibrant city. Yet, it is one of the worst big cities in the nation for poverty and health outcomes. Health and success are inextricable intertwined. Children do better in school when they are nourished. Families can lead more active lives and better connect to communities when neighborhoods are safe. Workers have better attendance and can pursue better opportunities when they can manage their chronic diseases and avoid hospitalization. In short, healthy individuals have the unfettered ability to learn, work and engage in their community and surroundings. At a time when more than a quarter of Philadelphians living in poverty, there is no one-size-fits- all solution to the Philadelphia Challenge. It will take targeted efforts addressing the multiple social determinants of health impacting each Philadelphia community. This report is the first major effort that P-CHE is making in the community. The following pages detail the health and social needs of the Latino Communities living in East North Philadelphia. The resulting priorities from this report will determine the P-CHE’s mission on how best to leverage health as a catalyst to help Philadelphia families in the region reach their full potential.

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Methods The assessment of the Latino Community in East North Philadelphia utilized a mixed methods approach that included analysis of data from the Public Health Management Corporations’ Household Health Survey (2018), key informant interviews, focus groups with community members and a photo documentation assessment (photovoice) involving youth. A Community Advisory Group (CAG) was formed to provide insight and assistance in conducting the assessment components. Specifically, the CAG determined the best approaches to engage community members in the assessment, provided assistance in identifying community stakeholders for interviews, and helped to conduct the youth photovoice project. The methods used are described below. Secondary Data Analysis of the Household Health Survey Data from the 2018 Public Health Management Corporation’s (PHMC) Household Health Survey, a random digit dialed telephone survey, was analyzed by Jefferson’s Center for Urban Health to inform the report using quantitative data. Longitudinal data from multiple years of PHMC’s Household Health survey were analyzed for longitudinal trends. Key stakeholder interviews This report integrates a variety of primary data sources. Key stakeholders (referred to as “stakeholders”) in the target community were identified by the CAG and community partners. Researchers interviewed stakeholders regarding their perceptions of the health needs in the community and to prioritize those needs. Stakeholders were also asked to identify other stakeholders to be interviewed to ensure the list was comprehensive. A total of 27 key stakeholder interviews were conducted. Thematic analysis was conducted by at least two researchers representing Jefferson’s Center for Urban Health Focus groups- adults and older adults Four community partners were each asked to recruit up to 20 participants (referred to as “residents”) for a single focus group session. Two focus groups were conducted with community members over the age of 18 and two focus groups were conducted with community members over the age of 50. Overall, 73 community members participated in focus groups which were conducted in both English and Spanish as needed. During focus group sessions, community members were asked to identify assets and barriers to their health and to prioritize the top health needs. Focus groups were recorded and transcribed. Researchers used thematic analysis to code all focus groups. Each focus group was coded by at least two members of the research team. PhotoVoice projects- youth PhotoVoice is a community-based participatory qualitative research method. It was selected by the CAG as it would be most engaging for youth participants while minimizing the effect of language barriers. Three community partners were each asked to recruit up to 20 participants (referred to as “students”) between the ages of 12 and 18 to conduct PhotoVoice projects. A total

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of 34 participants were recruited across three sites. Each site conducted individual interviews (27 total) and three group sessions. A fourth group session was conducted with participants from all three sites. In the first group session, participants were asked the research question, “What helps and what prevents you from being health in your community?” Participants were provided a brief photography lesson and asked to brainstorm around the research question. They were given one week or more to take up to 10 photos in their community of things related to the research question. Participants were provided a camera upon request. Participants were interviewed individually and asked to discuss their photos and how they related to the research question. These interviews were recorded and transcribed. Researchers used thematic analysis to code the interviews, and each interview was coded by at least two different members of the research team. Each participant was asked to choose three photos they felt were the most important and to write a caption explaining each. Of the 34 total participants, 30 were interviewed. After interviews were completed, each site conducted a second group session where the entire group from each site could view their peers’ photos and captions, and discuss how it may or may not relate to their own experiences. These sessions were recorded and transcribed for our records. In the third group session, participants from each site sorted the previously discussed photos into common themes. They then selected which photos within each of the themes would be in the final photo exhibit. Participants were asked to prioritize the themes and their respective health needs, and to determine how youth can help address those needs. In the fourth group session, participants from all three sites came together and presented their final PhotoVoice exhibits. Participants were asked to integrate the exhibits to produce one final product, and to collectively determine the priority of health needs. The PhotoVoice exhibit can be used by community partners to advocate for the health needs of their community and can be found on the P-CHE website. Prioritization The Community Advisory Group was asked to review the preliminary results from each of these data sources and develop a method for prioritizing identified needs. This was then used by members of the Community Advisory Group to finalize a list of the most important priorities. The final report, presented here, takes into account each of these data sources along with other available secondary data and reports. Details on the prioritization strategy and the final prioritization results can be found in the Priorities section of this report.

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Background An estimated 58.9 million Latinos live in the United States making up 18.1% of the American population. Between July 1, 2015 and July 1, 2016, over 1.1 million Latino’s immigrated to the United States resulting in a 2.0% increase in the overall Latino population. By 2060, 119 million Latinos are projected to be living in the United States and will make up 28.6% of the American population 1. In Philadelphia specifically, the US Census Bureau estimated that the Latino population rose from 12.29% in 2010 to 13.77% in 2016 2,3. Defining a Geographic Focal Region

The geographic region described in this assessment is based on contiguous zip codes in North Philadelphia with the highest Latino population density. As pictured on the map below, the assessment area includes zip codes 19122, 19124, 19133, 19134, and 19140. This region will be referred to as “East North Philadelphia” for the purposes of this report and is pictured in Figure 1.

Figure 1- This map shows the Latino population density by census tract and outlines the 5 zip codes that will act as the focal region for this report 4–6.

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Demographic Comparison

The Latino communities in Philadelphia, and especially East North Philadelphia, are experiencing some of the highest rates of poorer health outcomes and health risk factors. Figure 2a shows these trends in racial/ethnic groups in Philadelphia (left) and East North Philadelphia (right). In particular, this trend is seen most dramatically in the social determinants of health such as education, employment, and poverty 7.

Asthma

Total Population 21.5% 24.4%

Hispanic/Latino 25.9% 28.6%

Black, non-hispanic 23.4% 24.0%

White, non-hispanic 19.7% 20.1%

0.0% 10.0% 20.0% 30.0% 0.0% 10.0% 20.0% 30.0%

Diabetes

Total Population 13.8% 18.1%

Hispanic/Latino 15.6% 22.9%

Black, non-hispanic 17.2% 20.4%

White, non-hispanic 11.5% 10.8%

0.0% 10.0% 20.0% 30.0% 0.0% 10.0% 20.0% 30.0%

Uninsured

Total Population 12.9% 23.0%

Hispanic/Latino 22.0% 24.2%

Black, non-hispanic 13.1% 16.6%

White, non-hispanic 8.6% 12.7%

0.0% 10.0% 20.0% 30.0% 0.0% 10.0% 20.0% 30.0%

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Not seek care due to cost

Total Population 12.1% 14.5%

Hispanic/Latino 12.4% 14.8%

Black, non-hispanic 11.0% 11.0%

White, non-hispanic 13.1% 23.8%

0.0% 10.0% 20.0% 30.0% 0.0% 10.0% 20.0% 30.0%

Diagnosed mental health condition

Total Population 25.4% 34.4%

Hispanic/Latino 35.1% 38.1%

Black, non-hispanic 21.9% 22.5%

39.6% White, non-hispanic 26.2%

0.0% 10.0% 20.0% 30.0% 40.0% 0.0% 10.0% 20.0% 30.0% 40.0%

No access to parks or outdoor space

Total Population 25.5% 46.9%

Hispanic/Latino 34.4% 46.2%

Black, non-hispanic 27.1% 47.0%

White, non-hispanic 18.7% 44.0%

0.0% 15.0% 30.0% 45.0% 0.0% 15.0% 30.0% 45.0%

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No high school diploma or GED

Total Population 8.0% 22.2%

Hispanic/Latino 23.1% 36.2%

Black, non-hispanic 8.1% 13.9%

White, non-hispanic 4.4% 8.5%

0.0% 10.0% 20.0% 30.0% 40.0% 0.0% 10.0% 20.0% 30.0% 40.0%

Unemployment

Total Population 5.8% 6.9%

Hispanic/Latino 7.8% 12.7%

Black, non-hispanic 6.1% 3.1%

White, non-hispanic 4.1% 1.7%

0.0% 5.0% 10.0% 15.0% 0.0% 5.0% 10.0% 15.0%

Poverty

Total Population 24.6% 40.2%

Hispanic/Latino 36.6% 45.5%

Black, non-hispanic 30.5% 35.1%

White, non-hispanic 14.6% 33.4%

0.0% 20.0% 40.0% 60.0% 0.0% 20.0% 40.0% 60.0%

Figure 2a- These charts compare the rates of health outcomes and risk factors of racial/ethnic groups in Philadelphia (right) and East North Philadelphia (left) 7.

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Figure 2b shows that this area is also seeing high rates of disabilities, with most census tracts having a rate above 20%.

Figure 2b- This map shows the rate of disabilities in the target area8.

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Neighborhood History

The target area is focused on the Fairhill, Frankford, Harrowgate, Hunting Park, Juniata Park, Kensington, and Port Richmond neighborhoods 9. The early 19th century launched rapid industrialization of the North Philadelphia region. Throughout the 1800s, factories, warehouses, and workshops supporting the steel, textile, and shipbuilding industries amongst many others began to populate the region. These industries earned Philadelphia, specifically North Philadelphia, the nickname “The Workshop of the World.” This period brought an influx of people, culture, and wealth to the region as people arrived from around the world seeking work. Immigrants came first from Germany and Ireland, and later from Russia, Eastern Europe, and Southern Europe 10. At the turn of the 20th century, North Philadelphia saw a change in community as African Americans from southern states began to migrate to northern industrial centers. The region became a center for Black culture and activism. As white, European communities left the region, North Philadelphia saw increasing segregation in the 1950s and 1960s. Simultaneously, factories began to close causing increased stress on the communities on North Philadelphia neighborhoods. The late 1900s saw continued loss of industry and neglect by private investors, turning the neighborhoods from vibrant communities to those marked by decaying buildings and deserted streets. It was at this time that Puerto Ricans and other Latino demographic groups began to settle in North Philadelphia seeking work. The neighborhoods began to see Latin restaurants, bodegas, and cultural institutions dominate the region. The early 21st century is seeing rapid gentrification pushing north from Center City as wealthier, white culture has developed neighborhoods such as Fishtown and Northern Liberties and continues to push further into North Philadelphia 10. The interrelations of these themes have significant impact on the physical and mental health of the Latino Communities living in North Philadelphia. The communities are still feeling strong influences from the loss of industry and the eclectic and volatile history of a region in constant transition.

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Social Determinants of Health

Education

Education is a crucial protective factor for many health issues. The higher the level of education an individual has, the more likely they are to have better health overall when compared to people with lower education levels 11. Education affects health through economic, health behavior, social-psychological, and healthcare access pathways. Education leads to greater job security in higher quality jobs, which effectively improves financial security and is essential to accessing health services, being able to afford healthy food, and having access to safe and affordable places to be physically active. People with less education are more likely to engage in unhealthy behaviors such as smoking, poor eating habits, and physical inactivity largely due to lack of knowledge about health and inability to access needed health and social resources. Lastly, people with more education have been shown to have higher levels of social support and can better navigate the healthcare system 12.

Education begins in the early stages of development. The first five years from infancy to kindergarten can affect physical, mental, and social wellbeing and a person’s ability to learn. The trauma and poverty that accompanies many at this early age can slow their development 13. High- quality and safe early childhood education is essential to ensuring proper development of young minds. Some stakeholders (n=7) identified a need for quality childcare in the community. Of the 704 Pennsylvania Pre-K programs in Philadelphia County, 96 (14%) are found in East North Philadelphia despite that 18% of the population under age 6 in Philadelphia resides in this region. Only 11 of these programs have received a 3-4 Keystone STARS rating, indicating that there is a lack of high-quality, early childhood education programs in the area. Stakeholders (n=4) also indicated that the lack of affordable childcare acts as a barrier to their own employment, education, and access to healthcare.

Currently, nearly one in two Philadelphia school children start Kindergarten behind their peers and 44% of third-graders are not reading at grade level. Quality pre-K is linked to better health outcomes, increased graduation rates, and higher earning potential and needs to be more convenient and affordable for families. The goal of the Philadelphia pre-K program, funded but the Philadelphia Beverage Tax, is to ensure that all children enter kindergarten ready to learn 14.

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Have High School Diploma or GED 100.0% 90.0% 92.0% 90.0% 77.8% 80.0% 76.9% 67.5% 70.0% 63.8% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% United United Phila Phila LX EN Phila EN Phila LX States States LX

Figure 3- This chart shows the proportion of people living in six different geodemographic regions who have graduated high school or earned a GED7.

The low rates of people with a high school diploma or GED seen in Figure 3 indicate a higher risk for poorer health outcomes among Latinos in East North Philadelphia. The majority of stakeholders (n=15), all focus groups (n=4), and some students (n=6), identified education as a health determinant in the community, specifically concerns about the high dropout rates and the poorer quality of education available. In addition, high schools in East North Philadelphia have almost three times as many English Language Learners as other Philadelphia high schools, which may impact educational outcomes for the Latino community15.

Graduation Rates Under 60% 61%-80% Over 80%

Neighborhood 8 schools 14 schools 1 school Schools (n=23)

Special Admission, and Citywide 0 schools 5 schools 53 schools Schools (n=58)

Table 1- This table compared the number of neighborhood schools versus schools that select their students in Philadelphia by their graduation rates 15.

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A disparity between graduation rates of neighborhood schools and schools that have selection criteria also appears relevant. While special admission and other selective schools help students graduate, students who remain in the neighborhood school system are much less likely to graduate high school as evidenced in Table 1. A stakeholder said, “If I had not gotten into my Charter School, I don’t know where I’d be. The public schools are unsafe and I don’t think I would have graduated.” The school environment was identified as a potential factor in academic achievement by some stakeholders (n=5) who stressed that bullying, violence, and crime in schools can be sources of trauma that impact education. A resident said, “I feel as though our education system is built on the way the prison system is run because instead of having teachers and students, we have teachers, students, security guards, and police officers now.” This demonstrates how schools are perceived as unsafe. On the other hand, some schools are having a positive impact on students, as seen in Photo 1 below.

Photo 1- “This is about the great education system that the school has provided for me with the great teachers who have taught me a lot about being respectful and mature just like my parents. This school has taught me a lot that bring hope for many people in the community because they show and teaches kids to be good people.”

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A stakeholder said, “Schools need to respond, not react. They are currently designed to react to issues kids bring to school. They need to instead respond by preventing trauma in the first place… Resiliency can only occur at a certain level. Under complete hopelessness, resilience cannot push through.” The toxic stress that comes from traumatic events in and out of school prevents children from fully focusing and reaching their full potential in the current educational environment 16. Trauma and stress are further detailed in the Trauma, Safety, and Violence and Mental Health sections of this report. Another concern related to education is the need for parents to act as the first teachers in the home. A resident said, “It is very important that we look for help for young parents, so they can educate their children,” and another said, “Sometimes the problem, concerning children’s education, is that some parents expect that children’s education is given at school, while education comes from home.” Residents identified the busy lives of low-income parents and lack of knowledge around parenting as a barrier to providing children a proper education in and out of school. A resident said, “Parents need to help teach their kids… I think they should make more educational programs, especially for parents…she can’t work, her schedule doesn’t match… they don’t have insurance, they can’t get help.” Having resources to overcome some of these barriers can help parents fill the role of educators in the home.

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Trends in Bachelor's Degree Attainment 35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0% 2010 2011 2012 2013 2014 2015 2016 2017 United States Phila EN Phila

Figure 4- This chart shows the changes in bachelor’s degree attainment from 2010-2017 in the United States, Philadelphia, and East North Philadelphia17. There also appears to be a disparity in higher education between these geographic areas. While Philadelphia has been on a positive trend, nearing the national average of about 30% of people with bachelor’s degrees, East North Philadelphia remains at less than a third of the United States Average as seen in figure 4. The clear disparities in education in East North Philadelphia at each level put the communities at greater risk for poorer health outcomes.

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Employment and Financial Health

Maintaining a job with a living wage makes it easier for people to live in healthier homes, get an education, use childcare services, and purchase more nutritious food 18. As seen in Figure 5, Latinos in East North Philadelphia have the lowest rates of employment when compared to others in East North Philadelphia, or to the rest of the city 7. Most stakeholders (n=18), some students (n=4), and all focus groups (n=4) identified employment as a health problem. Specifically, stakeholders said that there are not enough jobs in the area so people have to commute far for work (n=4), and that many jobs do not pay a living wage (n=4). Many residents in the area work in the service industry 19. Employed Part-time or Full-time 70.0% 58.3% 58.7% 60.0% 50.0% 44.7% 41.5% 40.0% 30.0% 20.0% 10.0% 0.0% Phila PhilaLX EN Phila EN PhilaLX

Figure 5- This chart shows the proportion of people who are employed part-time or full-time in 4 geodemographic regions in 2018 7. Sometimes wages can be so low that it is actually cheaper for people not to work. A stakeholder said, “Why would someone travel far away to earn less money than it costs to put their kid in daycare? And then they don’t qualify for social services anymore.” Residents in focus groups confirmed this saying, “I had to quit my job because I did not have help with childcare…It’s hard. Especially when you don’t have family and no one to help you.” Beyond this, the lack of jobs paying a living wage has repercussions for youth as well. A student said that people often ask why he works when he is so young to which they responded, “…because I want food, I want money.” These barriers prevent people from working and from building skills to improve their job stability. As seen in Figure 6, over the past 20 years, employment in the Latino Communities in East North Philadelphia has remained around 40.0%. The rate in the city of Philadelphia has experienced little change, ranging between 50% and 60% of individuals reporting full or part time employment.

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Employed Full-time or Part-Time (1998- 2018) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 1998 2000 2002 2006 2008 2010 2012 2015 2018 Phila EN PhilaLX

Figure 6- This plot shows how employment rates have changed between 1998 and 2018 in Latino Community in East North Philadelphia and in the city as a whole17.

Most of the Latino-owned businesses in the area are small businesses and non-profit organizations. In regards to Latino small business owners in the area, a stakeholder said, “They are poor and their customers are poor. They operate with small margins, which creates issues with scalability.” Recent research has shown that self-employment likely acts as a risk-factor for poorer health 20. This is among many other factors that have prevented the community from seeing substantial economic growth since the loss of bigger industries in the late 20th century. Some stakeholders (n=5) noted poor financial health as an additional barrier to employment and healthcare. The poverty and deep poverty that has persisted has ruined the credit scores of many residents. A stakeholder said, “People are afraid to go to the emergency room because the bill will ruin their credit.” While this directly affects access to care, a history of poor credit also prevents people from obtaining small business loans, mortgage and home repair loans that can lead to stable employment and healthy, affordable housing, respectively 21.

The city of Philadelphia has initiated a new financial health program as part of the Philadelphia Neighborhood Home Preservation Loan Program to address this issue. Restore, Repair Renew is a new initiative of the City of Philadelphia and Philadelphia Redevelopment Authority (PRA) to help Philadelphia homeowners obtain low-interest loans to invest in their properties. Lenders participating in the program are offering 10-year, 3% interest loans that range from $2,500 to $24,999 to eligible homeowners. Restore, Repair, Renew loans can fund a range of home repairs that focus on health, safety, weatherization, accessibility, and quality of life. The program seeks to help low income Philadelphians improve their homes, make repairs that impact health such as asthma, improve home owners’ ability to remain in their homes, and strengthen communities 22. It is one of several initiatives in Philadelphia designed to improve financial circumstances of low-income individuals and families in an effort to reduce health and economic disparities.

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Poverty

Poverty is at the core of most health inequity. People who experience poverty have to make harsh choices that often result in knowingly putting their health at risk in order to obtain even the most basic needs. Oftentimes, poverty is reinforced by economic and political structures that marginalize groups of vulnerable individuals. These communities tend to experience serious cultural and social barriers that keep them impoverished and unhealthy. In addition, poor living conditions, the perpetuation of stress, and higher rates of trauma among people who experience poverty lead to poorer health outcomes overall 23. As we can see in Figure 7, Philadelphia has a poverty rate twice that of the United States, and the Latino community has some of the highest rates of poverty in the city, particularly the Latino Communities in East North Philadelphia. Figure 8 outlines our target area and shows that many people in this region are experiencing poverty. This puts the community living there at increased risk for poorer health outcomes.

Below 100% Poverty

50.0% 45.5% 45.0% 40.2% 40.0% 36.6% 35.0% 30.0% 24.6% 25.0% 19.4% 20.0% 15.0% 12.7% 10.0% 5.0% 0.0% United States United States Phila Philadelphia EN Phila EN Phila LX LX LX

Figure 7- This chart shows the proportion of people in six different geodemographic regions who live below the poverty line 7,24.

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Figure 8- This map shows how the percent of people who live in poverty by census tract in East North Philadelphia. The blank census tract in zip code 19140 is Hunting Park, and there is no data available for that area 5,6,25,26.

The majority of stakeholders (n=19) identified poverty as a major determinant of health. Namely, in addition to acting as a barrier to education, employment, and access to care, stakeholders (n=6) stressed that people in poverty are being exploited through gentrification and big business which is causing community trauma. A stakeholder said, “People come in, make money, and then they leave. The real estate market is bringing in new people and unfamiliar culture that neglects those already living here.” Some stakeholders (n=5) noted a strong link between poverty and trauma, which also leads to adverse mental and physical health outcomes. This relationship is explored further in the Housing section and the Trauma, Safety, and Violence section of this report.

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Figure 9- This chart shows how the Federal Poverty Line (FPL) is getting further away from the Median Family income. The Federal Poverty Line was established in 1963 based on household income levels and the number of people in the household amongst other factors. Every January, Health and Human Services (HHS) updates the FPL to account for inflation; however, some problems have been identified with the measure. For example, the same FPL is used throughout the continental United States , which does not account for the varying cost of living across the country. Also, Figure 9 shows that the disparity between median family income and the FPL has widened significantly, despite HHS attempting to keep up with inflation 27. The FPL is important because it determines eligibility for entitlement programs such as Social Security, Nutrition Assistance, and Medicaid. People living below 130% FPL qualify for food stamps, and people living below 138% FPL are eligible for Medicaid. Table 2 shows that there is a smaller proportion enrolled in these programs than those living below poverty 7. Since the FPL falls below 50% of the median income, many who do not qualify are likely to remain food insecure, cash poor, and uninsured.

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Entitlement Programs and Poverty in EN Phila <100% FPL Receive SSI Receive SSDI Medicaid Food Stamps Latinos 45.5% 35.6% 14.8% 27.9% 48.2% General Population 40.2% 32.6% 22.1% 28.3% 39.8% Table 2- This table shows the proportion of Latinos compared to all racial/ethnic demographics in East North Philadelphia who live below FPL and those who receive benefits from various entitlement programs 7.

According to the US Census Bureau, the median household income in the United States was $61,372 in 2017 28. Figure 10 shows household income brackets of four different geodemographic groups. It shows that 43% of Latino households in East North Philadelphia have an income of less than $15,000, and 91% have an income under $50,000. In this community, 26.9% of people live in deep poverty, or below 50% FPL 7. Deep poverty has been shown to persist for multiple generations due to extreme barriers to development, health, education, and employment29. This is evidenced by Figure 11, which shows the areas within East North Philadelphia experiencing persistent poverty, defined by at least 20% of the population living in poverty over the past 30 years or more 30.

Household Income Distribution: 2018

100% 5% 12% 12% 4% 90% 26% 6% 80% 14% 70% 41% 17% 28% 60% 32% 50% 25% 19% 7% 40% 16% 30% 15% 43% 20% 35% 26% 10% 17% 0% Phila Phila LX EN Phila EN Phila LX

<$15k $15k-$25k $25k-$50k $50k-$75k >$75k

Figure 10- This chart shows the Household Income Distribution of people in four geodemographic groups. It shows that the Latinos living in the East North Philadelphia have the highest percentage of people in the lowest income bracket, and the lowest percentage in the highest two income brackets 7.

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Figure 11- This map shows census tracts that experience persistent poverty (purple) in East North Philadelphia (orange) 30.

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Poverty affects health through a variety of pathways. First, children in poverty are less likely to get a quality education 31. In the Latino Communities in East North Philadelphia, 32.5% of those in poverty do not have a high school diploma or GED as compared to the 11.2% living above the Federal Poverty Line (FPL) 7. This is also related to employment as only 37.4% of people living below FPL are employed part time or full time compared to the 72.9% living above FPL 7. The relationship between education, employment, and health can be found in the Education section and Employment and Financial Health sections of this report respectively.

Health Condition by Poverty in the Latino Community in EN Phila Fair/Poor Asthma Diabetes Hypertension Mental Health Health Condition Below FPL 59.5% 34.4% 22.3% 34.9% 47.9% Above FPL 20.8% 19.9% 10.8% 26.4% 19.7% Health Condition by Poverty in Philadelphia Fair/Poor Asthma Diabetes Hypertension Mental Health Health Condition Below FPL 43.9% 25.7% 21.2% 44.3% 38.8% Above FPL 18.8% 20.0% 11.6% 30.9% 20.9% Table 3- This table shows the proportion of people who live above and below the Federal Poverty Line (FPL) who rate their health as fair or poor, or who have a specific health condition 7. The link between poverty and health in the Latino Community in East North Philadelphia is clear. Table 3 shows the prevalence of self-reported poor or fair health, asthma, diabetes, hypertension, and mental health conditions among Latinos in East North Philadelphia living above and below FPL. It clearly shows that Latinos living below FPL are experiencing higher rates of chronic conditions and poorer overall health. These conditions are discussed further in the Morbidity and Mortality section of this report.

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Health Behavior by Poverty in the Latino Community in EN Phila Obesity Smoking 1+ SSB/Day Below FPL 42.2% 35.8% 50.5% Above FPL 33.7% 13.9% 28.1% Health Behavior by Poverty in the Philadelphia Obesity Smoking 1+ SSB/Day Below FPL 36.1% 28.0% 42.3% Above FPL 29.4% 14.9% 25.1% Table 4- This table shows the proportion of people who live above and below the Federal Poverty Line (FPL) who engage in unhealthy behaviors 7. Those experiencing poverty are more likely to engage in unhealthy behaviors. There are many theories related to why this is the case. Poverty impacts cognitive development leading to poor health behavior and subsequent poor health outcomes 32. Poor parents are also less likely to believe they can shape their children’s behaviors, so children who experience poverty, living below the 100% FPL, are less likely to learn and develop healthy behaviors. This may create poor habits at a young age that can then persist through adulthood 31. Poverty has a relationship with health behavior among Latinos in East North Philadelphia. Table 4 compares rates of obesity, smoking, and sugar sweetened beverage (SSB) consumption of Latinos in East North Philadelphia and all demographics in Philadelphia as a whole, and between those who live above and below FPL. Those experiencing poverty are more likely to be obese, to smoke, and to consume one or more SSBs per day for both Latinos in East North Philadelphia and the entire city. Health behavior is discussed further in the Health Behavior and Health Education section of this report.

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Social and Political Context

The way society and politics influences people in their daily lives can create barriers to living a healthy lifestyle, accessing healthcare, and achieving a person’s full potential. Many stakeholders (n=12), some students (n=9), and all focus groups (n=4) discussed how politics can affect health. These discussions included how city, state, and federal policies, and the enforcement of those policies, can affect the condition of the built environment, affordable housing and development, access to mental and physical healthcare, and the ability to build businesses. For example, New York City has a Mandatory Inclusionary Housing policy that requires developers to include a certain amount of low-income housing. Developers may earn a bonus for providing more gross floor space 33. On the other hand, Philadelphia has the Mixed Income Housing Bonus where developers may earn a bonus for providing a certain amount of low-income housing. Unlike in New York, developers in Philadelphia can exclude low-income families from development, potentially displacing them from a developing neighborhood, as the Zoning Code includes criteria for a payment to the Philadelphia Housing Trust fund in lieu of providing the affordable units34. Stakeholders (n=3) identified a lack of Latino representation in government. One stakeholder said, “Latinos don’t have visibility like other demographics,” and another said, “Other communities have been able to build bigger voices for themselves and get attention.” An article reported that Latinos make up almost 20% of the United States population, but only 1% of all elected and appointed officials in the country are Latino 35. This is no different in Philadelphia. While stakeholders identified City Councilwoman Maria D. Quiñones-Sánchez as an outspoken Latina voice in government, there is still underrepresentation. A stakeholder said, “Councilwoman Sánchez is good, but she is only one person.” Underrepresentation of Latinos may contribute to feelings of neglect and may influence advocacy and policy efforts that impact this community. For example, many students and residents in the community discussed feeling neglected by the government in some way. One student said, “North Philly is actually part of the city – part of the state. There are citizens who live here. We vote, we pay our taxes. Like why not the government take care of the streets?” Similarly, a resident said, “We feel like we’re being used, and there’s a lot of folks, organizations and political folks saying ‘Oh we have to help them.’ I’ve heard it all… but then they get grant money and they just leave.” This perception of neglect and lack of commitment to the community can foster distrust in the government and organizations resulting in reduced engagement of residents in new initiatives and programming.

In particular, immigrants and migrants are affected greatly by the political climate. Several stakeholders (n=10) noted that immigrants are at a greater risk of poorer health. While most of East North Philadelphia is Puerto Rican and therefore United States citizens, they still feel the effects of immigration policy. A stakeholder said, “Racial tension is universal. People see their friends and neighbors being raided by ICE. The trauma is there regardless of whether they are at risk… People are afraid ICE will come after them, regardless of whether they are a citizen or not.” The effects of immigration issues can be traumatic. A stakeholder said,

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“Behaviorists see upsurges in anxiety when immigration issues come up on the news.” These immigrant populations may also have experienced trauma due to national disasters or fleeing a crisis. Trauma and mental health are further detailed in the Trauma, Safety, and Violence section and the Mental Health section of this report. In addition to tension around immigration policy, immigrants and migrants experience many of the same access, social, and environmental issues as the Latino citizens in the community, but with exacerbated issues. About 30% of immigrants in Philadelphia do not speak English, which creates greater language barriers in accessing healthcare and social services 36. In addition, unauthorized immigrants are uninsurable, which further prevents access to timely care 37. A stakeholder said, “People wait a long time to get care. Even small things like bronchitis can turn into something bigger, and then those illnesses spread to others.” In regards to their own transition, another student said, “It affects me because of the language, not knowing people or places… you have to look for a job, home, and school.” Immigrants can also see barriers to employment as seen in Photo 2. Beyond not having documentation, a student said, “If you don’t speak English in the country, you don’t get the job.” This demonstrates the everyday struggles that immigrants experience to clothe, feed, and house their family.

Photo 2- “I met this guy from Uruguay. His wife is working two jobs and he is doing what he can to make money without papers: selling metal to the junkyard. How is he and his family going to survive?”

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Another stakeholder said, “A lot of people in the community are undocumented and they do not come to things out of fear. Trust acts as a huge barrier in working with this population.” Fear and trust issues among immigrants can prevent or complicate access to the resources they need. Other cultural issues come in to play while people are transitioning into their new lives in Philadelphia. Stakeholders said, “Immigrants are not used to processed foods. Food available at food pantries are often not culturally appropriate.” This shows how cultural differences can adversely affect food access, especially among immigrant and migrant communities. Another stakeholder said, “There are very limited housing resources for undocumented immigrants.” While transitioning into a new city is already challenging, undocumented immigrants experience even more barriers to resources, access to care, and living a healthy lifestyle. An issue that intersects practically every topic covered in this report are structural, societal issues. Several stakeholders (n=9), focus groups (n=3), and students (n=7), identified classism and racism as a barrier to healthcare in the Latino communities. As a stakeholder said, “It is a multigenerational cycle – poor living environment, lower education, and low income all leads to poorer health.” Structural or systemic racism is not about individual prejudice or bias, but instead about a socio-political system that creates barriers to socioeconomic mobility for people of color. According to the 2010 census, the median net worth for a white family was $134,000 while the median net worth for a Latino family was $14,000. The median wealth for a single white woman was $41,000 while for a single Latina woman it was $140. A study showed that applying to a job with a “white-sounding” name made it 50% more likely to get a callback for an interview 38. The long-term ingraining of prejudice ideologies into American society throughout history has fostered a less conscious variant of segregation. For example, systemic racism and classism are further perpetuated by the entertainment, media, and film industries as they often cast minorities as criminals39. A student said, “People see things on the TV, there’s a lot on the news, they stereotype all around…like sometimes they believe everybody of that race or ethnicity are that type.” When there is already limited representation of people of color in the media, and most of that representation portrays violence, crime, and poverty, it reinforces people’s perceptions of other races. Another student says, “I grew up with Clifford The Big Red Dog. They live in the suburbs and we don’t live in the suburbs… it really affected me specifically because I wanted to be able to feel that type of connection with the cartoons and movies.” Essentially, while some media reinforces people’s perception of race, the lack of positive representation of people of color prevents the youth from connecting to content in a world strongly influenced by the media. A resident explains that this sends the message, “Why should we try? Why should we dream? Our kids are not going to amount to anything.” In this fashion, the media underpins the systemic racism that reduces opportunity for people of color to see vertical socioeconomic mobility40. Essentially, people of color, including Latinos, are placed at a disadvantage from birth. People in Latino communities are more likely to live in poverty, have a lower educational attainment, and be unemployed. This results in multiple generations of people experiencing the same or similar barriers and effectively keeping people of color from reaching their full

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potential. A stakeholder said, “Health and education are so far out of reach due to where power lies in the community with institutional racism.” While these systemic issues are difficult to address, they are at the core of health inequities. Another stakeholder said, “The people with power are outside of the community, but the work needs to be done from the inside.” In order to make systemic changes, people whose voices and experiences have not had ample consideration in interpersonal interactions, communities, organizations, and policies need to be incorporated at each of these levels.

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Environmental Factors Environmental factors are also considered social determinants of health, but given the complexity of the environment’s effect on health, and the importance the community placed on the environment during the assessment process, they have been organized as a separate section.

Food Access

Food insecurity is a complex issue that overlaps with other factors such as physical health, poverty, education, employment, and housing. In 2017, about 1 in 8 Americans were food insecure 41. Food insecurity can lead to poor diet and nutrition resulting in higher rates of obesity and subsequent chronic health conditions, such as asthma, heart disease, diabetes, and many cancers 42. When asked about food security, most stakeholders (n=20), all focus groups (n=4), and several students (n=14), identified it as a problem for Latinos living in East North Philadelphia. Many stakeholders (n=13), identified limited access to food as an issue, calling large portions of East North Philadelphia food deserts. This region has the highest proportion of people reporting that it is difficult or very difficult to find fruit when compared to the rest of the city. However, as seen in figure 12, Latinos were much less likely to report lack of access to fruits.

Difficult or Very Difficult to Find Fruit 16.0%

14.0% 2.5% 12.0%

10.0% 0.2% 0.0% 8.0% 2.9%

6.0% 12.2%

4.0% 8.4% 8.9% 7.0% 2.0%

0.0% Phila Phila LX EN Phila EN Phila LX Difficult Very Difficult

Figure 12- This chart shows the proportion of people who found it difficult or very difficult to find fruit in four different geodemographic groups 7.

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Figure 13- This map depicts food walkability in East North Philadelphia and the supermarkets and corner stores found in the five zip codes.

The map in Figure 13 shows that some areas in East North Philadelphia have poor or moderate walking access to healthy foods. Research shows that low-income communities of color are at the highest risk of being food insecure in the United States 43. Physical access to supermarkets are not the only reason why people are food insecure in East North Philadelphia. Stakeholders also identified high costs of food (n=7) and poor quality of food (n=6) as barriers to accessing healthy foods. A stakeholder said, “There’s a supermarket, but if people had the choice, I don’t think they would be going there. The food is so expensive and it goes bad in a couple of days.” Furthermore, a student said, “The places that are really nice that have the products I’m looking for are really far away. For me to be able to get fresh food instead of junk food, I’d have to go somewhere far like Center City.” The lack of access to affordable, high- quality food drives many to poorer food options such as fast food seen in Photo 3. A student said, “If I have five bucks in my pocket, am I going to stay hungry or am I going to buy fast food?”

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Photo 3- “Fast food is not healthy for the environment and communities. This is not healthy for any of us. Fast food and fast food, over and over again is not right.”

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Cut meal due to lack of money 30.0% 24.6% 24.7% 25.0% 22.2%

20.0% 18.8%

15.0%

10.0%

5.0%

0.0% Phila Phila LX EN Phila EN Phila LX

Figure 14- This chart shows the proportion of people who have cut a meal due to lack of money in four different geodemographic groups 7. Figure 14 shows that Latinos, and specifically Latinos in East North Philadelphia, are the most likely to cut a meal due to the lack of money 7. On the other hand, Figure 15 shows that while Latinos in East North Philadelphia are using food stamps, very few are receiving benefits from WIC. Knowing that 46.8% of Latinos in East North Philadelphia live in poverty, as described in the Poverty section of this report, people may be underutilizing food assistance programs. A student said, “One time we ran out of food, we went to a food bank and they gave us food. But we had a family that we knew that didn’t know what was a food bank. They didn’t even know that they give out food.” Lack of awareness around food assistance programs may act as a barrier to families. This is particularly troublesome since there are 27% more children under the age of 5 in East North Philadelphia than in the entire city 19.

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Households Receiving Households Receiving Food Stamps WIC 60.0% 8.0% 50.2% 7.1% 50.0% 5.7% 38.1% 6.0% 40.0% 35.0% 4.6% 4.0% 30.0% 23.2% 2.7% 20.0% 2.0% 10.0% 0.0% 0.0% Phila Phila LX EN Phila EN Phila Phila Phila LX EN Phila EN Phila LX LX

Figure 15- These charts show the proportion of households in four different geodemographic groups that receive (A) Food Stamps, and (B) WIC 7.

Stakeholders also made a point of identifying lack of access to culturally appropriate foods (n=8) in the area. About 72% of Latinos in Philadelphia are Puerto Rican 44. The Puerto Rican diet consists of fresh tropical fruits, corn, and seafood from the original creole culture, mixed with Spanish influences such as beef, pork, rice, and olive oil 45. A stakeholder said, “Most people are from Puerto Rico, Honduras, or the Dominican Republic. Each group shops differently and it usually is not what is found in stores,” while a resident said, “When we come here we adapt to the United States system of eating hamburgers, soda, hot dogs and those things, and that makes us develop certain diseases because of nutrition.” The lack of access to culturally appropriate food not only leaves people at a loss for cooking, but it also prevents them from engaging in nutrition education. The section in this report on Health Behavior and Health Education establishes a need for better education around diet, nutrition, and cooking. A stakeholder said, “Non-culturally competent food education classes are ineffective. People continue to eat the foods they are used to because they are not familiar with and do not like those being recommended.” In order to improve healthy eating, there is a need to improve access to high quality, culturally competent, and affordable foods and access to culturally competent nutrition and cooking classes.

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Housing

There is a large, growing pool of evidence demonstrating that housing has major effects on health. To be healthy, housing needs to be stable, safe, high quality, and affordable 46. People who face housing instability are more likely to experience poorer health when compared to those who live in stable housing. Unstable housing also puts youth at greater risk for teen pregnancy, early drug use, and depression 47. Housing instability has adverse affects on physical health, mental health, health behavior, and the built environment 48.

Rent or Own Home

60.0% 55.3% 53.9% 49.3% 51.3% 50.0% 46.7%

40.0% 35.3% 37.4% 36.0%

30.0%

20.0%

10.0%

0.0% Phila Phila LX EN Phila EN Phila LX Rent Home Own Home

Figure 16- This chart shows the proportion of people in four geodemographic regions who rent their homes versus the proportion of those who own their home 49. Housing stability is closely related to affordability. Spending more than 30% of your income on housing puts a heavy cost burden on the household 46. The majority of stakeholders (n=19), all focus groups (n=4), and many students (n=13), identified the lack of healthy, affordable housing in the area as a major concern for health. As seen in Figure 16, Latino communities in Philadelphia and East North Philadelphia tend to be more likely to rent their home. Figure 17 shows that renting a home comes with a higher cost burden than owning a home. Figure 18 shows that each year, less people in Philadelphia own their homes, and home ownership appears to be decreasing at a faster rate amongst Latinos living in East North Philadelphia. Regardless, over 50% of renters in North Philadelphia are cost burdened and over 30% of homeowners are cost burdened 50. A resident said, “A lot of people need help for the rent and bills.” This excessive cost burden in general, and specifically that comes with renting a home, prevents people from buying healthy food and accessing medical care, while contributing to additional stress 51.

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Figure 17- This map compares the cost burden of owning and renting a home by census tract 5,6,25,52,53. People who own their homes (1998-2018) 70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0% 1998 2000 2002 2004 2008 2010 2012 2015 2018 Phila EN PhilaLX

Figure 18- This plot show the proportion of people who own their home in Philadelphia compared to Latinos in East North Philadelphia from 1998-201817.

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Poor housing quality has been shown to be a major risk factor for many health outcomes as well 54. Pests, mold, structural issues, indoor air quality, and lead are all associated with chronic disease. They act as asthma triggers, and studies have shown that removing or improving 55 these in a child’s home can reduce the risk and severity of asthma . Stakeholders discussed low- quality housing (n=7) and specifically the presence of pests (n=3) as risk factors for health in the area. Figure 19 demonstrates that housing quality is much worse in renter-occupied homes. Since Latinos in East North Philadelphia are more likely to rent their homes than own their homes and quality of rented homes is more likely to be lower, housing is likely having adverse effects on the health of Latinos in this area.

Figure 19- This map compares the cost burden of owning and renting a home by census tract 5,6,25,56,57. People who experience chronic homelessness are at higher risk for poorer mental health, physical health, and premature death 47,58. In 2018, there were over 16,500 people experiencing homelessness in Philadelphia of which 8.2% were Latino 59. However, a phenomenon called the Latino Homeless Paradox shows that due to language barriers and a lack of available beds in their neighborhoods Latinos are much more likely to find alternative forms of housing before going to a shelter. These alternative situations are often dangerous or overcrowded. A student said, “We live in communities of Latinos…I feel in houses there’s more—there’s more than ten people.” The reduced proportion of Latinos using shelters prevents them from accessing housing programs that reach many people through shelters. In addition, it likely results in undercounting the number of truly homeless Latinos in Philadelphia and conceals the severity of the housing crisis in Latino communities 60.

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Environmental Health

Exposure to toxins found in the soil, water, and air can have a direct impact on a person’s health, while also reducing the value of nature in a community 61. Air quality can have adverse effects on many chronic health conditions, especially asthma. A resident said, “Another important problem in this community is asthma... It is because of the high level of pollution that exists. The contamination that exists everywhere is too important. The trash, the trucks, all of that,” while a student explained, “I went camping in the middle of the woods, I didn’t have an asthma attack, not once the whole week… I came back to Philly and asthma came back.” Figure 20 shows that Air Quality has been improving in Philadelphia, with less unhealthy days, and more moderate and good days.

Air Quality Index Days (1990-2014) 365

315

265

215

165

115

65

15

-35 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Good Moderate Unhealthy

Figure 20- This chart shows the number of good, moderate, and unhealthy Air Quality days in Philadelphia County between 1990 and 2014 62. Research has found that excess heat can exacerbate symptoms of respiratory conditions and increase mortality rates in the days following excessive heat. Less green space and more blacktop and concrete areas are associated with higher heat indexes 63. Figure 21 shows that East North Philadelphia has some of the highest heat indexes of the regions in Philadelphia 64. This puts people at a greater risk for poorer health and higher mortality rates.

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Figure 21- This map shows the heat index by block in Philadelphia County 64.

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Another source of poor air quality is particulate matter. Particulate matter refers to any small particle less than 10 micrometers in diameter (PM10) and less than 2.5 micrometers (PM2.5). Particulate Matter is associated with premature death for people with heart or lung disease, nonfatal heart attacks, irregular heartbeat, asthma, decreased lung function, and increased respiratory symptoms 65. Figure 22 shows the rates of particulate matter that is less than 2.5 micrometers in diameter over the last week of March 2019 measured by the Air Quality Index (AQI). The readings on monitors in Fairhill, Port Richmond, and Frankford tend to spark much higher, reaching as high as 164 AQI, than the monitors in Center City, reaching a max of 88 AQI. The 100 AQI boundary (orange zone) marks where sensitive groups, such as people with respiratory or cardiopulmonary conditions, may experience respiratory systems. The 150 AQI boundary (red zone), is when people in non-sensitive groups may experience symptoms as well 66. A B

C D

Figure 22- These plots show the PM2.5 AQI scores in the last week of March 2019 for air monitors in (A) Frankford, (B) Fairhill, (C) Port Richmond, and (D) Center City 67.

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Another contributor to environmental contamination is construction. Particulate matter, volatile organic compounds (VOCs), asbestos, carbon monoxide, carbon dioxide, and nitrogen oxides are common air pollutants, while VOCs, paints, glues, diesel, cement, lead, and oil can pollute groundwater. All of these may also pollute the soil and each of these toxins, with high enough exposure, can have adverse effects on people68. Figure 23 shows the increase in constructions and demolitions in the Kensington neighborhood between 2006 and 2016 69. In addition to increasing exposure to any of the listed pollutants, these increased levels of construction also increase noise pollution, which has been shown to increase both stress levels and blood pressure 68,70. These are discussed further in the Mental Health and Morbidity and Mortality sections of this report, respectively.

Figure 23- These maps show the number of construction and demolition permits in the Kensington Neighborhood in (A) 2006, and (B) 2016 69.

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Figure 24- This map shows former smelters and lead levels in the soil at various sites in Kensington and Port Richmond 69. In addition to current construction, some stakeholders (n=4) discussed soil contamination when industries left and abandoned their sites in the late 20th century. Figure 24 shows former sites of smelting in the Kensington and Port Richmond neighborhoods and nearby sites where the lead levels in the soil were tested 69. Areas near former smelting sites appear to show higher levels of lead in the soil than others. Looking at the rest of East North Philadelphia, Figure 25 shows a high density of former smelting sites along with the majority of the Environmental Protection Agency’s (EPA) active and archived sites in the city 69. The increased lead in soil around former smelting sites, and the high number of active EPA sites in East North Philadelphia put people at a higher risk for exposure to chemical toxins and reduces their ability to utilize outdoor spaces.

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Figure 25- This map shows where former smelting sites, active EPA sites, and archived EPA sited in Philadelphia County 69.

While lead exposure can be harmful to everyone, children are at the highest risk as even low levels of lead in blood have shown to affect IQ, ability to pay attention, and academic achievement. Blood lead levels of greater than 5 ug/dL are considered elevated, and those greater than 10 ug/dL are considered dangerous 71. Figure 26 shows higher proportions of children with elevated blood lead levels compared to those in Center City, but lower proportions when compared to West North Philadelphia in neighborhoods like Strawberry Mansion 72. The Philadelphia Water Department reports that they provide water to homes that is above the minimum EPA standards, so any lead contamination in water has to do with the pipes in people’s 73 homes .

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Figure 26- This map shows the proportion of children with high blood lead levels (at or above 5 ug/dL) in Philadelphia County 72.

Figure 27- This map shows the locations of Brownfield sites in East North Philadelphia 74.

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East North Philadelphia is also home to a number of Brownfield sites and a Superfund site. Brownfields are properties that cannot be used, developed, or expanded due to the presence of contaminants as designated by the EPA. There are an estimated 450,000 brownfields in the United States 75. The Brownfields in East North Philadelphia were caused by contamination of the Frankford Creek by Industries in the 19th and 20th centuries. The creek was a navigable channel between Frankford Avenue and the Delaware River, with over 30 factories sitting along the creek at the peak of the textile industry. These factories used the creek as a sewer and the city eventually converted many of its tributaries to underground pipes. As industries left, the contamination of those abandoned factories and the surrounding soil prevents development of these sites. Figure 27 shows the location of Brownfield sites in East North Philadelphia. The contamination of these sites puts the community at risk for exposure and prevents these spaces from being used by the public 74. Superfund sites are some of the nation’s most contaminated land. The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) in 1980, nicknamed Superfund, allows the EPA to clean up or fund cleanups of heavily contaminated sites 76. The 3- acre Franklin Slag Pile sits on the northeast side of the 19134 zip code and contains 68,000 cubic yards of slag, a byproduct of copper smelting. Slag from the Franklin Smelting and Refining Corporation, which operated in the latter half of the 20th century, drifted off the site in all directions. The slag contains leachable concentrations of lead and the air near the pile contains beryllium, copper, and lead. Investigations on how to clean up the site started in the early 2000s and are ongoing 77. However, like the brownfield sites, the air, soil, and water contamination increases risk of exposure to residents in the community, while preventing any productive use of this space. Community residents identified an increase in green space as a potential solution to issues in air quality, and mental health, as seen in Photo 4. A student said, “We don’t have air quality. In the summer, you don’t have shades because there are no trees. You have to basically put yourself in a building… by planting trees, and creating beautiful spaces, people can come outside, they can relate a little more, instead of being inside all the time.” The opportunity to socialize and improve air quality can create great opportunities to foster community wellness.

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Photo 4- “While it may be nothing new for some people, growing up in Kensington trees like this are rare. It has been around for as long as I can remember. Its branches reaching for the sky while giving us fresh air. While it is a weed tree, we need more trees like this one around, tall and towering above us, giving us health and fresh air.”

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Built Environment

The built environment has a significant influence on both the mental and physical health of the people who live and work in our neighborhoods and communities. Most stakeholders (n=18), all focus groups (n=4), and all students (n=27), identified the condition of the built environment as a major concern. Access to more green spaces has shown to be associated with improved health of residents through improved social support, physical activity, and mental health status 78. Figure 28 shows that people in East North Philadelphia are the less likely to have a park or outdoor space that they are comfortable visiting compared to residents of Philadelphia. Many stakeholders (n=11) identified the appearance of the community as a contributor to poorer mental and physical health, specifically the lack of safe green spaces (n=6). One stakeholder said, “I have never been to McPherson Park without witnessing multiple overdoses at a time.” Another said, “Hunting Park is getting better and it is a good asset, but it is still not safe at night.” In addition stakeholders (n=6) identified how high levels of trash and graffiti lining the streets also contributes to poorer health and perceived safety. In Philadelphia, and specifically East North Philadelphia, community residents clearly perceive and are concerned about the impact of the built environment on health and safety in their community and opportunities for socialization. This is explored further in the Trauma, Safety, and Violence section of this report.

Have a park or outdoor space in the neighborhood and comfortable visiting 80.0% 74.5% 70.0% 65.6%

60.0% 53.1% 53.8% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Phila Phila LX EN Phila EN Phila LX

Figure 28- This chart shows the proportion of people who have a park or outdoor space in their neighborhood that they are comfortable visiting 7.

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A few stakeholders (n=3) specifically mentioned high rates of short dumping, or illegal disposal of trash. Figure 29 shows that North Philadelphia is a hot spot for illegal dumping. While stakeholders noted that community residents and people from outside the neighborhoods are both responsible for short dumping, one said, “Illegal dumping does not happen in Center City because people wouldn’t get away with it… This is because impoverished communities of color are ignored. It goes to show how classism, racism, and systematic issues are the base of the problem. Health issues are merely symptoms of these systematic problems.” Racism, classism, and systematic issues are further discussed in the Social and Political Context section of this report.

Figure 29- This map shows areas that are considered hot sports for illegal dumping 79.

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Trash in the community has shown to have a significant impact on mental health. A recent study in Philadelphia found that cleaning lots showed a significant improvement in self- reported mental health status among community residents living nearby 80. Trash was a major concern among the community as seen in Photo 5. A student explains, “It doesn’t feel good because it doesn’t feel clean… It isn’t something you feel good about seeing every day as you walk down the street,” The lack of trash cans along the streets and the infrequency of trash collection was identified by residents as a barrier to maintaining a clean community. A student said, “I want more trash cans on each corner of the block, or at least if that’s too many to put, the most is three blocks away… I can walk six blocks without seeing a trash can,” while a residents said, “There are many communities where the city cleans, and there are others where the city does not go.” In Fall 2017, Philadelphia City Council increased the fine for first time offenders of short-dumping from $300 to $1,000 81. City council is considering raising these fines even more 82. However, stakeholders see the greatest problem as enforcement of these laws and fines, saying “No one does anything about it up here.”

Photo 5- “I see this going to work every day. Would you like to see this?”

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Figure 30- This map shows areas that are non-gentrifiable, non-gentrifyng, and the loss or gain of low-income housing in areas that are gentrifying 83.

Another major concern in East North Philadelphia is gentrification. Stakeholders (n=10) identified gentrification as a concern for people’s health and well-being in the community. Gentrification is the arrival of a wealthier, often white community that develops the area. Gentrification is defined as the transformation of neighborhoods from low value to high value, but there are some central characteristics that define gentrification 84. First is the displacement of the existing communities from the region due to shifts in racial and ethnic composition and household income. As one stakeholder shared, “Developers are usually exploitative and buy houses for less than their value. If you have lived in the community for a long time and have a house that needs work and you get what is perceived to be a good offer, people sell and move up North.” Figure 30 shows that gentrification is moving out from center city, and the portion moving north is reducing the number of affordable housing units in neighborhoods 83.

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People also see an arrival of a dominant culture that appears to take over as minority communities are displaced and new businesses flourish 85. A stakeholder articulated that, “Philly suffers from what makes it great. It used to be a city of neighborhoods built on blue collar people, but then white flight happened and the city changed.” Another stakeholder stated, “Development is good, but it has to be inclusive of the communities who have been living here for many years.” The displacement of vulnerable communities reduces access to affordable healthy housing, healthy food choices, quality schools, and social networks. Reduced access to these resources has a clear negative influence on health 84. Essentially, while the physical location is improving, the people who lived there are forced to move because they can no longer afford the rising cost of living. A student explained, “They are doing gentrification. They’re hopeless, they don’t want to leave, because this is all they know. But this is the only opportunity for them to sell and leave, because they don’t want to see no more trash… we have to train them, give them homes, make sure their self-esteem and everything gets back up by providing resources for them, and then I’m pretty sure everybody would start to stay.” This student suggests that instead of developing the area in a way that displaces the residents, creating affordable housing, supporting efforts to address the social determinants of health, and empowering residents can secure people in their community as the neighborhood sees progress. The United States Environmental Protection Agency defines the term “equitable development” as, “an approach for meeting the needs of underserved communities through policies and programs that reduce disparities while fostering places that are healthy and vibrant.” Focus group discussions and interviews with stakeholders shared that the concepts of equitable development are being applied in North Philadelphia, as a resident explains, “We are not profiting from it [gentrification] at all. We are not gaining anything. But we are still here.” More and more communities are recognizing equitable development as an effective method of strengthening and increasing livability of communities86.

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Trauma, Safety, and Violence

Safety is crucial to the stability of numerous health determinants including the built environment, education, and food security, all of which affect physical health and mental health. The majority of stakeholders (n=22) identified safety as a concern in the community. An unsafe and violent environment can cause serious trauma, especially among children 87. Table 5 displays the 12 types of trauma and their definitions.

Trauma Type Definition A deliberate and unsolicited action that occurs with the intent of Bullying inflicting social, emotional, physical, and/or psychological harm to someone who often is perceived as being less powerful. Community Exposure to intentional acts of interpersonal violence committed in Violence public areas by individuals who are not intimately related to the victim. Both children’s exposure to multiple traumatic events—often of an Complex invasive, interpersonal nature—and the wide-ranging, long-term effects Trauma of this exposure. Natural disasters include hurricanes, earthquakes, tornadoes, wildfires, Disasters tsunamis, and floods, as well as extreme weather events such as blizzards, droughts, extreme heat, and wind storms. Intimate Partner Violence (IPV), also referred to as domestic violence, Domestic occurs when an individual purposely causes harm or threatens the risk Violence of harm to any past or current partner or spouse. Early Childhood The traumatic experiences that occur to children. Trauma A set of psychological and physiological responses of children and Medical Trauma their families to single or multiple medical events. When a parent or caregiver commits an act that results in physical Physical Abuse injury to a child or adolescent. Many refugees, especially children, have experienced trauma related to Refugee Trauma war or persecution that may affect their mental and physical health long after the events have occurred. Sexual Abuse Any interaction where a non-consenting party is used for the sexual and Assault stimulation of the perpetrator or an observer. Families and children may be profoundly affected by mass violence, Terrorism and acts of terrorism, or community trauma in the form of shootings, Violence bombings, or other types of attacks. While many children adjust well after a death, other children have Traumatic Grief ongoing difficulties that interfere with everyday life and make it difficult to recall positive memories of their loved ones. Table 5- This table described the twelve discrete types of trauma as defined by the National Child Traumatic Stress Network 88.

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Almost all of the stakeholders (n=21), focus groups (n=4) identified trauma specifically as major concern in the community. Trauma leads to toxic stress that can persist through childhood, adolescence and adulthood. Research shows that trauma and its subsequent toxic stress is associated with learning and development, mental health and behavior, and chronic illnesses throughout the affected person’s lifetime 87. This section will discuss community violence, disasters and refugees, sexual abuse, early childhood trauma, and complex trauma. This is not to say that people in the community may be experiencing other traumas, and some are discussed in other sections. Domestic Violence The leading cause of trauma is domestic violence. 17.9% of adults in Philadelphia have witnessed domestic violence 89. Each year, the Philadelphia Family Court sees about 12,000 petitions for Protection from abuse orders. While domestic abuse affects people from all backgrounds, genders, and socioeconomic statuses, there are higher rates seen in people experiencing poverty and areas with high rates of community violence90. This infers that the target region in this report is more likely to be seeing domestic violence issues. However, due to fear, isolation, and stigma, victims of domestic violence are less likely to report their situations90. Regarding a friend’s experience, a student said, “His mom gets drunk and gets home from work just to hit him… they don’t care what happens to him.” Community Violence Community violence is prevalent in East North Philadelphia. More than half of the stakeholders (n=14), most focus groups (n=3), and several students (n=7), identified violence specifically as a source of trauma, saying, “Kids see crime, police arrests, raids, and drug use leading to severe trauma.” Table 6 shows that there are higher rates of shootings per 100,000 people, especially for Latinos, in East North Philadelphia. The rate of fatal shootings in East North Philadelphia is 2.24 times the rate of fatal shootings in the rest of the city 19,91.

Victims of Shootings per 100,000 (January, 2015- March, 2019) Latino Total Latino Location Total Victims Victims Fatalities Fatalities EN Phila 654 215 121 43 Not EN 285 14 54 3 Phila Table 6- This table shows the number of victims of gun violence per 100,000 in East North Philadelphia compared to the rest of Philadelphia from January 2015- March, 2019 19,91.

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Table 7 shows that there are higher rates of crime in the East North Philadelphia than in the rest of Philadelphia, particularly related to drug violations. The crimes have various forms of severity; however, all contribute to poorer perceived safety in the neighborhood and subsequent trauma. The high rates of crimes and violence implies high rates of community violence and subsequent trauma from experiencing or witnessing such events 87. Crimes per 1,000 people (2006-2015) Narcotic/Drug Robbery and Vandalism and Location Assault Violations Theft Criminal Mischief EN 129 89 156 60 Phila Not EN 109 36 155 63 Phila Table 7- This table shows the number of crimes per 1,000 people committed in East North Philadelphia compared to those not in East North Philadelphia from 2006-2015 19,92. The effects of violence and crime on the community, especially the children, can be extremely traumatic, as seen in Photo 6. A student said, “I know a lot of my friends who have died. Recently, one of my friends died on Fifth Street… People think it’s a game.” In another horrific incident, a resident describes, “We’ve had shootings close to the school…the kids that were outside, playing, they had to rush them in, and by the time the kids came to the after-school program, they were a mess.” The trauma effects of these frequent events are overwhelming and have an impact on the community as a whole.

Photo 6- “We gotta stop taking each other’s lives cause we are taking someone’s parent or sibling away from them. One of my old friends were killed and shot 5 times and everyone made a memorial for him.”

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Disasters and Refugees As mentioned, about 76.1% of the Latino Population in East North Philadelphia is Puerto Rican 19. Many of these migrants came to Philadelphia following natural disasters. Most recently, Hurricane Maria devastated Puerto Rico with 155 mile-per-hour winds and over 30 inches of rain. The island at one point lost all of its power. Many factors, namely controversy over the allocation of funds from the Federal Emergency Management Agency (FEMA), led to a long, difficult recovery for the island 93. A year later, Puerto Rico continues to be effected by the storm’s aftermath, with a death toll of 2,975 American lives 94. Some stakeholders (n=4) specifically identified displacement from Hurricane Maria as a source of trauma, saying, “People, especially kids, are experiencing PTSD [Post Traumatic Stress Disorder] from the Hurricane and they have anxiety and depression.” Beyond this, while Puerto Ricans are not immigrants as Puerto Rico is incorporated as a commonwealth in the United States, the migration from a tropical island to a vastly different environment in Philadelphia is traumatic. A student explained, “My family and me, we moved here with two aunts and they threw us out of their house just like that, and they knew that we didn’t know the language, or people, or places.” Mental health is affected in similar ways to other refugees as they also experience separation of family, housing instability, and physical difficulties of acclimating to a different climate. One stakeholder said, “People are not used to the weather. They lack vitamin D.” Research shows that natural disasters and forced migration lead to high levels of trauma, a significant psychological impact, and higher risk for poorer health 95. Sexual Abuse and Assault Unfortunately, the United States experiences high rates of sexual misconduct, particularly among women and girls (Table 8). Some stakeholders (n=5) specifically addressed issues of sexual crimes, violence, and abuse. Rape and sexual assault are also the most underreported crimes, with an estimated 63% not reported to the police 96. In East North Philadelphia, there were 650 non-commercial sexual offenses per 100,000 people reported to the police between 2006-2015 compared to 451 per 100,000 people in the rest of Philadelphia 92. This makes sexual crimes 144% more common in East North Philadelphia, and the true rates of sexual crime are likely much higher due to underreporting. A student said, “I see a lot of boys riding bikes. I don’t ride bikes because I’m afraid… I feel like I have it in my head that they might rape me.”

Sexual Abuse and Assault Rates in the United States Women Men Lifetime Rape 1 in 5 1 in 71 Lifetime Sexual Violence 1 in 3 1 in 6 Child Sexual Abuse 1 in 4 1 in 6 Table 8- This table shows the rate of sexual abuse and assault rates in the United States 96.

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Stigma about sexual activity in the Latino Communities may contribute to underreporting and unaddressed sexual traumas. A stakeholder said, “Sexual promiscuity, sexual abuse, and unhealthy sexual development and experiences have lasting psychological effects. The community doesn’t talk about these things and they are unaddressed.” While it is clear sexual trauma is a serious issue in the area, the stigma associated with it may be masking the severity of the problem and creating barriers to addressing it.

Complex Trauma The exposure to multiple traumas such as those previously described contributes to complex trauma, which has a compounding psychological effect on people 97. In East North Philadelphia, a common source of repeated, complex trauma comes from the high rates of opioid abuse. Opioids are a class of drugs developed from the opium poppy. They are often used as prescription painkillers by hospitals and healthcare providers, and used recreationally to achieve a euphoric high. The repeated use of opioids creates a strong physical dependence on the substance, making these drugs extremely addictive 98. Opioid abuse is a serious health concern that is detailed in the Mental Health section of this report, but a majority of stakeholders (n=16), all focus groups (n=4), and many students (n=13), also identified opioids as a source of trauma. The number of people experiencing homelessness in Kensington is up to 703 as of January 2019, accounting for about half of Philadelphia’s population experiencing homelessness99. A stakeholder explained, “People are flocking to Kensington for the cheapest, strongest heroin.” About 40% of the heroin responsible for overdoses in Philadelphia is laced with fentanyl and fentanyl analogues 100. Fentanyl is a synthetic opioid painkiller that is 50 to 100 times stronger than hospital-grade morphine, and even very small amounts can kill someone 98. Heroin in Philadelphia has been found to be laced with cocaine, methamphetamines, oxycodone, and cannabinoids, among other substances 100. In July 2018, a batch of heroin called “Santa Muerte” or “Holy Death” was believed to be responsible for 165 overdoses and 10 deaths in one weekend. Santa Muerte was contaminated with a mix of fentanyl and a toxic synthetic cannabinoid 101. Continual exposure to people suffering from opioid addiction in East North Philadelphia is creating serious safety and trauma issues for community residents. A stakeholder said, “People call the homeless addicts ‘the walking dead.’ We have had tenants stuck with needles accidentally and the street is littered with human feces… Residents have to deal with these circumstances. Children are walking over homeless to get to school and kids do not play outside anymore because of the needles.” Another said, “People feel they cannot leave their homes because they don’t feel safe.”

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The stories around living near so many people suffering from addiction are numerous. A student said, “I don’t want to step on it [trash] because there could … needles. I do not want to shoot myself with blood. It could give me a really bad infection and even AIDS, and I do not want to do drugs because that could ruin my life.” A resident told a story about walking their child home. They said, “This guy was shooting up…almost bumped into my daughter. I grabbed her and she said, ‘Mommy, what can we do for him?’ How do you tell an eight-year-old child, ‘There’s nothing I can do?’ When an eight-year-old child is asking these questions, it’s affecting our health, because my daughter is asking something that at an age that I don’t feel she should know.” This compounding trauma, especially at a young age, can have serious adverse mental and physical health outcomes in the long term. Photos 7 and 8 show some of what these children are seeing.

Photo 7- “He was injecting himself and Photo 8- “It’s bad for the community after that he was trying to put on his because there always kids running around. pants.” My quote means that there be kids playing around and they can fall and get cut from the needle and get sick. Also there are more in the sewers and that’s a health issue because the water gets polluted by whatever in the needle.”

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In January 2018, Pennsylvania Governor Tom Wolf announced a disaster declaration in response to the opioid crisis, leading to the Philadelphia Mayor’s Opioid Taskforce and the Philadelphia Resilience Project 102. The City’s response is being implemented in five parts: strengthening prevention and education, expanding access to treatment, preventing overdose, taking legal action, and expanding the role of law enforcement 103. The city’s most recent report in November 2018 shows an 11% decrease in opioid prescriptions from quarter four of 2017 to quarter two of 2018. It also shows that the city put 51,716 doses of naloxone in the hands of law enforcement agencies and other organizations 100. The city has also implemented a program for Police-Assisted Diversion (PAD). PAD involves an officer redirecting people engaged in drug abuse and prostitution to community based services, instead of making an arrest or leaving people without resources 104. One of the main initiatives has been closing the encampments in East North Philadelphia, which were home to large, open-air drug markets. In Fall 2017, Conrail, the company that owned the land that is known as “El Encampmento,” cleared a 5-block stretch of train tracks along Gurney Street that was one of the biggest encampments 105. The city cleared two encampments on Kensington Avenue and Tulip Street in the late spring of 2018 106. The encampment on Lehigh Avenue closed in November 2018 and “Emerald City” on Emerald Street closed in January 2019. During these closings, 44% of residents from the Kensington Avenue and Tulip Street encampments, 47% from Frankford Avenue, and 28% from Emerald Street encampments accepted treatment or shelter 107. The location of these encampments are found in Figure 31.

Figure 31- This map shows the location of the 5 encampments cleared by Conrail and the City of Philadelphia between Fall 2017 and early Spring 2019 106.

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This initiative marked an important start to addressing the opioid crisis in Philadelphia, but some of these initiatives have created new or exacerbated traumas for the community living there. For example, a stakeholder said, “Kids see as people inject themselves in front of the police and they don’t arrest them, while those kids have family members in jail for doing the same thing.” Furthermore, while many of those who lived in the encampments have been connected to services, the majority were not and have been displaced into the community after the encampments closed 107. As a result, people using drugs are now found in areas that are outside the geographic boundaries of the original encampments causing increased trauma exposure for youth and families living in these communities. A stakeholder said, “Drug misuse is not as much of a problem with residents of Kensington, but the trauma from homeless addicts are the burden. If everyone in Kensington stopped doing drugs, no problems would be solved.” The result of this is what some stakeholders (n=4) identified as a growing divide between the transient people suffering from addiction, and the residents living in homes in the community. One stakeholder said, “A lot of work in Kensington is going towards working with addicts, but this ignores the community that lives there.” Based on all the needs identified in this report, people are feeling neglected by the city as there is a perception that most of the resources are going towards people suffering from addiction. A stakeholder said, “The people in crisis are not from the community. They do not own homes in the community,” while another said, “Why do they get free needles when we cannot feed our children.” These feelings of neglect from disproportionate allocation of resources fosters community-wide trauma for residents living there. A stakeholder said, “It seems ironic that resources are being allocated right where gentrification is happening. The way they are ‘cleaning up’ the streets essentially cleans up the community for gentrification.” Gentrification is further described in the Built Environment section of this report.

Early Childhood Trauma Also referred to as Adverse Childhood Experiences (ACEs), early childhood trauma fosters toxic stress that persists through a person’s lifetime resulting in poorer health outcomes in adulthood and premature death 108. Each of these traumas, when affecting children, can be considered ACEs. Multiple ACEs have been associated with a compounding effect on a person’s mental and physical health 109. Figure 32 shows that people living in East North Philadelphia are more likely to experience four or more ACEs. A stakeholder said, “We are effectively creating a generation of people with mental health issues.” Preventing ACEs and learning to address the needs of people who have experienced ACEs is crucial to reducing poor mental and physical health outcomes, especially for people at greater risk of trauma.

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Figure 32- This map shows the proportion of people who have experience 4 or more ACEs by zip code in Philadelphia 110.

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Access to Care Healthcare access tends to be an important focus when looking into health disparities. This includes but is not limited to geographic access, financial access, cultural access, and transportation to primary and specialty care. One way to measure access is through rates of screenings in adults; if people are getting the screenings they need, we would expect that they are accessing care.

Exam EN Phila LX EN Phila non-LX Phila Healthcare 99.1% 86.3% 88.0% Provider Visit Pap Smear 56.7% 49.9% 52.4% Breast Exam 63.6% 59.2% 63.4% Mammogram 98.0% 79.7% 83.3% Colonoscopy 57.7% 64.6% 73.8% Table 9- This table shows the proportion of people from each population who got the exams they needed in the past year 7. Table 9 shows that Latinos in East North Philadelphia have similar rates of visiting a healthcare provider when compared to non-Latinos in the same region and to Philadelphia’s general population. Similar or higher rates of preventive screenings for cancer are evident for the East North Philadelphia Latino population when compared with Non-Latinos in East North Philadelphia and Philadelphia as a whole. Despite having similar or higher use of preventive screening and a regular visit to a healthcare provider, Latinos in East North Philadelphia experience higher rates of poor health outcomes (see the Morbidity and Mortality section of this report). Given this, there are likely other access issues or social determinants of health impacting the general health of the Latino Communities in East North Philadelphia. Figure 33 shows that about 1 in 4 Latinos in North Philadelphia report missing an appointment due to transportation. A resident said, “Many times we don’t have transportation and we have to go through many difficulties when going to visit the doctor.” Stakeholder interviewees (n=8) also identified transportation as a barrier to accessing care.

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Missed an appointment due to transportation 25.0% 23.5% 22.3% 21.1% 20.0% 15.5% 15.0%

10.0%

5.0%

0.0% Phila Phila LX EN Phila EN Phila LX

Figure 33- The above chart compares the proportion of people in four different geodemographic groups who have ever missed a medical appointment due to transportation 49.

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Latinos who did not seek care due to cost in the North Philadelphia 16.0% 14.0% 12.0% 4.6% 3.7% 10.0% 2.5% 2.1% 8.0% 6.0% 9.0% 9.4% 4.0% 8.7% 7.7% 2.0% 0.0% All Latinos Latinos with Latinos with Latinos with High Diabetes Asthma Blood Pressure Insured Uninsured

Figure 34- This chart shows the proportion of people who did not seek care due to cost among Latinos in the North Philadelphia and among Latinos with specific chronic diseases or conditions 49. It appears that cost of care also plays a role in the EN Philadelphia Latino community’s ability to access care. Compared to the 89.1% of people insured in Philadelphia, 86.1% of the Latino Community in North Philadelphia is insured 49. However, as seen in Figure 34, almost 1 in 10 people did not seek care due to cost, including those who suffer from diagnosed chronic conditions. The majority of those who did not seek care due to cost are insured. Almost half of stakeholder interviewee (n=13) agreed that costs are a major barrier to accessing care, the majority of whom (n=12) identified lack of insurance or providers who accept specific insurance as the major barrier. One stakeholder said, “It is cheaper to pay the fine than it is to get health insurance because it doesn’t cover anything. People from the Dominican Republic go to the Dominican Republic to get care because it is cheaper there.” Sometimes, even with insurance, costs can be too high. A resident said, “I have a copay, so it’s too expensive. And after being five hours there, they barely look at you.” Long wait times may have to do with understaffing due to lack of healthcare providers described below. Several stakeholders interviewed (n=4) identified other costs associated with accessing healthcare such as transportation and childcare.

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Stakeholders interviewed (n=9) also identified a lack of healthcare providers in the geographic region as a barrier to healthcare. With limited physician availability, it can take a long time to get an appointment, and the time spent with the doctor may be limited. Interviewees felt that this prevents physicians from giving patients the attention they need to resolve their respective medical issues. Figure 35 shows the number of patients per primary care provider in Philadelphia and demonstrates that large regions within our target area are underserved. Some stakeholders (n=4) believe co-locating health and social services for the whole family can improve access by limiting time spent away school and work. Lastly, multiple stakeholders (n=6) explained that losing patients to follow-up contributed to a reduced quality of care. When patients are referred to other health or social services, stakeholders explained that there is little infrastructure in place to ensure that patients access those services and information about utilization of these services is not consistently communicated back to the primary care provider. As a result, stakeholders identified a need for more care management in the target region.

Figure 35- This map shows the percentiles of lack of access to primary care providers by census tract in Philadelphia County 111.

Another major concern is cultural and language barriers. A majority of stakeholders (n=14) identified patient navigation as a barrier to healthcare. People do not know where they should be going for care in respect to what type of facility they should be seeking and where physically those facilities are located. Lack of awareness about health and social services available to patients prevents them from being able to access the care they need. Language barriers further exacerbate this issue. Figure 36 shows that the target area encompasses high rates of people who do not speak English. Many stakeholders (n=11) and most focus groups (n=3)

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identified language barriers as it pertains to healthcare services. A stakeholder said, “There is poor communication between English speaking providers and English speaking patients, and that communication is even worse when they do not speak the same language.” Non-English speakers may need to find providers who speak their language in order to access care when translation services are unavailable.” Federal and state law require all healthcare organizations that receive Medicare, Medicaid, or other sources of federal funds to provide certified medical interpreting services. Patients have the right to ask for an interpreter when consulting with a provider who does not speak their language 112.

Figure 36- This map shows the proportion of people in North Philadelphia who do not speak English by census tract5,6,25,113. The last major cultural barrier pertains to trust and communication issues. Stakeholders (n=13) identified trust issues between patients and providers as a major barrier to care, especially among unauthorized immigrants. This can come in many forms. Stakeholders identified a learned helplessness amongst the Latino community, meaning a failure for people to take responsibility in improving their own behaviors as they pertain to living a healthy lifestyle and a widespread perception that if they make an appointment, physicians should prescribe

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medications. A stakeholder said, “People see physicians as medicine dispensaries and if we do not prescribe meds, then they think we are bad doctors.” When a provider does not prescribe medications during a patient visit, this perception creates distrust for the patient. Most focus groups (n=3) mentioned feeling unheard by their providers. According to one resident, “You go to the doctor and they don’t have time to listen to you… So, many times the patient gets frustrated. They are prescribed the wrong thing, they don’t have time… and they go on, next patient.” Furthermore, Photo 9 illustrates how a student does not understand what is in the medication their doctor asked them to take. These concerns demonstrate how gaps in communication between providers and patients can lead to a lack of trust in this relationship.

Photo 9- “While I don’t know the name of this plant I know what it does, turn into drops for ear aches. With all we have improved in medicine, we have forgotten the natural instead of using both to make people healthier. I know the name of my medicine, but I don’t know what’s in it.” Some stakeholders (n=4) shared that the way in which physicians introduce a diagnosis can impact patient stress. Specifically, stakeholders noted that Latinos may perceive a cancer diagnosis as incurable, so extra time to explain the diagnoses is necessary when this is not the case. Similarly, a qualitative study of perceptions of coping among Latinos with a cancer diagnoses, found that patients and their families need positive reframing around their cancer diagnosis and that this may be reinforced by support from a healthcare provider 114. Other examples of distrust that stakeholders identified were discomfort with sharing health information, fear of miscommunication, lack of sustainable funding for healthcare outreach programs, and feeling neglected and unheard by healthcare providers. Stakeholders suggested that speaking the language of the patients, taking the time to understand the community, and showing compassion for patients can all help build trust.

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Health Status Morbidity and Mortality

In this region, there are higher rates of chronic diseases and mental health conditions in general, and specifically within the Latino community as seen in figure 37.

A Diabetes 25.0% 22.9%

20.0% 18.1% 16.9% 15.6% 15.0% 13.8% 9.4% 10.0%

5.0%

0.0% United States United States Phila Phila LX EN Phila EN Phila LX LX

B Asthma 35.0% 30.0% 28.6% 25.9% 24.4% 25.0% 21.5% 20.0% 15.0% 10.0% 8.3% 5.9% 5.0% 0.0% United States United States Phila Phila LX EN Phila EN Phila LX LX

Figure 37- The charts compare the Latino populations to the general populations in the United States, Philadelphia, and North Philadelphia. Latinos in North Philadelphia have the highest rates of (A) asthma, and (B) diabetes compared to the six geodemographic population groups depicted in the chart 7.

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When one demographic group has worse outcomes than others, it is an indicator that there are health disparities affecting this group. This is also true for populations in specific geographic areas. Within the Latino community in East North Philadelphia, 39.8% report fair or poor health as compared to Philadelphia’s 23.6% 49. Furthermore, the majority of stakeholders (n=19), all focus groups (n=4), and many students (n=13), identified physical health and chronic diseases as a health concern in the community. Specifically, stakeholders said that high rates or uncontrolled symptoms of asthma (n=9), diabetes (n=9), and cardiovascular disease (n=5) are significant issues in the Latino Community.

Figure 38- This map shows the rate of new Hepatitis C infections in Philadelphia. The target zip codes have higher rates of infections than other zip codes 115. Some stakeholders (n=5) also found infectious diseases to be of concern, namely Hepatitis C and HIV/AIDS. The Philadelphia Division of Disease Control found higher rates of Hepatitis C amongst males in every age category. The map in Figures 38 and 39 show that the target area (EN Phila) is seeing higher rates of Hepatitis C than other areas of Philadelphia 115. The AIDS Activities Coordinating Offices 2017 Surveillance Report showed that of the major demographic groups, Hispanics have the second highest incidence rate of HIV infections and are the only demographic group to see a rise in incidence between 2013 and 2017 of 16.9% 116. These higher rates of chronic and infectious disease in the Latino Population in North Philadelphia are of concern and need further investigation in order to optimize the positive impact that future interventions can have on the community.

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Hepatitis C

4.0% 3.6% 3.5% 3.0% 3.0% 2.6% 2.5% 2.0% 1.5% 1.5% 1.0% 0.5% 0.0% Phila Phila LX EN Phila EN Phila LX

Figure 39- This chart shows the proportion of people who have Hepatitis C in four different geodemographic groups in 20187. The place where you live can be a major determinant of your health. Table 10 shows the life expectancy in the five zip codes that serve as the target region of this report is lower than those who live in the center city zip codes. The place you live can be a major determinant of your health. The lower life expectancies seen in East North Philadelphia may be attributable to the social, environmental, and access issues discussed in this report. Life Expectancy at Birth by Zip Code East North Philadelphia Center City Zip Code Life Expectancy Zip Code Life Expectancy 19122 74 19102 80 19124 74 19103 83 19133 71 19106 88 19134 71 19107 81 19140 72 Range: 71-74 Ranges: 80-83 Table 10- This table shows the life expectancy by zip code for the East North Philadelphia and Center City regions117.

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Birth Rates (2015) Live Births Percent of live Teen births Percent of all (per 1,000 births at Low Birth per 1000 teen births people) Weight (<2,500 g) females born to ages 15-19 Latina All LX All LX mothers EN 18.2 21.8 11.3% 11.0% 1.9 60.0% Phila Phila 14.4 18.8 10.8% 9.8% 2.4 31.2%

Table 11- This table compares the proportion of live births, low birth weights, and teen births between East North Philadelphia and all of Philadelphia in 201519,118. Table 11 shows that there are higher birth rates in East North Philadelphia, and higher proportions of children born at a low birth weight compared to Philadelphia. While the teen birth rate in EN Philadelphia compares favorably to Philadelphia as a whole, 60% of teen births in EN Philadelphia were among Latina mothers. This is nearly twice the rate for Latinos in Philadelphia as a whole. Death Rates (2015) Deaths (per Infant Deaths Neonatal deaths Post-Neonatal 1,000 (per 1,000 live (per 1,000 live dealths (per people) births) births) 1,000 live All LX births) EN 8.4 5.3 9.1 6.0 3.1 Phila Phila 9.2 3.7 8.3 5.8 2.5

Table 12- This table compares the death rates, infant mortality rates, neonatal mortality rates, and post-neonatal mortality rates between East North Philadelphia and all of Philadelphia in 201519,119. Table 12 shows that while East North Philadelphia has a lower death rate when compared to the entire city, there is a higher death rate among Latinos when compared to Latinos in all of Philadelphia. The infant mortality rate in the United States in 2015 was 5.8 deaths per 1,000 live births120. While Philadelphia exceeds this rate, it is concerning that the rate in EN Philadelphia is even higher. This trend continues for both neonatal and post-neonatal deaths. Access to prenatal care, delayed or no prenatal care, social determinants of health (i.e. lack of insurance, transportation) the presence of chronic disease, and high teenage pregnancy rates are among the contributing factors related to the higher rates of infant deaths seen in Philadelphia and EN Philadelphia. 73

Mental Health

Approximately 1 in 5 adults in the United States experience mental illness in a given year121. Table 13 demonstrates that certain people in the United States are more likely to suffer from mental illness than others.

Demographic Group Proportion with a Current Mental Health Condition General United States Population 19% People Experiencing Homelessness 26% LGBTQ+ 37% Youth in Juvenile Justice Systems 70% Adults in State Prison Systems 24% Table 13- This table outlines the non-racial and non-ethnic groups that are disproportionately affected by mental illness in the United States 121. Philadelphia as a whole is seeing higher rates of people with mental health conditions than the rest of the country. Figure 40 shows that while Latinos have lower rates of mental health conditions than the general population nationally, they are at a higher risk in Philadelphia and especially in East North Philadelphia. Specifically, nearly 2 in 5 Latinos in East North Philadelphia have a mental health condition, which is more than double the national rate 7,121. This is clearly presented in the Figure 41, which depicts a map of the target region.

People with a Diagnosed Mental Health Condition 45.0% 38.1% 40.0% 35.1% 34.4% 35.0% 30.0% 25.4% 25.0% 18.5% 20.0% 16.3% 15.0% 10.0% 5.0% 0.0% United United Phila Phila LX EN Phila EN Phila LX States States LX

Figure 40- This chart shows the proportion of people with diagnosed mental health conditions in six geodemographic groups 7,121.

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Figure 41- This map shows the prevalence of people with poor mental health in East North Philadelphia. Philadelphia has seen a steady rise in mental health conditions since 20083. Figure 42 shows that the prevalence of mental health conditions in Philadelphia increased at a similar rate to Latinos residing in East North Philadelphia over the past decade. During the same timeframe, the prevalence of mental health conditions among Latinos in East North Philadelphia has remained higher than in Philadelphia. Like Philadelphia, Latinos in East North Philadelphia are seeing a rise in mental health issues. All of the stakeholders (n=27), all focus groups (n=4), and most students (n=17) identified mental health as a major health concern in this community.

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People with a Diagnosed Mental Health Condition 50.0%

40.0%

30.0%

20.0%

10.0%

0.0% 2002 2004 2006 2008 2010 2012 2015 2018 Phila EN Phila LX

Figure 42- This graph shows the prevalence of mental health conditions of Latinos in East North Philadelphia compared to the general population of Philadelphia from 2002-201817. Mental health is a co-determinant for chronic diseases. Having a mental health condition acts as a risk factor for chronic conditions, while having a chronic condition acts as a risk factor for mental health conditions 122. Figure 45 shows that this holds true for Latinos in East North Philadelphia as more than half of Latinos who rate their health as fair or poor or who have a chronic health condition also have a mental health condition. Almost half of the stakeholders interviewed (n=10) proposed having mental and behavioral health services co-located with doctor’s offices in order to improve access and navigation abilities for individuals and families. The National Alliance on Mental Illness found that 37% of students aged 14 and older drop out of school if they have a mental health condition 121. Co-locating services may improve access to mental health services so people get the care they need, while spending less time away from school and work. Stakeholders (n=10) also identified chronic stress as a major determinant of poor mental health and poor general health. East North Philadelphia has some of the highest composite stress index scores in the entire city of Philadelphia 64. Chronic stress impairs attention, memory, and the ability to deal with emotions while also contributing to issues in the cardiovascular, immune, metabolic, and endocrine systems in the body 123. Stakeholders identified poverty and poor financial health, unstable employment, and unstable housing as major sources of stress. However, the majority (n=7) of those who discussed stress identified a history of individual and community trauma as the main source of stress. Trauma is discussed further in the Trauma, Safety, and Violence section of this report.

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Mental Health and Physical Health 60.0% 50.7% 50.0%

40.0% 20.7% 31.6% 30.0% 28.6% 13.2% 11.0% 22.9% 20.0% 9.9% 30.0% 10.0% 17.6% 18.4% 13.0% 0.0% Fair/Poor Health Asthma Diabetes Hypertension Has Mental Health Condition Does not have Mental Health Condition

Figure 45- This chart shows the proportion of people in East North Philadelphia who have a mental health condition and report fair/poor health or have a chronic health condition 7. Nationally, Latinos are about half as likely to receive mental health treatment for their conditions than the general population 121. People often go multiple decades before receiving treatment for mental health conditions 124. Figure 46 shows that Latinos in Philadelphia are slightly less likely to receive mental health services when compared to other demographic groups. People in East North Philadelphia are more likely to receive mental health services than people in Philadelphia as a whole 7. Many stakeholders (n=10) said that while there are many mental health services in the area, the quality of some mental health services in the area are questionable or poor. A stakeholder said, “People prey on the patients.” While some services are high quality, they are often overwhelmed by patients resulting in long waitlists. Other places may not use certified mental health professionals and upcharge people for services that do not help and may even harm the patient. A stakeholder said, “There are poor quality therapists…a lot are not certified,” and another said, “Mental health professionals in the area are exploitative and abusive. The care is very expensive and the services are bad and time-consuming.” Some residents felt that mental health professionals were more likely to prescribe medicine than help people heal saying that they, “pump you with more junk instead of actually helping you.” Beyond this, stigma plays a major role in access to mental health services. Some stakeholders (n=6) identified stigma around mental health as a barrier to mental health services utilization. One stakeholder said, “People do not want others to see that they are getting mental health services.” This comes with trust issues as well. As a result, people wait to seek mental health treatment until their condition becomes dire. Another stakeholder said, “People do not see the doctor unless their problems are severe. As a culture, there is no normalization of our health in general, and the stigma is worse around mental health.” A student said, “…make sure that

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people who have mental disabilities are taken care of… I went to a dance for people who have mental disabilities and it made my mind open up more because it just show like these are people too… they shouldn’t be outcast to society in a way.” Stakeholders also identified a misunderstanding about the ability to treat mental health conditions saying, “We need to make it clear that this [mental health] is treatable. People don’t just have to endure it.” The stigma and lack of knowledge around mental health treatment remains a significant barrier to getting care.

Receiving Mental Health Treatment 70.0% 65.3% 58.1% 60.0% 57.9% 50.8% 50.0%

40.0%

30.0%

20.0%

10.0%

0.0% Phila PhilaLX EN Phila EN PhilaLX

Figure 46- This chart shows the proportion of people who have a diagnosed mental health condition who receive treatment for that condition 7. People of minority cultures experience reduced access to mental health care in the United States due to language barriers, poorer quality of care, and higher levels of stigma 121. As described, stigma and quality of care are major access issues for Latinos in East North Philadelphia; however, stakeholders were not consistent about language barriers in respect to mental health services. Most stakeholders recognize that there are many mental health services in the area, and while a few (n=2) identified language barriers as a problem, more (n=3) said that there are plenty of bilingual mental health care providers in the area, but many are uncertified and offering lower quality care. This indicates a need for high quality mental health services in the area where people do not need to wait on long lists just to get a quality appointment.

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Binge Drink 8+ times in Past Month 10.0% 9.0% 8.0% 7.0% 6.7% 6.0% 5.3% 5.0% 4.4% 4.4% 4.0% 3.0% 2.0% 1.0% 0.0% Phila PhilaLX EN Phila EN PhilaLX

Figure 47- This chart shows the proportion of people in four geodemographic groups who engaged in binge drinking (4 or more drinks at a time) eight or more times in the past month 7. Substance abuse in itself is a mental health condition, but it can also contribute to, coexist with, or result from other serious mental health issues 125. Figure 47 shows that Latinos in East North Philadelphia have higher rates of binge drinking than other Latinos in the area or in Philadelphia as a whole. However, few stakeholders (n=3) mentioned alcohol as a concern in the community, with most focusing on opioids as the central issue. One stakeholder said, “Alcohol shows up in Latino families until opioids takeover and get the most attention.”

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Figure 48- This map shows the number of opioid overdoses by zip code in East North Philadelphia in 2017. Opioid abuse is a major issue in East North Philadelphia, giving the area its reputation as a haven for heroin users. Figure 48 shows that the target area is seeing the highest number of deaths by opioid overdoses in the Philadelphia. Many people first access opioids through a narctoic prescribed to them or someone they know. Then people may turn to heroin as a cheaper, more potent alternative 126. While the high rates of opioid abuse is a characteristic of the area, Figure 49 shows that Latinos in East North Philadelphia are about half as likely to abuse a prescription that was not made on their behalf. Beyond this, only 10.9% of all hospitalizations due to opioid overdose from 2002-2017 in Philadelphia were Latino 127. These are indicators that the Latino Communities are not seeing as high rates of opioid abuse as other demographic groups. However, the trauma implications of living in an area where so much drug abuse takes place are substantial. This subject is further explored in the Trauma, Safety, and Violence sections of this report.

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Taken Prescription Meds without a Personal Prescription in Past Year 14.0% 12.9% 11.8% 12.0% 10.0% 8.0% 6.7% 6.0% 5.1% 4.0% 2.0% 0.0% Phila PhilaLX EN Phila EN PhilaLX

Figure 49- This chart shows the proportion of people in four geodemographic groups who have taken prescription medications without a prescription for themselves in the past year 7. Several stakeholders (n=10), all focus groups (n=4), and many students (n=13), identified high levels of stress in the community. A resident said, “Many mental health problems come because of problems existing in the community that make us scared and we get sick… lack of work, violence… too much confusion in and out of the house. You can’t find a way out… That leads to stress, which deteriorates you physically and mentally.” Meanwhile, a student said, “If you live a fast-paced life, I think that could be a real strain on your mental health and just your physical body in general.” These high levels of stress may be associated with traumas as described in the Trauma, Safety, and Violence section of this report. Many students identified a need for outlets to express themselves, often through performing and visual arts as seen in photos 10-12.

Photo 10- “Listening to music is something I enjoy doing very often. Doing this helps me stay away from negative things. Such as having communication with toxic people and getting distracted by unnecessary things. When listening to music I feel like I’m part of a different world outside of reality.”

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Photo 11- “Every Saturday I go to music class called T-VOCE. It is a free choir open to teens, and T-VOCE means Teen Voices of the City Ensemble. I go there every Saturday because I love to sing and I love music. My mother is very sick and we are very poor. That is why whenever I look at people performing music, like singing, dancing, and playing instruments, I realized that I wanted to study music. When I sing, I feel happy and relaxed, and I have fun. I want to perform and save money for my family so that our lives would change and be happy too.”

Photo 12- “In this photograph I wanted to establish how a creepy alley can become ones creative outlet. I also wanted to establish how being able to express yourself allows you to have a healthy state of mind as opposed to doing drugs or something else that can become harmful to yourself or to the people in your environment. Having a healthy state of mind allows one to be themselves and allows them to be more creative.”

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Health Behavior and Health Education

Health behavior, including diet and nutrition, physical activity, smoking, and obesity, plays a major role in an individual’s health. Figure 50 shows how much each of these risk factors contribute to deaths in the United States annually. These risk factors contribute to the onset of asthma, diabetes, cardiovascular disease, cerebrovascular disease, many cancers, and mental health 128. Taking action to make healthy behavioral choices can lower the risk for these chronic conditions and improve overall quality of life 129.

Behavior Risk Factors and Contribution to Total Deaths in the United States

Physical Inactivity 3.3%

Obesity 13.9%

Smoking 17.8%

Diet and Nutrition 19.2%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Figure 50- This chart shows the contribution of four behavior risk factors to the proportion of deaths in the United States in 2016 128.

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People who smoke 35.0% 30.9% 30.0% 28.1%

25.0% 21.6% 20.0% 18.1% 14.0% 15.0% 9.9% 10.0%

5.0%

0.0% United States United States Phila Phila LX EN Phila EN Phila LX LX

Figure 51- This chart compares the Latino populations to the general population in the United States, Philadelphia, and North Philadelphia. Among the six geodemographic groups depicted, Latinos in North Philadelphia have the highest rates of smoking 7,130. Within the Latino community in North Philadelphia, there are much higher rates of smoking. Smoking acts as a risk factor for numerous chronic diseases including heart disease, stroke, diabetes, asthma, and some cancers. However, in addition to affecting the individual smoker, smoking also lowers air quality, effectively putting others in the community at risk from second-hand smoke. Some stakeholders (n=4), most focus groups (n=3), and several students (n=9), identified smoking as a health concern, but stakeholders understand that smoking may be used as a coping mechanism for high levels of stress, which may partially explain higher smoking rates in the Latino community. Figure 51 shows that while Latinos nationally smoke less than other demographics, Latinos in EN Philadelphia have smoking rates that are more than twice the national rate and higher than the smoking rate in Philadelphia. In addition, Figure 52 shows that until this past year, the smoking rate for Latinos in East North Philadelphia remained about the same as the rest of Philadelphia over the past two decades. This rise in the smoking rate over the past three years is of concern and should be monitored.

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People who Smoke 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 1998 2000 2002 2004 2006 2010 2015 2018 Phila EN Phila LX

Figure 52- This plot shows the smoking rates of Latinos in East North Philadelphia compared to the rest of Philadelphia from 1998-201517.

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People who are obese 50.0% 47.0% 44.3% 45.0% 42.3% 39.8% 39.0% 40.0% 35.0% 31.1% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% United States United States Phila Phila LX EN Phila EN Phila LX LX

Figure 53- This chart shows the proportion of people who are obese in six different geodemographic regions 7,131. Beyond smoking, 44.3% of Latinos in East North Philadelphia are obese (Figure 53). While this is similar to Latinos in the United States as a whole, it is considerably higher than the rate for Philadelphia. In addition, Figure 54 shows that over the past three years obesity has increased among Latinos in East North Philadelphia while remaining relatively stable for the city as a whole.

Obesity Rates 50.0%

40.0%

30.0%

20.0%

10.0%

0.0% 2002 2004 2006 2008 2010 2012 2015 2018 Phila EN Phila LX

Figure 54- This graph shows changing obesity rates among Latinos in East North Philadelphia compared to Philadelphia as a whole from 1998-201817.

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Many unhealthy behaviors can lead to obesity. Some stakeholders (n=6) identified obesity specifically as a health concern, especially among children, with many (n=9) discussing poor diet, physical inactivity, and lack of knowledge regarding nutrition as major health determinants. In Philadelphia, 20.6% of children are obese, and that rate it is higher among Latinos at 22.0% for females and 25.7% for males 132.

People who Exercise 3+ Days per Week 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1998 2000 2002 2004 2006 2008 2010 2012 2015 Phila EN Phila LX

Figure 55- This graph shows the proportion of Latinos in East North Philadelphia who exercise for at least 30 minutes a day, 3 or more times per week compared to Philadelphia as a whole 17. The Centers for Disease Control and Prevention recommend that adults get 150 minutes of moderate-intensity physical activity each week 133. Figure 55 shows that only 50% of adults get the recommended level of physical activity; however, rates of physical activity have been improving among Latinos living in East North Philadelphia over the past 20 years. A stakeholder said, “The high crime and violence makes parents want to keep their kids indoors and there is limited green space in the area.” This shows that factors such as safety and the built environment may affect physical activity. These are further explored in the Built Environment section and the Trauma, Safety, and Violence section, respectively. Furthermore, figure 56 shows that Latinos in East North Philadelphia are less likely to consume enough fruits and vegetables. However, they are the more likely to be watching their salt intake, and have similar rates of sugar-sweetened beverage consumption and exercise as the rest of the city. While the low rates of fruit and vegetable consumption put this community at risk for poorer health outcomes such as the chronic diseases discussed previously, the rates of these other behaviors compare favorably or are similar to the rest of the city. This is an indication that other factors are likely contributing to the poorer health outcomes seen in East North Philadelphia’s Latino Communities.

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A Watching or Reducing B Eat 3+ Servings of Fruits Salt Intake and Vegetables per Day 80.0% 74.4% 50.0% 67.1% 39.9% 60.0% 52.0% 52.7% 40.0% 29.8% 28.1% 30.0% 40.0% 21.9% 20.0% 20.0% 10.0% 0.0% 0.0% Phila Phila LX EN Phila EN Phila Phila Phila LX EN Phila EN Phila LX LX

C Drink 1+ SSB per Day D Exercise 3+ Days per

50.0% 42.6% Week 36.3% 54.3% 54.4% 40.0% 32.6% 32.5% 60.0% 52.6% 51.6% 30.0% 50.0% 40.0% 20.0% 30.0% 10.0% 20.0% 10.0% 0.0% 0.0% Phila Phila LX EN Phila EN Phila Phila Phila LX EN Phila EN Phila LX LX

Figure 56- These graphs show the rates for behaviors that affect obesity in four different geodemographic groups. They include (A) watching or reducing salt intake, (B) Eating three or more servings of fruits and vegetables daily, (C) drinking one or more sugar sweetened beverage daily, and (D) exercising three or more days weekly 7. Many of the factors discussed, such as access to healthy and affordable food, consumption of sugar-sweetened beverages, and exercise lead to higher rates of obesity. One stakeholder said, “I have seen people fill baby bottles with coke. Soda used to be cheaper than water or milk, so this is what they bought.” This shows how financial health and access to healthy foods and beverages contribute to these behaviors. Many stakeholders (n=13), all focus groups (n=4), and several students (n=6), identified a need for health education. Topics include culturally competent nutrition education and cooking classes, financial health, and dealing with addiction. Details about these issues are found in the Food Access, Employment and Financial Health, and Mental Health sections of this report, respectively.

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Priorities To address the community health needs identified in the Latino communities in East North Philadelphia, the information from quantitative data analysis, stakeholder interviews, focus groups, and PhotoVoice were presented to the Community Advisory Group (CAG). Based on the Hanlon method of prioritization, the CAG selected 5 criteria and chose a 5-point scale to rank each identified health need. Agreed upon weights were assigned to each of the five criteria and used to calculate a final score. The researchers scored two criteria (size of the problem and community perceives the problem to be important) based on the needs assessment findings. The CAG scored the remaining criteria. A summary of these criteria, how they were scored, and their weight in the final score are summarized in table 14 below. Criteria Scoring Weight Scored based on the prioritizations Community perceives problem to be collected in stakeholder interviews, 40% important focus groups, and PhotoVoice projects. Scored based on the quantitative data Size of the problem 15% analysis.

Feasibility in addressing the problem Scored by the CAG 15%

Is the problem a root cause of other Scored by the CAG 15% problems Are there existing collaborations and Scored by the CAG 15% interventions to address the problem Table 14- This table summarizes how the needs of the community were prioritized based on the available data and input from the Community Advisory Group (CAG).

Table 15 below lists the final priorities and their respective scores on a scale from 1-5.

Rank Health Need Score 1 Mental Health 4.3 2 Trauma, Safety, and Violence 4.3 3 Housing 4.2 4 Built Environment 4.1 5 Health Behavior and Health Education 3.9 6 Education 3.7 7 Access to Care 3.4 8 Employment and Financial Health 3.2 9 Food Access 3.1 10 Social and Political Context 2.7 11 Physical Health 2.6 Table 15- This table summarizes the results of the prioritization and shows the highest priority needs of the Latino communities living in East North Philadelphia.

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