Resident Experiences With a Place-Based Collaboration to Address Health and Social Inequities: A Survey of Visitors to the East Harlem Neighborhood Health Action Center

Abstract

In 2016 and 2017, the New York City Department of Health and Mental Hygiene established Neighborhood Health Action Centers (Action Centers) in disinvested communities of color as part of a place-based model to advance health equity. This model includes co-located partners, a referral and linkage system, and community space and programming. In 2018, we surveyed visitors to the East Harlem Action Center to provide a more comprehensive understanding of visitors’ experiences. The survey was administered in English, Spanish, and Mandarin. Respondents were racially diverse and predominantly residents of East Harlem. The majority had been to the East Harlem Action Center previously. Most agreed that the main service provider for their visit made them feel comfortable, treated them with respect, spoke in a way that was easy to understand, and that they received the highest quality of service. A little more than half of returning visitors reported engaging with more than one Action Center program in the last 6 months. Twenty-one percent of respondents reported receiving at least one referral at the Action Center. Two thirds were aware that the Action Center offered a number of programs and services and half were aware that referrals were available. Additional visits to the Action Center were associated with increased likelihood of engaging with more than one program and awareness of the availability of programs and referral services. Findings suggest that most visitors surveyed had positive experiences, and more can be done to promote the Action Center and the variety of services it offers.

Keywords

health equity place-based interventions cross-sector collaboration local health departments neighborhood health

• What do we already know about this topic?

○ Development of linkages between clinical and community organizations and co-location of services have been shown to foster service integration and improve health outcomes, but studies on client satisfaction with such approaches are limited.

• How does your research contribute to the field?

○ These findings contribute to the limited literature on client satisfaction with the co-location of health and social services, while highlighting an innovative approach through which a local health department serves as the hub for co-location and cross-sectoral partnerships to improve neighborhood health.

• What are your research’s implications toward theory, practice, or policy?

○ Overall, findings support the utility of a co-located model through which a health department applies a placed-based strategy to address health inequities.

Introduction

Neighborhood conditions are recognized as a key driver of health disparities in the United States.¹ Racist practices and policies, including redlining and restrictive covenants, have systematically segregated people of color into less desirable neighborhoods, restricted access to public and private investments, and negatively impacted neighborhood characteristics that affect health, including housing quality, availability of social services, and the physical environment.^1-3 For example, practices such as building interstate highways through neighborhoods of color disrupted social fabrics, displaced residents, and destroyed housing.^4-6 These large roadways also contributed to “heat island effects” and exacerbated the overall impact of climate change in low income neighborhoods.^4,7-9 An interplay of such factors drives poorer health outcomes for residents of color.

To address these injustices in disinvested neighborhoods in New York City, the New York City (NYC) Department of Health and Mental Hygiene (Health Department) revitalized Health Department buildings to establish Neighborhood Health Action Centers in East Harlem (in the borough of Manhattan), Tremont (Bronx), and Brownsville (Brooklyn). These neighborhoods have been impacted by decades of racist and discriminatory practices and disinvestment.^10,11 Today, residents of these neighborhoods experience high rates of poverty (ranging from 23% to 31%) and have among the highest rates of premature mortality in NYC.^12-14 Established between 2016 and 2017, the Action Centers are part of a comprehensive neighborhood strategy to identify, dismantle, and mitigate the root causes of premature mortality and disproportionate burdens of morbidity in these communities.¹¹

The Action Center model was informed by the Bay Area Regional Health Inequities Initiative framework and the Robert Wood Johnson Foundation’s Culture of Health Framework.¹⁵ In particular, the framework’s Action Area on “Fostering Cross-Sector Collaboration to Improve Well-Being” was conducive to conceptualizing the alignment of a city health department and cross-sector community stakeholders to improve health and reduce inequities across neighborhoods. The Action Centers direct resources to disinvested neighborhoods by co-locating clinical and social services, facilitating referrals to social and health services, and offering community space at no cost. They also aim to build social cohesion, which has been defined as the “extent of connectedness and solidarity among groups in a society”¹⁶ and has been associated with positive health outcomes.^17,18 As part of establishing the Action Centers, the Health Department made capital improvements to revitalize the Action Center buildings and increased the number of front-line staff to include referral specialists, visitor navigators, and promoters, many of whom are neighborhood residents. The Health Department also invested in NowPow, an electronic referral system and resource directory used by more than 200 organizations citywide for which the Health Department provides licenses and training. To foster coordination and ensure responsiveness to community needs, each Action Center has a Governance Council comprised of co-located partners and Health Department staff.

Co-location of services is often contextualized as the “health home” model of primary care, whereby health care providers across specialties are housed together to optimize coordination and efficiency of services and improve quality of care in a fragmented health care system.¹⁹ Co-location models approach these objectives along a continuum from simple sharing of physical space to integrated collaborations with shared patient records and payment systems. Models such as “community-oriented primary care” have also integrated community health needs into primary care services.^20,21 The public health field has further developed this approach through community-centered models with a broader vision of primary care inclusive of community leaders and residents.^22,23 Being community-centered means grappling with social determinants of health—the conditions of the environments in which we are born, live, learn, work, play, pray, and age. The Action Centers innovate on this idea by placing local health department buildings within priority neighborhoods and fostering local partnerships across sectors, establishing the centers as integral to the health and social fabric of the neighborhood. Through its role as an enduring entity in these neighborhoods, the Health Department’s commitment to the Action Centers represents a long-term investment for neighborhood health.

Development of linkages between clinical and community organizations and co-location of services has been shown to foster service integration and improve health outcomes.^24,25 For example, studies of linkage systems have found improvements in health outcomes (e.g., cholesterol, systolic blood pressure, and predicted coronary heart disease mortality) and health behaviors such as diet, physical activity, and diabetes self-management.²⁴ A study of co-location in primary care practices in 34 countries, mostly in Europe, found that general practitioners believed co-location increased services provided and collaboration with other service providers. However, reports of patient satisfaction with such approaches have been mixed. The study across 34 countries found a negative relationship between co-location and patient experiences, possibly because patients perceived smaller practices as providing better quality care.²⁵ In contrast, a study in Italy found a positive association between patient satisfaction and their experience with co-located multidisciplinary teams at centers that co-located primary care providers with other professionals, especially for frequent health care users.²⁶ Similarly, a study of co-location of services for hepatitis C care in opioid treatment centers in Australia was positively received by the majority of clients for reasons such as convenience and ease of access to care.²⁷

With support from a Robert Wood Johnson Foundation Systems for Action grant, a team from the Health Department used a mixed-methods approach to evaluate the East Harlem Action Center and the broader neighborhood strategy to assess how this model fosters cross-sector collaboration to improve well-being. A qualitative component of this evaluation comprised of interviews with Governance Council members was previously published.²⁸ This paper shares findings from a visitor survey component of the evaluation. The aims of this survey were multifold. One aim was to better understand characteristics of Action Center clientele. Because of the Action Centers’ commitment to being a welcoming and open space, individual visitors are not registered or tracked in a systematic way; the survey provided an opportunity to address this limitation. Additionally, the survey aimed to assess visitor satisfaction and capture feedback for the purposes of quality improvement and accountability to the community. Finally, the survey aimed to explore how visitors experience co-location and cross-sector collaboration, and the potential benefits of this approach for visitors.

Methods

Setting

The East Harlem Action Center is situated in a vibrant neighborhood with a history of local activism, cultural contributions, and providing refuge for a diversity of groups including people of African descent, European immigrants, people coming from Puerto Rico, and more recently, from Mexico and other parts of Latin America. The neighborhood also has a small Asian population.^11,29 Established in late 2016, the East Harlem Action Center houses six co-located partners that offer a range of services including: environmental programs for youth through outdoor education and community engagement; behavioral health services for children and youth; benefits enrollment; nutrition, arts, and advocacy programs for self-identified women; and NYC’s inaugural identification card program for New Yorkers, IDNYC. The building also houses Health Department staff and programs, including referral services to any visitor, and a Family Wellness Suite, which provides parenting and childbirth classes, crib, and car seat distribution, breast-feeding support groups, and other programming. The East Harlem Action Center offers meeting and event space free of charge to local community groups and hosts pop-up services offered by local organizations, which have included fitness classes, legal services, a mobile food pantry, STI testing, education classes, and programs for indigenous groups. In 2018, the East Harlem Action Center received approximately 19,000 visits.

Data Collection and Analysis

Surveys were administered to visitors to the East Harlem Action Center over approximately 4 weeks in the summer of 2018 in English, Spanish, and Mandarin. Interviewers were typically stationed in the building lobby and invited all visitors to take the survey (unless the interviewer was in the process of administering a survey). In some cases, programs and partners informed clients about the opportunity to take the survey, for example, announcing the survey during workshops or other programming. To be eligible, visitors were required to be 18 years of age or older and to not have taken the survey previously. Participants received a two-fare MetroCard (valued at $5.50) and a small promotional gift.

To address the survey aim of better understanding characteristics of Action Center clientele, the survey included basic demographic questions as well as questions on connections to health care from the Health Department’s annual Community Health Survey, including questions on health insurance, primary care, and missing needed medical care.³⁰ A question on dental care was adapted from the Behavior Risk Surveillance Survey.³¹ A question on where respondents received routine care was adapted from a community health needs assessment.³² To assess visitor satisfaction and solicit feedback for improvement, respondents were asked a series of questions on their experiences with their service provider. These questions were adapted from key themes related to patient and client satisfaction.^33,34 Respondents were also asked how welcoming they found the Action Center and likelihood of returning. To understand visitor experiences with co-location and cross-sector linkages provided at the Action Center, respondents were asked about awareness of and participation in its programs and referral services. Respondents were also asked what they liked about the Action Center and to provide recommendations for improvement. Because of the Action Center’s goal of influencing social cohesion and connectedness, respondents were asked the extent to which they agreed that “people around here are willing to help their neighbors” (5-point Likert scale, from strongly agree to strongly disagree) from the Project on Human Development in Chicago Neighborhoods. The survey also included two questions developed by other Health Department programs: “how likely is it that people here would work together to improve their lives and their neighborhood” with response options of very likely, somewhat likely, or not likely; and, “how connected are to you the services in your neighborhood” with response options of very connected, somewhat connected, not very connected, or not at all connected.³⁵

Descriptive statistics were used to summarize responses. For key measures of interest, chi-square tests were used to compare residents of East Harlem vs other neighborhoods, and first time vs repeat visitors. Among repeat visitors, logistic regression was used to assess the dose-response relationship between number of visits (ranging from 2 through 5 or more visits) and awareness of and participation in referrals and programs at the East Harlem Action Center. The question on where people received routine health care was stratified by language spoken at home in order to understand the potential role of language access in determining where people received care. Analyses were conducted in SPSS 23.0 (IBM Corp, Armonk NY) with the threshold for significance set at P < .05.

This project was reviewed by the Health Department’s Institutional Review Board, which determined that it was not human subjects research.

Results

A total of 207 visitors completed the survey. Most identified as Latino (35%), Black or African American (31%), or Asian (30%) (Table 1). The median age was 56.5 years. The majority were women (74%), had been to the East Harlem Action Center previously (69%), and walked there (70%), suggesting respondents lived nearby. The language(s) most often spoken at home were most commonly English (48%), followed by Chinese (31%, spoken by 59 of the 60 Asian respondents), both English and Spanish (12%), and Spanish (9%). Most visitors were residents of East Harlem (69%), followed by Central Harlem (16%), a neighboring community. East Harlem residents were more likely to have been to the Action Center previously than others (78% vs 52%, P<.001).

Table 1.

Characteristics of East Harlem Neighborhood Health Action Center Visitors, 2018 Visitor Survey, East Harlem, NYC.

	N	%
Race/Ethnicity
Latino(a)	70	34.5
Black or African American	63	31.0
Asian	60	29.6
White	5	2.5
Two or more races or another race/ethnicity	5	2.5
Age Group
18–24	11	5.4
25–44	49	24.0
45–64	83	40.7
65 and older	61	29.9
Gender
Female	151	74.4
Male	52	25.6
Transgender	0	0.0
Gender non-conforming	0	0.0
Language spoken at home
English	98	48.3
Chinese languages	62	30.5
English and Spanish	24	11.8
Spanish	18	8.9
Another language	1	0.5
Neighborhood of residence
East Harlem (ZIPs 10029 and 10035)	140	69.0
Central Harlem (ZIPs 10026, 10027, 10030, 10037, and 10039)	32	15.8
Other	31	15.3

Missing values are excluded and all values will not sum to total N

Health

Almost all respondents had health insurance (95%) and a primary care provider (94%) (Table 2). A minority received routine health care within East Harlem (24%), even among East Harlem residents (32%). When this was further explored by language in order to understand language access as a potential factor in accessing health care, no East Harlem residents who primarily spoke Chinese at home received routine care in East Harlem. In contrast, the majority of respondents who spoke mostly English and Spanish (71%) or just Spanish at home (60%) received routine care in East Harlem, as did 49% of those who mostly spoke English at home.

Table 2.

Health Care Access among East Harlem Neighborhood Health Action Center Visitors, 2018 Visitor Survey, East Harlem, NYC.

	N	%
Location of Routine Health Care Provider
East Harlem	43	23.5
Central Harlem/Morningside Heights	26	14.2
Other	114	62.3
Connection to health care
Has a primary care provider	189	93.6
Has health insurance	192	95.0
Missed needed medical care in past 12 months	24	11.9
Last medical exam
Less than 6 months ago	149	74.1
6 months to 1 year ago	44	21.9
1 to 2 years ago	8	4.0
Last dental exam
2 years ago or less	153	76.9
More than 2 years ago	37	18.6
Never	9	4.5

Missing values are excluded and all values will not sum to total N

Almost one in five respondents’ (19%) last dental exam was more than two years ago, and 5% reported never having a dental exam. Twelve percent reported missing needed medical care in the last 12 months, with health insurance issues cited by 13 of the 22 individuals who provided a reason for missing care. Insurance-related barriers included lack of insurance, limited coverage, and providers not accepting certain insurance.

Action Center Experiences

Most visitors heard about the East Harlem Action Center through word of mouth (59%) or a referral (13%) (Table 3), with word of mouth more common among East Harlem residents than others (66% vs 46%, P=.01). On the day they were surveyed, about half (51%) of respondents’ main reason for coming was to visit Health Department or co-located partners that offer workshops in areas such as healthy eating and art therapy, almost a quarter (23%) were visiting IDNYC, and the remainder (26%) were visiting a variety of other programs or simply stopping by, including people who had come in to learn more about services offered. Eighty-six percent of respondents were “very likely” to return, and 83% found the East Harlem Action Center to be “very welcoming”. While there was variation in the proportion who selected “very welcoming” across race/ethnicity (data not shown), differences were not statistically significant.

Table 3.

Visitor Awareness of and Experiences with the East Harlem Neighborhood Health Action Center, 2018 Visitor Survey, East Harlem, NYC.

	N	%
How respondents heard about the Action Center
Word of mouth	122	59.2
Referral	26	12.6
Promotional materials	15	7.3
Used to come here before it reopened	13	6.3
Other (includes lives in area/walked by, online, and other)	30	14.6
Number of times been to the Action Center
1	63	31.0
2	32	15.8
3	29	14.3
4	10	4.9
5 or more	69	34.0
Repeat visitors (n=138) who visited more than one program at Action Center in past 6 months	76	55.1
Visitors who had received a referral at the Action Center	42	20.9
Among those receiving referrals (n=38), type of referral received
Action Center program	13	37.1
Health care agency outside of Action Center	13	37.1
Other service or agency outside of Action Center	9	25.7
Other	4	11.4
Aware that Action Center offers a number of programs and services	134	66.0
Aware of availability of referrals through Action Center	101	49.8
How likely respondents are to return to Action Center
Very likely	175	86.2
Somewhat likely	27	13.3
Not likely	1	0.5
How welcoming respondents find the Action Center
Very welcoming	164	83.2
Somewhat welcoming	30	15.2
Not very welcoming	3	1.5
Services respondents were interested in receiving at Action Center
Housing legal services	100	49.8
Health care services	98	48.8
Food assistance	95	47.3
Job training or placement	88	43.8
Adult mental health services	80	39.8
Services for mold or pests	78	38.8
Food industry training	75	37.3
ESL classes	74	36.8
Sexual health services	55	27.4
LGBTQ+ services	41	20.4

Missing values are excluded and all values will not sum to total N

Participants were asked about their experience with the staff at the program they visited on that day. The majority strongly or somewhat agreed that the main person they saw treated them with respect (98%), made them feel comfortable (98%), and spoke in a way that was easy to understand (97%). Most also agreed that they received the highest quality of service (96%) (Table 4).

Table 4.

Visitor Experiences with Program Staff at the East Harlem Neighborhood Health Action Center, 2018 Visitor Survey, East Harlem, NYC.

	Strongly agree N (%)	Somewhat agree N (%)	Neither agree nor disagree N (%)	Somewhat disagree N (%)	Strongly disagree N (%)
I was treated with respect by the person who helped me today	177 (87.2)	21 (10.3)	3 (1.5)	0 (.0)	2 (1.0)
The person who helped me spoke in a way that I could easily understand	169 (82.8)	28 (13.7)	5 (2.5)	2 (1.0)	0 (.0)
The person who helped me made me feel comfortable	180 (88.2)	20 (9.8)	3 (1.5)	1 (.5)	0 (.0)
I received the highest quality of service during my visit today	160 (78.4)	35 (17.2)	7 (3.4)	0 (.0)	2 (1.0)

Missing values are excluded and all values will not sum to total N

Among the 192 visitors who offered responses when asked what they liked most about the East Harlem Action Center, the most common theme was the programs, services, information, and resources offered (60%), with many respondents mentioning specific programs or classes offered at the Action Center, and receiving information and resources, including assistance with navigating needs such as legal and housing related issues. The second most common theme was the staff (20%), who respondents described with terms such as “helpful,” “nice,” and “respectful.” While less common, responses from 14% of visitors related to the welcoming and comfortable atmosphere, for example, noting a “warm,” “welcoming spirit,” and a “family vibe and sense of community.” Seven percent offered comments related to efficiency and ease of access to services provided, with comments such as “people can just walk in” and “speed of service”.

Among the 109 respondents who offered suggestions for improving the Action Center, common themes were adding or expanding programming, such as English classes, cooking and nutrition classes, and carpentry classes (28%); programming for specific audiences, especially children/youth and seniors, but also men and immigrants (27%); physical improvements like water fountains, more artwork, and improving the building lobby and interior (17%); offering programming and services in more languages and more bilingual staff, particularly Chinese-speaking staff (15%); and more outreach and promotion to increase awareness of the Action Center and services available (12%).

Respondents were read a list of services and asked to indicate their interest in receiving any of these services at the East Harlem Action Center. The top selections were housing legal services (50%), health care services (49%), food assistance (47%), and job training or placement (44%) (Table 3).

Co-Location and Referrals

Over half (55%) of returning visitors reported engaging with more than one Action Center program in the last 6 months, with no significant difference between East Harlem residents and others (59% vs 41%, P=.07). Twenty-one percent of respondents reported they received at least one referral at the Action Center, most commonly for co-located programs (37%), health care agencies (37%), and non-medical services outside the Action Center (26%) (Table 3). Repeat visitors were more likely to have received a referral (30% vs 2%, P<.001) as were East Harlem residents (25% vs 12%, P=.03). Two thirds of visitors reported that they were aware that the East Harlem Action Center offered a number of free programs and services, and 50% were aware that referrals were available. Repeat visitors were more likely to be aware of Action Center programming and referral availability (79% vs 38%, and 63% vs 19%, ps<.001, respectively). Compared with residents of other neighborhoods, East Harlem residents were significantly more likely to be aware of programming (72% vs 53%, P=.01), but not referral availability (53% vs 41%, P=.11). Among repeat visitors, logistic regression indicated a dose-response relationship between number of visits to the Action Center and engaging with more than one Action Center program in the last 6 months (OR=1.71, 95% Confidence Interval [CI] 1.29-2.28, P<.001), awareness of programs (OR=1.93, 95% CI 1.36-2.73, P<.001), and awareness of referral services (OR=1.75, 95% CI 1.30-2.34, P < .001). No dose-response relationship was found between number of visits and receiving a referral.

Community Connectedness and Social Cohesion

Because Action Centers aim to build connections to services and social cohesion within the neighborhoods where they are based, new and returning visitors’ responses were compared for measures related to community connectedness among East Harlem residents. Overall, 78% of the East Harlem residents surveyed felt very or somewhat connected to services in their neighborhood and 85% strongly or somewhat agreed that “people around here are willing to help their neighbors”; these reports were significantly higher among repeat visitors than first time visitors (84% vs 55%, P=.001, and 90% vs 69%, P=.015, respectively). Ninety percent of residents surveyed agreed that it was “very likely” or “likely” that “people in the neighborhood would organize and work together to improve the community and their lives”; this was not significantly different among new and returning visitors (92% vs 82%, P=.11).

Discussion

Conducted as part of a mixed-methods evaluation,²⁸ the effort to survey visitors to the East Harlem Action Center contributed to a more robust understanding of this initiative by providing insight into client characteristics and experiences with Action Center services and programs. Most visitors surveyed reported positive experiences, with key indicators of satisfaction with the provider from their visit nearly universally met, including perceptions of receiving high quality care, being treated with respect, being made to be feel comfortable, and receiving effective communication. Findings indicate that a significant proportion of visitors take advantage of the co-location and referral components of the East Harlem Action Center, with more than half of returning visitors having participated in multiple programs and one in five having received a referral. These findings are consistent with those from partner interviews that were a component of the broader evaluation. In qualitative interviews conducted across the Action Centers, partners reported that being part of the Action Center meant that their clients received increased access to community resources and referrals, and that many clients responded to positively to the Action Center’s aim to serve as an open space and came in repeatedly to access resources.²⁸

The majority of visitors to the East Harlem Action Center were residents of East Harlem, which is consistent with the Action Center’s aim to serve as a neighborhood resource. However, with a neighborhood population of more than 124,000, there is a continued need for outreach. Findings suggest that more can be done to increase awareness of the variety of services available, especially referral services. Half of respondents did not know that referrals were available, and roughly a third did not know that a variety of free programs were available. Several visitors recommended more outreach and promotion. These findings support results from the qualitative partner interviews in which partners expressed the need to increase awareness of the Action Center.²⁸

East Harlem residents who repeatedly visited the East Harlem Action Center were more likely to report feeling connected to services in the neighborhood and to agree that their neighbors are willing to help one another. While causality cannot be determined, it is encouraging that residents reported a high level of connectedness. The proportion of visitors from East Harlem who agreed that their neighbors are willing to help each other (85%) is higher than New Yorkers overall (67%) and East Harlem residents overall (70%), as reported in citywide survey data.³⁰ Across an array of situations, especially in the context of natural disasters, communities with higher levels of social cohesion as well as a willingness to intervene on behalf of the common good have demonstrated more resilience to adversity, as evidenced by better health and quicker recovery.^36-38 The potential for Action Centers to play a role in building social cohesion and connectedness is an ongoing area of interest for both programming and evaluation. This has been an especially salient issue in addressing the impacts of COVID-19. With substantial limitations to in-person service delivery experienced during the pandemic, many Action Center programs shifted to virtual programming, and Action Center staff have used the building to support COVID-19 vaccination efforts, promotion of test and trace, and distribution of personal protective equipment (PPE) and informational materials to partners and community residents.

The findings presented here contribute to the literature on place-based efforts to advance health equity through cross-sectoral partnerships and co-location. While much of the published literature on co-located services focuses on clinical services, such as primary care or pediatric care, the Action Center model is unique in that it features a local health department as the backbone for co-location, and aims to leverage co-location and cross-sectoral partnerships to improve neighborhood health.^19,25,39 Additionally, this evaluation contributes to literature on client experiences with co-location, including satisfaction with services provided and the extent to which visitors access multiple co-located programs. Published studies on this topic are limited, particularly for settings within the United States, and have yielded mixed findings.^19,26,27,39 Future research should undertake more in-depth, qualitative explorations of client experiences with this model, including their perspectives on the benefits of such approaches and barriers and facilitators to engaging with co-located services.

There are limitations to this study. The sample was not representative of East Harlem and was strongly shaped by programming offered during the survey period, leading to underrepresentation of clients from co-located partners that did not have building-based programming during the survey period. Additionally, social desirability bias may have influenced responses to some questions. There is no way to establish directionality of associations between repeat visitors and higher levels of connection to services and agreement that their neighbors will help each other; people who are already more connected to services and view their neighbors as helpful may be more likely to go to the East Harlem Action Center repeatedly.

Survey findings were used to inform planning and implementation of new programs and services. One suggestion for improving the East Harlem Action Center, predominantly voiced by respondents who spoke Chinese, was to increase the number of bilingual staff and to offer programs in additional languages. In response, the East Harlem Action Center has strengthened programming offered in Mandarin, trained staff to use a telephonic language interpretation service, and is working to hire staff with appropriate language skills. The East Harlem Action Center has leveraged partnerships to incorporate new services including English classes, and launched a workforce development initiative which aims to address employment discrimination and income inequality as root causes of health inequities. Technical limitations such as parameters in the NYC Charter that exclude legal services from the Health Department’s mandate, and requirements such as metal detectors in buildings where domestic violence services are provided, have created barriers to including such services in the Action Center building. The East Harlem Action Center has hosted some of these services on a pop-up basis as one way to address such gaps.⁴⁰

The East Harlem Action Center is part of a neighborhood-based Health Department bureau, with a full array of staff, including an Assistant Commissioner and Executive Director and unit teams led by Directors and Managers. Similar structures exist in the South Bronx and North and Central Brooklyn. This represents a unique model of investment by the Health Department in key neighborhoods experiencing a disproportionate burden of premature mortality and a wide spectrum of inequitable health and social outcomes stemming largely from decades of systemic disinvestment and marginalization. With passionate, skilled and diverse staff, operational and administrative support, and a leadership vision focused on closing the racial equity gap, shifting power, and transparent community engagement, this level of human resource investment has the potential to be a valuable force multiplier for health equity and to contribute to neighborhood transformation.

Implications for Practice

These findings support the acceptability and utility of a collaborative, cross-sector, co-located model through which a health department applies a placed-based strategy to address health inequities. Visitors reported high levels of satisfaction with their service provider, and the substantial numbers of visitors who returned to the East Harlem Action Center repeatedly and engaged with multiple programs and referral offerings may indicate that this structure is beneficial for participants. These findings support the efficacy of this model for building a culture of health.

Footnotes

Acknowledgments

The authors would like to thank those who helped to conduct surveys for this project, the individuals who graciously agreed to be surveyed, as well as all East Harlem Neighborhood Health Action Center staff and co-located partners for their support of this project.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this project was provided by NYC DOHMH and by a Robert Wood Johnson Foundation’s Systems for Action grant (Grant No. 75078), managed by the Systems for Action National Coordinating Center at the Colorado School of Public Health.

ORCID iD

Rachel Dannefer

Author Biographies

Rachel Dannefer, MPH, MIA is Director of Research and Evaluation at the Bureau of Harlem Neighborhood Health.

Luke Sleiter, MPH is Health Equity Program Evaluator with the Center for Health Equity at the American Medical Association.

Jessie Lopez is an MPH candidate and the Referral Specialist of the East Harlem Neighborhood Health Action Center, which is part of the Bureau of Harlem Neighborhood Health at the NYC Department of Health and Mental Hygiene.

Jaime Gutierrez, MPH is coordinator of the East Harlem Neighborhood Health Action Center, which is part of the Bureau of Harlem Neighborhood Health at the NYC Department of Health and Mental Hygiene.

Carl Letamendi, PhD, MBA is Chief Executive Officer and Cofounder of Ology Research Group in Salt Lake City, Utah.

Padmore John, MS is Manager of East Harlem Neighborhood Health Action Center, within the Bureau of Harlem Neighborhood Health at the NYC Department of Health and Mental Hygiene.

Zinzi Bailey, ScD, MSPH is Managing Director at Health Equity Research Solutions, LLC in Miami, Florida

References

Williams

Collins

. Racial residential segregation: a fundamental cause of racial disparities in health. Publ Health Rep. 2016;116(5):404-416. 10.1093/phr/116.5.404

Bailey

Krieger

Agénor

Graves

Linos

Bassett

. Structural racism and health inequities in the USA: evidence and interventions. The Lancet. 2017;389(10077):1453-1463.

Schomburg Center for Research in Black Culture. Black New Yorkers. The New York Public Library. https://blacknewyorkersnypl.org/slavery-under-the-british/. Published 2017. Accessed April 9, 2019.

Hoffman

Shandas

Pendleton

. The effects of historical housing policies on resident exposure to intra-urban heat: a study of 108 US urban areas. Climate. 2020;8(1):12.

Boisrond

West Farms 10460: A Bronx neighborhood reeling from the pandemic and a history of disinvestment. Gothamist. https://gothamist.com/news/west-farms-10460-bronx-neighborhood-reeling-pandemic-and-history-disinvestment. Published February 18, 2021. Accessed December 21, 2021.

Gonzalez

Evelyn

. The South Bronx. The Bronx. Columbia University Press; 2004.

Shandas

Voelkel

Williams

Hoffman

. Integrating satellite and ground measurements for predicting locations of extreme urban heat. Climate. 2019;7(1):5.

Kjellstrom

Friel

Dixon

, et al. Urban environmental health hazards and health equity. J Urban Health. 2007;84(1):86-97.

Jesdale

Morello-Frosch

Cushing

. The racial/ethnic distribution of heat risk–related land cover in relation to residential segregation. Environ Health Perspect. 2013;121(7):811-817.

10.

Wallace

. A Plague on Your Houses: How New York Was Burned Down and National Public Health Crumbled. New York: Verso; 1998.

11.

Dannefer

Wong

John

, et al. The neighborhood as a unit of change for health: early findings from the East Harlem Neighborhood Health Action Center. J Community Health. 2019;45:161-169.

12.

Hinterland

KNM

King

Lewin

, et al. Community Health Profiles 2018, Brooklyn Community District 16: Brownsville. 2018;40(59):1-20.

13.

Hinterland

KNM

King

Lewin

, et al. Community Health Profiles 2018, Bronx Community District 6: Belmont and East Tremont. 2018;18(59):1-20.

14.

Hinterland

KNM

King

Lewin

, et al. Community Health Profiles 2018, Manhattan Community District 11: East Harlem. 11(59). 2018:1-20.

15.

Bay

Area

Regional Health Inequities Initiative Framework. Bay Area Regional Health Inequities Initiative website. https://www.barhii.org/barhii-framework. Accessed December 21, 2021.

16.

Kawachi

Berkman

. Social cohesion, social capital, and health. In: IBL

Kawachi

Berkman

, eds. Social Epidemiology. New York: Oxford University Press; 2000:174-190.

17.

Stanley

. What do we know about social cohesion: the research perspective of the federal government's social cohesion research network. Can J Sociol/Cahiers canadiens de sociologie. 2003:5-17.

18.

Fone

DWJ

Farewell

Kelly

, et al. Effect of neighborhood deprivation and social cohesion on mental health inequality: a multilevel population-based longitudinal study. Psych Medicine. 2014;44:2449-2460.

19.

Ginsburg

Colocating Health Services: A Way to Improve Coordination of Children's Health Care? Vol 41. New York, NY: Commonwealth Fund; 2008.

20.

Lefkowitz

. Community Health Centers: A Movement and the People Who Made It Happen. New Brunswick, NJ: Rutgers University Press; 2007.

21.

Longlett

Kruse

Wesley

. Community-oriented primary care: historical perspective. J Am Board Fam Pract. 2001;14(1):54-63.

22.

Mikkelsen

Cohen

Frankowski

. Community‐centered health homes: Engaging health care in building healthy communities. Natl Civ Rev. 2014;103(1):57-59.

23.

Mor

Hobor

Riccardo

Robinson

. From theory to practice: a 2-year demonstration of the community-centered health home model. J Public Health Manag Pract. 2017;23 (suppl 6):S47-S53.

24.

Porterfield

DSHL

Kane

Horne

McAleer

Roussel

. Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan. Am J Public Health. 2012:S375-S382.

25.

Bonciani

MSW

Barsanti

Heinemann

Groenewegen

. The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries. BMC Health Serv Res. 2018;18:132

26.

Bonciani

MBS

Murante

. Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy. BMC Health Serv Res. 2017;17(1).

27.

Treloar

CRJ

Grebely

Dore

. Client and staff experiences of a co-located service for hepatitis C care in opioid substitution treatment settings in New South Wales, Australia. Drug Alcohol Depend. 2013;133(2):529-534.

28.

Pierre

Letamendi

Sleiter

Bailey

Dannefer

Shiman

. Building a culture of health at the neighborhood level through Governance Councils. J Community Health. 2020;45(4):871-879.

29.

Nieves

Dannefer

De La Rosa

, et al. Block by Block: Walking for a Healthier East Harlem. New York, NY: New York City Department of Health and Mental Hygiene; 2018.

30.

NYC Department of Health and

Mental Hygiene. Community Health Survey. https://www1.nyc.gov/site/doh/data/data-sets/community-health-survey-public-use-data.page. Accessed December 21, 2021.

31.

National Center for Chronic Disease Prevention Health Promotion , Division of Population Health. CDC - BRFSS - Questionnaires. Centers for Disease Control and Prevention. https://www.cdc.gov/brfss/questionnaires/index.htm. Published 2019. Accessed December 21, 2021.

32.

St . Catherine of Siena Medical Center. Community Health Needs Assessment Survey. https://www.surveymonkey.com/r/SNXP6FR. Accessed December 21, 2021.

33.

Audet

A-M

Davis

Schoenbaum

. Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med. 2006;166(7):754-759.

34.

Gerteis

Edgman-Levitan

Daley

Delbanco

. Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, CA: Jossey-Bass; 1993.

35.

Earls

Buka

. Project on Human Development in Chicago Neighborhoods. Washington, DC: National Institute of Justice. 1997;1:997.

36.

Greene

Paranjothy

Palmer

. Resilience and vulnerability to the psychological harm from flooding: the role of social cohesion. Public Health. 2015;105(9):1792-1795.

37.

Sherrieb

Norris

Galea

. Measuring capacities for community resilience. Soc Indicat Res. 2010;99(2):227-247.

38.

Townshend

Awosoga

Kulig

Fan

. Social cohesion and resilience across communities that have experienced a disaster. Nat Hazards. 2015;76(2):913-938.

39.

Bradbury

Edwards

Laca

Maher

. Building co-location: A report for the Marion County Commission on Youth and the Early Intervention and Prevention Initiative. Indianapolis: Collaboration of Local Organizations (CoLO) School of Public and Environmental Affairs; 2011.

40.

Towe

Leviton

Chandra

Sloan

Tait

Orleans

. Cross-sector collaborations and partnerships: essential ingredients to help shape health and well-being. Health Aff. 2016;35(11):1964-1969.