March 2006

Grant Results

SUMMARY

Dennis P. Andrulis, M.P.H., Ph.D., and researchers at SUNY Downstate Medical Center in Brooklyn, N.Y., produced a series of five reports documenting the health and social progress and challenges of the nation's 100 largest cities and their suburbs between 1990 and 2000. The final report, on urban and suburban hospital trends, included data from 1996, 1999 and 2002. The reports and accompanying tables are available on the medical center's Web site.

Key Findings
The project director highlighted the following findings from the reports:

  • On average, the cities and their suburbs met, or made progress towards meeting, Healthy People 2000 goals (set by a coalition of national health agencies) for reducing infant mortality, AIDS, tuberculosis, syphilis and homicide between 1990 and 1999 or 2000. No cities and only two suburbs met goals for reducing low birth weight.
  • The most consistent, and in many cases, strongest improvements in measures of health and social status occurred among non-Hispanic African-American residents in cities and suburbs.
  • Substantial gaps in health and social status remain between whites — who are better off — and other racial and ethnic groups, including Hispanics, African Americans and Asians.
  • People in poor suburbs make up more than two-fifths of the total population of the suburbs, but use only about one-fifth of hospital care in the suburbs. These results focus attention on the extent to which residents of poor suburbs — disproportionately Hispanic and foreign born and more likely to lack health insurance relative to those in wealthy suburbs — may face major problems in availability and access to acute and specialty hospital care in their areas.
  • Findings on the overall distribution of hospital services indicate, for the most part, that people in poor cities do not appear to face the same problems around general availability of acute and specialty hospital care as do those in poor suburbs. This may reflect urban areas' longer history of providing care to diverse populations or greater concentrations of individuals within smaller geographic localities. However, the report did not address specific issues around access within these cities.

Funding
The Robert Wood Johnson Foundation (RWJF) provided a grant of $748,296 to the Research Foundation of the State University of New York, a private nonprofit organization that administers externally funded contracts and grants for the university and its medical center.

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THE PROBLEM

In 1995, RWJF provided support for the publication of the Chartbook on Urban Social Health that profiled the social health status of people living in the nation's 100 largest cities (see Grant Results on ID# 022724 for more information on this report). The report integrated information on health status, socioeconomic status and health care utilization.

In 1999, RWJF supported publication of The Health and Social Landscape of Urban and Suburban America (see Grant Results on ID# 036934) using similar data to compare cities and their suburbs.

Project director Andrulis directed the production and publication of the two reports at the National Public Health and Hospital Institute in Washington. RWJF staff reported that the documents helped policy-makers draw connections between federal health and social policies and the health and welfare of the nation's communities.

After the 2000 census was completed, it provided the opportunity to examine the health, social and health system consequences of such forces as urban revitalization, suburban sprawl, increasing racial and ethnic diversity and welfare reform — all happening during the 1990s.

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THE PROJECT

Project staff gathered information for the five reports from national data sources (see Appendix 1 for more details about the sources of information). They also arrayed the information in tables to give an overview of the similarities and disparities between U.S. cities and their suburbs, to rank metropolitan areas relative to each other and to provide individual profiles of each metropolitan area.

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RESULTS

Andrulis and staff published five reports:

  • Progress in Meeting Healthy People Goals for the Nation's 100 Largest Cities and Their Suburbs reviewed progress reducing infant mortality, low birth weight, AIDS, tuberculosis, syphilis, gonorrhea and homicide.
  • Dynamic of Race, Culture and Key Indicators of Health in the Nation's 100 Largest Cities and their Suburbs profiled the status of African Americans, Hispanics, Asians and whites on such health and social measures as poverty, income per capita, low birth weight, early prenatal care and tuberculosis rates.
  • Before and After Welfare Reform: The Uncertain Progress for Poor Families and Children in the Nation's 100 Largest Cities and Their Suburbs documented changes in the status of children and families resulting from the welfare reform legislation of 1996.
  • Quality of Life in the Nation's 100 Largest Cities and Suburbs looked at changes in the rates of such quality-of-life indicators as extreme poverty and concentrated poverty, adults with no high school diploma, unemployment, violent crime and English proficiency. See Glossary for definitions of terms.
  • Hospital Care in the 100 Largest Cities and Their Suburbs, 1996–2002: Implications for the Future of the Hospital Safety Net in Metropolitan America examined the volume and capacity of hospital care from 1996 through 2002. It also provided analysis of the data by hospital ownership and by three levels of poverty in both cities and suburbs.

See Appendix 2 for further details on the health and social indicators used in developing the reports. The reports and accompanying tables are available on the medical center's Web site.

Andrulis and staff disseminated the reports to policy-makers, community-based organizations, service providers and researchers and the media. Through a subcontract, Burness Communications in Bethesda, Md., publicized the release of each report by organizing press releases and news conferences reaching to local and national media outlets. They also contacted various public health and other policy organizations.

The project director reported these results from the dissemination effort:

  • The New York Times and the Washington Post reported on the findings about the rise in low birthweights published in the report, Progress in Meeting Healthy People Goals for the Nation's 100 Largest Cities and Their Suburbs. The report also received local newspaper coverage in 50 percent of the cities studied.
  • A video news release about the findings on teenage birth rates in the report, Dynamics of Race, Culture and Key Indicators of Health in the Nation's 100 Largest Cities and their Suburbs, generated 215 stories and reached 7 million viewers, according to a report Burness Communications submitted to RWJF. For the release of the report, Burness organized a news conference at the National Press Club in Washington, and the RWJF Television Health Series produced the video news release.
  • By the close of the grant, the project director estimates that over 4,000 visitors had gone to the Web site carrying the five reports and accompanying tables.
  • Project staff published an article on low birth weight and infant mortality in the nation's 100 largest cities and their suburbs in the September 2004 edition of the Journal of Urban Health. See the Bibliography for publication details.

Findings

In an interview, project director Andrulis highlighted the following findings from each report:

Progress in Meeting Healthy People Goals for the Nation's 100 Largest Cities and Their Suburbs

  • On average, the cities and their suburbs met or made progress towards meeting Healthy People 2000 goals for lowering infant mortality, AIDS, tuberculosis, syphilis and homicide between 1990 and 1999 or 2000.
  • By 1999, none of the 100 largest cities and only two of their suburbs had met the Healthy People 2000 goal of 5 percent of live births that are low birthweight. Rather, there were increases in low-birth-weight rates that extended to cities and suburbs in all regions with suburban communities leading the way.

Dynamics of Race, Culture and Key Indicators of Health in the Nation's 100 Largest Cities and Their Suburbs

  • The most consistent, and in many cases, strongest improvements in measures of health and social status occurred among non-Hispanic African-American residents in cities and suburbs.
  • Hispanics experienced more modest gains in health and social status than non-Hispanic African Americans, and, on some indicators, made negligible progress.
  • Changes among Asian populations were similar to those for non-Hispanic whites, who overall made modest improvements during the 1990s.
  • Substantial gaps in health and social status remain between whites and other racial and ethnic groups, with the other groups continuing to fare worse than whites.
  • One notable exception was low birthweight: city and suburban whites led the way in rates of increase in low birthweight. Andrulis commented that these higher rates of low birth weight among whites might indicate their better access to assisted reproductive technologies, which can lead to more multiple births.

Before and After Welfare Reform: The Uncertain Progress for Poor Families and Children in the Nation's 100 Largest Cities and Their Suburbs

  • Cities and suburbs made considerable progress in reducing households on public assistance during the 1990s. They made more modest reductions in poverty among children and single-mother families.
  • The cities and suburbs with the largest declines in public assistance rates between 1990 and 2000 did not show similar declines in child poverty or well-being.

Quality of Life in the Nation's 100 Largest Cities and Suburbs

  • Between 1990 and 2000, rates of extreme poverty and concentrated poverty dropped substantially in many urban and suburban areas across the United States.
  • Violent crime rates declined more dramatically in the cities (32 percent) than in the suburbs (26 percent) over the 1990s. But despite this decline, by 2000, rates of urban violent crime remained three times greater than suburban rates.
  • The study results suggested that many suburban areas may be facing new challenges related to the growing racial and ethnic diversity of their residents. Andrulis indicated that because cities have long dealt with diverse populations, there are more advocates and more political support for ensuring adequate programs and facilities for such residents; such advocacy and support is not yet available in most suburban areas.

Hospital Care in the 100 Largest Cities and Their Suburbs, 1996–2002: Implications for the Future of the Hospital Safety Net in Metropolitan America

  • For-profit and nonprofit hospitals are playing an increasing role in the care of Medicaid patients in urban areas, while the role for public hospitals is shrinking.
  • People in poor suburbs make up more than two-fifths of the total population of the suburbs, but use only about one-fifth of hospital care in the suburbs. Andrulis noted that these results focus attention on the extent to which residents of poor suburbs — disproportionately Hispanic and foreign-born and lacking health insurance relative to those in wealthy suburbs — are facing financial, transportation and other barriers to needed hospital care.
  • People in poor cities do not appear to have the same barriers to availability of hospital care as do those in poor suburbs. This may reflect urban areas' longer history of providing care to diverse populations or greater concentrations of individuals within smaller geographic localities. However, the report did not address specific issues around access within these cities.

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LESSONS LEARNED

  1. Reports that break out information for each metropolitan area by city and suburb highlight disparities and increase their usefulness for local leaders and policy-makers. The findings on disparities between Milwaukee and its suburbs prompted Milwaukee's mayor to request extra copies of the report on quality of life. The local newspapers in Milwaukee and the wealthier suburb of Waukesha both published editorials on the findings. (Project Director)
  2. Ranking cities and suburbs on Healthy People goals is an effective way to bring local attention to national health goals. Showing where cities or suburbs ranked relative to their peers and how many of the seven Healthy People targets each had met by 2000 brought a large amount of local publicity about public health issues across communities through front-page newspaper stories and editorials, and local radio coverage. (Project Director)
  3. Reports that are striving for policy uses benefit from a substantial communications budget. The Research Foundation of the State of New York subcontract with Burness Communications and as a result Andrulis' reports received much more exposure for the results than had been Andrulis' previous experience. (RWJF Program Officer Leviton)

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AFTER THE GRANT

There has been a small but continual stream of inquiries about the reports and their findings from various sources. For example:

  • The work on hospitals was referenced in a "Health Leaders" publication and cited in a recent Health Affairs article.
  • The Brookings Institution has invited the research team to make this resource available and discuss it at a February 2006 meeting on resources for urban markets.

Andrulis and the research team have also developed a proposal to examine in more depth the lack of hospital resources in high poverty suburban areas.

One proposed focus is California, particularly health care in high poverty suburbs of Los Angeles and Fresno — the status of and implications for availability, access, and quality for racially and ethnically diverse residents. California is a natural place to go given it is one of the states with a concentration of high poverty suburbs, but other states could be selected. It will be submitted to a foundation for funding.

The researchers are also considering submission of its hospitals report to the Journal of Urban Health or Health Affairs.

Andrulis is now director of the Center for Health Equality, a collaboration between the Drexel University School of Public Health in Philadelphia and its College of Nursing and Health Professions. Founded in 2003, the center's mission is to partner with community and government to improve the health and well-being of communities through the elimination of health disparities.

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GRANT DETAILS & CONTACT INFORMATION

Project

Development and Dissemination of a Report on Urban/Suburban Social and Health Indicators

Grantee

Research Foundation of the State University of New York (Brooklyn,  NY)

  • Amount: $ 748,296
    Dates: November 2001 to December 2004
    ID#:  040836

Contact

Dennis P. Andrulis, M.P.H., Ph.D.
(215) 762-6957
dpa28@drexel.edu

Web Site

http://www.downstate.edu/healthdata

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APPENDICES


Appendix 1

Sources of Information

Project researchers chose cities based on population counts from the 2000 U.S. census. Where some of the 100 largest cities are part of the same metropolitan area, such as Minneapolis and St. Paul, city data were combined to create a single urban area that could be compared with the surrounding suburban area. So the 100 largest cities were combined into 82 distinct urban areas.

Project researchers used the following sources of information for their analyses:

  • U.S. census data on race and ethnicity, foreign born-status and language use for 1980, 1990 and 2000.
  • Federal Bureau of Investigation crime report data on murder and violent crime for 1980, 1990, 2000 and certain interim years.
  • National Center for Health Statistics (U.S. Centers for Disease Control and Prevention [CDC]) data on infant and child health — that is, infant mortality, births to teens, low birth weight for 1980, 1990, 2000 and certain interim years.
  • CDC mortality data: 1980, 1990 and 2000 and interim years.
  • CDC data on selected diseases (syphilis, gonorrhea, chlamydia, tuberculosis and AIDS) for 1990, 2000 and certain interim years.
  • American Hospital Association annual voluntary hospital survey: 1996, 1999 and 2002.
  • Bureau of Primary Health Care (U.S. Department of Health and Human Services) annual compulsory survey of community health centers for 1999 and 2002.
  • National Association of City and County Health Officials profile of local health departments surveys.


Appendix 2

Report Topics and Indicators

  • Healthy Cities, Healthy Suburbs: Progress in Meeting Healthy People Goals for the Nation's 100 Largest Cities and Their Suburbs reviewed progress towards the Healthy People 2000 and 2010 goals in reducing infant mortality, low birth weight, AIDS, tuberculosis, syphilis, gonorrhea and homicide. Healthy People goals are developed and set by the U.S. Department of Health and Human Services and other public and private organizations.
  • Dynamics of Race, Culture and Key Indicators of Health in the Nation's 100 Largest Cities and Their Suburbs profiled the status of African Americans, Hispanics, Asians and whites on such health-related measures as poverty, income per capita, low birth weight, early prenatal care and tuberculosis rates.
  • Before and After Welfare Reform: The Uncertain Progress for Poor Families and Children in the Nation's 100 Largest Cities and Their Suburbs documented changes in the status of children and families resulting from the welfare reform legislation of 1996, which dissolved Aid to Families with Dependent Children (AFDC) and created Temporary Assistance for Needy Families (TANF). These reforms aimed to move welfare recipients into work and limit the amount of time families can receive assistance. The report looked at rates of public assistance, single-mother families, child poverty and a "child well-being index" that integrates data on percent of families headed by single mothers, child poverty rate, percent of low birth weight babies and infant mortality rate.
  • Quality of Life in the Nation's 100 Largest Cities and Suburbs looked at changes in the rates of such quality-of-life indicators as extreme poverty and concentrated poverty, adults with no high school diploma, unemployment, violent crime and a "social deprivation index," that integrates data on poverty, per capita income, prevalence of high school diploma, violent crime and English proficiency.
  • Hospital Care in the 100 Largest Cities and Their Suburbs, 1996–2002: Implications for the Future of the Hospital Safety Net in Metropolitan America examined the volume and capacity of hospital care from 1996 through 2002. The researchers analyzed the data by hospital ownership and by three levels of poverty in both cities and suburbs.


Appendix 3

Glossary

Extreme poverty. Extreme poverty rates are based on the percentage of the total population of an area living in neighborhoods where 40 percent or more of the population lives in poverty.

Concentrated poverty. Concentrated poverty rates are based on the percentage of the poor population living in neighborhoods where 40 percent or more of the population lives in poverty.

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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.)

Articles

Duchon LM, Andrulis DP and Reid HM. "Measuring Progress in Meeting Healthy People Goals for Low Birth Weight and Infant Mortality among the 100 Largest Cities and Their Suburbs." Journal of Urban Health, 81(3): 323–339, 2004. Abstract available online.

Reports

Andrulis DP, Reid HM and Duchon LM. Healthy Cities, Healthy Suburbs: Progress in Meeting Healthy People Goals for the Nation's 100 Largest Cities and Their Suburbs. Brooklyn, N.Y.: SUNY Downstate Medical Center, August 2002. Also available online.

Andrulis DP, Reid HM and Duchon LM. Dynamics of Race, Culture and Key Indicators of Health in the Nation's 100 Largest Cities and Their Suburbs. Brooklyn, N.Y.: SUNY Downstate Medical Center, February 2003. Also available online.

Andrulis DP, Reid HM and Duchon LM. Before and After Welfare Reform: The Uncertain Progress for Poor Families and Children in the Nation's 100 Largest Cities and Their Suburbs. Brooklyn, N.Y.: SUNY Downstate Medical Center, July 2003. Also available online.

Andrulis DP, Reid HM, Duchon LM. Quality of Life in the Nation's 100 Largest Cities and Suburbs. Brooklyn, N.Y.: SUNY Downstate Medical Center, June 2004. Also available online.

Andrulis DP and Duchon LM. Hospital Care in the 100 Largest Cities and Their Suburbs, 1996–2002: Implications for the Future of the Hospital Safety Net in Metropolitan America. Brooklyn, N.Y.: SUNY Downstate Medical Center, August 2005. Also available online.

World Wide Web Sites

www.downstate.edu/healthdata. The Web site includes the five project reports and all accompanying tables.

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Report prepared by: Janet Heroux
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Laura Leviton