February 2002

Grant Results

SUMMARY

Between 1996 and 2000, the National Public Health and Hospital Institute, Washington, and the New York Academy of Medicine, New York, developed and disseminated a report comparing the social health status of people living in the nation's 100 largest cities with those living in the surrounding suburbs.

It built upon a 1995 project (see Grant Results on ID# 022724) profiling similar data for cities alone.

Key Findings
Researchers at the National Public Health and Hospital Institute published The Social and Health Landscape of Urban and Suburban America in 1999. The findings included:

  • Population growth in suburbs surpassed growth in central cities, but cities have greater rates of increase in the proportion of the population that is very young.
  • Many cities have reduced rates of tuberculosis, syphilis, and AIDS since the 1995 study.
  • A significant association of child poverty and low birth weight with violence and minority female-headed households was found in cities but not in counties.
  • Suburbs increasingly have the diversity of black, Hispanic, and foreign-born populations once attributed only to cities.
  • Central cities generally led their counties in either reducing or holding steady violent crime rates.
  • There was a significant drop in hospital discharges and a moderate decline in emergency room use in the 1990s for central city public hospitals, and a surge in discharges in for-profit hospitals in both cities and suburbs.
  • Community health centers continued to focus on vulnerable populations, and local urban health departments offered a broad range of critical screening services.

Funding
The Robert Wood Johnson Foundation (RWJF) supported the project with two grants totaling $654,606 between September 1996 and July 2000.

 See Grant Detail & Contact Information
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THE PROJECT

Researchers at NPHHI developed and disseminated a report comparing the social health status of people living in the nation's 100 largest central cities with those living in the surrounding suburbs. It built on a 1995 NPHHI report by these researchers, Urban Social Health: A Chartbook Profiling the Nation's One Hundred Largest Cities (see Grant Results on ID# 022724), which focused exclusively on cities.

The project described here:

  1. Profiled demographic information, socioeconomic indicators, crime statistics, and child welfare indicators for central cities (updating the 1995 report's city information) and their surrounding counties.
  2. Profiled hospitals, community health centers, and local health departments according to type, and type of geographic area (city, suburb).
  3. Provided trend data on HIV/AIDS for metropolitan areas, and secondary syphilis and tuberculosis data for central cities.
  4. Presented a "Deprivation Index" and a "Child Welfare Index," making city-to-city and county-to-county comparisons.

The data covered the years 1980 to 1996. Researchers relied on seven national federal or association databases (see Appendix 1 for a listing of these sources). An advisory group assisted in this project (see Appendix 2).

Project data and researchers' conclusions appear as an information sourcebook, The Social and Health Landscape of Urban and Suburban America, published in 1999 by the American Hospital Association Press. The American Public Health Association's executive director has described the report as "a critical resource for health planners and policymakers for many years to come."

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FINDINGS

In The Social and Health Landscape of Urban and Suburban America, the researchers reported findings in seven areas:

1. Population Growth and Disease Trends in Urban America

  • With few exceptions, central cities lagged behind their counties in population growth, frequently by wide margins. Population growth in the metropolitan areas of the West and the South far outpaced the national average from 1980 to 1994.
  • The majority of cities, especially in the Northeast, made significant strides in reducing key diseases, including tuberculosis, syphilis, and AIDS. The Southern city syphilis rate is now the highest in the country, four times the Northeastern city rate.

2. Being Young and Growing Old in Urban America

  • From 1980 to 1990, cities witnessed greater rates of increase in the proportion of the population that is very young (under 5), while counties got older. All areas declined in the proportion of youth (ages 5 to 18).

3. Culture and Race in Urban America

  • Greater metropolitan areas now reflect the diversity once attributed only to cities. African-American, Hispanic, and foreign-born populations are becoming more suburbanized, although Asian populations have become more concentrated in central cities. The proportion of the population that is white declined in all areas, with the greatest changes occurring in Northeast cities and counties.

4. The Welfare of Children in America's Cities and Suburbs

  • Child poverty remained entrenched in many cities, but some areas had markedly smaller increases or actual reductions. Cities in the Northeast experienced lower increases in low-birthweight infants than the surrounding suburbs between 1985 and 1995.
  • Significant association of child poverty and low birth weight with violence and minority female-headed households was found in cities but not in counties. This suggests that other factors affect children's welfare in counties.

5. Crime in the Cities and Suburbs of America

  • One third of major cities led their counties in violent crime rate declines in the 1990s. The 25 largest cities turned a 30 percent violent crime rate increase in the 1980s into an 11 percent decline in the 1990s, while the average county rate rose 1 percent. Urban area rates varied substantially, but overall the most challenged cities were the ones to achieve major improvement.
  • Violent crime appears to be a regional urban phenomenon: what happens in the cities is likely to be found in the surrounding counties.

6. Rich and Poor in Urban America

  • Poverty increased more in cities than in their counties between 1980 and 1990. Without exception, cities led their county groups in poverty increases, lagged in adjusted per capita income increases, and were the only urban areas where unemployment rose between 1980 and 1990.
  • There was a wide range among cities in the proportion of income represented by the top fifth of the income earning population. For example in Atlanta the top fifth of the income-earning population accounts for 60 percent of area income, whereas in San Jose the top fifth accounts for 41 percent of area income. Cities with the greatest discrepancies were concentrated in the South; the Western region had 6 of the 12 cities where discrepancies were the smallest.
  • On average, income was distributed more evenly in the suburban areas than in the central cities. Urban counties consistently demonstrate fewer extremes in income distribution.
  • The total central city population living in high-poverty neighborhoods increased dramatically from 1980 to 1990. The poor were more likely to be "ghettoized" in poor neighborhoods.
  • Several cities that were better off in 1980 improved significantly by 1990, while those with the worst rankings in 1980 tended to retain them.

7. Urban Hospital Care and the Health Safety Net

  • Central city public hospitals saw a significant drop in discharges and a moderate decline in emergency department use from 1990 to 1996. For-profit hospitals across cities and their suburbs saw a surge in discharges and a growth in the numbers of beds despite a continuing drop in occupancy rates to about 50 percent.
  • Dramatic increases in Medicaid revenues occurred among nonprofit and for-profit urban hospitals from 1990 to 1996.
  • Medicaid revenues as a share of total public hospital revenues plateaued in the mid-1990s after showing a substantial growth at the beginning of the decade. For-profits saw a consistent increase in the Medicaid share of total revenues. Substantial declines in self-pay/other — that is, traditional charity care — occurred across hospital groups.
  • Reports on community health centers through the 1990s reaffirmed the centers' focus on the poor, as well as the reliance of vulnerable populations on these providers.
  • In the 1990s local health departments in urban areas served diverse populations and offered a broad range of critical screening services and, to a lesser extent, direct patient care. Increased revenues in central cities reflected a high dependency upon non-Medicaid-related government support. Most departments developed relationships with managed care organizations to provide clinical services.

Communications

A second RWJF grant, ID# 036934, funded dissemination of the study findings. A subcontractor, Burness Communications in Bethesda, Md., distributed press releases tailored to individual metropolitan areas and arranged a July 21, 1999, press conference in Washington, D.C. Print, television, and radio media in about 60 percent of the metropolitan areas studied carried stories about the report's findings.

The project director presented findings at three congressional staff briefings in 1999, attended by 56 health professionals and staff members; he also presented project findings at the National Association of City and County Health Officials Metro Area Conference, the Annual Meeting of the American Public Health Association, the National Health Policy Forum, the Heritage Foundation, and the US Chamber of Commerce, among others. Data from the report appears online. (See the Bibliography for details.)

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AFTER THE GRANT

Researchers have been awarded an RWJF grant for a follow-on grant to support a new version of the project's information based on the 2000 US Census data and other updated information. In addition researchers are working with an organization in Texas to develop regionally focused data resources from project results, as well as with the Brookings Institution to study the changes in health care in older suburbs.

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GRANT DETAILS & CONTACT INFORMATION

Project

Analyzing Urban/Suburban Social and Health Indicators

Expanded Analysis of Health and Sociodemographic Factors in Urban Areas

National Public Health and Hospital Institute (Washington,  DC)

  • Amount: $ 462,544
    Dates: September 1996 to December 1999
    ID#:  029644

Dissemination of a Chartbook on Urban/Suburban Social and Health Indicators

The New York Academy of Medicine (New York,  NY)

  • Amount: $ 192,062
    Dates: June 1999 to July 2000
    ID#:  036934

Contact

Dennis P. Andrulis, Ph.D.
(718) 270-7726
dandrulis@netmail.hscbklyn.edu

Web Site

http://www.downstate.edu/urbansoc_healthdata

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Project Report Sources

Sources to date for the project report, The Social and Health Landscape of Urban and Suburban America, Chicago, Ill.: AHA Press, 1999.

[Note: The scope of the project was constrained by the limited availability of nationally recognized sources of information for the cities and counties studied. While data on crime, selected diseases, maternal and child characteristics, and hospitals were available for the years 1990 to 1996, all information concerning population, census, ethnic groups, poverty, income, and socioeconomic status came from 1980-to-1990 data.]

  • US Census Bureau, 1980 and 1990 Census of Population and Housing. Both sources are based on the census sample of one-sixth of the population weighted to represent the total population.
  • Federal Bureau of Investigation Uniform Crime Reports. The reports are based on statistics submitted by law enforcement agencies.
  • National Center for Health Statistics — Vital Statistics. City and county data on infant mortality, low-birthweight infants, and teen births for 1985, 1990, and 1995 were provided by the center at special request. The center cautions that data are reported by place of residence rather than place of death, and in some areas, Miami in particular, this skews the numbers.
  • American Hospital Association Annual Survey. Data presented in survey results are limited to short-term, general, non-federal institutions located in the 100 largest cities in the United States.
  • The US Bureau of Primary Health Care, Health Resources and Services Administration 1990, 1993, 1995 BCRR (Bureau Common Reporting Requirements) and 1996, 1997 UDS (Uniform Data System). These sources provide data on only those community health centers that are funded by the Bureau of Primary Health Care.
  • The National Association of County and City Health Officials (NACCHO) 1992/1993 and 1996/1997 national Profile of Local Health Departments Survey. Data in the survey are presented for local health departments serving either the 100 largest cities (including those that serve only the city and those that serve a larger geographic area that includes the city) or any of the areas (smaller cities or outlying counties).
  • Centers for Disease Control and Prevention, Reported Tuberculosis in the United States — 1980, 1985, 1990, 1996.
  • Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report — 1987/1997.
  • Centers for Disease Control and Prevention, Division of STD Prevention. Sexually Transmitted Disease Surveillance Report — 1980, 1985, 1990–1996.


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Advisory Group
(affiliation at time of the project)

Thomas Chapman
President and CEO
The Hospital for Sick Children Foundation
Washington, D.C.

Marilyn Gaston
Director
Bureau of Primary Health Care
Rockville, Md.

Mary Guinan
Chief
Urban Research Centers
Centers for Disease Control and Prevention
Atlanta, Ga.

Jack Hadley
Former Director
Institute for Health Care Research and Policy
Georgetown University
Washington, D.C.

Dan McLaughlin
Director of Health Strategy and Policy
Hennepin County Health Care System
Minneapolis, Minn.

Paul Nannis
Director of Planning, Evaluation and Legislation
Health Resources and Services Administration
Washington, D.C.

Nancy Rawding
Former Director
National Association of Country and City Health Officials
Washington, D.C.

Trish Reilly
National Academy for State Health Policy
Portland, Maine

Sara Rosenbaum
Director
Center for Health Policy Research
George Washington University
Washington, D.C.

Charles Rover
National Program Director
RWJF Urban Health Initiative
Seattle, Wash.

Nick Zill
Vice President
Westat
Bethesda, Md.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Andrulis D and Goodman N. The Social and Health Landscape of Urban and Suburban America. Chicago, Ill.: American Hospital Association Press, 1999.

Presentations and Testimony

Dennis Andrulis, "The Social and Health Characteristics of Urban America" at the National Association of City and County Health Officials Metro Area Conference, May 1998, Nashville, Tenn.

Dennis Andrulis, "Patterns and Changes in Social Heath of Urban America," at the Annual Meeting of the American Public Health Association, November 17, 1998, Washington, D.C.

Dennis Andrulis, "The Changing Social and Health Landscape of Cities and Suburbs: New Directions for Improving the Welfare of America's Children," at the National Health Policy Forum meeting, February 22, 2000, Washington, D.C.

Dennis Andrulis, "The Changing Social and Health Landscape of Cities and Suburbs: New Directions for Improving the Welfare of America's Children," at the National Association of Counties 2000 Legislative Conference, March 5, 2000, Washington, D.C.

World Wide Web Sites

www.downstate.edu/urbansoc_healthdata provides general information on the report findings and population characteristics, Brooklyn, N.Y., SUNY Downstate Medical Center.

News Conferences and Briefings

News conference on "Study Compares How Cities and Their Suburbs Are Faring When It Comes to Social and Health Challenges," produced by Burness Communications, Washington, D.C., July 21, 1999. Attended by 35 journalists, 26 participated through audio hookup.

Congressional briefing on the Southern Region findings, Washington, D.C., October 22, 1999. Attended by 17 health and other staff members.

Congressional briefing on the Northeast Region findings, Washington, D.C., November 5, 1999. Attended by 16 health and other staff members.

Congressional briefing on the West Region findings, Washington, D.C., December 14, 1999. Attended by 23 health and other staff members.

Press Kits and News Releases

A press kit explaining regional findings in 85 news releases developed to detail specific areas from each metropolitan area was sent July 21, 1999, to 450 journalists.

Print Coverage

"Report: Resident Better Off in City than in Country," in The Bakersfield Californian, July 21, 1999.

"Population of Honolulu Rising, Unlike Most Cities," in The Honolulu Star-Bulletin, July 21, 1999.

"Child Poverty Rate Here Among the Worst," in The Cincinnati Post, July 21, 1999.

"US Cities Report Changing Rates of Infectious Disease," in Health Headlines, July 22, 1999.

"Suburbia, Cities Share Same Issues," in USA Today, July 22, 1999.

"Suburbs Not Always Safer Than Cities, Rates Similar for Social, Health Problems," in The Arizona Republic, July 22, 1999.

"Suburbs Are Increasingly Facing the Problems of Violent Crime and Poverty that Were Once Confined to the Inner Cities," in The Arkansas Democrat-Gazette, July 22, 1999.

"Oakland Lingers Behind Fremont in Health Report," in The Oakland Tribune, July 22, 1999.

"Oakland Lingers Behind Fremont in Health Report," in The Alameda Times-Star, July 22, 1999.

"Urban Ills Creep Inland Sweeping Study Shows: Suburbia No Haven for Crime, Poverty," in The Press-Enterprise, July 22, 1999.

"Suburbs Inherit Problems from Urban Areas," in The Orange County Register, July 22, 1999.

"Fremont Called Best City for Kids; Public Health Study Ranks it No. 1 in Overall Child Welfare," in The San Francisco Chronicle, July 22, 1999.

"Big-City Problems Increasingly at Home in the Suburbs," in The Chicago Herald, July 22, 1999.

"Cities, Suburbs Share Crime and Poverty," in The Chicago Tribune, July 22, 1999.

"Suburbs get Cities' Woes," in The Wichita Eagle, July 22, 1999.

"Health Risks in BR, Suburbs Even Out," in The Baton Rouge Advocate, July 22, 1999.

"Crime, Health Problems Escalate in Suburbs," in The Baltimore Sun, July 22, 1999.

"Urban Problems Moving to Suburbia," in The Boston Globe, July 22, 1999.

"Social, Health Woes Growing in Suburbs," in The Patriot Ledger (Quincy, Mass.), July 22, 1999.

"City Problems Seep into Nation's Suburbs," in The Detroit Free Press, July 22, 1999.

"Suburbs Feel the Sting of Rising Poverty, Crime: Detroit Among Cities that Sees Ills Dip, Move to Other Areas, Study Says," in The Detroit News, July 22, 1999.

"Social, Health Issues Now Seen in Suburbia, Report Says," in The Port Huron Times Herald, July 22, 1999.

"Urban Blight Spreads to Suburbia," in The Sun News (Biloxi, Miss.), July 22, 1999.

"Lincoln Compared Favorably in Study," in The Lincoln Journal Star, July 22, 1999.

"Woes of Cities Now in Suburbs, Too," in The Omaha World-Herald, July 22, 1999.

"Report: Problems Creeping Outward," in The Las Vegas Review-Journal, July 22, 1999.

"Social, Health Problems Once Unique to Cities Seen as Growing in 'Suburbs'," in The Buffalo News, July 22, 1999.

"Report: Urban Issues Affect "'Suburbs,'" in The Brooklyn Daily Eagle, July 22, 1999.

"Charlotte, N.C., Area Tops Quality-of-Life Ranking," in The Charlotte Observer, July 22, 1999.

"Study Tracks Urban Trends," in The News and Record (Piedmont Triad, N.C.), July 22, 1999.

"Study Confirms Steady Spread of Urban Ills into the Suburbs," in The Akron Beacon Journal, July 22, 1999.

"City Concerns Move to Suburbs," in The Cleveland News-Herald, July 22, 1999.

"Area Makes Gains; Poverty Persists," in The Dayton Daily News, July 22, 1999.

"Poverty Report Ranks Dayton 95th Out of 100 Major Cities," in The Springfield News-Sun, July 22, 1999.

"Report: We Can't Escape Crime," in The Dayton News, July 22, 1999.

"Study Indicates Urban Problems; Move to Suburbs," in The Daily Oklahoman, July 22, 1999.

"Urban Problems Move to Suburbs," in The World (Tulsa, Okla.), July 22, 1999.

"Suburbs No Longer Safe from Growing Social Ills," in The Dallas Morning News, July 22, 1999.

"Report Spotlights Growing Pains; Author Touts Lessons for City Planners," in The Arlington Morning News, July 22, 1999.

"Social Health Issues Now Seen in Suburbia," in The Columbian (Vancouver, Wash.), July 22, 1999.

"Troubles of Cities Moving to Suburbia," in The Spokesman Review (Spokane, Wash.), July 22, 1999.

"City, Suburbs Share Similar Crime Stress," in The Capital Times (Madison, Wis.), July 22, 1999.

"Fremont Leads Oakland in Children's Health, Study Says," in The Los Angeles Times, July 23, 1999.

"Fremont Ranks High for Children," in The San Jose Mercury News, July 23, 1999.

"Crime, Other Ills Move to Suburbs; 'Pleasantville' a Myth," in The Cincinnati Post, July 23, 1999.

"State Health Experts See Urban Woes in Suburbs," in The Daily Oklahoman, July 23, 1999.

"Report Urges City-Suburban Cooperation," in The Dayton Daily News, July 27, 1999.

"City-Suburban Gap Closes," in The Austin American Statesman, July 29, 1999.

"Shifting Population Indicates Need for Regional Health Planning," in NurseWeek/HealthWeek, August 2, 1999.

Partial Print Coverage

"Poverty, TB rates up; crime down in San Diego," in The Copely News Service, July 21, 1999.

"Poverty Rates Increase in Baton Rouge, New Orleans, Shreveport," in AP, July 21, 1999.

"Low Infant Birth Weight Rates Growing in New Orleans, Shreveport," in AP, July 21, 1999.

"Report: Urban Issues Affect Suburbs," in AP On-line, July 22, 1999.

"Suburbs No Longer Safe from Growing Social Ills," Knight Ridder Newspapers, July 22, 1999.

"Suburban Health: Facing 'Urban' Problems," in American Health Line, July 23, 1999.

Television Coverage

Channel 3 News at Six, WKYC-TV (CBSO), Cleveland, Ohio, July 21, 1999.

The Ten O'Clock News, WCCB-TV (Fox), Charlotte, N.C., July 21, 1999.

6 News Today, WCNC-TV (NBC), Charlotte, N.C., July 21, 1999.

Eyewitness News, WBNS-TV (CBS), Columbus, Ohio, July 21, 1999.

Eyewitness News Morning, WWL-TV (CBS), New Orleans, La., July 21, 1999.

5 News at 5 AM, KOCO-TV (ABC), Oklahoma City, Okla., July 22, 1999.

Fox News Now, The Cavuto Business Report, July 22, 1999.

CNN Headline News, July 22, 1999.

Daily Edition, CLTV-TV, Chicago, Ill., July 22, 1999.

Eyewitness News This Morning, KPIX-TV (CBS), San Francisco/Oakland, Calif., July 22, 1999.

Eyewitness News at Noon, KPIX-TV (CBS), San Francisco/Oakland, Calif., July 22, 1999.

Newscenter Four Daybreak, KRON-TV (NBC), San Francisco/Oakland, Calif., July 22, 1999.

Morning on Two, KTVU-TV (Fox), San Francisco/Oakland, Calif., July 22, 1999.

The Noon News, KTVU-TV (Fox), San Francisco/Oakland, Calif., July 22, 1999.

News 15 at Noon, KNXV-TV (ABC), Phoenix, Ariz., July 22, 1999.

Fox 10 News at Noon, KSAZ-TV (Fox), Phoenix, Ariz., July 22, 1999.

Fox News at 10, KPDX-TV (Fox), Portland, Ore., July 22, 1999.

Eyewitness News 13 News at Five, WTHR-TV (NBC), Indianapolis, Ind., July 22, 1999.

6 News Today, WCNC-TV (NBC), Charlotte, N.C., July 22, 1999.

Eyewitness News at 12:00, KSL-TV (NBC), Salt Lake City, Utah, July 22, 1999.

News 3 at 5:00, WWMT-TV (CBS), Grand Rapids/Kalamazoo, Mich., July 22, 1999.

Eyewitness News at Noon, WWL-TV (CBS), New Orleans, La., July 22, 1999.

5 News at 5 AM, KOCO-TV (ABC), Oklahoma City, Okla., July 22, 1999.

Channel 27 News, WKOW-TV (ABC), Madison, Wis., July 22, 1999.

22 News, WWLP-TV (NBC), Springfield/Holyoke, Ill., July 22, 1999.

KTNV News First Edition, KNTV-TV (ABC), San Jose, Calif., July 22, 1999.

Radio Coverage

News, KTOP-AM, Washington, D.C., July 21, 1999.

KFWB, News 98, KFWB-AM (IND), Los Angeles, Calif., July 22, 1999.

WBBM Newsradio 98, WBBM-AM (CBS), Chicago, Ill., July 22, 1999.

WGN-AM News, WGN-AM (IND), Chicago, Ill., July 22, 1999.

Morning Drive Time, KKGO-AM (ABC), San Francisco/Oakland, Calif., July 22, 1999.

News, WTOP-AM, Washington, D.C., July 22, 1999.

Noon Drive News, KTRH-AM (CBS), Houston, Texas, July 22, 1999.

News, KSL-AM (IND), Salt Lake City, Utah, July 22, 1999.

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Report prepared by: Janet Spencer King
Reviewed by: James Wood
Reviewed by: Robert Narus
Program Officer: Paul A. Tarini

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