LOUISVILLE METRO HEALTH EQUITY REPORT The Social Determinants of Health in Louisville Metro Neighborhoods

2011

LOUISVILLE METRO HEALTH EQUITY REPORT The Social Determinants of Health in Louisville Metro Neighborhoods

This report was produced by the Metro Department of Public Health and Wellness’ Center for Health Equity. The Center for Health Equity works to address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

Authors: Patrick Smith, AICP Margaret Pennington, MSSW Lisa Crabtree, MA Robert Illback, PsyD

REACH of Louisville, Inc. www.reachofl louisville.com

Comments, questions, and requests for additional information can be directed to: C. Anneta Arno, PhD, MPH Director, Center for Health Equity Louisville Metro Department of Public Health and Wellness 2422 West Chestnut St. Louisville, KY 40211 (502) 574-6616

Design: REACH of Louisville, Inc.

Cover Photo Credits: Child on Bicycle - © Photo courtesy of Louisville Metro Group exercising - © Courier Journal All other photos courtesy of the UofL Urban Design Studio

EXECUTIVE SUMMARY The social and physical conditions into which people are born, live and work, profoundly THE SOCIAL DETERMINANTS OF affect well-being and longevity. The inÀ uence of place and neighborhood is increasingly HEALTH ARE THE seen as a major, if not the most signi¿ cant, determinant of health. Thanks to a growing record SOCIAL, ECONOMIC, & of research and reporting, the body of evidence continues to amass on how the shape and PHYSICAL CONDITIONS fabric of communities and neighborhoods impact our health. Rather than simply functioning THAT CONTRIBUTE OR as the setting for interventions designed to change individual health and health behavior, DETRACT FROM THE community environments must be understood to have at least equal importance as health HEALTH OF PEOPLE AND determinants. NEIGHBORHOODS

Much of the research on place and health has been articulated through a set of constructs termed “the Social Determinants of Health” (SDOH). The SDOHs consider how social Income & and neighborhood conditions come together to impact health outcomes. Research has Employment demonstrated that access to proven health protective resources like clean air, healthy food, recreational space, opportunities for high-quality education, living wage employment, and decent housing, is highly dependent on the neighborhood where one lives. Some of the implications for Louisville described in the report are as follows:

Louisvillians in the poorest neighborhoods have lower life expectancies, sometimes by as much as ten years shorter Environmental Quality than the overall Louisville Metro life expectancy (see page 5).

Louisville residents ages 40-65 who earn less than $20,000 annually are signiÀ cantly more likely to report that they have had a heart attack (see page 17).

Neighborhoods that have been labeled as “food deserts” have diabetes mortality rates that are two to three times higher than the total Louisville Metro rate (see pages 15 and 38-41).

Opportunities for physical activity in some neighborhoods could be impeded by safety issues including hazards for Food pedestrians and bicyclists, or high rates of violent crime Access in or near public parks (see pages 37 and 51).

Health The primary goal of the Louisville Metro Health Equity Report is to promote a community- Care wide understanding of the root causes of health inequities in Louisville Metro. It can also Access serve as an impetus for discussing the neighborhood conditions that contribute to health in all of Louisville’s neighborhoods. Key to fostering this understanding is thoughtful engagement with health and social determinant data and research. The research and data Community accumulated within this report should be of broad interest to community members, but our Safety greater desire is that the ¿ ndings portrayed within the report will be used to move discussions beyond individual choice-making toward the underlying community environmental factors Parks & that perpetuate poor health. Physical Activity CONTENTS

INTRODUCTION ...... 2 Place Matters and Neighborhood Counts...... 2 Health Equity Report Framework ...... 3 The Social Determinants of Health ...... 3 Social Inequalities, Structural Racism, and the Social Determinants ...... 4 Historical Context ...... 6 Report Methodology ...... 7

DEMOGRAPHICS...... 8

HEALTH STATUS ...... 12

INCOME & EMPLOYMENT...... 16

HOUSING ...... 22

ENVIRONMENTAL QUALITY ...... 27

EDUCATION ...... 31

TRANSPORTATION ...... 35

FOOD ACCESS ...... 38

HEALTH CARE ACCESS ...... 41

COMMUNITY SAFETY ...... 46

PARKS & PHYSICAL ACTIVITY ...... 50

CONCLUSION ...... 52

REFERENCES ...... 53

Appendix A: Neighborhood Area Detail Maps...... 59

Appendix B: Work Group Listings ...... 68

Special thanks to the National and Local Work Groups: See Appendix for listing.

Special thanks to Catherine Fosl, PhD for contributions for Louisville’s historical context, and to Ray Yeager, MPH for analysis on age-adjusted life expectancies and mortality rates. LIST OF FIGURES

Adult Report of Heart Disease & Heart Attack, 2009…………………...... ………..……13

Age-Adjusted Cancer Incidence (New Cancers) Rates per 100,000 ……....…...... …….14

Adults Diagnosed with Diabetes, 2009 ……………………………...... ……15

Income Below Poverty Level, 2009 ………………...... …..16

Per Capita Income by Race/Ethnicity, Louisville MSA, 2009 …………...... …………...17

Heart Attacks, By Income, 2009 …...... …17

Hourly Wages in Louisville Metro, 2008 …………………...... …18

Estimated Unemployment Rates, by Race/Ethnicity, 2005-2009 ...... ………………18

Self-Reported Poor Health by Employment Status, Ages 18-64, 2009 …...... …………….18

Health Insurance Coverage by Employment Status, 2009 ……………...... ………….19

Households with Assistance Income in Louisville Metro, 2009...... …………………19

Fair Market Rents for Louisville Metro, 2001-2011 ………………...... …………………22

Homeowners by Race/Ethnicity, 2007-2009 ...... …...... 23

Home Purchase Loans Denied by Race/Ethnicity and Income, 2009 ...... ……………….24

People Ages 25-65 Reporting ‘Good’ or ‘Excellent’ Health, by Education Level, 2009 ...... 31

People Ages 25-65 Reporting Risk Behaviors, 2009 …...... ………..31

People Ages 25-65 Reporting Chronic Conditions, 2009 ...... …………………32

Birth Outcomes by Mother’s Education Level, 2008-2009 ...... ……………………….32

Average Annual Pedestrian Deaths per 100,000, 2000-2009 ...... ……………………36

Percent without Any Type of Health Coverage, Ages 25-65, 2009 ...... ……………………41

Percent with Any Type of Health Coverage, 2002-2009 …...... ………….42

Adults with 20+ Minutes of Vigorous Physical Activity 3+ Days per Week, 2009 ...... ………….50 LIST OF MAPS Age-Adjusted Life Expectancy, in Years, 2006-2008…...... 5 White, One Race, 2005-2009 …………...... ………………………8 Black or African American, One Race, 2005-2009 ...... ………..….…..8 Hispanic or Latino, of Any Race, 2005-2009.………………...... ……………………………..………9 Asian, 2005-2009 …………...... ……………………………………………………………..……..9 People Ages 65 & Over, 2005-2009 …...... …………………………………………………….………..…….10 Children Under Age 5, 2005-2009 …...... …………………………………………….…………..…10 Households Where Grandparent Is Responsible for Own Grandchildren Under 18 Years 2005-2009, …...... ….11 Foreign Born Population, 2005-2009 ……………...... ……....………………………………………..…11 Deaths Due to All Causes (Age-Adjusted Rate per 100,000 Population), 2006 -2008 ……...... …………....12 Deaths Due to Diseases of the Heart (Age-Adjusted Rate per 100,000 Population), 2006 -2008 …...... …...13 Deaths Due to Cancer (Age-Adjusted Rate per 100,000 Population), 2006 -2008 …………...... …..….…14 Deaths Due to Diabetes (Age-Adjusted Rate per 100,000 Population), 2006 -2008 ………...... ………...….15 Unemployment (Civilian Labor Force, Ages 16 and Older), 2005-2009 …………………...... ………….….20 Families Earning Less than $15,000 (Income & Benefi ts in 2009 Infl ation Adjusted Dollars) 2005-2009 ...... …21 Foreclosure Auctions, 2009 ……...... …...... ……………………………………………………………23 Foreclosure Rate (Estimated Foreclosure Starts/Estimated Number of Mortgages), 2007- June 2008 ...... ……25 Renters Paying 35% or More Households Paying 35% or More of Income for Rent), 2005-2009 ...... ……...26 Respiratory Risk from On-Road Pollution Source, 2002 ……………….…...... …………………...28 Total Respiratory Risk from All Sources, 2002 …………………….....…...... ……………………….28 On-site Toxic Releases from Facilities, 2009 ……………………………...... ………………………….29 Pre 1950’s Housing (Percentage of Older Housing Stock per Neighborhood Area), 2005-2009 …...... ……...30 Ninth Grade Education or Less (25 or Older with 9th Grade Education or Less), 2005-2009 ………...... ………33 College Degree or Higher (25 or Older with at Least a Bachelor’s Degree), 2005-2009 ...... ……………………..34 Bicycle and Pedestrian Collisions, (Rate per 1000 people), 2009 ………...... ………………………..37 Fast Food Outlet Density, (Number of Fast Food Outlets per Mile), 2010 …...... ……………………40 Federally Qualifi ed Health Centers and LMPHW Preventative Health Clinics …...... ……….…….42 Language Other than English Spoken at Home, Population 5 Years and Over 2005-2009 ………...... 44 No Vehicles Available, Occupied Housing Units with No Vehicles, 2005-2009 ………...... ………….…….45 Package Liquor Store Density, (Package Liquor Stores per Square Mile) …………...... …………….…….47 Serious Crimes, Rate per 10,000, (Assaults, Burglaries, and Homicides), 2010 …………...... ……………48 Vacancy Rates, (Residential Vacancies/Total Residences), 2010 ………………………...... …….…………49 Assaults within 1000 ft of Metro Parks, (Rate per 10,000 People), 2010 ……...... …………………..51 TECHNICAL NOTE The demographic and Social Determinant data in this report are depicted using groups of Census 2000 tracts that correspond to data from the 2005-2009 American Downtown- Community Survey Estimates. These groups of Census Phoenix Hill- Old Louisville- Tracts attempt to represent established city neighborhoods Smoketown- University Shelby Park and residential communities or areas of the county (see page 7 for a more detailed description). Northeast Chickasaw- Portland Butchertown-Clifton- Shawnee Crescent Hill St. Neighborhood Areas Russell Matthews California- Parkland Highlands Algonquin - Park Hill - 18 Park Duvalle German- town Southeast J-town Louisville South Shively Central Louisville Buechel-Newburg- Airport Indian Trail Fern South Louisville Creek

Pleasure Ridge Park Floyd’s Fork

Highview- Okolona Fairdale Valley Station

5

Miles

TECHNICAL NOTE 16 Downtown- Because Louisville Metro’s legislative Phoenix Hill- governance structure is confi gured along Old Louisville- Smoketown- University Shelby Park Council District lines, a map overlaying both 17 the neighborhood and the Council District Northeast Chickasaw- Portland 7 boundaries has been provided. While the 5 Butchertown-Clifton- Shawnee St. overlapping lines make it diffi cult to read, Crescent Hill Russell 4 9 Matthews 19 hopefully it will serve as a reference for California- Parkland Highlands 18 those who base their work on current (2011) Algonquin - Park Hill6 - Park Duvalle German- 8 legislative boundaries. town 26 Southeast J-town Louisville 3 South 1 Shively Central 11 Louisville15 10 21 Buechel-Newburg- Airport Indian Trail 2 Fern South Louisville Creek 12 20 Pleasure Ridge Park Floyd’s Fork 24 25 Highview- 22 Okolona 13 23 Fairdale Valley Station

5 14 Neighborhood Areas Miles Council Districts, 2011

Metro Louisville Council Boundaries provided by LOJIC, Louisville/Jefferson County Information Consortium INTRODUCTION

Place Matters & healthy food, parks and opportunities for research. Data that illuminate the Neighborhood Counts physical activity. Collectively, they tend underlying conditions that perpetuate Social, physical, and economic to be manifested in places -- therefore health inequities at the community conditions shape the places into which place matters and neighborhoods count level are important to illustrate social we are born, and where we live, learn, in opportunities for health! and economic conditions that lead to work, play, and age. The characteristics health inequities in communities.2 The of a given neighborhood or community A social-determinants lens also helps to research and data accumulated within represent the interplay of contemporary shine light on the underlying ‘root causes’ this report should be of broad interest and historical burdens and benefi ts of health inequities. Health inequities are to community members, but our greater associated with these conditions. There unfair, avoidable, systemic differences desire is that its contents will be used are signifi cant differences in health in health status, morbidity and mortality to move discussions beyond individual status between groups in society who are rates. Social-determinants demonstrate choice-making toward the underlying economically and socially advantaged that the underlying cause of individual community environmental factors that and those who are not (due to factors and community health outcomes are not perpetuate poor health. such as socioeconomic status, race/ primarily the inevitable result of genes ethnicity, sexual orientation, gender, or individual health behaviors; nor the To achieve this broader goal, the Health and disability).1 Research now provides result of some ‘natural’ health-wealth Equity Report has three primary objectives: compelling evidence that group calculus. Neither is access to ‘health differences in health status are, at least care’ the primary driver. While genes, 1. To portray current social, economic and environmental factors associated with in part, attributable to the infl uence of health behaviors and access to care are inequities in health; place. Place is not merely the physical critically important, collectively, they location where one lives (and within contribute to only half of the entire 2. To assist local organizations in which health interventions occur); health equation. facilitating community dialogues place is a major determinant of risk regarding health inequities, focusing on root causes, rather than just individual and protective factors associated with Health Equity Report behaviors; health status and worthy of examination Framework in its own right. This is the essence of a The primary goal of the Louisville Metro 3. To encourage community-based social-determinants of health and health Health Equity Report is to promote actions related to social, economic, equity perspective. The underlying a community-wide understanding of and environmental determinants of determinants are pervasive, and are the root causes of health inequities in community health. evident in the quality and quantity Louisville Metro. It can also serve as an Health inequities are disparities in of housing (including the degree of impetus for discussing the community health or health care that are systemic residential segregation), education, conditions that contribute to health and avoidable, and therefore considered income and employment, transportation, in all of Louisville’s neighborhoods. unfair. Healthy People 2020 defi nes a natural and built environment, as well Key to fostering this understanding health disparity as “a particular type as community safety, and access to is thoughtful engagement with health and social determinant data and of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health “Health Equity is the attainment of the highest level of health for disparities adversely affect groups all people. Achieving health equity requires valuing everyone of people who have systematically equally with focused and ongoing social efforts to address experienced greater obstacles to avoidable inequalities, historical and contemporary injustices, health based on their racial or ethnic and the elimination of health and health care disparities.” group; religion; socioeconomic - Healthy People 2020

2 LOUISVILLE METRO HEALTH EQUITY REPORT status; gender; age; mental health; These social and physical factors are about health from those available to cognitive, sensory, or physical referred to as the Social Determinants of them. Individual choice is a factor; disability; sexual orientation or gender Health (SDOH), and through learning however, some environments do not identity; geographic location; or other more about the SDOH, community contain the health promoting resources characteristics historically linked to members can learn more about the root that are necessary for maintaining good discrimination or exclusion.”3 Different causes affecting health outcomes in health, such as grocery stores with neighborhoods in Louisville Metro can communities. fresh, affordable produce and parks that have very different health outcomes for are safe. Also, some neighborhoods their resident populations, and many of It is important to note that this report have a disproportionate concentration these differences are associated with operates under the understanding that of negative factors, including vacant social inequities related to income, race, health does not equal health care.5 buildings, crime, fast food retailers, or ethnicity, gender, or immigration status. Access to health care is a crucial need toxic polluting industries that can lead Poor health is concentrated among low that is addressed within the report, but to serious health problems and shorter income people and people of color it is not the most important determinant life spans for residents. residing in certain places.4 of good health. In fact, only “...10 to 15 percent of preventable mortality has This report seeks to elevate the The Louisville Health Equity Report been attributed to medical care.” 6 community discourse regarding health provides a baseline for understanding beyond issues of individual behavior the root causes of health inequities in There is a common perception that or access to medical treatment by Louisville Metro, and also serves as a individual behavior is the primary examining the relationships between mechanism for providing more localized determinant of health. This presumes social inequities and the neighborhood data about neighborhood conditions that some individuals choose to be conditions that shape overall health. that contribute to health outcomes. unhealthy, and that such choices are As the focus is narrowed to the places This report will examine income or within the control of every individual. where people live, rather than individual race based health inequities, and will This report counters this belief by citing choices and decisions, the infl uence of also present indicators addressing the data that suggest that people are, in large social inequity becomes more clear. social and physical environment of part, the products of their environment, neighborhoods that contribute to health. and are often limited to making choices

The Social Determinants of Health Much of the research on place and health has been articulated through a set of constructs termed “the Social Determinants of Health” (SDOH). The SDOHs consider how social and neighborhood conditions come together to impact health outcomes. Research has demonstrated that access to proven health protective resources like clean air, healthy food, recreational space, opportunities for high- quality education, living wage employment, and decent housing, is highly dependent on the neighborhood where one lives.7

Health can also be affected by the presence of risk factors. For ex- ample, the lack of a supportive neighborhood environment can lead to social and psychological circumstances that work to cause long-term stress, anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life. These psychosocial risks accumulate during life and increase the chances of premature death.8

Neighborhoods where people live have been associated with all-cause mortality, cause-specifi c mortality, coronary heart disease, low birth weight, perceived health status and rates of violent crime.9

Introduction 3 Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.

Social Inequalities status is evident across all races and federal housing policies that not only The Louisville Health Equity report ethnicities. This is demonstrated by the fact denied homeownership to urban African- continues the discussion surrounding that neighborhoods that are predominantly Americans but physically destroyed many the root causes of poor health outcomes white, but poor, will frequently have black neighborhoods under the policies along socioeconomic, racial and ethnic mortality rates equal to or greater than the of urban renewal.12 While it is beyond lines. These differences in health are mortality rates of neighborhoods of color the scope of this report to fully address strongly related to social inequities that with equal or higher income levels. An the history of structural racism in this have historically resulted in unequal example is the low life expectancy rates community and the full extent of its impact, opportunities to be healthy.10 in the predominantly white, low income this report will provide references to the Portland neighborhood of Louisville. impact of these forces on the root causes Life expectancy is shorter and many of health. diseases are more common further Structural Racism down the social ladder, as measured by Structural racism examines racial and Social Determinants socioeconomic status.11 ethnic impacts that stem from a history This report also provides information of disenfranchisement and policies that and indicators on determinants of health Though people of color often experience favored those in power. Consequently, the that have implications for the health of poorer health outcomes, these relationships origins of urban inequality for communities all Louisville’s neighborhoods, not just are by no means permanently fi xed; the of color cannot be separated from structural those with poor health. Neighborhoods health impact of income and socioeconomic racism. An example is the history of that are above the poverty level and

4 LOUISVILLE METRO HEALTH EQUITY REPORT Age-Adjusted Life Expectancy, in Years, 2006-2008

67.3 - 70.5 Downtown- Old Louisville- Phoenix Hill- Smoketown- 70.6 - 74.1 University Chickasaw- Shelby Park 74.2 - 78.2 Shawnee Northeast Portland Butchertown-Clifton- 78.3 - 83.1 St. Crescent Hill Russell Matthews Airport California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Southeast J-town South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5 Mile

LOUISVILLE METRO* LIFE EXPECTANCY IS 77.4 *Airport Census Tracts not included due to unreliabale ACS population estimates

In Jefferson County, the neighborhood in which one lives neighborhoods with lower concentrations of racial and can serve as a predictor of life ethnic minorities can also be affected by poor social expectancy. and physical conditions. Even though needs may not seem as immediate or apparent in these communities, they should nevertheless be addressed. For example, Neighborhoods that have the lowest low-density, large lot zoning policies can result in life expectancies are the same disconnected neighborhoods with poor accessibility neighborhoods with high levels of to health-promoting environments. Additionally, many poverty, crime, vacancies, payday Louisvillians live too far away from their job and lenders, and fast food retailers. from services and therefore spend too much time in their cars, resulting in measurable health detriments. Neighborhoods may not have concentrated poverty, These associations provide strong but they may be burdened with poor environmental evidence that the quality of the conditions including pollution or fl ooding. While the social and physical environment problems of the relatively better off are not as immediate may play an important role in as those living in poverty, they also encounter determining the health of community preventable problems that could be addressed through 9 thoughtful and informed community design. residents.

Introduction 5 HISTORICAL CONTEXT

Many conditions in Louisville Metro neighborhoods were not allowed to eat in most restaurants or to try on today are not the result of chance or of individual clothing in downtown shops. In the area of housing, choice. They are the result of policies and widely a city ordinance segregated the races by law until held ideas that developed, in part, out of our nation’s 1917. Even when the ordinance was overturned, tragic history of slavery and racial discrimination. whites continued to act to keep blacks out of many That history has a continuing impact on the health residential areas through strategies that ranged of our community today, leaving Louisville with some from restrictive clauses in deeds to community-wide striking racial and economic disparities. petitions to outright violence.

In the fi rst generations of Louisville’s existence, Only people organizing together in massive social the practice of slavery stripped the vast majority of protest movements brought about long-overdue African American residents of any hope of economic and meaningful change in the years after WWII. advancement—this meant that no matter how hard Landmark civil rights laws (1964) and open housing they worked, they could not acquire wealth as other laws (1967) ended legal segregation and many Americans could. Slavery also deprived them of the forms of discrimination. Yet some unfair policies and most basic rights, including the rights to education practices continued, especially in housing, where and legal marriage. Even the city’s sizeable free whites remained resistant to living in neighborhoods black population—though it managed to grow and with an infl ux of African American residents (such thrive—was kept out of many occupations and as in Louisville’s western neighborhoods). In 1968, places, and barred from voting. a protest there against the actions of a white police offi cer turned violent; two teenagers were killed and The Civil War brought an increase to the city’s African numerous stores were looted and damaged. When American population as black soldiers fl ocked into the riots ended, white business owners decided the Union Army through its Louisville headquarters not to rebuild. They took their investments to other and toward the freedom the war achieved in 1865. parts of town. Many white churches followed suit. By 1900, Louisville had the nation’s seventh largest Increasingly, well-to-do people of both races moved concentration of African Americans among U.S. out as well. West Louisville, lacking the infusion of cities (19.1%), a population growth that brought commercial development or new resources, became overcrowding and new majority-black neighborhoods even more economically and racially isolated. While such as Smoketown, California, and “Little Africa.” county-wide busing after 1975 integrated area schools and widened educational opportunities, Although Black Louisvillians organized themselves many students returned to long-standing disparities and advanced socially, educationally and politically, in their neighborhoods. their opportunities remained limited by racial segregation and discrimination. Until World War II, This brief review of Louisville’s history will hopefully most black Louisvillians were unwelcome in higher- contribute to a fuller understanding of the social paying industrial jobs and were hired only for unskilled determinants of health and of the disparities that labor, domestic services, or in institutions catering exist among Louisville Metro neighborhoods. only to blacks. Prior to the 1960s, African Americans

6 LOUISVILLE METRO HEALTH EQUITY REPORT REPORT METHODOLOGY Literature Review overcome the mismatch. In the core of measures that were the best proxies for In understanding the critical importance the city, neighborhood areas were kept social determinants of health. Mortality of social and physical environments in relatively small in population size and data from Kentucky Vital Statistics was spatial area in an attempt to maintain determining population health outcomes, averaged for the years 2006-2008 (the historical distinctions between places.” this report will present recent research latest fi nal versions available at the time 13 that illustrates the connections between of report productions). place and health. For organizing data at the sub-county Many of the Social Determinant level, the report chooses to use indicators were derived from the 2005- Social Inequities & Neighborhood Areas rather than Zip 2009 American Community Survey Health Outcomes Codes or Council Districts for a number (ACS) Estimates, which are available at This report includes recent data from of reasons. The most important reason the Census Tract level (using Census 2000 the Centers for Disease Control and being that the Neighborhood Areas help Tract boundaries). Beginning with Census Prevention (CDC) Behavioral Risk connect the statistics to the actual places 2010, the Census Bureau began replacing Factor Surveillance System (BRFSS)*, and people they are describing. When the traditional long form with data from organized by factors including race a Neighborhood Area is associated the ACS. But as the ACS data is a sample and income to illustrate the health with a particular indicator, the reader survey, it has a higher margin of error inequities experienced in low-income creates a mental picture much more than the prior collection method. For this neighborhoods and communities of color. easily than would be possible if Zip reason, Social Determinant indicators that Codes or Council Districts were the include population statistics for Census A local work group comprised of unit of enumeration. Further, most Zip Tracts in the ‘Airport’ Neighborhood Area community organizations and local Codes and Council Districts overlap and were not included due to unreliability agency representatives worked to identify segment traditional neighborhood areas associated with sampling very small the indicators and guide the primary across Louisville Metro. Any given Zip populations. content presented in this report. Code or Council District can contain bits and pieces of several traditional Many data sources were derived from state Social/Environmental Louisville neighborhoods that are often or local government agencies in list or Determinants & very different from one another socially, database formats that were geocoded and Louisville Neighborhood economically, or physically. However, analyzed using Geographic Information Areas compartmentalizing neighborhood Systems. These data include locations This report presents a range of social data is complex and imperfect, and of crimes, fast food outlets, bicycle and Neighborhood Area boundaries will not and environmental indicators for pedestrian collisions, etc. Neighborhood Areas in Louisville perfectly refl ect realities of everyday life in communities. Neighborhoods do not that provide localized data about the Most of the thematic map data depicted exist in isolation, but for the purpose of neighborhood conditions that contribute is this report is organized using the understanding some of the immediate to health. In this context, Neighborhood “Jenks” Natural Breaks data classifi ca- and powerful determinants of health Areas are defi ned as… tion method. This classifi cation statisti- inequities, it is helpful to artifi cially isolate cally determines the best arrangement the neighborhood context and examine it “… groupings of census tracts, of values into classes by seeking to neighborhood areas represent independent of the larger county-wide minimize each class’s average deviation established city neighborhoods and context. 14 from the class mean, while maximizing residential communities or areas of the each class’s deviation from the means of county. To improve statistical reliability, smaller city neighborhoods with similar Data Sources the other groups.The method reduces the populations were often combined into This report includes the most recent data variance within classes and maximizes a single neighborhood area. Census that could be analyzed at a sub-county the variance between classes. tract boundaries were sometimes level that was available at the time of not consistent with neighborhood report production. Within the available boundaries, but combining data sources, researchers selected the *See note regarding BRFSS neighborhoods often allowed us to data at the bottom of page 17

Introduction 7 SELECTED DEMOGRAPHICS

Race & Ethnicity

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Jefferson Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Southeast J-town South Louisville Central Shively Louisville Percent of Population by Buechel- Newburg-- Neighborhood Who Are Airport Fern Indian Trail White, One Race South Creek Louisville

2005-2009 ACS Estimate 65 Pleasure Ridge Park Floyd’s Fork Highview- 5.6% - 10.5% 63 Okolona

10.6% - 64.6% 62 Fairdale Valley 64.7% - 87.5% 58 Station 5 87.6% - 95.0% Miles

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Jefferson Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews California- Parkland Highlands Algonquin - Park Hill - German- Park Duvalle town Southeast J-town South Louisville Central Shively Louisville Percent of Population by Buechel- Newburg-- Airport Fern Neighborhood Who Are Black or Indian Trail South Creek African American, One Race Louisville 2005-2009 ACS Estimate Pleasure Ridge Park Floyd’s Fork Highview- Okolona 1.8% - 4.9% Fairdale 5% - 13.9% Valley Station 5 14% - 59.6% Miles 59.7 - 92.4%

Residential Segregation: Black & White The Index of Dissimilarity compares the amount of spatial segregation or spatial dissimilarity between two populations (or ethnic/racial/immigrant groups) across geographic units that make up a larger geographic entity. The index ranges from 0 to 100, with 0 meaning no segregation or spatial disparity, and 100 being complete segregation between the two groups with no spatial overlap. The index of dissimilarity for the white and black populations of Metro Louisville Neighborhood Areas is 53%. This means that 53% of the black population would have to move in order for the white and black population to be spatially integrated.

8 LOUISVILLE METRO HEALTH EQUITY REPORT Percent of Population by Neighborhood Who Are Hispanic or Latino, of Any Race 2005-2009 ACS Estimate Downtown- 0.5% - 1.0% Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 1.1% - 1.7% Shawnee Northeast Jefferson 1.8% - 4.3% Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 4.4% - 8.0% California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Southeast J-town South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

Percent of Population by Neighborhood Who Are Asian Downtown- Old Louisville- Phoenix Hill- Smoketown- 2005-2009 ACS Estimate University Chickasaw- Shelby Park Shawnee Northeast 0% - 0.1% Jefferson Portland 0.2% - 0.8% Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 0.9% - 2.2% Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 2.3% - 3.9% town Southeast J-town South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles Census Defi nition of Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. It includes people who indicate their race as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japanese,” “Vietnamese,” and “Other Asian” or provide other detailed Asian responses. http://quickfacts.census.gov/qfd/meta/long_RHI405210.htm

Selected Demographics 9 Age

Percent of People Age 65 & Over Downtown- by Neighborhood Old Louisville- Phoenix Hill- Smoketown- University 2005-2009 ACS Estimate Chickasaw- Shelby Park Shawnee Northeast Jefferson 6.2% - 9.6% Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 9.7% - 13.3% California- Parkland Highlands Algonquin - Park Hill - 13.4% - 17.2% Park Duvalle German- town Southeast J-town 17.3% - 24.3% South Louisville Central Shively Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork 65 Highview- Okolona 63 Fairdale Valley 62 Station 5 58 Miles

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Percent of Children Under Age 5 Jefferson by Neighborhood Portland Butchertown-Clifton- St. 2005-2009 ACS Estimate Russell Crescent Hill Matthews California- Parkland Highlands Algonquin - Park Hill - 2.3% - 3.5% Park Duvalle German- town Southeast J-town 3.6% - 6.5% South Louisville Central Shively Louisville 6.6% - 11.1% Buechel- Newburg-- Airport Fern Indian Trail 11.2% - 16.8% South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

10 LOUISVILLE METRO HEALTH EQUITY REPORT Selected Demographics

Percent of Households where Grandparent is Responsible for Own Grandchildren under 18 Downtown- Old Louisville- Phoenix Hill- Smoketown- Years by Neighborhood University Chickasaw- Shelby Park 2005-2009 ACS Estimate Shawnee Northeast Jefferson Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 0.1% - 1.3% California- Parkland Highlands 1.4% - 3.2% Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 3.3% - 6.1% South Louisville Central Shively Louisville 9.0% Buechel- Newburg-- Airport Fern Indian Trail South Creek Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona 65 Fairdale 63 Valley Station 5

62 Miles 58

Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park Shawnee Northeast Jefferson Percent of Foreign Born Population Portland by Neighborhood Butchertown-Clifton- St. Russell Crescent Hill Matthews 2005-2009 ACS Estimate California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 0.2% - 2.4% town Southeast J-town South Louisville Central 2.5% - 5.1% Shively Louisville Buechel- 5.2% - 8.5% Newburg-- Airport Fern Indian Trail South Creek 13.4% Louisville

Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

Selected Demographics 11

HEALTH STATUS - Selected Mortality & Disease Rates Deaths Due to All Causes (Age-Adjusted Rate per 100,000 Population) { 2006 -2008 Vital Statisitcs

1572 Portland In a 2003 study involving blacks, Mexican- 1528 Fairdale Americans, and whites in the United States, Algonquin-Park Hill mortality rates for all gender and racial/ 1500 -Park Duvalle ethnic groups were two to four times higher Phoenix Hill-Smoketown for those with the lowest incomes who lived 1418 -Shelby Park in the lowest SES neighborhoods compared 1404 California-Parkland with those with the highest incomes who 1378 Russell lived in the highest SES neighborhoods.

South Central Louisville 1217 Deaths would hypothetically be reduced by 1178 Fern Creek about 20% for each subgroup if everyone had the same death rates as those living in the 1085 Shively highest SES neighborhoods. Downtown-Old Louisville 1065 -University Winkleby MA, and Cubbin C. (2003). J Epidemiol Chickasaw-Shawnee 1064 Community Health. 2003 Jun;57(6):444-52. 1028 Pleasure Ridge Park 1007 Germantown Louisville Metro* rate is 832 South Louisville 899 *not including Airport Census Tracts Buechel-Newburg 896 -Indian Trail Downtown- Old Louisville- Phoenix Hill- Smoketown- University 860 Valley Station Chickasaw- Shelby Park Shawnee Northeast Jefferson 858 Highlands Portland Butchertown-Clifton- St. Butchertown-Clifton Russell Crescent Hill Matthews 837 -Crescent Hill California- Parkland Highlands 837 Highview-Okolona Algonquin - Park Hill - Park Duvalle German- town Southeast J-town Floyd's Fork South Louisville 820 Central Shively Louisville 691 Southeast Louisville Buechel- Newburg-- Airport Fern Indian Trail 661 J-town South Creek Louisville Northeast 617 Pleasure Ridge Park Jefferson Floyd’s Fork Highview- 561 St. Matthews Okolona

Fairdale Valley Station 5

Miles

12 LOUISVILLE METRO HEALTH EQUITY REPORT Deaths Due to Diseases of the Heart (Age-Adjusted Rate per 100,000 Population) 2006 -2008 Vital Statistics 677 Fairdale

555 Fern Creek Adult Report of Heart Disease or Heart Attack 466 Portland Adult Report of Coronary Heart Disease 408 California-Parkland 2009 CDC BRFSS 6.0% 387 Pleasure Ridge Park 4.7% 3.8% Algonquin-Park Hill 373 -Park Duvalle 342 Shively US Kentucky Louisville Metro 328 Germantown Adult Report of Heart Attack 318 Chickasaw-Shawnee 2009 CDC BRFSS 5.9% South Central Louisville 4.6% 315 4.0% Phoenix Hill-Smoketown 309 -Shelby Park US Kentucky Louisville 287 South Louisville Metro 282 Downtown-Old Louisville -University 259 Russell 248 Floyd's Fork Louisville Metro* rate is 236 233 Buechel-Newburg -Indian Trail *not including Airport Census Tracts 232 Highview-Okolona Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 220 Valley Station Shawnee Northeast Jefferson Butchertown-Clifton Portland 219 Butchertown-Clifton- St. -Crescent Hill Russell Crescent Hill Matthews California- 200 Highlands Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 198 Northeast Jefferson town Southeast J-town South Louisville Central 195 Southeast Louisville Shively Louisville Buechel- Newburg-- J-town Airport Fern 173 Indian Trail South Creek Louisville 145 St. Matthews Pleasure Ridge Park Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

Health Status 13 Deaths Due to Cancer, All Types (Age-Adjusted Rate per 100,000 Population) 2006 -2008 Vital Statisitcs 677 555 318 California-Parkland Algonquin-Park Hill 302 -Park Duvalle 293 Phoenix Hill-Smoketown Age-Adjusted Cancer Incidence -Shelby Park (New Cancers) Rates per 100,000, 285 Russell Kentucky Cancer Registry 2006-2008

275 South Central Louisville

265 Fern Creek Kentucky 559

262 Fairdale 259 Portland Louisville Metro 580 228 Shively 0 100 200 300 400 500 600 Downtown-Old Louisville 226 -University

218 Germantown Louisville Metro* rate is 189 215 Pleasure Ridge Park *not including Airport Census Tracts 213 Highview-Okolona 206 Chickasaw-Shawnee

South Louisville 203 Downtown- Old Louisville- Phoenix Hill- Smoketown- Buechel-Newburg University 196 -Indian Trail Chickasaw- Shelby Park Shawnee Northeast Jefferson 191 Valley Station Portland Butchertown-Clifton- St. Butchertown-Clifton Russell Crescent Hill Matthews 186 -Crescent Hill California- Parkland Highlands Algonquin - Park Hill - Floyd's Fork Park Duvalle 175 German- town Southeast J-town South Louisville 170 Southeast Louisville Central Shively Louisville J-town Buechel- Newburg-- 158 Airport Fern Indian Trail South Creek 154 Highlands Louisville Pleasure Ridge Park St. Matthews Floyd’s Fork 154 Highview- Okolona 146 Northeast Jefferson Fairdale Valley Station 5

Miles

14 LOUISVILLE METRO HEALTH EQUITY REPORT Deaths Due to Diabetes (Age-Adjusted Rate per 100,000 Population) 2006 -2008 Vital Statisitcs

466 Algonquin-Park Hill 82 -Park Duvalle Adults Diagnosed with Diabetes, Phoenix Hill-Smoketown 2009 CDC BRFSS 77 -Shelby Park 15 59 Portland

51 California-Parkland 12 13.0% 11.5% 48 South Central Louisville 9 8.3% 48 Germantown 6 Downtown-Old Louisville 46 -University 3 46 Shively 0 Fairdale US Kentucky Louisville 46 Metro 45 Valley Station

Pleasure Ridge Park 45 Louisville Metro* Chickasaw- rate is 28 43 Shawnee *not including Airport Census Tracts 41 Russell

38 Fern Creek

Buechel-Newburg Downtown- Old Louisville- Phoenix Hill- 34 -Indian Trail Smoketown- University Chickasaw- Shelby Park South Louisville Shawnee Northeast 31 Jefferson Portland 30 Highview-Okolona Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 25 Floyd's Fork Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town 22 Highlands Southeast J-town South Louisville Central Butchertown-Clifton Shively Louisville 22 -Crescent Hill Buechel- Newburg-- Airport Fern Southeast Louisville Indian Trail 19 South Creek Louisville

16 J-town Pleasure Ridge Park Floyd’s Fork Highview- 16 Northeast Jefferson Okolona

St. Matthews Fairdale 11 Valley Station 5

Miles

Health Status 15 INCOME & EMPLOYMENT

Poverty and Health pressure, obesity, weakened immune The fi ndings from research about the system. links between poverty and poor health • Chronic diseases like diabetes, heart outcomes are compelling: Poverty in Louisville Metro disease, and many types of cancer. • People who are poor face increased In Louisville Metro, 12.7% of all odds of developing disease. Income • Infectious diseases ranging from HIV/ families have incomes below the and wealth are the strongest AIDS to seasonal fl u. poverty level, and 15.7% of all determinants of positive health people have incomes below the outcomes, and the strength of this • Disabilities like blindness, mental poverty level.7 Both measures for 1 relationship is increasing. illness and decline of physical Jefferson County are higher than the strength. national rates of 10.5% and 14.3% • Lower socioeconomic status respectively. is adversely associated with psychosocial factors linked to In Louisville, poverty rates for Blacks coronary heart disease, particularly and Hispanics are nearly three times hostility and depression.2 higher than the poverty rates of • Heart and lung diseases are whites. disproportionately found among those living in low income households.3 Income Below Poverty Level, • Both individual poverty and 2009 ACS ESTIMATE neighborhood poverty are associated with poorer health outcomes.4 BLACK OR 31.9% AFRICAN • Poverty limits access to health- AMERICAN promoting resources, including ALONE access to healthy food and favorable housing, as well as adequate medical care and stable health insurance.5 HISPANIC People lower on the socioeconomic OR 31.7% LATINO scale are more likely to experience:6

• Newborn health problems like premature birth, low birth weight, and birth defects. WHITE ALONE 11.1% • Signs of future disease like high blood

In terms of dollars, federal poverty guidelines are set each year by the U.S. Department of Health & Human Services as a national measure used to determine eligibility for an array of programs and services. These guidelines are sometimes referred to as the Federal Poverty Level, or FPL. The 2009 poverty level for one person is $10,830 in annual income and $22,050 for a family of four (U.S. Dept. of Health & Human Services. www.aspe.hhs.gov).

16 LOUISVILLE METRO HEALTH EQUITY REPORT Income Inequality Per Capita Income by Race/Ethnicity, and Health Louisville Metropolitan StaƟ sƟ cal Area (MSA), 2009 Poverty is by itself a risk factor, but the size of the gap between those with high $27,447 incomes and those at the lower end $16,897 of the economic scale appears to pose $12,410 additional risks. A growing amount of research shows that health outcomes are WHITE BLACK OR HISPANIC AFRICAN directly connected to how evenly income AMERICAN is distributed across the population.8 While the reasons for this are still being Income Inequality explored, some researchers believe that The gap between rich and poor is increasing at a high larger rich-poor gaps may lead to spatial rate in Kentucky. A study released in 2007 showed that concentrations of race and poverty that from the late 1990s to the mid 2000s, the poorest 20% 9 lead to poorer health outcomes. saw their incomes fall by 9.7%, and families in the middle income range saw decreases of 5.8%, while the drop for those at the top was only 1.3%.10

One example of the higher rates of disease Heart Attacks by Income among people living in poverty is evident 25% Percentage of People Ages 40-65 in the chart to right.The chart shows ReporƟ ng a Heart AƩ ack, By Income+ that for BRFSS* respondents ages 40- 20% Louisville Metro BRFSS, 2009 65 in Jefferson County (2009), the rate 15% of people who report having had a heart

attack who live in households making less 10%

REPORTED 11.6% than $20,000 is more than twice that of HEART ATTACKS respondents in households making more 5% than $20,000. 3.6% 4.2% 0% Less than $20K to More than $20K $35K $35K n = 251 n = 194 n = 359 +Respondents earning less than $20K annually INCOME are more likely to report a heart attack x2 = 15.6, df = 2, p-value = 0.0004

*The Behavioral Risk Factor Surveillance System (BRFSS) is performed under the auspices of the Centers for Disease Control and Prevention (CDC). This state-based telephone surveillance system is designed to collect data on individual risk behaviors and preventive health practices related to the leading causes of morbidity and mortality in the United States. The version of the BRFSS used in this report was administered by the KY Department of Public Health, and made available by the CDC. The Louisville Metro Department of Public Health and Wellness uses the same survey instrument in selected years, but did not administer the BRFSS in 2009.

Income & Employment 17 Lack of job opportunities with adequate wages Hourly Wages in Louisville Metro, 2008 In trying to make ends meet in the face of low wages and the high costs of living, low income people are forced to make diffi cult 1 Adult 1 Adult, 2 2 Adults, 2 Adults, 1 Child Adults 1 Child 2 Children choices in paying for basic needs, including housing, food, transportation, and health care.11 Living Wage $7.93 $15.5 $12.29 $19.9 $26.04 The scope of the problem is demonstrated through the following Poverty $5.04 $6.68 $6.49 $7.81 $9.83 example. The American Community Survey (2009) estimate of Wage the number of people in the Louisville Metro who are employed Minimum in service occupations is 60,983, or 17.8 percent of the population. Wage $7.25 $7.25 $7.25 $7.25 $7.25 The typical hourly wage for a Food Preparation and Service Worker in the Louisville Metro for 2008 was $7.92. Therefore, within one Source: Dr. Amy K. Glasmeier and The Pennsylvania State University industry, approximately 60,000 people in the Louisville Metro could be earning an average wage of just $7.92 an hour, barely a living wage for one adult, much less for a family with children.

Employment Rates 25 Hispanic and black communities in metropolitan areas generally Estimated Unemployment rates in experience greater hardship from unemployment than whites.12 20 Louisville Metro, by Race/Ethnicity, 2005-2009

The single-year ACS estimates for 2009 give an unemployment 15 14.9% estimate for Louisville Metro of 10.4%, higher than the 2009 Louisville Metro KY/IN Metropolitan Statistical Area (MSA) rate 10 of 10.1%.13 The 5-year ACS estimate for 2005-2009 shows the UNEMPLOYMENT RATE 8.6% black unemployment rate at more than double that of whites. This is 5 6.3% believed to be an underestimate because of the way unemployment 3.4% 0 rates are calculated. These rates are based on the proportion of BLACK OR HISPANIC WHITE ASIAN estimated adult workers who are currently receiving unemployment AFRICAN OR LATINO ALONE AMERICAN benefi ts. Because of the extended nature of the recession, the period ALONE of unemployment for many people has exceeded the eligibility period; and these individuals are no longer refl ected in the count.

Unemployment and Health 25 Unemployment is associated with premature death, cardiovascular Self-Reported Poor Health by disease, hypertension, depression, and suicide.14 Evidence shows 20 Employment Status, Ages 18-64 that, even after allowing for other factors, unemployed people and Louisville Metro BRFSS, 2009 their families suffer a substantially increased risk of premature 15 death.15 10 8.5% The chart to the right shows that for BRFSS respondents ages 18-65 POOR HEALTH 5 in Jefferson County in 2009, the rate of poor self reported health for 2.1%

the unemployed was four times higher than the rate for respondents PERCENT OF ADULTS WITH 0 that were employed for wages or self employed. Unemployed Employed for Wages n = 117 or Self Employed n = 568

REPORTING POOR HEALTH

18 LOUISVILLE METRO HEALTH EQUITY REPORT Job Insecurity and Employment and Health Health Benefi ts In the current economy, workers are The United States has a long-standing Health Insurance Coverage increasingly worried that they may be tradition of linking health insurance to by Employment Status in Louisville Metro laid off. Unemployed workers may employment, a relationship that was eventually be forced to take temporary cited recently in the Louisville Health 2009 ACS ESTIMATE employment with agencies that do not Status Report.20 The Institute of Medicine have the workers’ long term interests at (2001) found that families with at least heart.16 one full-time, full-year worker are 86.7% more than twice as likely to have health This sort of insecurity has been shown to insurance coverage, compared to families impact mental health (particularly anxiety whose wage earners work as part-time and depression), self-reported ill health, employees, as temporary workers, or EMPLOYED WITH INSURANCE heart disease and risk factors for heart in which there is no wage earner.21 disease.17 Having little control over one’s Individuals without health insurance work is strongly related to an increased frequently forego timely health care, risk of low back pain, absenteeism, and suffer more severe illness, and are more cardiovascular disease.18 likely to die a premature death than their 49.0% insured counterparts.22 Examining inequities in job insecurity, blacks are more likely than Latinos The 2009 ACS estimates 12.1% of the or whites to work nonstandard hours, population in Louisville Metro (85,000 UNEMPLOYED WITH INSURANCE including rotating shifts, which is people) do not have health insurance associated with greater health risks.19 coverage.23 While high, this is less than the overall KY rate of 16.1%.24

25 Households with Assistance Income support programs With the lack of “good paying” jobs and jobs with 20 Income in Louisville Metro 2009 ACS ESTIMATE suffi cient health benefi ts, people are increasingly 15 12.8% looking to supplement shrinking incomes with income- supporting programs, such as Medicaid, W I C, food 10 stamps, and Section 8 Housing benefi ts. 4.1% 5 2.8%

0 FOOD SUPPLEMENTAL CASH STAMP SECURITY PUBLIC BENEFITS INCOME ASSISTANCE

Income & Employment 19

UNEMPLOYMENT (PERCENT) (Civilian Labor Force, Ages 16 and Older) { 2005-2009 ACS ESTIMATE

22.7% Russell Unemployment is 21.5% California-Parkland associated with premature mortality, cardiovascular 20.2% Algonquin-Park Hill -Park Duvalle disease, hypertension, 20.1% Portland depression, and suicide.+

17.3% Phoenix Hill-Smoketown -Shelby Park Evidence shows that, even 16.2% Chickasaw-Shawnee after allowing for other 15.4% South Central Louisville factors, unemployed people and their families suffer a 11.7% South Louisville Louisville Metro* substantially increased risk 11.5% Shively rate is 7.9% of premature death. ++

10.1% Valley Station *not including Airport Census Tracts Buechel-Newburg 10.0% -Indian Trail 9.9% Fairdale

9.6% Downtown-Old Louisville -University 8.6% Germantown

8.3% Pleasure Ridge Park Downtown- Old Louisville- Phoenix Hill- Smoketown- University 7.6% Butchertown-Clifton Chickasaw- Shelby Park -Crescent Hill Shawnee Northeast Jefferson 6.5% Highview-Okolona Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 4.9% Fern Creek California- Parkland Highlands Algonquin - Park Hill - 4.8% Southeast Louisville Park Duvalle German- town Southeast J-town South Louisville 4.6% Northeast Jefferson Central Shively Louisville Buechel- 4.5% Floyd's Fork Newburg-- Airport Fern Indian Trail South Creek 4.0% St. Matthews Louisville

Pleasure Ridge Park 4.0% J-town Floyd’s Fork Highview- Okolona 3.6% Highlands Fairdale Valley Station 5

Miles

+ Cornwall, A. & Gaventa, J. (2001). Users and choosers to makers and shapers: Repositioning participation in social policy. Working Paper 127 Sussex. East Sussex, UK: Institute of Development Studies, University of Sussex.

++ Wilkinson, R. & Marmot, M. (Eds.) (2003). Social determinants of health: the solid facts. 2nd edition. Geneva, Switzerland: WHO Press, World Health Organization

20 LOUISVILLE METRO HEALTH EQUITY REPORT

FAMILIES EARNING LESS THAN $15,000 (PERCENT) (Income & Benefi ts in 2009 infl ation adjusted dollars) { 2005-2009 ACS ESTIMATE

44.6% California-Parkland People lower on the 40.4% Russell socioeconomic scale are more + Phoenix Hill-Smoketown likely to experience: 38.8% -Shelby Park • Newborn health problems like Algonquin-Park Hill premature birth, low birth weight, and 33.5% -Park Duvalle birth defects. 32.4% Portland • Signs of future disease like high blood pressure, obesity, weakened 27.5% Downtown-Old Louisville -University immune system.

25.4% South Central Louisville • Chronic diseases like diabetes, heart disease, and many types of 20.0% Chickasaw-Shawnee cancer. Buechel-Newburg 20.0% • Infectious diseases ranging from -Indian Trail HIV/AIDS to the seasonal fl u. 16.5% Germantown • Disabilities like blindness, mental South Louisville illness and decline of physical 13.9% strength.

11.8% Shively

11.0% Fairdale Louisville Metro* rate is 9.8% 9.0% Valley Station *not including Airport Census Tracts 8.4% Butchertown-Clifton Downtown- Old Louisville- Phoenix Hill- -Crescent Hill Smoketown- University Chickasaw- Shelby Park 8.1% Pleasure Ridge Park Shawnee Northeast Jefferson Portland 7.2% Highview-Okolona Butchertown-Clifton- St. Russell Crescent Hill Matthews 5.4% St. Matthews California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 5.0% Southeast Louisville town Southeast J-town South Louisville Central 3.9% Highlands Shively Louisville Buechel- 3.3% Fern Creek Newburg-- Airport Fern Indian Trail South Creek 3.1% J-town Louisville Pleasure Ridge Park Floyd’s Fork 2.5% Northeast Jefferson Highview- Okolona 2.3% Floyd's Fork Fairdale Valley Station 5

Miles

+Adler, N. & Stewart, J. (2008). Reaching for a healthier life: Facts on socioeconomic status and health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.

Income & Employment 21 HOUSING Housing is a dynamic, multi-faceted housing (the links between poor health, and have higher rates of specifi c issue. In this brief overview of the ways housing conditions and a range of chronic health conditions in comparison in which housing can contribute to health preventable and chronic diseases are to similar people living in affordable or disease, the following factors are addressed more fully in the section on housing.6 considered: Environment and Health on page 32). When looking specifi cally at renters, • Housing Affordability • Lose out on the opportunity for “wealth research shows signifi cant associations • Home Ownership accumulation” that has traditionally between unaffordable rent, and • Foreclosures come from homeownership; or inadequate childhood nutrition and • Fair Lending they can risk a fi nancial crisis and growth.7 Higher rents, especially for low- • Housing Segregation bankruptcy when they are over- income families, drastically reduce the • Subsidized Housing and Housing extended. Wealth accumulation income that a family can devote to other associated with homeownership Supports basic needs, including food, clothing, improves access to neighborhoods • Housing Instability and Residential medicine, health care and family with more health promoting assets, Displacement activities that help provide exercise and such as grocery stores, places to 8 • Homelessness emotional stability. exercise, and good schools, as well as 2 In low-income neighborhoods and to higher quality housing. communities of color, adverse housing • Are at risk for a myriad of poor health factors are disproportionately present outcomes associated with the impact Fair Market Monthly Rents for and their cumulative effect can take a of accumulated stress. Financial Louisville Metro serious toll on the health of their citizens. strain related to housing is linked with FY 2001 - FY 2011 $1200 poor health outcomes including all- Housing & Health cause mortality, a higher prevalence 4 BEDROOM Housing can be a determinant of the $1000 of chronic conditions, and a higher health of individuals, families, and 3 BEDROOM incidence of depressive symptoms.3 the communities in which they live. $800 Health is not only affected by the 2 BEDROOM 1 BEDROOM physical characteristics of housing $600 Housing Affordability & units and neighborhood design, but it Health 0 BEDROOM is deeply impacted by the social and High housing-related costs lead to health $400 economic factors that underlie housing risks in a variety of ways, with families statistics, such as neighborhood stability having to make tough decisions between 20012002 2003 2004 2005 2006 2007 2008 2009 2010 2011 and the building of wealth through housing costs and health insurance, homeownership. Housing not only To afford Fair Market Rent (2010) for a 2 Bed medications, and healthy foods.4 provides basic shelter, it can determine Room unit in Louisville, a household needs an annual income of $27,360 where people shop, go to school, play, The stress experienced as a result of and work, and it can infl uence who their unaffordable housing is associated 46% of Renters in Louisville are unable to afford the Fair Market Rate for 2 Bed Room friends are and the opportunities they with a increased risk for developing 1 housing unit have to be an active part of a community. hypertension, lower levels of psychological well-being, and more Source: U.S. Department of Housing and Urban Development Families that have diffi culty affording *data for years 2001 and 2002 are for the Louisville, KY/IN MSA visits to the doctor.5 housing:

• Often live in neighborhoods of For both homeowners and renters, disinvestment with more risk factors, those living in unaffordable housing are including larger stocks of substandard more likely to report cost-related health care nonadherence, poor self-reported

22 LOUISVILLE METRO HEALTH EQUITY REPORT Homeownership and Health 100% Percent of Homeowners by Race/Ethnicity Historically, homeownership has been the 2007-2009 ACS ESTIMATES primary, long-term strategy for building LOUISVILLE/JEFFERSON COUNTY wealth in the United States, and wealth UNITED STATES is one of the strongest determinants of 75% 74.8 health.9 But many families continue 72.4 to deal with obstacles to accessing and 59.3 50% maintaining homeownership, including 51.2 the ever-increasing cost in utilities, health 48.4 46.2 care, food, and other necessities and the 40.6 39.5 impact of fl at or declining income.10 25%

Nationally, homeownership rates have dropped to their lowest levels since 1998, 0% and homeownership rates for Hispanics WHITE ASIAN HISPANIC BLACK OR ALONE OR LATINO AFRICAN and African Americans have dropped AMERICAN 11 nearly twice as much as for whites. ALONE This represents a massive drain of wealth from Latino and African American stability in these communities brought on borrower losses due to foreclosure communities, who were starting with by foreclosures present an acute public nationally represent 46% of total losses homeownership rates some 25 points health crisis.15 to foreclosure, even as these two groups lower than whites. This disparate drop in represent only 27.9% of the population homeownership exacerbates the growing Many of the neighborhoods impacted by of the United States. The loss of wealth racial wealth gap.12 high foreclosure rates already bear the among African American and Latino sub burden of the poorest health outcomes, prime borrowers due to foreclosure is A reduction in homeownership has with the life expectancy in these areas estimated at $213.1 billion, compared also been linked to a reduction in local being up to 10 years less than other areas to a loss of $462.2 billion for sub prime businesses, which not only affects the of the city.16 In a recent study conducted borrowers as a whole.18 goods and services that are available, but on foreclosures in Louisville, 50% of also affects the employment opportunities the foreclosure study participants cited for local residents. The ripple effect medical expenses or health issues as a continues in that the loss of jobs can, in primary

! factor ! ! ! ! turn, lead to increased foreclosures, and ! ! ! ! ! ! Foreclosure Auctions, 2009 ! ! ! ! ! 13 ! ! leading to the ! ! ! general disinvestment. ! ! !! ! !! !!! ! ! ! ! ! !! !! ! One Foreclosure Auction ! ! ! ! ! ! ! ! 17 !!! ! ! ! !! ! ! ! !!! ! !! ! ! ! !!! foreclosure. ! ! ! ! ! ! !!! !! ! ! ! ! ! ! ! ! ! !!!! !!! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! !! !! !! ! ! ! !! ! !!! ! !! ! ! ! ! !!! ! ! !! ! !! ! ! ! !! ! !!!!!! ! !! !! ! !!!!!!!!! !!!!!! ! ! ! ! !! ! ! !!! !!! !!!!!!!!!! !! ! ! ! ! ! !!!!! !!! !!! !!!! ! ! ! ! !!!! ! ! !! ! !! !!!!!!! ! !!! !!! !! ! !! ! ! ! ! ! !! ! ! !! ! !!!! ! !!!!!! !!!!!! ! ! !! ! ! ! ! ! ! !! !!! !!!! ! !!!!! ! ! !! ! ! ! ! ! ! ! At the root ! ! !!!! ! !!!!!!!!!!! ! !! ! ! ! ! ! ! !!!!! !! !!! !!!! ! ! ! ! ! ! ! ! ! !!!!!!!!! !!!!!!!! !! ! ! ! ! ! ! ! ! ! !! !!!!!!!!!!!!! ! ! !!!! ! ! ! ! ! !! !! ! ! ! ! ! ! ! Foreclosures !! !! !!!!!!!!! !!!!!!! ! !! ! !! ! ! ! ! ! ! ! ! ! ! !! !! ! ! !!!!! !!! ! ! !! ! ! ! ! ! ! ! ! ! ! ! ! !! !! !! ! ! ! ! ! !! ! ! ! ! ! !!!! !!! !!!! !! ! ! ! ! ! !!!! !! !!!!!!!!! ! ! !! ! ! ! ! ! ! ! ! ! !! !!!!!! !!!!! !! ! ! !! !!! ! ! ! ! ! !!!!! !!!!! !!!!!!!!! ! ! !!!!!!!!! !!!! !!! ! ! ! ! ! ! ! ! ! !!!!!!!! !! !!!!!!!!! !!! ! ! ! ! ! !! of many !!!!!!!!! !!!! !! ! !! !! !!!! ! ! ! ! ! ! ! ! !! ! ! ! !!! ! ! ! ! ! !!! ! !!!!!!!!! ! ! ! !! !!! !!!! ! !! !!!! ! ! !! ! ! ! Foreclosures can have devastating health !!!!!!!!!! !!! !!!!!!!!!! ! ! !! ! ! !! ! ! ! !! ! !! ! !!! !!!! !!! ! ! ! ! ! ! ! ! !!!!!!!!!! !! !! !! !! !! !!! ! ! !! ! ! ! !!!! !!! !! !! !!!! ! ! ! ! !!!! !!!!!!! ! !! !! !! !! ! ! ! ! ! ! ! !! !!! !!!! !!! !!! !! !! !! ! ! ! ! !! !! !! !! ! ! ! ! ! ! ! ! !!! !! !! ! ! ! ! ! ! ! !! ! ! ! ! !! !!!! ! !! ! ! ! !! ! ! ! ! ! ! !!! !!! ! ! ! ! !!! !! ! ! foreclosures !! !!! !!!! !!!! ! ! ! ! !! ! !! ! ! ! ! ! !! ! ! ! ! ! ! !! ! !!! !!! ! ! ! ! ! !! ! !!! !! ! impacts, not only for individuals and ! ! ! !! ! ! !!! !! !! ! !! ! ! !! ! ! ! ! ! ! ! ! !! ! !! !!!! ! !! ! ! ! ! ! !! ! ! !! ! !!! ! ! ! !!! ! ! ! ! ! !! ! ! !!! ! ! ! ! !! ! ! !!!! !!!!! !! ! ! !! ! ! !! ! ! ! ! ! !!! ! ! ! !!!! ! ! ! ! ! ! !! ! ! ! ! ! !! !!! ! !!!!!! !! !!! ! !!! ! ! ! !! ! ! ! ! !!! !!!!! ! ! !!!!!!! !!!!! !!! ! !! ! ! ! !!! !! !! ! !!!! !!!!! !!!!! ! !!! !!! !!! ! ! ! ! ! !!!! ! ! !!!! ! ! !! ! ! ! ! ! ! ! !!! !! ! ! ! !!! ! ! !!!!! ! !! !!! ! !!!! ! ! !! ! ! !! ! !! ! ! are high cost ! !! !! ! ! ! ! !!!!!!!!!! ! ! ! ! ! !! ! ! !! !! ! ! ! ! ! ! ! ! !! !! ! ! ! ! ! ! !! ! !!! ! !!!!!! ! ! ! ! !!!!!!! !!! ! ! ! families undergoing severe stress and loss ! !!!!! ! ! !!!!! !!! !! !!!! ! !! !! ! ! ! ! ! ! ! ! !!!!! !! !!!!! ! !! ! ! ! !! !!! ! ! !! ! ! !! ! ! ! ! !! ! ! ! ! !!!! ! ! !!! !!! ! ! ! !! !! !! ! !! ! ! ! ! !! ! ! ! !! ! ! ! !!!! !! !! ! ! ! ! ! ! ! ! ! ! !! ! ! ! !! ! !! !!!! ! ! !! ! ! !!! ! ! !! ! !! ! ! !!! ! ! !!! !!! !!! ! ! !!!!! !! !! ! !!! !! ! !!! ! ! !!! ! !! ! !!!!! ! ! !! !!! ! !! !! !! !! ! ! ! ! ! !! ! !! !!! ! ! !! ! ! ! ! !! !! !! ! !!! ! ! ! ! ! ! ! ! !!! ! ! ! !! !! !!!! ! ! ! loans and !!! !!! !! ! !! !! !! !!!! ! !!! !! ! ! ! ! ! ! ! ! ! !!! !!!! !! !! ! !! ! ! ! ! !!! !! ! ! ! ! of wealth from the process, but also for !!!!!!!! ! ! ! !!! !! ! ! !!!!! ! !!!!!!! ! !!! ! ! !!! !!! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! !! ! ! !!! !!! !! ! ! ! ! ! !!! ! ! ! !! ! ! ! !!!! ! ! !! ! ! ! ! ! ! ! ! !! !! ! ! ! ! !! ! ! ! !! ! ! ! ! !! ! !!!! ! ! ! ! ! ! ! ! !! ! !! ! !! ! ! ! ! ! ! !! ! ! ! ! !! !! ! ! ! ! ! ! !! ! ! ! !! !!! ! ! ! ! ! ! the practice !! !!!!! !! ! !! ! ! !!!! ! !! ! ! ! !! ! !!!! ! !! ! ! !! ! !! ! ! ! ! !! ! ! ! ! ! !! !! !! ! ! !!! !!!! ! ! !!! !! ! entire neighborhoods that experience the ! ! ! ! ! ! ! !! ! !! ! !!! ! ! ! !! ! !! ! ! ! ! ! ! !! ! ! ! ! !!! ! ! ! ! ! ! ! !!!!! !!! ! !! ! ! ! !! !!!! ! ! ! ! ! ! ! ! ! ! ! !! ! !!!! ! ! ! ! ! ! ! ! ! !!! ! !!!! ! ! ! !! ! ! ! ! ! !!!! ! ! ! !! !! !! !!! ! !! ! ! ! ! !! !! !!! !! ! !! ! ! !! !! ! ! ! ! ! ! !! !! ! ! ! ! ! !!!! !! ! ! !!! ! !! ! ! ! ! !! !! ! ! ! !! !! ! ! of sub prime ! ! ! ! ! ! ! !!! ! ! ! ! ! ! !!!! !! !! ! ! !! ! !!!! ! effects of intensifi ed disinvestment. Homes !! !!! !! ! ! !!! ! !! !! ! !!! ! ! ! ! !! !! !!! ! ! ! ! !! ! ! ! ! ! !! ! ! ! !! ! ! !! !!! ! ! ! ! ! !! ! ! !! !!! ! ! ! !!! ! ! ! ! ! !! !!! ! ! ! !! ! !!!!! ! ! ! ! !! ! ! !! ! !!! ! !! ! ! ! ! !!! ! ! !! !!!!!!!! !! ! ! ! !!!! ! !! ! ! ! ! ! !!! ! !! !!! !!! !!!! ! ! ! ! !! !! ! ! lending. ! !! !! ! ! ! !! ! ! ! !! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! sold through foreclosure auctions at a ! ! !! !!! ! !! ! ! !! ! ! !!!!! !! !! ! !!! ! ! ! ! ! ! !! ! ! ! ! !! !!! ! !! !! ! ! ! !! !!!!! ! ! ! !! ! ! ! ! !! ! ! ! ! !!! ! ! !! ! !!! ! ! !! ! ! ! ! ! ! ! !! !!!! ! ! African ! !!! ! ! ! considerable discount will further depress !! !

! !! !!!!! ! ! !!!!!!!! ! ! ! American !!!! ! ! ! values of surrounding properties, directly !!!! ! ! !! 5 !!! impacting the quality of the community.14 and Latino Miles ! Combined, the loss of health, wealth, and sub prime Data Source: Jefferson Circuit Court Commissioner’s Offi ce

Housing 23 Housing Segregation individual attitudes of people wanting Home Purchase Loans Denied by Living in racially segregated neighbors with similar characteristics, Race/Ethnicity and Income, neighborhoods has been associated such as race, color or religion; Louisville KY/IN MSA 2009 with higher rates of infant mortality, however, extensive studies confi rm LESS THAN 50% OF MEDIAN INCOME that in many cases people with low overall mortality, violent crime, chronic BLACK OR 28.3% AFRICAN AMERICAN disease, and higher risk for transmission incomes live together not through WHITE ALONE 23.0% of infectious diseases such as mechanisms of “self-segregation”, but ASIAN 17.1% 19 rather by not having any other choice.21 tuberculosis. A signifi cant contributor HISPANIC OR LATINO 14.6% to these conditions is the poverty that Since housing choice is directly related exists in many of these neighborhoods. to housing affordability, families live in 50% - 99% OF MEDIAN INCOME Poverty is exacerbated by diminished areas with the most affordable options, BLACK OR 21.7% opportunities for accruing wealth even if that means living in an area that AFRICAN AMERICAN 13.5% through homeownership in a safe is harmful to health. WHITE ALONE 18.3% and desirable neighborhood and the ASIAN HISPANIC OR LATINO 11.1% discriminatory practices of unfair lending practices. Research has shown Fair Lending that African American homeowners The stress related to high cost 100% OR MORE OF MEDIAN INCOME BLACK OR 22.3% accumulate less equity in their homes loans, mortgage debt, and insecure AFRICAN AMERICAN because they often own homes in homeownership is associated with WHITE ALONE 9.4% segregated neighborhoods.20 a greater likelihood of developing ASIAN 9.8% hypertension, lower levels of HISPANIC OR LATINO 16.7% Some segregation can be linked to psychological well-being, and increased visits to the doctor.22 Louisville was ranked as the displacement affects community health. 26th most segregated of 150 Latinos and African Americans receive When people lose their homes, or high costs loans at a higher rate than metropolitan areas according are threatened by losing their homes, whites, regardless of income. A study to an analysis of the 2000 they experience high levels of stress conducted in 2009 found that Latinos Census by the University of and emotional strain. The impact of and African Americans received high- Louisville. Forty-fi ve percent this loss can be exacerbated given the cost loans at a rate two to three times person’s emotional attachment to their of Louisville residents live in 23 that of whites. Among borrowers home.25 extreme racial segregation, with the highest FICO (Fair Isaac despite Louisville’s increase Corporation) scores (>720), 13.5% of Displacement not only means a in racial and ethnic diversity Latino and 12.8% of African Americans disruption in one’s living situation, in recent decades - these received high-cost loans, compared to but it can result in loss of job, diffi cult factors have contributed to 2.6% of white borrowers with FICO school transitions, and the loss of decreasing homeownership scores above 720.24 health protective social networks.26 rates for African-Americans Displacement can be extremely diffi cult on all members of a family and people in Louisville, during a period Housing Instability of all ages. Research has shown that when the homeownership 27 and Residential it can affect child development. A rates have increased for longitudinal study of the impact of Displacement African Americans in most residential stability on health outcomes Whether it involves homeowners other metropolitan areas in found that residential stability at struggling to maintain their homes the country. childhood (as measured by moving during foreclosures, or families 0-2 times) increases the odds that relocating as public housing is torn Metropolitan Housing Coalition, 2010 an individual will have better health down, housing instability and residential outcomes later in life.28

24 LOUISVILLE METRO HEALTH EQUITY REPORT

FORECLOSURE RATE (Estimated Foreclosure Starts/Estimated Number of Mortgages) { 2007- June 2008 - HUD

10.8% California-Parkland Many of the neighborhoods Russell 10.3% impacted by high foreclosure 9.5% Chickasaw-Shawnee rates already bear the burden of the poorest health 9.3% Portland outcomes, with the life Algonquin-Park Hill 9.2% expectancy in these areas -Park Duvalle being up to 10 years less 8.5% South Central Louisville than other areas of the city.+ 8.3% Shively In a recent study conducted 7.6% Buechel-Newburg -Indian Trail on foreclosures in Louisville, 6.1% Valley Station 50% of the foreclosure study participants cited medical 6.0% Fairdale expenses or health issues 5.7% Phoenix Hill-Smoketown -Shelby Park as a primary factor leading to the foreclosure action 5.5% Pleasure Ridge Park against them.++ 5.1% South Louisville

5.1% Highview-Okolona Louisville Metro* rate is 4.2% 4.1% Fern Creek *not including Airport Census Tracts

4.0% Germantown Downtown- Old Louisville- Phoenix Hill- Smoketown- Downtown-Old Louisville University 3.6% Chickasaw- Shelby Park -University Shawnee Northeast Jefferson 3.2% Southeast Louisville Portland Butchertown-Clifton- St. Crescent Hill J-town Russell Matthews 3.0% California- Parkland Highlands Butchertown-Clifton Algonquin - Park Hill - 2.9% Park Duvalle German- -Crescent Hill town Southeast J-town South Louisville 2.8% Floyd's Fork Central Shively Louisville 2.4% Northeast Jefferson Buechel- Newburg-- Airport Fern Indian Trail South Creek 2.2% St. Matthews Louisville

Pleasure Ridge Park 1.9% Highlands Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

+ Just Cause and Alameda County Public Health Department. (2010). Rebuilding neighborhoods, restoring health: A report on the impact of foreclosures on public health. Oakland, CA.

++Metropolitan Housing Coalition. (2008). Housing insecurity: Neighborhood conversations on health care costs. Louisville, KY.

Housing 25

PERCENTAGE OF HOUSEHOLDS PAYING 35% OR MORE OF INCOME FOR RENT { 2005-2009 ACS ESTIMATE

54.5% Portland High housing-related 53.5% Chickasaw-Shawnee costs lead to health risks + 53.2% Algonquin-Park Hill in a variety of ways: -Park Duvalle 50.7% South Central Louisville • Such as when families have to make tough decisions between 49.6% Valley Station housing costs and paying 49.6% Shively health insurance, medications, and healthy foods; 49.2% California-Parkland • Through the potential Downtown-Old Louisville 45.1% -University association with housing quality and neighborhood features; 42.8% South Louisville and, 42.2% Russell • As an indicator for low 41.3% Phoenix Hill-Smoketown socioeconomic status -Shelby Park associated with material 41.2% Louisville Metro* Pleasure Ridge Park deprivation and housing rate is 39.3% 38.3% Highview-Okolona instability *not including Airport Census Tracts Buechel-Newburg 38.0% -Indian Trail 37.5% Germantown Butchertown-Clifton 36.3% Downtown- -Crescent Hill Old Louisville- Phoenix Hill- Smoketown- University 35.6% St. Matthews Chickasaw- Shelby Park Shawnee Northeast Jefferson 34.4% Southeast Louisville Portland Butchertown-Clifton- St. Crescent Hill Fairdale Russell Matthews 34.4% California- Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 32.3% Northeast Jefferson town Southeast J-town South Louisville 29.8% Fern Creek Central Shively Louisville Buechel- 29.0% Floyd's Fork Newburg-- Airport Fern Indian Trail South Creek 28.3% J-town Louisville

Pleasure Ridge Park 26.9% Highlands Floyd’s Fork Highview- Okolona

Fairdale Valley Station 5

Miles

+ Pollack, C., Griffi n, B., & Lynch, J. (2010). Housing affordability and health among homeowners and renters. American Journal of Preventive Medicine, 39(6), 515-521.

26 LOUISVILLE METRO HEALTH EQUITY REPORT ENVIRONMENTAL QUALITY Indoor Environmental allergies.5 Materials used for building or vehicles. Together they contribute a huge Quality & Health for pest control can be additional sources amount to pollution in the air.11 The impact on health of having access to of danger: pesticide residues can cause safe, affordable housing was addressed in neurological disorders, and pressure- Exposure to traffi c-related pollution is a previous section. However, the internal treated wood can contain dangerous associated with health problems including environment within a home can also carcinogens.6 asthma, reduced lung function, certain create threats to health. These threats types of cancers, cardiopulmonary and can come in the form of hazardous While not all old housing is dangerous, stroke mortality, and premature births.12 substances used in the building of the large stocks of older housing in Particulate matter from cars and trucks home. For example, Asbestos in older disinvested neighborhoods are likely to creates higher rates of cardiovascular homes can cause lung cancer, asbestosis, contain many of the physical features disease and asthma, leading to hospital and mesothelioma1; and, lead paint, associated with substandard housing. visits and premature death.13 More also found in older homes, can be a For example, areas in Louisville with specifi cally, research has shown that serious risk to the health of children and high concentrations of poverty and living within 1000 feet of high traffi c pregnant women. Health implications communities of color have much of the roads (measured by some as 100,000 for children exposed to lead paint include housing built before 1950; however, it vehicles a day) leads to measurably higher an increased risk for asthma, learning was not until the 1970s that the ban on non-cancer health risks.14 On a typical disabilities, seizures, and lead poisoning.2 lead in paint took effect.7 In an analysis urban freeway with large truck traffi c of of housing conditions and other risk 10,000-20,000 a day, particulate matter Health threats can also be caused by a factors related to health, Louisville’s from diesel represents about 70 percent of deterioration of the home’s structure Metropolitan Housing Coalition found the potential cancer risk from the vehicle or an infestation of pests within the that problems related to poor indoor traffi c. Diesel particulate emissions structure. Furthermore, the ability air quality were highly concentrated in are of particular concern as research to control the climate in the living northwest and southwest portions of demonstrates an association between unit is compromised when doors and Metro Louisville.8 particulate matter and premature mortality windows do not fi t properly; and, in those with existing cardiovascular improperly winterized homes can Outdoor Environmental disease.15 lead to the secondary use of improper Quality & Health heating devices. Improperly installed Air pollutants are causal factors for or poor quality heating devices have increased rates of mortality, disease and caused respiratory ailments and even illness.9 Airborne pollutants can cause 3 death. Exposure to rain or other forms increased sickness and premature death of moisture caused by a leaky roof from asthma; bronchitis; emphysema; or internal pipe can compromise the pneumonia; and cardiovascular disease, home’s internal environment by causing including coronary artery disease, mold and mildew. These biological abnormal heart rhythms, and congestive contaminants can lead to respiratory heart failure.10 Air pollution comes from diseases such as asthma or allergic a variety of sources: both stationary and 4 symptoms. mobile. The stationary sources stem from industrial uses and utilities, and Homes that are open to the elements are include steam production, process boilers, vulnerable to pest infestation and mold coal fi re, and other forms of electricity and mildew; both of which can cause generation. Mobile sources include the respiratory diseases such as asthma or emissions from cars, trucks, and other

Environmental Quality 27 Louisville has a number of high traffi c volume highways. Respiratory Risk from Three interstate highways traverse Jefferson County and they On-Road Pollution Source, converge in downtown Louisville. EPA 2002 The high number of industrial, chemical, and manufacturing plants in the county can also contribute to poor environmental quality. Two recent studies point to the particular problem in Louisville’s poor and minority communities.

• A study of air toxins conducted in 2000-2001 found that chronic risk levels from outdoor air pollution were higher in every West Louisville testing site.16

• In a 2009 nationwide study, looking at the largest discrepancies between the percentage of minorities at 5 risk of poor health outcomes from industrial air toxins and Miles their percentage of the population, Louisville, KY-IN MSA Hazard Quotient The ratio of the potential exposure to 1.3 - 2.1 was ranked sixth from the top. In the MSA encompassing the substance and the level at which 2.2 - 2.7 Louisville Metro and Southern Indiana, minorities account for no adverse effects are expected. If the 37% of the health risk while making up only 18% of the total Hazard Quotient is calculated to be 2.8 - 3.5 less than 1, then no adverse health population.17 3.6 - 5.0 effects are expected as a result of exposure. If the Hazard Quotient is greater than 1, then adverse health In addition to air pollutants, low-income persons, racial and ethnic effects are possible minorities, children, the elderly, and those with disabilities suffer disproportionately from environmental pollutants in the soil and ground water near low income neighborhoods.18 Undesirable land uses such as power plants and factories are often situated in Total Respiratory Risk low-income neighborhoods.19 The most polluted locations often from All Sources, have signifi cantly higher-than-average percentages of blacks, EPA 2002 Latinos, and Asian-American residents.20

Abandoned industrial sites, known as brownfi elds (which may be contaminated) can be a burden for communities with low levels of investment.21 Brownfi elds can provide environmental hazards in any of several domains. As described by the EPA, brownfi elds can be the source of the following risks:22

• Safety – abandoned and derelict structures, open foundations, other infrastructure or equipment that may be compromised due to lack of maintenance, vandalism or deterioration, controlled substance contaminated sites (i.e., 5 methamphetamine labs) and abandoned mine sites; Miles Hazard Quotient 1.8 - 3.0 • Social & Economic – blight, crime and vagrancy, reduced The ratio of the potential exposure to social capital or community ‘connectedness’, reductions in the substance and the level at which 3.1 - 3.8 no adverse effects are expected. If the local government tax base and private property values 3.9 - 4.9 the Hazard Quotient is calculated that may reduce social services; and, to be less than 1, then no adverse 5.0 - 7.9 health effects are expected as a • Environmental – biological, physical and chemical from result of exposure. If the Hazard site contamination, groundwater impacts, surface runoff or Quotient is greater than 1, then adverse health effects are possible migration of contaminants as well as wastes dumped on site.

28 LOUISVILLE METRO HEALTH EQUITY REPORT ON-SITE TOXIC RELEASES FROM FACILITIES (Total On-Site Disposal or Other Releases in Pounds) EPA TOXIC RELEASE INVENTORY 2009

Valley Station 5,646,717

Pleasure Ridge Park 1,489,107

1,417,704 Shively TECHNICAL NOTE: On-site disposal or other releases include emissions to the air, discharges Northeast Jefferson 296,059 to bodies of water, disposal at the facility to land, and disposal in Airport 188,928 underground injection wells.

South Louisville 172,215 Toxic Relief Inventory (TRI) data refl ect releases and other waste management activities of chemicals, not whether (or to what degree) the Buechel-Newburg 119,145 public has been exposed to those chemicals. Release estimates alone -Indian Trail are not suffi cient to determine exposure or to calculate potential adverse Downtown-Old Louisville 56,148 effects on human health and the environment. TRI data, in conjunction with -University other information, can be used as a starting point in evaluating exposures 35,737 California-Parkland that may result from releases and other waste management activities 25,434 which involve toxic chemicals. The determination of potential risk depends Highview-Okolona upon many factors, including the toxicity of the chemical, the fate of the Algonquin-Park Hill 11,889 chemical, and the amount and duration of human or other exposure to the -Park Duvalle chemical after it is released. Phoenix Hill-Smoketown 4,726 -Shelby Park Russell 2,495

J-town 705

South Central Louisville 5 Butchertown-Clifton Downtown- Old Louisville- Phoenix Hill- 0 Smoketown- -Crescent Hill University Chickasaw- Shelby Park Shawnee Northeast Chickasaw-Shawnee 0 Jefferson Portland Fairdale 0 Butchertown-Clifton- St. Russell Crescent Hill Matthews California- Fern Creek 0 Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town Floyd's Fork 0 Southeast J-town South Louisville Shively Central Germantown 0 Louisville Buechel- Airport Newburg- Highlands 0 Indian Trail Fern South Creek Louisville Portland 0 Pleasure Ridge Park Floyd’s Fork Highview- Southeast Louisville 0 Okolona

St. Matthews 0 Fairdale Valley Station 5

Miles

Environmental Quality 29

PRE 1950’s HOUSING (Percentage of Older Houing Stock per Neighborhood Area) 2005-2009 ACS ESTIMATE {

75.9% Portland

75.6% Germantown Areas in Louisville with high 71.0% California-Parkland concentrations of poverty and communities of color 69.3% Highlands have much of the housing built before 1950; and, it 67.3% Chickasaw-Shawnee was not until 1950 that the Downtown-Old Louisville fi rst regulations limiting lead 64.0% -University appeared nationally.+ Phoenix Hill-Smoketown 60.9% -Shelby Park In an analysis of housing 57.8% Russell conditions and other risk factors related to health, Algonquin-Park Hill 52.0% -Park Duvalle Louisville’s Metropolitan Butchertown-Clifton Housing Coalition found that 50.1% -Crescent Hill problems related to poor indoor air quality were highly 49.2% South Central Louisville concentrated in northwest and 26.2% Southeast Louisville southwest portions of Metro Louisville.+ + 24.6% South Louisville Louisville Metro* rate is 23.7% 23.3% St. Matthews *not including Airport Census Tracts 16.0% Shively Downtown- Old Louisville- Phoenix Hill- Smoketown- Fairdale University 14.3% Chickasaw- Shelby Park Shawnee Northeast Buechel-Newburg Jefferson 8.4% -Indian Trail Portland Butchertown-Clifton- St. 8.4% Pleasure Ridge Park Russell Crescent Hill Matthews California- Parkland Highlands 5.8% Valley Station Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 4.8% Northeast Jefferson South Louisville Central Shively Louisville 4.7% Floyd's Fork Buechel- Newburg-- Airport Fern Indian Trail 3.1% J-town South Creek Louisville

3.1% Highview-Okolona Pleasure Ridge Park Floyd’s Fork Highview- 2.6% Fern Creek Okolona

Fairdale Valley Station 5

Miles

+ Metropolitan Housing Coalition. (2010). The state of fair housing in Louisville: Impediments and improvements. Louisville, KY. + + Ibid

30 LOUISVILLE METRO HEALTH EQUITY REPORT EDUCATION Education and Health Inequalities in education and income are at People Ages 25-65 Reporting ‘Good’ the root of many health disparities in the or ‘Excellent’ Health, by Education Level* U.S. The population groups that suffer the Louisville Metro BRFSS, 2009 worst health status also are those that have 100 College Grad Some or More College the highest rates of poverty and the lowest 80 High School/GED levels of education.1 For people ages 25- No High 83.8% 60 75.2% 64, the overall death rate for those with less School 68.8% 40 than a high school education is more than 41.5% twice that for people with 13 or more years 20 of education.2 0

*Respondents with higher ediucation levels are more likely to report ‘Good’ or ‘Excellent’ health While income levels are an important x2 = 58.9, df = 3, p-value = 0.0000001 determinant, research has shown that independent of income, education level is illustrates the link between educational associated with improved health outcomes Higher levels of inequality between level and healthy behaviors. Nineteen and -- each additional year in school is rich and poor in a society correlate with a half percent (19.5%) of adults in the associated with increased life expectancy.3 increased mortality among occupants of Louisville Metro who have a college degree the lower economic segment.7 Lack of a report eating three or more vegetables a An individual’s health is highly correlated high school education accounts for much day; while fewer than fi ve percent (4.3 %) with success in school, and the number of of this income inequality effect and is a of Louisville Metro adults without a high years spent in school are major factors in powerful predictor of mortality variation school degree report eating three or more 8 11 determining social and occupational status among U.S. states. vegetables a day. Similar trends are noted in adulthood.4 for physical health and smoking. Education & Risk Behavior ““EducationEducation isis a strongstrong Education, Health and Lower levels of education are connected to increased health risk behaviors such as ppredictorredictor ofof long-termlong-term Wealth smoking, being overweight or engaging in hhealthealth andand qualityquality ofof Educational attainment is one of the llife”ife” minimal physical activity.9 Higher levels strongest predictors of income, and income of education are associated with better is directly related to our health.5 Education health decision making.10 indirectly impacts health through enhanced access to necessary resources (e.g., health Persons with high levels of education care). Further, as incomes rise, people are also display healthier eating habits. The more willing and able to pay for health care most recent data from the Behavioral and preventive health care.6 Risk Factors Surveillance Survey (2009)

LLowow andand LowLow , 22006006

People Ages 25-65 Reporting Risk Behaviors, Louisville Metro BRFSS, 2009 NOT EATING 3 OR MORE SMOKE NO PHYSICAL ACTIVITY VEGETABLES DAILY* EVERYDAY** OUTSIDE OF WORK*** NO HS DIPLOMA 95.7% 52.0% 33.1% HIGH SCHOOL/GED 94.3% 43.9% 21.6% SOME COLLEGE 90.3% 40.0% 15.2% COLLEGE OR MORE 81.5% 20.4% 11% *Respondents with more education are more **Respondents with more education ***Respondents with more education likely to eat 3 or more vegetables daily are less likely to smoke more likely to exercise x2 = 24.6, df = 3, p-value = 0.00002 x2 = 32.6, df = 3, p-value = 0.0000004 x2 = 32.95, df = 3, p-value = 0.0000003

Education 31 Education & Chronic Parental Education Dropping out of High Conditions Level School In a recent CDC survey, Louisville There is a powerful connection between Health factors often drive the decision respondents ages 25-65 with less than a infant and child health and level of to leave school early. Pregnancy, family 12 illness and chronic conditions (e.g., high school education were more likely to maternal education. The impact seems asthma, learning disability or physical to begin in the womb, as numerous have been diagnosed with diabetes, stroke, disability) are all examples of health studies have found strong correlations heart disease, and asthma compared to related reasons for withdrawing.20 between educational attainment of the respondents with a college degree. 13 mother and birth outcomes. Mother’s Dropping out of school can lead to limited education is an important predictor of the employment opportunities, poverty, and People Ages 25-65 Reporting health of children even after controlling poor health, and is also associated with Chronic Conditions for income, health environments, and adolescent substance abuse, delinquency, 21 Louisville Metro BRFSS, 2009 other socioeconomic variables.14 injury, and pregnancy.

NO HIGH SCHOOL Adolescents living in high poverty HIGH SCHOOL/GED The education level of parents has also SOME COLLEGE neighborhoods often have lower level been shown to affect levels of obesity. COLLEGE OR MORE of educational achievement and a higher In one study, parental education level risk of dropping out of school.22 ASTHMA* *Signifi cant differences was the strongest predictor of children’s among groups 27.1% (x2 = 7.6, df = 3, obesity and children of the lowest social p-value = 0.05) status had more than three times the Birth Outcomes by Mother’s Education Level, 20.6% risk of being obese than children of the 2008-2009 17.0% 15 16.5% highest social status. Jefferson County Vital Statistics

NO HIGH SCHOOL HIGH SCHOOL/GED High Quality Child Care SOME COLLEGE Research has demonstrated the COLLEGE OR MORE signifi cance of early childhood Low Birth Weight development as a foundation for long- 11.8% DIABETES** **Signifi cant differences 16 10.8% among groups term health and well-being. The ability 10.0% 24.6% Signifi cant (x2 = 17.2, df = 3, p-value = 0.0006) to succeed in school and later in life 7.2% differences among groups 19.0% is heavily infl uenced by factors that 2 = 17.3% (x 74.9, are determined before children start df = 3, p-value = school.17 0.0000001) 9.6%

Higher quality child care can help Premature Deliveries 11.4% 11.5% improve school readiness and enhance 10.7% 9.2% Signifi cant language skills among children differences HEART DISEASE experiencing the negative developmental among groups (x2 = 21.7, effects of poverty.18 One study found df = 3, 7.6% 6.1% 5.1% p-value = 4.1% that young adults who had consistent 0.00007) child care as children scored higher on tests of academic skills, were more likely Infant Mortalities Signifi cant (rate per 1000) differences STROKE to attend a four year college, and were 5.5 among groups more likely to still be in school at age (x2 = 11.7, 5.1% 4.8% 4.2% 3.9 3.3 3.8% 21.19 df = 3, 1.8 p-value = 0.008)

32 LOUISVILLE METRO HEALTH EQUITY REPORT

NINTH GRADE EDUCATION OR LESS (Percentage of People 25 or Older with 9th Grade Education or Less) 2005-2009 ACS ESTIMATE {

8.4% Portland Phoenix Hill-Smoketown 8.4% -Shelby Park Educational attainment is one 8.2% South Central Louisville of the strongest predictors of income, and income is directly 7.2% Shively related to our health.+ 6.7% Germantown

6.4% South Louisville Education indirectly impacts Downtown-Old Louisville health through enhanced access 6.4% -University to necessary resources (e.g., 6.3% Buechel-Newburg -Indian Trail health care). Further, as incomes 6.1% California-Parkland rise, people are more willing and able to pay for health care and 6.0% Russell Louisville Metro* preventive health care.++ Algonquin-Park Hill 5.8% -Park Duvalle rate is 4.1% 5.5% Fairdale *not including Airport Census Tracts

5.4% Valley Station

4.6% Chickasaw-Shawnee Downtown- Old Louisville- Phoenix Hill- 4.5% Pleasure Ridge Park Smoketown- University Chickasaw- Shelby Park Shawnee Northeast 4.4% Highview-Okolona Jefferson Portland Butchertown-Clifton Butchertown-Clifton- St. 4.2% -Crescent Hill Russell Crescent Hill Matthews California- 3.9% Southeast Louisville Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town 2.9% J-town Southeast J-town South Louisville Central Shively Louisville Highlands 2.1% Buechel- Newburg-- Airport Fern Indian Trail 2.0% Fern Creek South Creek Louisville

1.5% Floyd's Fork Pleasure Ridge Park Floyd’s Fork Highview- 1.4% Northeast Jefferson Okolona

1.2% St. Matthews Fairdale Valley Station 5

Miles

+ Freudenberg, N., Ruglis, J. (2007). Reframing school dropout as a public health issue. Prev Chronic Dis, 4(4). Retrieved from: http://www.cdc.gov/pcd/issues/2007/oct/07_0063.htm. Accessed February 19, 2011. +Ross, C. & Mirowsky, J. (1999). Refi ning the association between education and health: the effects of quantity, credential, and selectivity. Demography, 36(4), 445-460.

++Cutler, D. M. (2006). Education and health: Evaluating theories and evidence. National Bureau of Economic Research Working Paper 12352.

Education 33

BACHELOR’S DEGREE OR HIGHER (Percentage of People 25 or Older with at least a Bachelor’s Degree) 2005-2009 ACS ESTIMATE {

60.1% Highlands

54.9% Northeast Jefferson An individual’s health

53.2% St. Matthews is highly correlated

Butchertown-Clifton with success in school, 43.6% -Crescent Hill and the number of 39.1% Floyd's Fork years spent in school 37.3% J-town are major factors in 33.6% Southeast Louisville Louisville Metro* rate is 28.2% determining social and Downtown-Old Louisville 26.5% -University *not including Airport Census Tracts occupational status in 24.3% Fern Creek adulthood.+

21.4% Germantown Phoenix Hill-Smoketown 18.3% -Shelby Park

15.6% Highview-Okolona

14.1% South Louisville Buechel-Newburg 10.9% -Indian Trail Downtown- Old Louisville- Phoenix Hill- Smoketown- University 10.3% Pleasure Ridge Park Chickasaw- Shelby Park Shawnee Northeast Jefferson 10.1% Chickasaw-Shawnee Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews 8.9% Shively California- Parkland Highlands Valley Station Algonquin - Park Hill - 8.3% Park Duvalle German- town Southeast J-town South Louisville 8.1% Fairdale Central Shively Louisville 7.7% South Central Louisville Buechel- Newburg-- Airport Fern Indian Trail South Creek 6.9% California-Parkland Louisville

Algonquin-Park Hill Pleasure Ridge Park 6.8% Floyd’s Fork -Park Duvalle Highview- Okolona 2.8% Russell Fairdale 2.7% Portland Valley Station 5

Miles

+ Ross, C. & Mirowsky, J. (1999). Refi ning the association between education and health: the effects of quantity, credential, and selectivity. Demography, 36(4), 445-460.

34 LOUISVILLE METRO HEALTH EQUITY REPORT TRANSPORTATION

Transportation & Health they found that lower-income working While the lack of access to services and “Expanding the availability of, safety for, families ($20K-$35K) living away from employment is a problem for low-income and access to a variety of transportation employment centers spent 37% of their individuals, diffi culties with access options and integrating health-enhancing income on transportation.5 Another can affect anyone at any income level choices into transportation policy has study found that the poorest fi fth of auto- who lives in a part of town that lacks the potential to save lives by preventing owning Americans spend 42% of their alternative transportation options.13 Many chronic diseases, reducing and preventing annual household budget on automobile people must live far away from their jobs motor-vehicle-related injury and deaths, ownership, more than twice the national to fi nd affordable housing. Others choose and improving environmental health, average.6 the suburbs or more rural areas of the while stimulating economic development, county for other reasons. Regardless of and ensuring access for all people.”1 When faced with high housing costs, the basis for choosing a home outside of many families are forced to make the city-center, long commutes diminish Research shows that land-use planning diffi cult choices, primarily in the area of the amount of time for social/civic and transportation decisions, directly transportation.7 Many working families engagement and contribute to poor air and indirectly affect our health.2 Poor (whose incomes are between $20,000 and quality. Both the loss of time for other decisions in these areas can: $50,000) that move far from work to fi nd activities and the increase in air pollutants affordable housing, can end up spending have consequences on our health.14 • Reduce opportunities for physical much of their savings on transportation.8 activity, contributing to rising obesity and other negative health consequences Public Transit & Health associated with minimal exercise; Having an effi cient alternative to • Increase the amount of air pollution, automobile travel can contribute to the contributing to respiratory and health and vitality of a community. While cardiovascular illness and accelerating the lack of such a system can be a source climate change; of health risks for everyone, the inability • Increase traffi c accidents, and the to access public transit disproportionately injuries and deaths that result from these affects vulnerable populations: the poor, accidents; and the elderly, people who have disabilities • Exacerbate poverty and inequity by and children.9 People who cannot afford placing especially heavy burdens on a car or who are unable to drive face a vulnerable populations.3 relative lack of mobility options when it comes to jobs, housing, education, social Transportation Costs services, and activities.10 Lower income families are disproportionately affected by the absence The relationship between public of affordable forms of transportation. transportation and access to employment Households generally pay around 20% options has been the focus of many studies. of their income for transportation, but These studies have found signifi cant lower income families can spend a much employment effects from increased bus higher percentage of their more limited access and improved accessibility to resources. One study documented that employment hubs.11 In a study focusing on lower income families spend up to 30% single women receiving public assistance, IInn LouisvilleLouisville MetroMetro or more, depending on the location of the researchers found that women without 33.3%.3% ofof workersworkers neighborhood where they live.4 When an automobile experienced employment ccommuteommute viavia publicpublic these researchers looked at the data for 28 benefi ts from increased access to public ttransportationransportation ACS ESTIMATE 2005-2009 Metropolitan Statistical Areas (MSAs), transportation.12

Transportation 35 Further, every additional hour spent in a car in a rural area is double or even triple the per day is associated with a 6% increase rate in urban areas, as motor vehicles tend in the likelihood of obesity; while each to travel faster in rural areas.23 additional hour walked per day is associated Expanding the availability with a 4.8% reduction in the likelihood of While biking and walking can be healthy of, safety for, and obesity.15 Another study found that transit options for getting to employment or access to a variety of users met the recommended levels of services, pedestrians and bicyclists can face transportation options physical activity by walking to and from serious dangers in areas that are designed and integrating health- the transit stops.16 mainly for cars. Many communities enhancing choices into are taking on the safety challenge by transportation policy has improving their infrastructures and making the potential to save lives Pedestrian & Bicycle their roadways more accommodating to by preventing chronic Safety walkers and cyclists. One such approach diseases, reducing In the U.S., traffi c crashes continue to is Complete Streets. A “Complete Street” and preventing motor- be the greatest single cause of death and is safe, accessible, and convenient for all vehicle-related injury and disabilities for Americans 1-44 years of users, regardless of transportation mode, deaths, and improving age.17 Pedestrians and bicyclists are at an age, or physical disability.24 Complete environmental health, even greater risk of death from crashes than Streets adequately provide for bicyclists, while stimulating economic those who travel by motor vehicles.18 pedestrians, transit riders, and motorists; development, and ensuring and, they promote healthy communities access for all people. Areas with high traffi c volume can be and reductions in traffi c congestion by particularly dangerous, and higher rates of offering viable alternatives to driving. Centers for Disease Control, 2010 traffi c fl ow generally lead to higher rates of They are designed to prevent injury and to pedestrian injury.19 promote health.

Conversely, research has shown that areas with greater pedestrian fl ows experience Average Annual Pedestrian Deaths per 100,000 (2000-2009) less risk of pedestrian-vehicle collision.20 Numerous studies show that motorists are less likely to collide with pedestrians and 1.7 cyclists if more people are walking and cycling.21 Such research helps demonstrate 1.3 that there is safety in numbers as more 1.1 1.0 people have the opportunity to walk or bike 0.9 to destinations. 0.8

The more rural, less developed areas of the county face different issues. They often lack pedestrian walkways such as Louisville KY Indianapolis IN Cincinnati OH MSA MSA MSA sidewalks, paths, and/or shoulders that Out of the 52 MSAs with at least one million inhabitants, the Louisville MSA are critical for pedestrian safety.22 Another ranks the 19th most dangerous for pedestrians. The Louisville MSA had 192 difference is the speed with which vehicles pedestrian fatalities from 2000 to 2009. travel. While there are more pedestrian/auto Transportation for America, 2011 collisions in urban areas, the risk of fatality

36 LOUISVILLE METRO HEALTH EQUITY REPORT

BICYCLE AND PEDESTRIAN COLLISIONS WITH MOTOR VEHICLES (Rate per 1000 people) 2009 KSP Collision Data {

Phoenix Hill-Smoketown 4.7 -Shelby Park 4.4 Downtown-Old Louisville -University In the U.S. traffi c crashes 2.3 Russell continue to be the greatest

2.3 California-Parkland single cause of death and disabilities for Americans 1-44 2.1 Portland years of age.+ 1.7 Highlands Algonquin-Park Hill Pedestrians and bicyclists are 1.4 -Park Duvalle at an even greater risk of death 1.2 South Central Louisville from crashes than those who 0.9 St. Matthews travel by motor vehicles.++

0.8 Germantown Louisville Metro* rate is 0.76 Shively 0.7 *not including Airport Census Tracts Butchertown-Clifton 0.7 -Crescent Hill 0.7 South Louisville 0.7 Chickasaw-Shawnee Downtown- Old Louisville- Phoenix Hill- Smoketown- University Buechel-Newburg Chickasaw- Shelby Park 0.6 Shawnee Northeast -Indian Trail Jefferson Southeast Louisville Portland 0.6 Butchertown-Clifton- St. Russell Crescent Hill Matthews 0.5 Valley Station California- Parkland Highlands Algonquin - Park Hill - German- 0.5 Pleasure Ridge Park Park Duvalle town Southeast J-town South Louisville Central 0.4 Highview-Okolona Shively Louisville Buechel- 0.4 J-town Airport Newburg-- Indian Trail Fern South Creek 0.3 Floyd's Fork Louisville Pleasure Ridge Park Floyd’s Fork 0.3 Fern Creek Highview- Okolona 0.2 Northeast Jefferson Fairdale Valley 0.1 Fairdale Station 5

Miles

+Litman, T. (2003). Integrating public health objectives in transportation decision-making. Victoria Transportation Policy Institute. ++Centers for Disease Control and Prevention. (2010). CDC recommendations for improving health through transportation policy. Retrieved February 12, 2011, from http://www.cdc.gov/transportation/docs/ FINAL%20CDC%20Transportation%20Recommendations-4-28-2010.pdf.

Transportation 37 FOOD ACCESS Nutrition & Health education, and to die prematurely. Local Diet-related disease is one of the top • Lack of access to supermarkets is researchers have concluded that Louisville causes of preventable deaths among correlated with the prevalence of would show similar results given a more people in the U.S.1 Poor nutrition has been diet related diseases like diabetes complete analysis.9 known to cause or contribute to: obesity, and obesity.4 hypertension, high cholesterol, diabetes, heart disease, stroke, some cancers, and • The longer the distance necessary WEST LOUISVILLE FOOD other health problems. Research has to travel to a full service grocery ASSESSMENT found diet and nutrition to be especially store, the higher the body mass important for children because of the link index (BMI). For a 5’5” person, Research conducted by between hunger, malnutrition and delayed traveling 1.75 miles or more to brain development.2 get to a grocery store equaled a the West Louisville Food weight difference of about 5 pounds Assessment Research Food Access and Health compared to someone who did not Advisory Team found that cost have to travel that far.5 Evidence of the impact of these and quality of food available to challenges has been documented by many Louisville residents depends researchers. A few examples of research • Better access to a supermarket or in this area are listed below: large grocery store is associated on where they live within with healthier food intakes.6 the city. The problem was • Vehicle access is a major issue when particularly acute for residents living in a neighborhood with less • Limited knowledge about nutrition of the low-income West healthy food options, as residents among many individuals living Louisville and East Downtown in low-income communities are less in low-income neighborhoods, likely to own a car and less likely combined with a retail food areas who were likely to have to have a grocery store within their environment that offers few choices to spend more for healthy 3 neighborhood. for nutritious food and/or too foods and to have the least many options for less nutritious access to high-quality foods.10 alternatives, place these individuals at greater risk for poor health outcomes.7 The analysis found that West Louisville had only 1 full- Food Deserts service grocer per 25,000 The lack of grocery access has residents, compared to a caused many low-income, inner city neighborhoods to be labeled as Food Jefferson County ratio of Deserts. Food Deserts are “large and 1 grocery for every 12,500 isolated geographic areas with no, few, residents.11 or distant mainstream grocers offering a variety of fresh foods and nutritious foods that support a balanced and healthy The same report found that diet”.8 Research has demonstrated East Downtown was also that residents of food deserts are more underserved by supermarkets likely to suffer from diet related diseases and grocery stores.12 after controlling for race, income, and

38 LOUISVILLE METRO HEALTH EQUITY REPORT Convenience Stores and small food stores can be signifi cantly between fast food restaurants and black Corner Stores higher than the cost in larger groceries and low income neighborhoods may The trend toward fewer and larger and supermarkets. contribute to an understanding of the grocery stores, often locating in environmental causes of the obesity the suburbs, caused more urban epidemic in these populations”.20 neighborhoods to meet their grocery Concentration of Fast needs through convenience and corner Food Retailers stores.14 These stores are easy to access Large concentrations of fast food for residents without transportation, restaurants are related to higher diet- they have convenient hours, and some related disease rates.18 People on limited provide culturally appropriate foods and incomes, such as young families, the The health implications products for immigrant communities.15 elderly and the unemployed, are least of living in a food desert However, they typically carry no or able to eat well, and often substitute were documented in a limited fresh produce, they sell a greater inexpensive, processed foods for fresh 2006 survey of residents food.19 While high-fat, high sodium fast proportion of processed foods, and in West Louisville, where they sometimes incorporate a fast-food food options are pervasive throughout 37% of respondents carry-out.16 many communities in the United States; their impact can be particularly harmful reported having high blood In one regional study, the USDA in neighborhoods where there are few pressure, 74% reported found that the average full-service other options. being overweight or obese supermarket offered three times as and 12% reported having many kinds of fruit, six times as many A study conducted in New Orleans found diabetes.13 kinds of vegetables, and nine times as that predominantly black neighborhoods many kinds of meat as the average small had 2.4 fast food restaurants per square store.17 In low-income neighborhoods, mile compared to 1.5 restaurants in access to healthy foods is further limited predominantly white neighborhoods by price, as the cost of food items in with the conclusion that, “the link

Food Access 39

FAST FOOD OUTLET DENSITY (Number of Fast Food Outlets per Square Mile) 2010 Food Inspection Data { Downtown-Old Louisville 16.0 -University 5.8 Germantown Large concentrations of fast food 5.6 St. Matthews (Including Mall St Matthews & Oxmoor Mall) restaurants are related to higher diet- related disease rates .+ 5.4 South Central Louisville

4.0 California-Parkland People on limited incomes, such as young families, elderly people and 4.0 Phoenix Hill-Smoketown -Shelby Park the unemployed, are least able to eat 3.7 Southeast Louisville well, and often substitute inexpensive, processed foods for fresh food.++ 2.9 Russell Buechel-Newburg Many poorer communities have 2.8 -Indian Trail more than their share of fast food 2.8 J-town restaurants that provide unhealthy, high-fat foods, and pose risks for 2.7 Butchertown-Clifton -Crescent Hill community nutrition.+++ 2.4 Highlands

2.2 Highview-Okolona Louisville Metro rate is 1.6 2.0 Fern Creek

Downtown- 2.0 South Louisville Old Louisville- Phoenix Hill- Smoketown- University Shelby Park Algonquin-Park Hill Chickasaw- 1.9 Shawnee Northeast -Park Duvalle Jefferson Portland 1.9 Portland Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 1.8 Pleasure Ridge Park Parkland Highlands Algonquin - Park Hill - Park Duvalle German- town 1.8 Shively Southeast J-town South Louisville Shively Central 1.3 Valley Station Louisville Buechel- Airport Newburg- 1.0 Northeast Jefferson Indian Trail Fern South Creek Louisville 0.8 Chickasaw-Shawnee Pleasure Ridge Park Floyd’s Fork Highview- 0.2 Floyd's Fork Okolona

0.1 Fairdale Fairdale

Valley 5 Station Miles

+Centers for Disease Control and Prevention. (2010). CDC recommendations for improving health through transportation policy. Retrieved February 12, 2011, from http://www.cdc.gov/transportation/docs/FINAL%20CDC%20Transportation%20 Recommendations-4-28-2010.pdf.

++Wilkinson, R. & Marmot, M. (Eds.) (2003). Social determinants of health: The solid facts. Second edition. Denmark: World Health Organization

+++Community Farm Alliance/ West Louisville Food Working Group. (2007). Bridging the divide: Growing self-suffi ciency in our food supply. Louisville, KY: Community Farm Alliance/West Louisville Food Working Group.

40 LOUISVILLE METRO HEALTH EQUITY REPORT HEALTH CARE ACCESS Access to quality, affordable health care 12.9 million people.3 The primary driver of this increase is the loss of employer- infl uences how a person uses health care PERCENT WITHOUT ANY TYPE OF and ultimately impacts the person’s health. sponsored coverage. HEALTH COVERAGE, AGES 25-65 People with good access to a trusted Louisville Metro BRFSS 2009 provider or primary care clinic are more • The average employee’s costs for health likely to use preventative services and have insurance rose, while income fell. 21.7% lower hospitalization rates.1 Conversely, Nationwide, the average cost an employee paid for a family insurance policy rose 81% people who experience barriers to health 14.8% from 2000 to 2008. During the same period, care, including the poor and the uninsured, median household income fell 2.5 percent suffer higher rates of disease and premature (adjusted for infl ation). Those with low death.2 incomes, including the working poor, make up a disproportionately large share of the WHITE BLACK OR AFRICAN While there are many factors that affect 4 n = 458 AMERICAN uninsured. n = 566 a person’s access to health care, primary **Blacks are more likely to be without any type of among them are: • In a 2010 analysis conducted by the Kaiser health coverage than whites x2 = 7.9, p-value = 0.002 Foundation, they found that 40% of the • Insurance coverage uninsured have family incomes below the • Location and operating hours of physician federal poverty level ($22,050 a year for eligibility rules are numerous and practices and available capacity among a family of four); and nine in ten of the complex, and vary by state, a person primary care uninsured have family incomes below 400% typically has to be poor, disabled or a providers 5 of poverty. member of a family with a dependent • Transportation child or a pregnant woman. • Language and cultural barriers When employer-based insurance is not available, some people are able to pay for Medicare is a resource for individuals The Role of Insurance their own private insurance. However, over the age of 65 and for people with A person’s health insurance status may be this is often very expensive, and is disabilities, who have contributed to the single most important determinant in beyond the reach of many individuals Medicare or are eligible through the whether or not an individual has access to who have limited fi nancial resources. Medicare contributions of a family primary care services. In the United States, member. Because Medicare does not there has been a long history of health More than one in fi ve adults under age adequately cover many outpatient insurance being part of the benefi t package 65 (22%) was uninsured in 2009, a services, most recipients purchase associated with full time employment. condition that puts both their health supplemental insurance to cover the This arrangement has worked fairly well 6 and their fi nancial security at risk. gaps. for those who are in salaried positions and African Americans, rural residents, and employed full time, or who are the spouse people with incomes between $10,000 Because health care costs have been or child of someone who is in one of these and $20,000 were most likely to have rising faster than benefi ciaries’ income, positions. inadequate coverage.7 the purchase of supplemental Medicare packages has become increasingly The employer-linked health care system is When the private sector does not address diffi cult for many people. In an becoming increasingly expensive, to the the need, many people turn to the public analysis conducted by the Kaiser Family employer and the employee; and, it leaves sector for coverage, through Medicaid or Foundation, ten percent (10%) of out those who are employed part-time, Medicare. However, these programs do Medicare recipients had no supplemental those who work as contractors, and those not cover everyone; and typically leave coverage in 2008. Among those who who are unemployed. out non-disabled adults between the ages were lacking supplemental coverage, of 22 and 65 who are not responsible for there was an over-representation of • A 2010 report by the Robert Wood Johnson individuals within the following groups: Foundation (RWJF) found that more a dependent child. people under-65 years of age, the middle-class Americans are uninsured. Medicaid is a state run program that disabled, the near poor (incomes between The total number of uninsured, middle- requires both income eligibility and $10,000 and $20,000), rural residents, class Americans increased by more than categorical eligibility. While the 8 2 million between 2000 and 2008, to and African Americans.

Health Care Access 41 and a means of obtaining recommended urban area with public transportation, preventive services.12 Living in a getting to medical appointments can be PERCENT WITH ANY TYPE OF HEALTH COVERAGE, poor neighborhood also reduces the a problem. The challenges include long Louisville Metro BRFSS 2002-2009 likelihood that a person will have travel times determined by the route map 85.6% 87.1% 85.5% 86.5% 87.6% 88.8% 87.9% 88.1% access to products and services, such as and the need for transfers; the diffi culties pharmacies or places to exercise, that associated with walking to the bus stop and are a part of recommended treatment boarding the bus while traveling with one or preventive care.13 These conditions or more young children. increase the likelihood of having unmet medical needs.14 A paper on the barriers to care presented a number of studies demonstrating how 2002 2003 2004 2005 2006 2007 2008 2009 In an effort to mitigate the disparities transportation can be a barrier to health 15 In 2009, 88% percent of Louisville Metro residents associated with the distribution of care. A few fi ndings from these studies reported some type of health care coverage. This is private sector practitioners, publicly are listed below: slightly higher than the nation (86%) and higher than funded clinics have been established the state (84%).9 in underserved areas. For example, • A analysis of data from the 2002 Behavioral Louisville Metro has a network of Risk Factor Surveillance System yielded the However, according to an analysis by the Louisville public health clinics and family health fi nding that 9% of people ages 65 and older Metro Department of Public and Health and Wellness care centers. Some of these clinics did not get needed medical care because of (LMPHW), the percent of Louisville Metro African operate under the direction of the transportation problems, suggesting that Americans who report having health care coverage Louisville Metro Department of Public they might be people living in rural areas, has decreased since 2004, with 75% reporting some Health and Wellness, while others are no longer drive, or depend on others or type of health coverage in 2008, compared to 79% in public transportation.16 2004.10 privately operated Federally Qualifi ed Healthcare Centers. • A door-to-door survey of the non-elderly In reviewing 2009 data from the Behavioral Risk urban poor found that 30% of respondents Factor Surveillance System (BRFSS), it can be seen Transportation & Health that while the proportion of white respondents ages Care Access had a transportation barrier to health 17 25-65 with some sort of insurance is comparable to Not having a working vehicle or the lack care. the state and national average rates, the percentage of access to public transportation can be for African American respondents ages 25-65 is much a signifi cant barrier to care. Even in an lower that the state and national average rates.

Federally Qualified Health Centers Neighborhoods and LMPHW Preventative Health Clinics Access to Health Care The location of physician practices and Family Health Center - Portland primary care providers also affect health care access. Even in an urban area with Park DuValle Family Health Center - East Broadway at City View LMPHW Middletown large numbers of practitioners, access to Phoenix Health Center Health Center for the Homeless care can be compromised by the geographic Park DuValle Community Health Center distribution of the primary care providers. Park DuValle at Newburg Family Health While there are signifi cant variations Center - Iroquois Family Health LMPHW Newburg Health Center Center Americana between different neighborhoods and an individual’s ability to access primary LMPHW Dixie Health Center care, a neighborhood’s social capital and Family Health Center - Fairdale health care resources can signifi cantly predict an individual’s access to primary 5 care.11 Living in neighborhoods with low Miles levels of investment has been found to reduce the likelihood that families and individuals will have a usual source of care

42 LOUISVILLE METRO HEALTH EQUITY REPORT • Research fi nds that public transportation from the following countries: Cuba, Haiti, the pain source is less important. Because barriers have adverse effects on the Columbia, Bhutan, Iraq, Iran, Afghanistan, they often use terms that are more general populations that depend most on them for Burma, Nepal, Somalia, Ethiopia, Congo, or vague, a Western trained physician may health services access, namely the poor and Sudan, and Rwanda. Recent arrivals and have diffi culty in understanding the reason 21 older persons.18 their languages are added to the already for the visit. diverse population of immigrants, including • Immigrants from Asia may believe that • One study described bus service to Vietnamese, Cambodian, and Bosnians. Western medications are too strong and may clinics as inconsistent, leading to missed While Catholic Charities, one of Louisville not take them in the prescribed doses. They appointments.19 This same study found Metro’s two resettlement agencies, has also may be at risk for drug interactions some bus stops to be poorly maintained and interpreters for 40 different languages, due to the concurrent use of herbs and other perceived to be unsafe by people trying to these individuals are not always available in traditional medicines.22 get to health care.20 the health care setting. Without an effective means of communication, it is diffi cult • Conservative values related to sexuality Louisville Metro has an extensive system for health care professionals to diagnose may contribute to female immigrants from of bus routes and a system for providing and prescribe the most effective forms of conservative cultures being less willing medical transportation through the public treatment. to obtain mammograms or gynecological transit system. Depending upon where a exams. person lives and where the person needs to go, their route can be complex and time A recent survey • Health prevention among Somalis is consuming. For example, the major routes of nearly 200 area practiced primarily through prayer and outside the Watterson Expressway tend Hispanics conducted living a life according to Islam. Many Somalis “believe that illness may be caused to follow a spoke-like design toward the by Norton Cancer by a communicable disease, by God, by city-center. If a person who lives beyond Institute and members spirit possession, or by the “evil eye”.23 the expressway and wants to travel a short of St. Rita Catholic distance to the west or east, it is likely that Church found that • Health literacy includes the ability to he/she will have to travel one route into the many — largely negotiate complex health care systems, city’s center, transfer buses, and ride the because of linguistic, understand doctor’s directions and consent second bus out beyond the expressway to cultural, and other forms and the instructions on prescription the desired location. 24 barriers — simply don’t drug bottles. Gaining effective access to know where to go for health care often assumes high levels of Language and cultural health literacy, regardless of education certain services. barriers to Health Care level and insurance status. Ensuring health Access Courier Journal - Jan. 21, 2011 equity means going beyond saddling health Two additional barriers relate to the growth www.courier-journal.com/article/20110121/ consumers with full responsibility for health NEWS01/301210083/New-survey-shows- and diversity of the immigrant population. Louisville-s-growing-Hispanic-population- literacy. While not only immigrant and refugee lacks-access-health-care populations face cultural barriers to health In summary, immigrants and refugees often care access, these communities face barriers face formidable challenges in their efforts to maintain health and receive care. Not only associated with language and culture in A person’s culture and traditions can also are they dealing with the shock and stress of addition to those mentioned previously. create barriers to accessing health care and acculturating to a new country, but they also The ability to communicate symptoms and to complying with the regimen of treatment. are subjected to new environmental risk medical history is severely compromised Much has been written on the role of factors. When these stressors are combined when the patient and provider do not culture in health and health care and the with the diffi culty in obtaining health care speak the same language or when a trained myriad of barriers that stem from different coverage and the language barriers they interpreter is not available. The number belief systems and values. However, the encounter in seeking care, it is not surprising and increasing diversity of immigrants and discussion is limited to a few examples that that they are at risk for diminished health refugees coming into the U.S., particularly relate to the cultures of recent refugees into outcomes. Health care providers and into the urban centers, have made these the Louisville Metro area: barriers even more formidable. For example, institutions need to proactively respond to in 2010, the two resettlement agencies • Haitians tend to believe that pain affects the a broader range of cultural, language and within Louisville Metro resettled people whole body system; therefore the origin of health literacy capabilities.

Health Care Access 43

LANGUAGE OTHER THAN ENGLISH SPOKEN AT HOME Population 5 years and over { 2005-2009 ACS ESTIMATE

15.7% South Louisville • The ability to communicate symptoms and medical history is Buechel-Newburg 9.3% -Indian Trail severely compromised when the patient and provider do not speak 9.0% Downtown-Old Louisville -University the same language or when a 8.5% J-town trained interpreter is not available.

Phoenix Hill-Smoketown • The number and increasing 8.4% -Shelby Park diversity of immigrants and 8.4% Southeast Louisville refugees coming into the U.S., particularly into the urban Northeast Jefferson 7.9% centers, have made these barriers even more formidable. 7.8% Fairdale

7.6% South Central Louisville

7.2% Highview-Okolona

7.2% Butchertown-Clifton Louisville Metro* -Crescent Hill rate is 6.8% 6.0% Floyd's Fork *not including Airport Census Tracts

5.1% Fern Creek

5.1% Germantown

4.6% St. Matthews

4.5% Highlands Northeast Jefferson Portland Butchertown-Clifton-Crescent Hill 2.9% Chickasaw-Shawnee St. Matthews Russell Russell Phoenix Hill-Smoketown-Shelby Park Downtown-Old Louisville-University California-Parkland Highlands 2.9% Shively Algonquin-Park Hill-Park Duvalle Germantown J-town Algonquin-Park Hill Southeast Louisville 2.6% -Park Duvalle Shively South Central Louisville 2.5% Pleasure Ridge Park Buechel-Newburg-Indian Trail

South Louisville Airport Fern Creek 2.2% California-Parkland Floyd's Fork Pleasure Ridge Park

1.9% Valley Station Highview-Okolona

1.4% Portland Fairdale

1.3% Chickasaw-Shawnee Valley Station 5 Miles

44 LOUISVILLE METRO HEALTH EQUITY REPORT NO VEHICLES AVAILABLE (as a Determinant of Health Care Access) { Occupied Housing Units with No Vehicles 2005-2009 ACS ESTIMATE Phoenix Hill-Smoketown • A door-to-door survey 49.4% -Shelby Park of the non-elderly urban 43.3% Russell poor showed that 30% of respondents had a Downtown-Old Louisville 37.2% transportation barrier to -University health care.+ 34.4% California-Parkland • Research fi nds that 30.7% Portland public transportation Algonquin-Park Hill barriers have adverse 29.5% -Park Duvalle effects on the populations that depend most on 18.9% Chickasaw-Shawnee them for health services 18.9% South Central Louisville access, namely the poor and older persons.++ Buechel-Newburg 13.8% -Indian Trail 12.7% Shively

12.1% Germantown

11.4% South Louisville Louisville Metro* rate is 9.7% 8.6% Butchertown-Clifton -Crescent Hill *not including Airport Census Tracts 6.5% Southeast Louisville Downtown- Old Louisville- Phoenix Hill- Smoketown- 6.3% Highlands University Chickasaw- Shelby Park Shawnee Northeast 5.5% Pleasure Ridge Park Jefferson Portland Butchertown-Clifton- St. 5.2% Valley Station Russell Crescent Hill Matthews California- Parkland Highlands 5.0% St. Matthews Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 4.6% Highview-Okolona South Louisville Central Shively Louisville 4.5% Fairdale Buechel- Airport Newburg-- Indian Trail Fern 4.2% J-town South Creek Louisville

3.4% Fern Creek Pleasure Ridge Park Floyd’s Fork Highview- 3.0% Northeast Jefferson Okolona

1.8% Floyd's Fork Fairdale Valley Station 5

Miles

+ Ahmed, S., Lemkau, J., Nealeigh, N., & Mann, B. (2001). Barriers to healthcare access in non- elderly urban poor American poplantion. Health and Social Care in the Community, 9(6), 445-453.

++ Rittner, B. & Kirk, A. (1995). Health care and public transportation use by poor and frail elderly people. Social Work, 40(3), 365-373.

Health Care Access 45 COMMUNITY SAFETY Crime, Insecurity, and diseases.4 And, once released, they may Health bring these conditions back to their Crime is a public health issue, and has families and their neighborhoods. implications for the victims and their social networks, as well as the perpetrators The Role of the Built and their families. Crime can directly Environment affect health, through physical harm and The physical condition of the properties emotional trauma; and the fear of violent in a neighborhood along with the types crime can indirectly affect health, through of businesses within a neighborhood can increased rates of anxiety and stress.1 play a role in community safety. A study Threatened by crime or other forms of conducted by the Baltimore City Health insecurity, our bodies react in the form Department (2010) found that negative of fear, anxiety, depression, dizziness, health and safety outcomes are associated chest pains, trouble breathing, nausea, with pockets of vacant properties, upset stomach, and weakness, which including assault-related injuries, CCrimerime isis a all come together to contribute to poor homicide, and fi re-related injuries.5 In a ppublicublic healthhealth health.2 The fear of crime can also lead to study on the impact of home foreclosures iissue,ssue, andand hashas social isolation, and loss of opportunities on public health (Alameda County, iimplicationsmplications for exercise within a crime threatened California), researchers summarized the fforor thethe victimsvictims environment. problem with the following statement: aandnd theirtheir socialsocial “In addition to being an eyesore and nnetworks,etworks, asas wwellell asas thethe Research also has documented that visual reminder of neighborhood pperpetratorserpetrators aandnd criminal victimization can affect the instability, vacant properties can attract ttheirheir families.families. victim’s self perception of their own rodents and mosquitos, vandalism, health.3 Even after the physical wounds trespassing, drug dealing, and other have healed, and even when there is no illegal activities.”6 Researchers also have in low-income communities has implications physical evidence of injury remaining, found that the presence of abandoned for health and quality of life in these victims can believe themselves to be buildings, overgrown lots, and graffi ti, neighborhoods.9 “damaged goods”. This perception can often associated with vacant properties, affect self esteem and be a trigger for can lead to an increase in perceived •Higher concentrations of liquor stores are depression. crime, and the fears associated with that associated with higher levels of crime.10 A perception.7 Ultimately, the presence of study by Gruenewald and Remer (2006) found The impact of crime and the criminal vacant homes can contribute to a loss of that “each six (6) additional liquor outlets justice system can also have health neighborhood cohesion and a decrease accounted for one additional violent assault implications for the perpetrator and for in property values, particularly in that resulted in at least one overnight stay at the neighborhoods into which they return. neighborhoods that may already have low a hospital”.11 Individuals involved in the criminal levels of investment.8 This loss in home justice system often have poor health values diminishes wealth and contributes •Higher rates of liquor outlets in a and numerous health risks before the to the poverty that is associated with poor neighborhood are associated with higher commission of the crime. These risks can health and poor access to health care. rates of motor vehicle accidents.12 include poverty, lower levels of education, limited job prospects, inadequate housing, A high density of liquor outlets in a •Higher concentrations of liquor outlets are and higher incidences of substance abuse. neighborhood presents particular risks. associated with increased perceptions of Once incarcerated, they are exposed to a Research in this area has found: insecurity and limited walkability, contributing population with signifi cantly higher rates to lower levels of physical activity.13 of HIV, tuberculosis, and other infectious • The higher density of liquor outlets found

46 LOUISVILLE METRO HEALTH EQUITY REPORT This exposure to violence and the concern about safety also impact a child’s

0.1 - 0.5 Downtown- ability to engage in outdoor, Old Louisville- Phoenix Hill- Smoketown- University 0.6 - 1.0 Chickasaw- Shelby Park physical activities in their Shawnee Northeast 1.1 - 2.0 Jefferson neighborhood.19 Unless Portland Butchertown-Clifton- St. 2.1 - 6.4 Russell Crescent Hill Matthews exercise and the Vitamin California- Parkland Highlands D that comes through Algonquin - Park Hill - Park Duvalle German- town sunshine is obtained in other Southeast J-town South Louisville Central ways, restricted outdoor Shively Louisville Buechel- play time can contribute to Newburg-- Airport Fern Indian Trail South Creek obesity and to the problems Louisville associated with vitamin Pleasure Ridge Park Floyd’s Fork Highview- D defi ciencies, including Okolona loss of bone strength and Fairdale Valley diminished immunity to a Station 5 Miles host of chronic diseases.

While children may suffer from child abuse and are the indirect victims of other crimes, the concern As with most other social determinants of Safety of Young People about youth-on-youth violence extends to health, the impact of crime and insecurity Safety concerns for children and youth both perpetrators and victims. In 2008, can have a devastating effect on the can cover a wide range of threats, and the national Conference of Mayors and biological, psychological and social include child abuse, dating violence, the Prevention Institute called for youth development of children and adolescents. youth-on-youth violence, and other violence to be treated as a public health forms of harm by adults. According crisis. The reasons for their concern Even when researchers control for to the Centers for Disease Control and were present in data on emergency socioeconomic status, children living Prevention (CDC), one in every four teens room utilization and criminal justice in urban communities who are exposed self-report physical, verbal, emotional involvement. In 2007, over 696,000 to violence are more likely than other or sexual abuse every year.14 A second young people in the U.S. ages 10 to 24 children to become victims or perpetrators report from research conducted under years were treated in emergency rooms for of the same kind of violence later in life.17 the auspices of the CDC found that one injuries sustained as a result of violence.20 One study found that being a victim of in eleven (1 in 11) adolescents reported In some cases, these injuries lead to death. violence during adolescence carried a 38% having been the victim of physical dating The U. S. Bureau of Justice Statistics cites higher likelihood that the young person violence.15 The effects on victims are that homicide is among the leading causes affected would have worse employment serious, not only including the immediate of death among youth between the ages of experiences, be more likely to commit a physical injuries, but the longer term 10 and 24; and, for every homicide, there crime, and be less likely to have a positive health problems like post traumatic stress are close to 1,000 nonfatal violent assaults support network.18 disorder (PTSD), depression, anxiety, and involving young people.21 substance abuse.16

Community Safety 47

SERIOUS CRIMES, RATE PER 10,000* Number of Assaults, Burglaries,677 and Homicides/ACS 2005-2009 Population { 2010 Louisville Metro 555Police Data 466 235 California-Parkland Crime can directly affect health, through physical 221 Phoenix Hill-Smoketown -Shelby Park harm and emotional trauma; 205 Russell and the fear of violent crime can indirectly affect health, 197 Portland through increased rates of + Downtown-Old Louisville anxiety and stress. 163 -University 131 South Central Louisville Threatened by crime or other forms of insecurity, our bodies Algonquin-Park Hill 125 -Park Duvalle react in the form of fear, anxiety, depression, dizziness, Shively* 118 chest pains, trouble breathing, 106 Chickasaw-Shawnee nausea, upset stomach, and weakness, which all come Buechel-Newburg together to contribute to poor 102 -Indian Trail health.++ 63 South Louisville Louisville Metro* 63 Germantown rate is 54 40 Pleasure Ridge Park *not including Airport and St. Matthews Census Tracts

32 Highlands Downtown- Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 31 Southeast Louisville Shawnee Northeast Jefferson Valley Station Portland 31 Butchertown-Clifton- St. Crescent Hill Butchertown-Clifton Russell Matthews California- 31 -Crescent Hill Parkland Highlands Algonquin - Park Hill - Park Duvalle German- 27 Fairdale town Southeast J-town South Louisville Central 26 Highview-Okolona Shively Louisville Buechel- Fern Creek Airport Newburg-- 12 Indian Trail Fern South Creek 11 J-town Louisville Pleasure Ridge Park Floyd’s Fork 10 Northeast Jefferson Highview- Okolona

9 Floyd's Fork Fairdale Valley Station

Miles

++ Middleton, J., 1998. Crime is a public health problem. Medicine, confl ict, and survival. Jan- Mar;14(1):24-8.

+Hill TD, Ross CE, Angel RJ. 2005. Neighborhood disorder, psychophysiological distress, and health. Journal of Health and Social Behavior 46 (2):170-186.

48 LOUISVILLE METRO HEALTH EQUITY REPORT

VACANCY RATES (as a Determinant of Neighborhood Safety) Residential Vacancies/Total Residences { 2010 USPS ESTIMATES

21.2% California-Parkland In addition to being an 20.3% Portland eyesore and visual reminder of neighborhood instability, vacant 13.7% Russell properties can attract rodents 12.7% Algonquin-Park Hill and mosquitos, vandalism, -Park Duvalle trespassing, drug dealing, and 12.3% Chickasaw-Shawnee other illegal activities.+ Phoenix Hill-Smoketown 12.1% -Shelby Park Researchers also have found South Central Louisville 9.8% that the presence of abandoned Downtown-Old Louisville buildings, overgrown lots, and 9.0% -University graffi ti, often associated with 6.1% Germantown vacant properties, can lead to an

5.9% Shively increase in perceived crime, and the fears associated with that 4.6% South Louisville perception.++

4.4% Valley Station Louisville Metro* rate is 4.3%

4.0% Highlands *not including Airport Census Tracts Buechel-Newburg 3.5% -Indian Trail Downtown- 3.3% Fairdale Old Louisville- Phoenix Hill- Smoketown- University Chickasaw- Shelby Park 2.7% Southeast Louisville Shawnee Northeast Jefferson Portland 2.6% Highview-Okolona Butchertown-Clifton- St. Russell Crescent Hill Matthews California- 2.6% Pleasure Ridge Park Parkland Highlands Algonquin - Park Hill - Butchertown-Clifton Park Duvalle German- 2.5% town -Crescent Hill Southeast J-town South Louisville Central 1.9% J-town Shively Louisville Buechel- Newburg-- 1.6% Fern Creek Airport Fern Indian Trail South Creek Louisville 1.0% St. Matthews Pleasure Ridge Park Floyd’s Fork 0.9% Northeast Jefferson Highview- Okolona 0.9% Floyd's Fork Fairdale Valley Station 5

Miles

+Just Cause and Alameda County Public Health Department. (2010). Rebuilding neighborhoods, restoring health: A report on the impact of foreclosures on public health. Oakland, CA.

++Taylor RB. The Incivilities or ‘Broken Windows’ Thesis. Department of Criminal Justice. Temple University. Philadelphia, PA

Community Safety 49 PARKS & PHYSICAL ACTIVITY

Physical Activity and Health Adults with 20+ minutes of • Without outdoor places to play, vigorous physical activity three children are less likely to get regular or more days per week The physical characteristics of a exercise and may face elevated risks Louisville Metro BRFSS, 2009 neighborhood, the presence of sidewalks, for diabetes and obesity.9 parks, and houses with front porches, can encourage physical activity and neighbor YES • A study included in the American to neighbor relationships. Parks and public 22.1% Journal of Preventative Medicine spaces provide affordable opportunities found that access to a place to exercise for physical activity and they function as NO results in a 5.1 percent median places to socialize and build community. increase in aerobic capacity, along They are places for scheduled and 77.9% with a reduction in body fat, weight supervised activities for youth, and they loss, improvements in fl exibility, and can be places of refuge to enjoy nature.1 an increase in perceived energy.10

• Spending time in a natural Historically, physical activity was a • Not getting enough exercise is environment and green space can greater part of the day-to-day routine. a contributing cause of coronary have a positive effect on health People worked in jobs that demanded heart disease, colon cancer, and and wellbeing. It can reduce stress physical exertion, they often lived near diabetes, and modest increases in and fatigue and improve mental their workplace and could walk to work, physical activity are associated with health.11 and they had less access to private substantial reductions in the negative transportation. Today, people have to health outcomes related to these While the health benefi ts of physical be more intentional about exercise; conditions.4 and for those who cannot afford gym activity are far ranging, many people fi nd it diffi cult to maintain a routine that includes memberships or team registration fees; • Physical activity levels are highly the recommended amount of activity. A public parks can be an excellent option. related to obesity, one of the fastest study published in 2003, in the journal of For these venues to be used, they must be rising public health problems. In 2 Physical Activity and Public Health, found perceived as attractive, clean, and safe. 2008, over 16% of children were that more than half of U.S. adults are not When park space becomes neglected, and obese (12 million are overweight); physically active on a regular basis; and is either overgrown or strewn with trash and the majority of adults (66%) are that 1 in 4 adults report no leisure-time and broken glass, and when it becomes a overweight or obese.5 haven for crime or for people perceived as activity at all.12 threatening to others, then it is less likely • Parks provide opportunities for to be used. physically active lifestyles by providing relatively inexpensive Access to Opportunities The research base related to the connection options for exercise and recreation.6 for Physical Activity between physical activity and health is Parks, recreational facilities, and other considerable. Selected fi ndings from • According to a study conducted by public spaces in low-income neighborhoods that research are provided below. These the CDC, enhanced access to spaces are often underutilized because of a fear of are just a few examples of the myriad for physical activity resulted in 25% crime or a lack of adequate maintenance.13 of implications of physical activity and more people exercising three or more Many communities with high densities exercise on health: days per week.7 of people of color have fewer physical activity facilities and a decreased number • Physical activity is associated with • Having a place to be physically of facilities has been associated with lower reductions in premature mortality, the active, combined with outreach rates of moderate to vigorous physical prevention of chronic diseases and and education, can produce a 48% 3 activity.14 improvements in mental health. increase in frequency of physical activity.8

50 LOUISVILLE METRO HEALTH EQUITY REPORT

ASSAULTS NEAR PARKS Assaults within 1000 ft of Metro677 Parks, (Rate per 10,000 people) 555 { 2010 Louisville Metro Police Data 466 73.9 Portland Crime can serve as a Phoenix Hill-Smoketown 72.2 -Shelby Park very serious to barrier to the accessibility of Russell 50.9 parks, even if parks 41.4 California-Parkland are nearby and contain quality exercise Algonquin-Park Hill amenities. While many 25.4 -Park Duvalle poorer neighborhoods 22.2 Downtown-Old Louisville -University may have a greater proximity-based access 17.4 South Central Louisville than people in suburban 15.9 Chickasaw-Shawnee Louisville Metro* or rural Louisville, overall rate is 15.2 access is likely limited by 7.5 Buechel-Newburg -Indian Trail *not including Airport and St. perceptions of safety in Matthews Census Tracts parks. 6.7 South Louisville

5.7 Germantown

4.3 Butchertown-Clifton -Crescent Hill

3.5 Highlands Downtown- Old Louisville- Phoenix Hill- Smoketown- Fairdale University 3.3 Chickasaw- Shelby Park Shawnee Northeast 2.9 Southeast Louisville Jefferson Portland Butchertown-Clifton- St. Crescent Hill 2.4 Shively Russell Matthews California- Parkland Highlands 2.3 Valley Station Algonquin - Park Hill - Park Duvalle German- town Southeast J-town 1.5 Highview-Okolona South Louisville Central Shively Louisville 0.7 Floyd's Fork Buechel- Airport Newburg-- Indian Trail Fern Northeast Jefferson South Creek 0.5 Louisville

Pleasure Ridge Park 0.5 Pleasure Ridge Park Floyd’s Fork Highview- Okolona 0.4 J-town Fairdale 0.0 Fern Creek Valley Station 5

Miles

Parks & Physical Activity 51 CONCLUSION

Like their fellow Americans, Louisvillians born at the beginning of the 21st century can expect to live, on average, 30 years longer than people born at the beginning Healthy of the 20th century. The introduction of antibiotics, vaccines and other medical People 2020 advances have been important, but the majority of the increase in life expectancy Charge can be attributed to improvements in our physical and social environments. Clean water, clean air, effective sewer systems, safe food production, workplace and ‘Create social traffi c safety, restrictions on the sale and use of tobacco products and improvements and physical in housing conditions have yielded the greatest benefi ts. Yet, these benefi ts have environments that not been uniformly distributed across neighborhoods, races, and socioeconomic lines. promote good health for all’ Healthy People 2020 charges us to ‘Create social and physical environments that promote good health for all’ as one of four overarching goals for the decade. It is clear from the information and analysis presented in this report that in order to ensure all Louisvillians have the opportunity for good health, advances are needed well beyond health care and the traditional health sectors. As shown, population health to a large extent is determined by living conditions and other social and economic factors, and are therefore often best infl uenced by policies and actions in fi elds such as education, childcare, housing, business, law, media, community planning, transportation and agriculture. Making these advances, therefore requires working together to explore how programs, practices and policies in these areas affect the health of individuals, families, and communities. Our embrace of a “health in all policies” approach would facilitate common goals, complimentary roles, and ongoing constructive relationships between public health, health care and other critical sectors.

The Center for Health Equity works to eliminate social and economic barriers to good health. As a catalyst for collaboration between communities, organizations and government entities, The Center commissioned this report as a starting point for community-wide conversations to reshape the public health landscape. As a starter ‘health equity lens’, the determinants of health underscore the need for an explicit concern for health and equity in all areas of policy. The focus of this approach extends beyond individual factors and lifestyles, to addressing how these can be infl uenced by complimentary policy-related strategies contributing to improved population health.

Going forward, community participation and insight are critical as we actively seek to create the social and physical environments that will promote good health for all Louisvillians.

Join the conversation!

52 LOUISVILLE METRO HEALTH EQUITY REPORT REFERENCES

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Conclusion 53 Survey, 2009, 1-year estimates. Washington, DC: ENVIRONMENTAL Government Printing Offi ce. 12 Ibid. QUALITY 24 Robert Wood Johnson Foundation. (2011). State of the 13 Gonzalez-Rivera, C. (2009). People of color hardest states: Laying the foundation for health reform. Princeton, hit by the foreclosure crisis. The Greenlining Institute, 1 US Environmental Protection Agency. Lead in paint dust NJ: Robert Wood Johnson Foundation. Retrieved from: Berkeley, CA. and soil. Retrieved from: http://www.epa.gov/lead/pubs/ http://www.rwjf.org/coverage/product.jsp?id=71835. leadinfo.htm#facts. Accessed July 1, 2009. 14 Ibid. US Environmental Protection Agency. (1990). Asbestos. 15 Just Cause and Alameda County Public Health Depart- Retrieved from: http://www.epa.gov/asbestos/pubs/help. HOUSING ment. (2010). Rebuilding neighborhoods, restoring health: html#Info. Accessed July 1, 2009. 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References 57 Clinical and Experimental Research, 30 (7), 1184-1193. Transportation%20Recommendations-4-28-2010.pdf. Accessed February 12, 2011. 12 Scribner, R., MacKinnon, D., & Dwyer, J. (2004). Alcohol outlet density and motor vehicle crashes in Los Angeles 5 Centers for Disease Control and Prevention. (2008). County cities. Journal of Studies on Alcohol, 55 (4), Overweight and obesity. Retrieved from: 447-453. www.cdc.gov/nccdphp/dnpa/obesity/index.htm. Accessed February 1, 2011. 13 Alameda County Public Health Department, (2008). Life and death from unnatural causes: Health and social 6 Transportation Research Board of the National inequity in Alameda County. Alameda County Public Academies. (2005). Does the built environment infl uence Health Department, Oakland, CA. physical activity? Examining the evidence. TR News, Issue 237, 31-33. Washington, DC: Transportation 14 Centers for Disease Control and Prevention, (2009). Research Board. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 7 Centers for Disease Control and Prevention. (2001). Increasing physical activity: A report on recommendations 15 Ibid. of the task force on community preventive services. Retrieved from: http://www.cdc.gov/mmwr/preview/ 16 Lynch, M. (2003). Consequences of children’s exposure mmwrhtml/rr5018a1.htm. Accessed March 8, 2011. to community violence. Clinical Child and Family Psychology Review, 6 (4), 265-74. 8 Kahn, E. (2002). The effectiveness of interventions to increase physical activity. American Journal of 17 Bingenheimer, J., Brennan, R., & Earls, F. (2005). Preventative Medicine, 22, 87-88. Firearm violence exposure and serious violent behavior. Science, 308, 1323-1326. 9 The Trust for Public Land. (2004). No place to play: a comparative analysis of park access in seven major cities. 18 Offi ce of Justice Programs. (2002). Overview of San Francisco, CA: The Trust for Public Land. the research literature on consequences of criminal victimization. National Criminal Justice Referral Service. 10 The Trust for Public Land. (2005). The benefi ts of parks: US. Dept. of Justice. Retrieved March 7, 2011, from http:// Why America needs more city parks and open space. San www.ncjrs.gov/html/ojjdp/yv_2002_2_1/page1.html. Francisco, CA: The Trust for Public Land.

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21 Bureau of Justice Statistics. Criminal Victimization in the 12 Frank, L., Engelke, P., & Schmid, T. (2003). Physical United States, 2003: Statistical Tables. activity and public health. In health and community design: The impact of the built environment on physical activity. Washington, DC: Island Press.

PARKS & PHYSICAL 13 Center for Quality Growth and Regional Development, ACTIVITY Georgia Institute of Technology. (2006). Healthy housing: Forging the economic and empirical foundation. Atlanta, GA: Georgia Institute of Technology. 1 Cohen, D., McKenzie, T., Sehgal, A., Williamson, S., Golinelli, D., & Lurie, N. (2007). Contribution of public 14 parks to physical activity. Am J Public Health, 97(3), Gordon-Larsen, P, Nelson, M. C., Page, P., & Popkin, 509-514. B. (2006). Inequality in the built environment underlies key health disparities in physical activity and obesity. Center for Quality Growth and Regional Development, Pediatrics, 117, 417-424. Georgia Institute of Technology. (2006). Healthy housing: Forging the economic and empirical foundation. Atlanta, GA: George Institute of Technology. CONCLUSION

2 Frumkin, H., Frank, L., & Jackson, R. (2004). Urban 1 Woolf SH, Johnson RE, Fryer GE, Rust G, Satcher D, sprawl and public health. Designing, planning, and The Health Impact of Resolving Racial Disparities: An building for healthy communities. Washington, DC: Island Analysis of US Mortality Data, American Journal of Public Press. Health, December 2004: 94 (12); 2078-2081.

3 Powell, K., Martin, L., & Chowdhury, P. (2003). Places to walk: Convenience and regular physical activity. American Journal of Public Health, 93(9),1519-1521.

4 Centers for Disease Control and Prevention. (2010). CDC recommendations for improving health through transportation policy. Retrieved from: http://www. cdc.gov/transportation/docs/FINAL%20CDC%20

58 LOUISVILLE METRO HEALTH EQUITY REPORT Appendix A: Neighborhood Area Maps

Airport Buechel-Newburg-Indian Trail

t S I 65 1 d 70 y I6 3 o l 5 Allgeier F Atkinson S Squa s re e B Gardiner ik u all H e Cir 8 E c cle Of astmoo M hel P Cham 6 r d pio 4 r a n s fo r Ro k ba Legho h I nita rds rn s B a a 6 S h B l 4 g R 5 264 26 Hu a 31 v 31 6 oo z d 1 B I P D a e l Ramp 4 B p f law a I 26 6 op o i are rd n P r 5 C r h s e s k t a l i g o D it N w I a B ia hy n rr e r n t e n 65 a n o n u ss ll s L w B e 6 e et e erna b t re P c b l d 5 e v P u u A r g No

in e rfo n d 6 e in g lk o o l r h e 5 e

t E P c

t w r

Pr i

x e r

6 o e

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d n e l u s l 0 K l

a i 1 h e St 3 H i

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5 s Po er t1 e D e i 6 i s d M I r r 2Nd x a l I o p e

x e Vim ll E R a l

a h r a i enn

n o rL p V

n D o Rural e t e r T Vera v h r u c

e or i b e S t te e n l a

N i r s o k a n a n t s d inO u a e i r A Tw o R R W Ce o o v s on Norene e t t e g u C r t a s s a

t F o t o t e s L R e r ange L i l e an N d d Ga

r t g o e e e 4 y Rd l e lle o Fern Va F a a n L i r Q d 7Th uiet b y P e k o O l e u range n r a i r n e s G n F h L s O t a a e o il Ulrich n e d e e J F a r ern Valley h r u t P S G l a r i

n e e g s

M i e G lton Ave t Acapolca S 6 o Industrial n 5 Tower 1 Sunday

I Mile 6 5 p oo I uterL 65 op O r Lo Zib L Oute n

n

Dr rL ivew o ay in M

1 S Park Rd 1 Mile State Hwy 84

Algonquin-Park Hill-Park Duvalle

Dumesnil St WilsonAve t

S t

t

h t S c W t d S ood e h l S a Gibso S hS R nd n Ln e ou T A ther 3 v y n Ave s T e B 8 s 5 2 t w 2 e 2 k S S

S P pr S h W Yo y Bu t n un rn T g Ave ett A 264 C ve S I 5 W ui H 3 i Bohne A e ll St ve Duv v Th S alle Dr A 5 4 y 1 gonq 6 n l o w W Hill S A B S u t t ls rwellA H I2 ve i t S W e W t S i Lee St W Cott S h er D d ix S r T D h h St 0 ip W T yand 2N otte Ave 1 p 2 h 1 A 1 T S ve S 3 S y Algon t 1 M w quinPk S wy S St ix Th A eH Th 7 v 1 i 6 e x Be S t i rnheim Ln S D S1 Mile h T

4

I S ndu s t tr S y R d

Th

9 t

S

S

h

T

4

S

Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 59 Butchertown-Clifton-Crescent Hill

d R er iv R 1 I 7 Moc Rd king M bi ver rd Va e i 2 Z l t R it G le a x o y R l E r r d L n e n A e H v n e r ig i 71 h d M I wo g e ocki

o L Wi d e n ngb L L v D J ig itte A n r a h d i r f v ir t t o re d fo n S r o NB is to le w V o ul O ll de L t F R e e a R h M E ir v n l d L c A ley Rd d io d Pr h i n le th N yo w el S Rd o ad I A t BertieAv H r o M d 65 xit 5 e i A d R I 64 E te ro e v A bo I6 v A e v ns Dr 4 v e row af A Bi e B rle ry ljan nte to a D Wi S e r F v N e enl t Av e A ield F v

S t l E ldAve e e ie A e a S F v r w y p n A e i dA o ve n r v Co n g u

o P A K e a l b A S l J e llwo S FrankfortA k o ve n ve e S c B t G S N ne M p S la r a H ec

r B Payne St l d i i C n t t S k e y g A t ra en A il Ca S v A z C b v r t e v A h b n i I 6 e d 4 e v e s n e g I 6 r I v t 4 e r L o o A e S y n n laRd llis L ull E L sL i n H xit n W e 8 n v ve t A St A e rs nz rr ge Na a Ro B 1 Mile

Chickasaw- I 6 Shawnee 4 I64 N

3

3 wy Rd Northwestern Pk S

t Bank St Parker Ave

Dunc California-Parkland a t n St S W M t arke Th S t St 8 3 h W Broa t He 4 dway W Broadway r S m N 6 an t S h t t 40T I2 S T l S t 0 S W e J d S e z fferson 4 2

St a 6 N M ap h 2 S le S L 2 t a H rkwo I T od Av 2 0 d e Ga rla 1 nd S R Av W e t Ken t tuc S V kySt S t ermo t S t n t A S ark ve h S Date St S T P y h Th t t h t 5 w T 7 T t S S 1 t t S 2 G 1 4 S r 1 G een H ra w 1 h S nd ood A S 3 h t ve Av 4 e e h S T t i T h S S x S T 4 S S i 8 Th S

T 6 4 h 2 hawnee D 9 7 d 2 T S S 3 N G S 6 t allag S t S H her S W Broa 2 al dwa 3 e t y S A S ve S 3

S h h S c T e WO 4 ak S e Du t G 3 mesnil y ar S land Ave B t S w

k

d St P 4 W 6 Wi Ormsby h lson Ave n Green 2 Ave r w T kR ood Av I r e e 5 t

a 4 s Sun 1 P se t St e Ave S

w w h St Mile h t a T t

s t d 3 u

a 1 S o k Vi rginia St S Av h c e S

i 43R T 0Th S h h

1 1 S e T C v 3 1 7 t S A i l x Kirby S S i E Ave c e 4 C 6 2 W Mag I nolia Av Gibson Ln e

1 Mile

Map Data Sources: U.S. Census Bureau and ESRI

60 LOUISVILLE METRO HEALTH EQUITY REPORT Downtown-Old Louisville- University

d R 1 n 3 I w y 6 o lt w 5 Fern Creek il H I B

s 65 U WattersonT R rl iv Michae a le Ln r nn D L P Rd a T a or er lls c alith iv i a a D D R r t Exit4 River Rd I 64 H r i W t e r c I 64 u m GutenbergR o ln d C WM a Dr ain St W t E Main S t Sa Fairgroun 5 B Michael d Rd W 6 a Edwar Jeffe r i d Dr rson Pro I d n St duce P sto t lz w G n a Bi t t R b d r Huds ll S S NalanDr ie on L t l n o h h n w I 65 L ll L T e T G n D n 9 ry 5 ut hrie St Ma R

S S l d

r

5 T Brandy H wyne D r r 5 6 t n a D I me o S

s e

t r s W 106 h t ims e e T a S t L y T t t S r W r t c ay 8 t d w e D h Y E e d r o N se S rk T l Ln S n t Wa 4 2 e a Ne ll J S wb S r S id ge ate H R t d Mi t Ferndale S W l Rd B d reckinr r hS id g T e St R T d d e r 6 l i R on

R a C S s t t k d x e d S w o S n illeR t e v e F n t tter e o i r at d l e S g S S I a v n R G n i B h 1 6 r n nC W a T 5 n r S e r 7 S u e S3 ds F R F S t W O ow ak St Gl Ar E Oak S aserLn tis Way n t R d 265 Par E O A I k Ave rmsby Av spen Green e hurch Rd Ln y BeulahC e W l M l agnolia Ave Woodb r A in e St D

e 5 u 6

S I 2 y W H r ill St a

E n 1 H M ill St L

e e

v

b

A Mile W Lee o St h y

e S l t i t S R S r

t u h S t

1 r A 1 l S P t y S t 5 Mile i d 6 y

I Un o l

F

t Fairdale

S

kS d

o

o Ram ve ry Dr Br p A Glengar Cut R e S 5 dl w n 6 i Ex I H it I 8 Ne

65 41 Far 65 y 8 W I 2 Hw Manslick Rd m te er

d 5

ta 1 R N S 6 S a s W Ln t e t I al io d e rd n R l a r c Fai lT ge h n d Mo p S ra D R u k t 3 ll d nt e P G i r i d H B Ex R o a H R l l r ly a n n il R k u d R rr 41 so R ic r f d e k f l ell H wy 8 o s H h Jef W c H R e it H

5 tat o a d

rr 6 S M ls i c so I la n w Ln H i ll Rd R TopHill d

n d d L R

R f p f k d e a o R re nsG G C vi b le mp o B a n c K r a e B Rd

p

a

G

s t t

P o en c dle S ton Rd 1 Mile Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 61 B a r re t A v Germantown e St pton Lam Floyd’s Fork V in e Rd t St ille S yv elb S n Sh helbyville a R B d w T r r B e u S ir n D E Ken t c c d tuc k h leR ky S S d a il t l v e n y t L m lb e e t r ton h r i S U R S S f k d n t t n S a c a k i a t O i sL E e o W Sw v b A n r I 64 I 64 b fe R u 5 R d d Ho ve 6 d R A 2 n I R iso n l o l e R i S E l l a i un A m at v s l t h u r r n S

e d T e S l i 5 n h k t S R o t 6 r s g h i 2 a c B l

t A ck I s i E F r C S h L d o t S e o k o

t e S v o k

A p y St w T

z o t a t e r l y r v s l ncoc e t b Ro a a C l Po o S Ch Rd SP 8 e ille E 4 H y e ylorsv T 1 S h r v d Ta u y rt R a p o a o A Bayp en t w SH S gner A t y h k la ig c s a R l H i o a r o 5 S x W L P d r H wet L d 6 y T s e o a I T d e v R t y E i v t i D a l l s l h o e l e B r eR S el lo l R s u t Ru v e r R d i v A rn lle A v d d is e e n pew L de SPr tt mRd a Rd n u o d ra A Eas R ke B v H n E B e y e ma r R r s kw r D d a to Thu ate t d nP l n er 5 e G S e t 6 l y S s 2 rid t t a I B r A E o v d e S l Bradbe R F e B r at i EchoT t onv ll S ill to ller Exi e w d i t 1 R n M 7 d R 5 P

R E t 6 C r c t e d h

I o u ri e st n H v il o t o L l T t A B r

re R e y ntlin l a n ith ger Ln n v Er e H d m B O Av w S ru ld e s H S h wn y e n R a la d u d y t n y a Ln o R R D d

M y R d k u c G r Ro n t e Rd u R L n n ocust u d 1 Ln R t R s r 3 am y d 5 B a 1 d Ad L dgeR o Ri ar ry

d n R r Fairmount y D

d B 0.5 s Hw t Rd ow ckRun e Ba t a Mile n St d R

v l d

B

s Rd l

l

i

k

H e

e Pin B e ta Valle a 2 y s

T i r rl d rCr V s a t o Miles d Th ixtonLn w n Ce R d

Highlands

t e S tead Dr yn Grins G Lexington Rd Natche Pa a zLn T d rd R o R e a p ton n m H ng Dr d E p i i R ll x e t Le l R es y d Re A ee C v Alt W h e a Vi a Alley C r sta Ct Pee m h d D y b er a w e e o te k rr v k s P I A ee rin d 64 y ty G e R D s R ir Al I 6 hri B d E e ple 4 r C ax v k a C taV rcle Hill Rd e o Ci t r r M a e e lt O tt e ist r A h A A ve a ld v Ba C p R C e r o d e ds o a Av tow L n r S n fe n ic o u e u n C R R v n l e d A e e g s a v c r Mi Pe L n v and S a n A A ve n a l e o dgel y lt lv n e w A W v ood E k R a V s A P al l L n ew e d e e o s rn v l e n llis o te A R e E B R as y tta R a E a S d e r Ln rr p r e e N r s Rd Mur e i e t tAve Hill o v n geD S r A g la e Rd er H ri d il Av s ee D V C ar vd ne ruis Pl Sp r l ur a M C r t B o r m r ss b o c D D d a D la o li c n d g o n o ra a u i e n W a y y l A o o v D A t n h A v m e W o l h v v sL a ya e ic a n n o R r A e y a D e D m R eb h W r utc Driveway D 1 Mile Map Data Sources: U.S. Census Bureau and ESRI

62 LOUISVILLE METRO HEALTH EQUITY REPORT Ba rd sto wn Rd

Woodhaven Rd

n

L

h

s

S u

b t

o

n

n

e

e

g

e B

F l u

f

f

R Sunnyhill Rd d Fern Valley Rd W at MandevilleRd ch Highview-Okolona H il l R I B d 6 r Oaklawn D i Mo 5 D r lli orhaven Dr Rossmoor Dr M e ie L Tangelo D o r ow n B Minor Ln na Lipps L c Briscoe Fe n o Ln I Clay Ave ge 6 D nb 5 u r s Ou h Ln ter Loop Outer Loop P Pi S d nec r ie A roft e s pplegate Ln R Dr st L t a e ind l o l n W e Ram a a bo Way H y h y R c n w d o d w L d y R k t R d Blue e l P R s il lick o kR ns v a

c d Ma 5 B i n L s n Miles R d E r

6 be L d th y 5

I 1 er e Exit e B l nR lDr h m

u l d u I 265 ck R S B i sl R hep Man S E a i

S Par n k r Rd a B

v D l a

G y t

len a I R e 2 ose Toebb s 6 R e Ln n 5 d s

n

r a

t n R 1 D

e n e

v d

a w P

A Ol L e dshire Rd i r Mile

V o ve R h ve ed e Sp T ruce

k A Dr i n zA

t p n L r Cooper C n hapel R e d r ve i Leisur Ku e

u a Ln m

T M C aple or Sprin

5 N g Dr Brook Bend Way 6 I Hillcross Dr Mount d Washing R ton Rd k M r c udLn i L D A arkgrov L nt e y le Dr Dr e e l

u k l o B o Br

y a Shelbyville R W d BullittLn Shelbyville Rd n d a i R 4 Main St st W 6 y Rd ri d 2 e R le tt h C ton I li s f o A rn ul C B lo s u F n e y in Ox e x Wa B ch y M l J-Town lA P ur ey 4 db R m l Le o d 6 n y o s 2 d e o w I e r r k r rso B D L R k n P la o nP d ro n b m n k k a w e Lyn h B I y n g Cir ro 64 imberwood b n T wn P i a t k a t r e s k o s r L h N d P n ir d Linn Station R e R B Exit 17 k I 64 I 64 E L ee u I 64 w x n r ns y it T C e d 19 g P o R n n rl ick A i la b y Taylorsvi w P T pe L lle R a a d lo k n n B Po t l lueg S B w t ra e s ss Pkw W so y id D v y r r a

A eD D e r r t t t e y t i a a b Driv w r w e e way e W T t B e uc D a l H G a r k n Dr D e r r k 1 D ng r D ld Ln i e e fie w ta S d r S n i e a t s m le b t um i O D a Mile s S l Ct a t a M d e ion E S er k i p Dr e ix xM n m ro r Galle S A lect R on D il E P r e ve d Ln A k Dr Grand d w lson Six Mile Ln l R y Co Galene Dr Reh y Bartlett Rd w e Sue Helen Dr D k v y e P d r l R A n w l R el Dominion Way D k d k g n Willowwood Way e e k d a ieL P ri re l o n R k C 65 eddin e g Rd c l n 2

n n r o n ro u li r I L Rich B B R b T B u m ar o y a s d n R u b st t o o x s w hand a

r St T n c R u a d H

N

S Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 63 2 4 y W w e H s s to U v B F e a r o s D s x M R c r a d r yf o Northeast Jefferson a f ir A t v R e d

E Marina Dr ld Wo e lf P r n en L L Bra n 2 h S nc s ta hR i te 42 Hw v y 84 d Miles

A 1 ay S Ballardsville Rd pr in ghw gd i E M B W H a x u a 1 le it34 r o s rb I 7 p o Rd h d U o y We s L u id i r C L st e m L h n po e n a rt R 1 m C R d K I 7 ley Dr d o d R i Dar t R b e ln or ll a tp e in m I L G s r n e la s e d n r W L rs i e in R a B e n F L n n l n L d a om re n Fa d H n la ss A cto lo y ry R i ke w B nc Ln r ll I H s e s 2 n o iv n 6 H ho R T b 4 R u O r a n il r l To d s k H z l I R a W e e Dr L g t r 2 r m d ay F e r a e l L 6 nh n at m L r R C n 4 O Fa R ock n r l r d R u R d vd m D b L R l d d y ry A L W n sb O en ike n ps D a d y ld H rB n R o o d e s L U l d n r H O h n N s R m b L id l u e a ge R 5 a n H y r d r r d 6 n u P D L o 2 Po A r d lo s o n d F I d Rd l ie v l s nR lds l t r L e i o R n b s C n o M 5 uL n s s o e sa n d r r s 6 p a o n p u y e N ti i 2 A W h h r e d a nR n I t W k R o u e S J a R n R y 7 y P e d e g ik 2 l k n A t k w i c o x L y E Be N S helby vill e Rd Phoenix Hill-Smoketown-Shelby Park

I 6 Exit 4 M 6 5 I6 A il E l C dam x S abel i t t 7

5 t s 6 S S S I Pleasure Ridge Park I t y t 6 a 4 5 l

6 0.5 C Fra e I nklin St v N ry A Mile Sto E Main S 5 t I 6 E M arket St y B r a a D E Jeff a W e x t rson St Log er g te is ub in r t H M d E E Li ics a l Dr Mu bert A r hamma y St R D gu r ie d Ali Bl v iv r er F a vd e ite e L D ict rp eD o l v t o w r y r e y n S t r w I D H o l l r u H E Ch D est e n nut S I te e t b nter r E G d m d s xi p o ray St dal D T i R r r r c m e D t r yR a r 5 St d r D E o y r lD B C 6 roadw a k a y e P w R ls I r c T l S e i

o d H t g st M c t l d A t S n t t e e l d nR t S b A S sh A y u H kS n ve n Ha y o Ru i o l e l t a a S l o l e s g eR Gr r S ee F n r wood Rd id C o n B S n G e L a r S Fu o D S C r D s t Jes y W k ly t s a r S mine ay c s Ln A y a

A s rde b llaC l t e hur r l e SJ n y Ma h ryma e nR L d Winstead D hD r K S t

St S or W Page A f s Ln n r a n o Ba t r r one e ol ss Av L s e D d T S n ra lzie L a to re de E k P w e wn P or e e t i r E D i O v n a v d S k St r iew L Rd A g e V l i H e

p D ter a

s r

M Cam e Johnsontown Rd Rd Street Rd p St h 3

C 5

6 I M arret Ave A Ln shby 1 od Ln rwo I 65 Mile Silve

Map Data Sources: U.S. Census Bureau and ESRI

64 LOUISVILLE METRO HEALTH EQUITY REPORT I 64 Rudd Ave Rudd Ave

Ty le lfred Rd Portland r Av t A e S I N 6 h 4

3 T M 3 9 M ar R o i 2 ntg ne S d N om h e S ip S ry S Co t p t Po t rnw in t r a g E tland ll p L S o x ytle A t r hS i t v tD t S e T T y S t 1 G le 4 illi r A r h g v 3 t an e T S 5 t N hS t 3 t 0 Parke T S 5 r Ave N 0 B 1 t 3 an h Th S k y S T 8 S t N t 4 Ly w h 2 t S 2 leSt H T N h N s 5 St S T 3 Gar h ain U N 8 fie ld Ave T t X e 3 Je N l well Ave 6 av lig 2 ierS a N I t n 2 Slev N t A No 6 in St G S v 4 ri e ffi d r t ths th St N w S A t Alfo ve 2 t r St d St e h Av S e h 2 h s S T h te T T B d 7 t N T 9 h t t a r 5 t 1 n 3 N i S 9 rd 3 T S S S P 2 2 N 4 h t St k N 3 h O N w h 3 en S wy T N t T N 1S 0 N 0 36T 2 t 3 t Dun 2 S ca S N n S N h N t W N M I T ain S h t t 7 2 T 1

S 6 Crop R Co 9 N 4 S ow lu t t a m d n b 1 St ia S t W M t t ark R S t S et St S N 3 h S St h C t olu h 3 T mb T ia h h S T S t 0 S t T 9 T 3 St h C 18 8 S r 5 2 op t St T S 2 St 1 W h N S 6 Th S

T S 2 1 N d 4 25 Rd 3 t S 2 3 N y W S S 2 P M 2 irtle S ain S S w t t 2 h S t H T S C 8 s 1 n U

1 S

ono Mile M

Russell

WMa rket St I 6 4 I 64 W Mar t ket S S 2 Con t gress t t St h i S

x T

h 3 E W T C Main S 4 ongre W Ma t ss rk N1 2 St et S Green Aly t EddySt S t 4 W Je f S t f t R Eddy St Ceda erson St r S S S a E t t h dd t I 26 y S mp t t S T h h S V 2 erm S T T ont A h 1 h ve St 0 0 o T h neA R T l St 1 ive y t r 3 S Pa T r t k 1 D t r S t 8 h S2 1 S S S 2 T S h St S1 M h S h a 8 t diso W T S n A M a 1 D ly d T T A el i S P so 6 lley t n arkT Th St e 9 Th 0 1 r t W S 9 S h M t u 1 7 h 3 amm S t 2 T ad W 1 S A S t t Ch li Bl t e v s S 5 d S S t h nut S St S C S 1 S 1 T

Th 3 h 6 d S 7

on T 2

l S N M 2 ag 4 azine Ply 2 m S St outhC S Ell 3 iottA t ve S ade E S3 squ S ir e A 1 M WBroadway ly W Broadway 2 R t ea W Broadway T dAly S h W Bro S a Th dway t 3 1 W S B roadway 1 Mile

Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 65 Shively Alg onquin P Bells Ln kwy r D Oregon Ave t h C 4

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Map Data Sources: U.S. Census Bureau and ESRI

66 LOUISVILLE METRO HEALTH EQUITY REPORT Southeast Louisville I 264 V a r ll D N e k e tt 64 o w a 2 ro R R I b b ill ic u N d H h r o l g rri A a 4 v n R s r D 6 d d D I 2 o P u B n M A l le n e e 4 R v a d v t 6 e Y A t I 2 d e D e y lb e on ix rs Ln Ln o Tayl ie Rd e r Ln u orsville Rd r L r r D V le o e n St a Em Ty w in d ay lle d lv e w Ne y e ar k l G Ave onB A ar w V lA t ve P ve r bu is T lice Ra an Ln A D rg ta re v A t s ey m e di S e inl E er Rd R an k ck a rl d r o Hi M g Eh D n c le n t D r eRd y S lo D B Ln P a y il r w ss a W lv D do r re e s an a a D c Locust Ln H y s ili n n Ln e nn k kw ev Wa rL h M A e P Tr ne it le n n F i m a r bo in y rd D i I 6 du c olds d 5 u r a I n Ga e g A D s ll G v r e l t in L n r A n D na le o L Ke r L y L i ff p L rd R i o risD e ke ro n a s u e d i e C d sh i H rr n d A h i th Pa n m B u y u lo o ve c S r N L on Dr K P D S ew n r r e D r a v b D d P rA 4 ur r or D Six MileL r lm lo 6 g df n e e ay 2 R ra n s T I B o B t t d o n x n tt L u H rre 1 B w Du y Mile y w H e ixi D Dr lou an Valley Station y W S a to

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Map Data Sources: U.S. Census Bureau and ESRI

Appendix A 67 Appendix B: Work Group Listings

Local Work Group Emily Beauregard Family Health Centers, Inc. Sasha Belenky YMCA of Greater Louisville The local Work Group was made up Mike Bramer YMCA of Greater Louisville of key local agency and community Luther Brown Communtiy Activist organization representatives. This group Nancy Carrington Center for Neighborhoods provided critical advice and assistance Khalilah Collins Kentucky Health Justice Network in the development of the Health Equity Karen Cost Louisville Metro Board of Health Report, and was involved in developing Angelique David Louisville Urban League and refi ning report content, assistance Michael Dean California Collaborative in raw data acquisition, and in thinking Catherine Fosl Anne Braden Institute for Social Justice, Univeristy of Louisville about utilization of the report. Rus Funk Community Organizer Tiffany Gonzales Center for Health Equity Special thanks to Ray Yeager, MPH Tom Gurucharri Hispanic-Latino Coalition of Louisville for analysis on age-adjusted life Makeda Harris Louisville Metro Public Health & Wellness expectancy and mortality rates by Tina Hembree Norton Cancer Institute cause for Neighborhood Areas in Rodney Martin YMCA of Greater Louisville Louisville Metro. Carolyn Miller-Cooper Louisville Metro Human Relations Commission Regina Moore Louisville Metro Public Health & Wellness Special thanks to Catherine Fosl, Ebony O’Rea Center for Health Equity (Contractor) PhD for writing and research for the Chris Owens Louisville Metro Offi ce for Women section on the historical context. Haritha Pallum Louisville Metro Public Health & Wellness Kendria Rice-Lockett Louisville Metro Parks & Recreation Angel Rubio Center for Health Equity (Contractor) Shalonda Samuels Center for Health Equity Judy Schroeder Metro United Way Lavonne White Louisville Metro Public Health & Wellness Anthony Williams Louisville Metro Parks & Recreation Deonna Williams University of Louisville Dental School National Work Group Ray Yeager Louisville Metro Public Health & Wellness (Contractor) As a part of the Health Equity Report process a national-level Work Group was organized to provide direction Ashely Bowen National Association of County and City Health Offi cials (NACCHO) for the project. A series of conference Karen Cost Louisville Metro Board of Health calls were conducted with agency Helen Deines Race, Community and Child Welfare Initiative representatives from communities that Amber Duke Anne Braden Institute for Social Justice, Univeristy of Louisville have produced Health Equity Reports in Cate Fosl Anne Braden Institute for Social Justice, Univeristy of Louisville their communities. Through the series Sharon Mierzwa Connecticut Association of Directors of Health, Inc. of conference calls the participants Carolyn Miller-Cooper Louisville Metro Human Relations Commission discussed what these communities Neba Noyan Social Compact Inc. had learned in their own Health Equity Ebony O’Rea Center for Health Equity (Contractor) Report processes, and provided key input Haritha Pallum Louisville Metro Public Health & Wellness in the conceptualization of a framework Bob Prentice Bay Area Regional Health Inequities Initiative (BARHII) for the Louisville Health Equity Report. Michael Royster Virginia Department of Health Lisa Tobe Center for Health Equity Carolina Valencia Social Compact Inc. Ray Yeager Louisville Metro Public Health & Wellness (Contractor) Ianita Zlateva Connecticut Association of Directors of Health, Inc.

68 LOUISVILLE METRO HEALTH EQUITY REPORT Appendix B