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Home My WebLink Aboutcommunity-health-needs-assessment-2022-2025-remediated-2Community Health Needs Assessment 2022-2025 2 Director Kimi Watkins-Tartt Alameda County Public Health Department I am pleased to share with you the Alameda County Public Health Department’s 2022 Community Health Needs Assessment (CHNA). In the following pages, you will ﬁnd an informative, data-rich roadmap for continued health improvement throughout Alameda County. The CHNA takes a comprehensive look at the health of Alameda County residents by studying a combination of the social determinants of health and speciﬁc health outcomes of individuals, neighborhoods, and populations. The CHNA is completed once every three years and is an important tool for informing the community about Alameda County residents’ health, identifying key priorities for the county, and gaining a better understanding of health inequities. This year, we expanded our work to provide insights regarding the impact of COVID-19 on the health and well-being of our residents. The report paints a compelling and broad picture of health and the challenges to achieving health in Alameda County; from life expectancy to differences in health status by place (i.e., cities and neighborhoods) and racial and ethnic groups to the impact of COVID-19. The CHNA is also a key part of Alameda County Public Health Department (ACPHD) achieving and maintaining national Public Health Accreditation, which we earned in March 2022. Accreditation means that the department meets national standards for ensuring essential public health services and improving and protecting the community’s health. With the CHNA, we demonstrate our ongoing collaboration with the local health systems that include Kaiser Permanente, Sutter Health, Stanford ValleyCare, John Muir, St. Rose Hospital, UCSF Benioff Children’s Hospital, and the Hospital Council of Northern and Central California. I commend the ACPHD team for this outstanding report and extend my gratitude to the numerous community members and partners who also contributed. Our enduring efforts are essential to fulﬁll our mission to protect and promote the health and well- being of all in Alameda County. Kimi Watkins-Tartt ACPHD Director 3 Hospital Council Northern and Central California Rebecca Rozen, Regional Vice President Kaiser Permanente— Diablo and East Bay Molly Bergstrom, MS, Community Health Manager, External and Community Affairs Sutter Health Bay Area Mindy Landmark, Regional Manager Bryden Johnston, MPH, Community Health Coordinator Acknowledgments This Community Health Needs Assessment (CHNA) is conducted every three years in partnership with local health systems. This CHNA meets the hospital’s Affordable Care Act IRS requirements as well as the Public Health Accreditation Board requirements. The health systems that worked in partnership with ACPHD and their respective staff are recognized below. Hospital Council Northern and Central California Rebecca Rozen, Regional Vice President Kaiser Permanente— Diablo and East Bay Molly Bergstrom, MS, Community Health Manager, External and Community Affairs Sutter Health Bay Area Mindy Landmark, Regional Manager Bryden Johnston, MPH, Community Health Coordinator UCSF Benioff Children’s Hospitals Baylee Decastro, MPP, Executive Director, UCSF Center for Child and Community Health John Muir Health Jamie Elmasu, MPH, Director, Community Health Improvement Stephanie Rivera, MPH, Former Director, Community Health Improvement Community Affairs Kaiser Permanente—East Bay and Greater Southern Alameda Susanna Osorno-Crandall, MPA, Community Health Manager, External and Community Affairs Stanford Health Care Tri-Valley Denise Bouillerce Senior Director – Government & Community Relations, PR/ Marketing St. Rose Hospital Michael Cobb, Foundation Executive Director 4 In addition to the health systems, the following consultant groups provided technical assistance in data collection, analysis, and report writing. Applied Survey Research Susan Brutschy, President Kimberly Carpenter, PhD, Project Director Kimberly Gillette, MPH, Senior Research Analyst II Sara Vega, PhD, Senior Research Analyst Actionable Insights, LLC. Melanie Espino, Co-Founder and Principal Jennifer van Stelle, PhD, Co-Founder and Principal Ad Lucem Consulting Lisa Craypo, MPH, RD, Principal Liz Schwarte, MPH, Principal ACPHD convened an Internal CHNA Advisory Board where staff from different divisions participated to inform and guide the CHNA process. Participating staff are as follows. Chair: Kimi Watkins-Tartt Director Alameda County Public Health Department George Ayala, PsyD Deputy Director Alameda County Public Health Department Nicholas J. Moss, MD, MPH Alameda County Health Ofﬁcer Public Health Department, Alameda County Health Care Services Agency Evette Brandon Director Quality Improvement and Accreditation Division Ofﬁce of the Director Alameda County Public Health Department Liz Maker Epidemiologist III /Evaluation Manager Community Assessment Planning and Evaluation Alameda County Public Health Department, Health Care Services Agency Maria Isabel Aguilar Medical Social Worker DREAMS Program Family Health Services Carmelina Calmo Community Health Outreach Worker DREAMS Program Family Health Services Prarthana Joshi COVID Therapeutics Coordinator Therapeutics COVID Mitigation and Prevention Services Angela Ball Director Nursing Administration Public Health Nursing Kim Baranek Outreach and Education Specialist Child Health and Disability Prevention and California Children’s Services Family Health Services Andrea Dodge, MPH, MSW Program Coordinator Older Adults and Life Care Planning Programs Chronic Disease Program Community Health Services 5 Kathleen Willkom-Nicholas Director Women Infants and Children (WIC) Community Health Services María D. Domínguez, J.D. Local Policy Coordinator Health Equity, Policy, and Planning Ofﬁce of the Director Aiyana M. Knowles Interim Supervising Program Specialist Health Promotion and Community Partnerships Unit Ofﬁce of the Director Karla Navarro Perinatal Services Coordinator Perinatal and Reproductive Equity Family Health Services Maternal, Paternal, Child, and Adolescent Health Sandi Galvez Director Health Equity, Policy, and Planning Ofﬁce of the Director Kelly Morgenroth RBA Program Specialist, Performance Management Quality Improvement and Accreditation Unit Ofﬁce of the Director Ieshia Sheppard Program Specialist Community Capacity-Building Program Manager STD/HIV Control and Prevention Division of Disease Control and Prevention Gabriela Castillo Program Specialist Quality Improvement and Accreditation Unit Ofﬁce of the Director Carolina Guzman Quality Improvement Manager Quality Improvement and Accreditation Unit Ofﬁce of the Director Served as a Project Manager for the CHNA on behalf of ACPHD Jessica Scully Copyedited this document Mena Kamel Designed this document 6 Community Health Needs Assessment 2022-2025 An empty Niles Blvd in Fremont California allows the old buildings to show their beauty. Photo by John Roche. Fremont, CA. 7 Introduction 9 County Demographic Proﬁle 13 Process and Methods 17 Prioritized Health Needs 19 Income and Employment 25 Housing and Homelessness 29 Access to Care 31 Community Safety 36 Mental and Behavioral Health 40 Next Steps 46 44 Footnotes Appendix 50 Contents 8 Introduction Welcome to the 2022 ACPHD Community Health Needs Assessment (CHNA). The CHNA takes a broad view of health conditions and status in Alameda County. In addition to providing local disease and death rates, this CHNA also provides data and information on social determinants of health: social structures and economic systems, which include the social environment, physical environment, health services, and structural and societal factors. The CHNA is the foundation for Alameda County’s nonprofit hospitals' comprehensive community health needs assessment and is one of the requirements for public health accreditation. This document intends to inform our department’s work to better serve the people of Alameda County. Understanding why health outcomes exist here in Alameda County can help gear our efforts toward addressing root causes and developing better interventions, policies, and infrastructure. 9 The CHNA involves four steps: Community health status assessment Review of prior assessments 01 02 03 04 Community engagement Health needs identiﬁcation and prioritization 10 11 Report Availability, Comments, and Adoption The ACPHD’s CHNA is available on its website. The full report and accompanying data tables, maps, and presentations are available. In addition, the public is welcome to request data or reports from the CHNA by completing a data request form. The CHNA was also shared with the public through community health events, key collaborators and stakeholders, the Public Health Commission, and the Alameda County Board of Supervisors, and various human services organizations and agencies throughout the county. ACPHD provided opportunities for the public to comment on the CHNA report through a series of community listening sessions conducted across the county during the 2021 fall months (October through November). These listening sessions were convened with the community partners who participated in the key respondent interviews (Appendix 1) and included residents who participated in the community focus groups. These comments were incorporated in the ﬁnal adoption of the 2022–2025 CHNA. Community Served Alameda County is one of nine counties that comprise the San Francisco Bay Area. It is rich in the arts, political activism, world-famous higher education institutions, entrepreneurship, and breathtaking natural terrains, and it has an enviable Mediterranean climate. Alameda County is home to 1.6 million people and is the most racially and ethnically diverse county in the San Francisco Bay Area. It is the seventh-most populous county in California1 and one of the most ethnically diverse regions in the Bay Area2 and the nation. More than 30 percent of the students in the Oakland Uniﬁed School District are English language learners3 . People who live in or are interested in moving to Alameda County can choose from 14 incorporated cities and six census-designated places to reside. A map of the county by zip code is shown in Figure 1. Figure 1: Alameda County by city and zip code 12 County Demographic Profile Population and Socioeconomic Data Total Population Population Estimates, July 1, 2021 1,648,556 Persons in Poverty 8.6% Median Household Income in 2020 dollars $104,888 $49,883 in 2020 dollars Per Capita Income in the past 12 months Income Compared with the state of California, Alameda County has a lower poverty rate (8.6 percent compared with 12.3 percent) and a higher median household income ($104,888 to $78,672). It also is signiﬁcantly more diverse, with a much smaller white population (47.8 percent to 71.1 percent), a larger Asian population (33.8 percent to 15.9 percent), a larger Black population (10.7 percent to 6.5 percent), and a lower percentage of people with Hispanic heritage (22.4 percent to 40.2 percent). 13 Race & Hispanic Origin Source: US Census Bureau QuickFacts4 47.8% 10.7% 1.1% 33.8% 29.2%22.4%5.6%1.0% White alone Native Hawaiian & Other Paciﬁc Islander alone Black or African American alone Two or more races American Indian & Alaska Native alone Asian alone Hispanic or Latino White alone, not Hispanic or Latino 14 Structural Racism and Inequities Over the past 50 years, the health and well-being of Alameda County residents has improved. These beneﬁts, however, are not experienced equally within the county and across population subgroups. Profound and persistent inequities exist by race, and structural conditions of inequality have concentrated resources and opportunities for health and well- being in certain places. Figures 2 and 3 demonstrate this. Figure 2 shows the percentage of the non-white population by ZIP code in Alameda County, while ﬁgure 3 shows the neighborhood deprivation index (NDI) by ZIP code. Comparing the two ﬁgures clearly shows the overlap between a number of communities with largely non-white populations and higher levels of neighborhood deprivation. NDI measures the socioeconomic status of a neighborhood by identifying the following key variables: wealth and income, education, occupation, and housing conditions. Figure 2: Non-white population by ZIP code 15 The inequities that have existed for people of historically under- represented groups, such as communities of color, women, and low-income communities, have been made more visible by the COVID-19 pandemic. Data show that Hispanic, Black, and Indigenous populations are disproportionately affected by the disease and its economic impacts. In addition to the health crisis and ampliﬁcation of existing health disparities, COVID-19 has also brought troubling reports of bias and discrimination against Asian Americans and others. Speciﬁc data on disparities for each city covered in this report is provided in the “Identiﬁcation and Prioritization of the Community’s Health Needs” section. Figure 3: Alameda County NDI by ZIP code 16 Process and Methods The CHNA process includes data collection and interpretation; identiﬁcation, prioritization, and selection of health needs; and the creation of the ﬁnal CHNA report. ACPHD joined Kaiser Permanente, Stanford Health Care, John Muir Health, Sutter Health, UCSF Benioff Children’s Hospitals, and other organizations in the planning, implementation, and completion of this CHNA. Primary data, i.e., focus groups and key respondent interviews, were collected by ACPHD staff and the hospitals’ consultants. Sources of secondary data included data collected by ACPHD and Kaiser Permanente’s data platform. Methods Used to Identify and Prioritize Needs Secondary Data The CHNA collected primary data through key respondent interviews with individuals and groups of individuals. To identify issues that most impact the community’s health, local public health experts, community leaders with expertise on local health needs, and individuals with knowledge and/or lived experience of racial health inequities were recruited to participate in focus groups or key respondent interviews. Community Input ACPHD’s Community Assessment, Planning, & Evaluation (CAPE) Unit provided secondary data on relevant morbidity and mortality trends. These data were augmented by Kaiser Permanente’s data platform. The data platform provides access to a core set of approximately 100 publicly available indicators to understand health using the County Health Rankings population health framework, which emphasizes social and environmental determinants of health. The data platform is available to the public at kp.org/chnadata. Speciﬁc sources and dates of secondary data are listed in Appendix 2. 17 Identiﬁcation and Prioritization of the Community’s Health Needs The following criteria were used by residents and participants in the community input sessions to prioritize the list of health needs: Severity and magnitude of need How measures compare to national or state benchmarks, the relative number of people affected, impact of COVID-19 on the need. Community priority Where the community ranked the health need in relation to others that were observed. Clear disparities or inequities Differences in health factors or outcomes by geography, race/ ethnicity, economic status, age, gender, or other factors. These criteria were used when reviewing the secondary, population-level data. 18 Prioritized Health Needs The following sections describe the priority health needs identified through the assessment. These sections focus on Oakland for several reasons. It is the largest city in Alameda County, and its larger size provides the most data and prevents generalization that could occur with smaller numbers. Oakland’s population is also the county’s most diverse. There are 5 priority health needs: Employment Housing Access to Care Mental and Behavioral Health Community Safety 19 1 Income and Employment Economic opportunity provides individuals with jobs, income, a sense of purpose, and chances to improve their economic circumstances over time. Residents in Oakland, for example, experience higher unemployment rates and greater levels of income inequality compared with the state. Oakland youth experience higher rates of being neither in school nor working compared with the state, and some neighborhoods suffer alarmingly high rates of poverty. Disproportionality is found among youth, not in school and not working, with higher prevalence in ZIP codes that tend to have higher Black populations. Key respondents reported that because of the COVID-19 pandemic, many people lost their jobs, and some communities were disproportionately affected, such as people of color and people with undocumented status. 20 2Housing Having a safe place to call home is essential for the health of individuals and families. Soaring housing costs across the Bay Area push affordable housing out of reach for many, including those in Alameda County. Residents in Oakland experience a high housing burden, measured as a household that spends more than 50 percent of its members’ income on housing, and high rates of overcrowded housing compared with California. Overcrowded households are households where the number of people exceeds the number of rooms. Neighborhoods of West Oakland, Chinatown and Downtown, San Antonio, Fruitvale, and East Oakland, along with Central, Downtown, and South Berkeley, tend to experience higher rates of severe housing burden than other regions throughout Oakland. Key respondents noted the growing number of homeless encampments, especially in Oakland, and that transgender people, Black persons, and older adults face discrimination when they try to rent an apartment. Those who identiﬁed in more than one of these groups have the hardest time. 21 3 Access to Care Access to comprehensive, quality health care services— including having insurance, local care options, and a usual source of care—is important for ensuring the quality of life for everyone. Despite record high rates of insured populations for California at the end of 2021, many residents still lack adequate access to care. Within Alameda County, rates of physicians and dentists are higher than state and national rates. Even with higher unemployment and greater income inequality, Medi-Cal participation rates are lower in Oakland compared with national and state rates. Neighborhoods of color, including Hispanic neighborhoods and Black neighborhoods, have higher rates of uninsured populations (including children), worse outcomes for COVID-19 (higher rates of death and lower vaccination rates), as well as higher rates of infant mortality, which is a key measure of maternal care. Key respondents reported barriers to accessing care, such as transportation, the cost of insurance, and the cost of health care. 22 4 Community Safety The level of risk of violence and injury in a community affects the ability of its residents to prosper and thrive. Community safety issues, including gun violence, premature death by injury, and pedestrian accident death, present major health barriers in the Oakland area, especially for Black populations. Premature death, particularly due to injuries from gun violence, work-related incidents, and car crashes, is higher in the Oakland area compared with Alameda County. Between 2016 and 2020, the injury death rate was twice as high for Black residents of Oakland than for Oakland residents overall. According to key respondents the COVID-19 pandemic and shelter-in- place orders increased gun violence, domestic violence, and anti-Asian hate crimes. 23 5 Mental and Behavioral Health Mental health affects all areas of life, including a person’s physical well-being, ability to work and perform well in school, and participation in family and community activities. One reason for concern is higher suicide rates in Oakland than in Alameda County. Further evidence indicates that American Indian residents in Oakland experience a rate of deaths of despair—those due to suicide, drug overdose, and alcoholism—ﬁve times higher than Oakland in general. Another reason for concern is that Alameda County seventh graders report being bullied at school more often than California seventh graders. Black and Asian high school-aged youth report being bullied at higher rates than youth of other ethnicities. Key respondents reported that residents are traumatized due to over-policing, anti-Asian hate crimes, fear of being deported, and intergenerational trauma. Respondents cited evidence that COVID-19 exacerbated the mental and behavioral health needs in Oakland, highlighting how youth and older adults experienced isolation because of the shelter-in- place orders. Detailed descriptions of the signiﬁcant health needs identiﬁed through the Community Health Assessment follow. These data sections are provided by Kaiser Permanente and Stanford Valley Care hospitals. 24 Income and Employment Economic opportunity provides individuals with jobs, income, a sense of purpose, and opportunities to improve their economic circumstances over time. People with steady employment are less likely to have an income below poverty level and more likely to be healthy. Currently, around 11 percent of people living in Kaiser Permanente communities—and 14 percent of children—live in poverty. Those without adequate resources to meet daily needs, such as safe housing and enough food to eat, are more likely to experience health- harming stress and die at a younger age. Americans with lower incomes are more likely to live in neighborhoods lacking access to healthy food and safe physical activity and have higher exposure to environmental pollutants. Compared with white Americans, those who identify as Black, Hispanic, or American Indian are more likely to have lower incomes, fewer educational opportunities, and shorter life expectancies. Income inequality has been increasing over recent decades. During the ﬁrst year of the COVID-19 pandemic, higher levels of economic inequality were associated with higher levels of COVID incidence and death. County & City-Speciﬁc Data Income and employment are signiﬁcant issues for Alameda County residents. Education generally correlates with income; therefore, educational statistics that differ by race/ethnicity are particularly concerning. Smaller proportions of Alameda County’s Black, Latinx, Native American, and Paciﬁc Islander 11th graders meet or exceed grade-level English language arts standards compared to California 11th graders overall. Also, a smaller percentage of Black, Latinx, and Paciﬁc Islander 11th graders meet or exceed math standards versus California’s 11th graders. Related to these statistics, much smaller proportions of Alameda County’s Black and Paciﬁc Islander high school graduates completed college- preparatory courses compared with high school graduates statewide. The high school drop-out rate is particularly high among Alameda County’s Latinx youth compared with all California youth. Building on these ﬁgures, in its 2019 CHNA report, Stanford Health Care found a higher proportion of the Tri-Valley area’s Latinxs, Paciﬁc Islanders, and residents of other ethnicities over ages 24 without a high school diploma compared with all Californian adults over age 24. In Oakland, residents experience higher unemployment rates5 and greater levels of 25 income inequality compared with the state. In some neighborhoods, poverty rates are 22 to 24 percent. Oakland youth experience higher rates of being neither in school nor working compared with the state, and some neighborhoods suffer alarmingly high rates of poverty. Disproportionality is found among youth not in school and not working, with higher prevalence in ZIP codes that tend to have higher Black populations. In 2020, unemployment affected more ZIP codes with higher Black populations compared with the city of Oakland in general. In San Leandro, the geographic accessibility to jobs, as measured by the job proximity index, presents a major barrier for residents in the labor force, who must travel for employment6. Additionally, San Leandro contains higher rates of students eligible for free and reduced-price lunch7 along with higher rates of poverty within some neighborhoods compared with the state8 , highlighting the need for income and employment supports. Residents in some neighborhoods experience poverty rates of 28 percent and 21 percent, compared with the average rate of poverty for San Leandro overall at 10 percent9. San Leandro neighborhoods with relatively high Black populations also experience lower median income levels. The two ZIP codes with the highest proportions of Black residents (31 percent) have the lowest median incomes in San Leandro ($43k and $53k, respectively, compared with $89k)10 . Fremont residents beneﬁt from higher employment rates11 and higher median income levels than the state of California, along with lower rates of poverty12. However, access to jobs, as measured by the job proximity index for Fremont, is 31 percent worse than Alameda County and 33 percent worse than the state of California13. The index measures the distance of jobs from a neighborhood or city. As a bedroom community to Silicon Valley, Fremont does not have a high concentration of jobs. Respondents reported that few jobs are available that enable residents to afford the high cost of living. Some neighborhoods within Fremont experience higher rates of students eligible for free and reduced-price lunch14, highlighting greater need for income support. Respondent Perspectives Respondents shared that residents working in low-wage jobs often make too much to qualify for Medi-Cal but too little to be able to afford private insurance, and so remain uninsured. Not being able to pay for basic needs results in feelings of shame, trauma, stress, depression, and even suicide for some. Respondents advocated for employers to provide jobs with livable wages and health care. Respondents suggested investing in more job training in Alameda County. They also promoted universal basic income, describing that it will help people be able to live in Alameda County 26 and help to balance inequities of structural racism. “The costs of housing are going up, and there aren’t any jobs, especially for those who have ‘no skills.’ Fremont is part of Silicon Valley, and you have to be an engineer or very well educated to afford to live here. –Nonproﬁt organization leader Key Fremont respondents reported few jobs are available that enable residents to afford the high cost of living in Fremont, suggesting residents need advanced degrees or speciﬁc skills to earn a livable wage. Therefore, they recommend investing in workforce training for careers in well-paying industries. The residents most affected by income disparities in Fremont— as noted by the respondents—are people with undocumented status, Black, Hispanic, and American Indian people, and people with disabilities. Focus group participants believed there were not enough employment opportunities in the Tri-Valley area that paid enough to afford the expensive rents in the area. Key respondents pointed to signiﬁcant disparities in income and stated that many families are struggling to stay in the area for jobs and school, despite it being difﬁcult to afford the cost of living. Respondents shared that before the COVID-19 pandemic, certain populations found it harder to get a job and were being paid less (e.g., transgender women, people with physical disabilities, and the Hispanic population) and this became even worse during the pandemic. Other populations that the respondents highlighted as having a difﬁcult time ﬁnding a job are older adults, people who were formerly incarcerated, youth, and people who are undocumented. The respondents noted that many residents lost their jobs due to the COVID-19 pandemic and that it disproportionately affected residents who are Hispanic, Asian, and Paciﬁc Islander. Focus group participants said that small businesses struggled to survive the pandemic. This had a ripple effect throughout the economy, leading to loss of income and unemployment and subsequently a loss of housing. According to key respondents, pandemic-related job loss was a signiﬁcant issue in the community that had broad effects, including increased food insecurity, homelessness, and signiﬁcant mental health issues. Respondents shared that due to loss of income residents had to choose between paying rent, buying food, or paying for health care. This created a huge spike in the need for food and people accessing food banks. It was also noted that parental job loss due to the COVID-19 pandemic had a trickle-down effect on families contributing to students who withdrew from school due to stressors at home. Further, the virtual learning environment left many students behind academically. Statistics from before the pandemic indicated greater proportions of Black students in Alameda County experienced low school connectedness compared with all California students. Key respondents also stated that childcare continues to be a major issue. Affordable care is limited for low-income parents, and fear of exposure to COVID-19 has kept many parents wary of using childcare services. Additionally, childcare facilities that can support children who have experienced homelessness or other trauma are needed. 27 Families Living Below Poverty Level by Race/ Ethnicity in Alameda County Source: American Community Survey 5-Year (2017-2021) 12.3% 10.1% 9.3% 6.4% 2.6% 5.5% 11% 8.6% 4.5% Two or More RacesNative Hawaiian/ Paciﬁc Islander Hispanic/Latino White, non-Hispanic AsianBlack/African American American Indian/Alaska Native OverallOther 28 Housing and Homelessness Having a safe place to call home is essential for the health of individuals and families. American families’ greatest single expenditure is housing, and for most homeowners, their most signiﬁcant source of wealth. Because of historic discriminatory lending policies and some current lending practices, people of color—especially Black community members—have been denied the opportunity to purchase a home, leading to enduring inequities. Housing costs have soared in recent years, with many families having trouble paying for housing. Black and Hispanic renters are more likely to live in cost-burdened households and face housing instability. Job loss associated with the COVID-19 pandemic coupled with expiration of the federal eviction moratorium has made many renters’ situations even more precarious. Homelessness across the US was on the rise before the pandemic, including for families with children. In 2020, the number of single adults living outdoors exceeded the number living in shelters for the ﬁrst time. Even more individuals and families moved outside because of the pandemic, leading to a crisis in street homelessness in many American cities. County & City-Speciﬁc Data Housing prices have soared in recent years across Alameda County, which has pushed affordable housing out of reach for many. In Oakland, residents experience high housing burden and high rates of overcrowded housing compared with California15 . Neighborhoods more heavily populated by people of color, including West Oakland, Chinatown and Downtown, San Antonio, Fruitvale, and East Oakland, tend to experience higher rates of severe housing burden, measured as a household whose members spend more than 50 percent of their income on housing, than other regions of Oakland16. Overcrowded households are households where the number of people outnumber the number of rooms. Fruitvale, a heavily Hispanic neighborhood, experiences an overcrowded housing rate of 21 percent, compared to 6 percent for Oakland in general17. In San Leandro, rates of overcrowded housing, rental cost, and housing burden, the percentage of income residents pay for housing, are all higher than California18. Rates of overcrowded housing is 38 percent higher in San Leandro (11 percent of households) than California (8 percent of households)19. Homeownership, a powerful means of building wealth, is lower for some neighborhoods with higher Black and Hispanic populations. San Leandro’s rate of 29 homeownership is 56 percent, but home ownership in the ZIP code with the largest Black population and the second largest- Hispanic population is the lowest of all ZIP codes in San Leandro at 46 percent.20 In Fremont, although housing affordability is on par with the state of California, the median rental cost is higher. Measures of housing burden, such as overcrowded households (people outnumber rooms) are also higher:21 Median rental cost for Fremont ($2,356) is 40 percent higher compared with the state ($1,689). ZIP code 94539 has the highest median rental cost ($2,652) out of all Fremont. Over one in 10 (11 percent) of households in Fremont are overcrowded, higher than rates across the state of California (8 percent) and the nation (3 percent). Fremont neighborhoods with higher Hispanic populations also experience a higher rate of moderate housing burden. This occurs when households pay between 30 and 50 percent of their income for housing. Respondent Perspectives Key respondents noted the growing number of homeless encampments, especially in Oakland. Additionally, transgender people, Black persons, and older adults face discrimination when they try to rent an apartment, and those identiﬁed in more than one of these groups have the hardest time. Many noted that increasing numbers of older adults are experiencing homelessness and that foster youth often face unstable housing. The respondents pointed out that without shelter, already vulnerable populations are at even higher risk of experiencing signiﬁcant challenges because of crises like COVID-19 and wildﬁres. For example, during the COVID-19 shelter-in-place mandate, many programs and services did not go to homeless encampments to provide much- needed health and wellness checks or distribute food. We have an aging population in our permanent supportive housing, and we are seeing more medical needs and supporting older adults in perma- nent supportive housing. –Nonproﬁt organization leader “Respondents emphasized the importance of the relationship between housing, mental health, and substance use. For example, they shared that during the COVID-19 shelter-in-place mandate, people experiencing homelessness who were provided hotel-style housing with wrap- around services (including primary care, mental health, and case management) were much more likely to move into stable 30 housing. Therefore, respondents felt it is important to continue to offer individual housing units with on-site resources and services, in addition to investing in permanent housing. Respondents shared that demand for affordable housing and housing for people with lower incomes has increased. They highlighted that people with disabilities and older adults are most in need of housing assistance. In addition, the respondents noted in Fremont multiple families are living together in small apartments, and living in close quarters made it more likely to spread COVID-19. The respondents suggested investing in ways to help keep residents in their homes, including rental assistance, in addition to creating affordable housing options. 31 If folks aren’t being stably housed, it affects their whole health, and that’s been a huge issue here in Alame- da County, speciﬁcally Oakland. It’s affecting people’s health across the board. That’s why we’re seeing a lot of disparities with health, mental health, substance use, because of housing. –LGBTQ focus group participant “ Access to Care Access to comprehensive, quality health care services—including having insurance, local care options, and a usual source of care—is important for ensuring quality of life for everyone. The Affordable Care Act (ACA) helped extend insurance coverage to many previously uninsured individuals and families, especially in Medicaid expansion states. Still, families with low incomes and people of color are more likely to be uninsured, and even with the ACA, many ﬁnd insurance unaffordable. Health insurance coverage increases use of preventive services and helps ensure people do not delay seeking medical treatment. Having an adequate number of primary care resources in a community also is important, including Federally Qualiﬁed Health Centers (FQHC), which serve patients regardless of ability to pay. Insurance by itself does not guarantee access to appropriate care, and many community members experience barriers related to language, transportation options, and differential treatment based on race, as well as access to fewer health care resources. Furthermore, the COVID-19 pandemic has disrupted health care for millions of Americans as health care resources were diverted from primary and preventive care, with telehealth becoming an increasingly important source of care. Existing racial and health inequities have been brought to light by the pandemic, with people of color accounting for disproportionate shares of COVID-19 cases, hospitalizations, and deaths. County & City-Speciﬁc Data Access to comprehensive, quality health care services is important for ensuring quality of life for everyone in Alameda County. Oakland has fewer uninsured residents compared with other areas of the state, but some measures such as Medi-Cal enrollment are lower despite higher levels of poverty.22 Oakland has lower Medi-Cal enrollment rates (32 percent) than both the state (38 percent) and the nation (35 percent), despite a poverty rate of 14 percent, which is higher than the state rate (13 percent). 23 Two Oakland neighborhoods with higher Hispanic populations (53 percent) have higher rates of uninsured children (5 percent) compared with Oakland in general (17 percent of Hispanic and 3 percent of uninsured children).24 25 Rates of infant mortality are 200 percent worse for Multiracial infants (10.5 per 1,000 live births) and 165 percent worse for Black infants (9.2 per 1,000 live births), compared with the city as a whole (3.5 per 1,000 live births).26 San Leandro experiences better outcomes across many measures of access to care. These include higher rates of insured populations compared with California27 and other measures such as infant mortality,28 which are on par with Alameda County. However, rates of these measures differ across racial and ethnic groups and neighborhoods. Black residents experience higher rates of infant mortality than San Leandro generally. COVID-19 death rates were highest among Multiracial and Black residents, compared with all other racial and ethnic groups.29 The ZIP code with the highest proportion of Hispanic residents had the highest rate of uninsured, both for total population and for children.30 Though Fremont experiences low rates of uninsured residents, other measures highlight access to care barriers for maternal care and the impact of the COVID-19 pandemic for certain groups. Across 2016 to 2020, premature birth rates as a percentage of all live births were higher for Black (11 percent), Multiracial (9 percent), and Hispanic (8 percent) residents, compared with Fremont overall (7 percent).31 Rates of low birth weight for all live births were highest for Black infants (7 percent) between 2016 and 2020 in Fremont, higher than both Fremont overall (6 percent) and for Alameda County (6 percent).32 Paciﬁc Islander residents had the highest rate of COVID-19 cases across the Fremont (8,643 per 100,000 people), as of November 2021, while white residents had the highest rate of death (91 per 100,000 people). Fremont’s overall case rate was 5,127 per 100,000 people, and the death rate was 63 per 100,000 people.33 32 Chronic Preventable Hospitalizations by Race/ Ethnicity in Alameda County Source: Ofﬁce of Statewide Health Planning and Development (OSHPD) (2000-2011) Asian/Paciﬁc Islander 425.2 Hispanic/Latino 632.2 Black/African American 2,055.1 American Indian/Alaska Native 684.6 White 673.8 Overall 787.5 400 800 1,200 1,600 2,000 0 33 34 Respondent Perspectives Key respondents reported barriers to accessing care, such as transportation and the cost of insurance and health care. Oakland respondents appreciated that community clinics are easily accessible and that their staff reﬂect the cultural diversity of the community. However, respondents highlighted that, in East Oakland in particular, there are no major hospitals, pharmacies, or specialty care services, and without personal transportation it is difﬁcult to access these needed services. Respondents spoke about the limited dental services in Oakland, and that people who are undocumented cannot get dental insurance. Respondents shared stories about people with serious dental pain who are not getting care or are going to the emergency room to be treated. Respondents mentioned LGBTQ community members were choosing to go without health care because they reported being judged and misgendered. During the height of the COVID-19 pandemic, a lot of preventive health did not happen, especially for people who are unsheltered, according to respondents. They noted that there is distrust in the COVID-19 vaccine, especially in the Black and Hispanic communities. The COVID-19 pandemic brought on numerous access challenges. While the shift to telemedicine helped increase access for some, the respondents highlighted that other residents, especially older adults, struggle with the technology. It was also noted that residents were not getting preventive health screenings during the pandemic. The pandemic exacerbated existing racial and health inequities, with people of color accounting for a disproportionate share of COVID-19 cases, hospitalizations, and deaths. Focus group participants agreed that the pandemic disproportionately impacted communities of color. Key respondents mentioned that some communities are not accessing the vaccine because of their legal status. It’s very expensive, they can’t afford the insurance. Some families are not eligible for Medi-Cal but Covered Cali- fornia is so expensive. –Nonproﬁt organization leader “ Respondents pointed out the importance of considering the social determinants of health, and the need for providers to look at factors like housing, job stability, and food security, rather than a simple medical approach, to address structural racism’s impact on health. Respondents suggested that health care providers employ mobile health vans or pop-up clinics to increase access in communities. Respondents also reported that telehealth appointments are helpful for some, but for those without access to the Internet or a private space, other options need to be available. They mentioned that all services (including websites and forms) need to be offered in multiple languages, especially in Asian languages. In addition, they suggested that providers be trained in cultural humility. Respondents recommended using case managers to direct people to various resources. They also proposed cross- sector partnerships between hospitals and nonproﬁt organizations to integrate services, to include other methods of care, such as healthy food and acupuncture, and to increase access to care and utilization. Respondents highlighted the “food as medicine” model as an example of a collaborative model that addresses multiple needs, especially if the food is grown locally. Key respondents noted the high costs of health care as a barrier to accessing care. They shared that some families are making too much to qualify for Medi-Cal, but not enough to afford Covered California. As a result, they are choosing to go without health insurance. According to the respondents, those who do qualify for Medi- Cal have a difﬁcult time ﬁnding quality providers accepting new patients and even a harder time if they want a provider in a language other than English. They also shared concern that providers are using family members as translators. Therefore, the respondents recommended investing in a diverse health care workforce as well as cultural humility training for health care providers. The respondents advocated for lower-cost health insurance options. They pointed out that methods deployed during the pandemic were very successful and suggested these continue. These include partnering with trusted leaders (e.g., faith based) to connect with populations less likely to be early adopters of health care. They also requested deeper partnerships between hospitals and nonproﬁt organizations for collaboration in addressing all residents’ needs. San Leandro respondents said that residents can be on hold for hours trying to schedule an appointment, or when they do get an appointment, it is via phone, which makes it difﬁcult to show where they are in pain. Additionally, they noted that people who are seeking asylum or have undocumented status are afraid to get care. When you come to the clinic and they are misgendering you in 2021, you’re not coming back. –Transgender focus group participant “ 35 36 Focus group participants linked transportation with health, stating that trafﬁc, road work, and a lack of cheap public transportation options made it difﬁcult for them to access health care / get to their appointments. Key respondents noted that many specialty services are in Oakland or San Francisco. This is a barrier to access for many who do not have adequate transportation. Multiple key respondents pointed to a disparity in infant mortality in the Black community. They cited factors like a lack of culturally competent care, having to choose between signiﬁcant others and doulas in the delivery room due to the pandemic, shortcomings in post-natal care, and racial tension and anxiety due to the pandemic. Statistics corroborate these observations: Infant mortality is higher among Alameda County’s Black, Latinx, and multi- ethnic populations than in California overall. Low birth weight was a concern for the Alameda County Paciﬁc Islander and multi- ethnic populations. Finally, breastfeeding rates are especially low among Paciﬁc Islander mothers compared to mothers statewide. Community Safety The level of risk of violence and injury in a community affects the ability of its residents to prosper and thrive. People can be victims of violence, witness violence or property crimes, or hear about crime and violence from others. Children and adolescents exposed to violence are at risk for poor long-term behavioral and mental health outcomes. Within families, intimate partner violence (IPV) and child maltreatment frequently occur together, each with adverse health effects. One in four American women reports IPV during her lifetime. Communities that have been systematically marginalized experience higher rates of violence, including deaths and injuries from ﬁrearms. Chronic stress from living in unsafe neighborhoods can have long-term health effects, and fear of violence can keep people indoors and isolated. In addition, the physical and mental health of youth of color—particularly males—is disproportionately affected by juvenile arrests and incarceration related to local policing practices. Community safety also reﬂects injuries caused by accidents—unintentional injuries are the leading cause of death for children, youth, and younger adults and account for nearly 30 percent of emergency department visits. 37 1.4 6.6 7.0 27.5 7.5 Asian/Paciﬁc Islander Hispanic/Latino White Black/African American Overall Age-Adjusted Death Rate due to Firearms by Race/ Ethnicity in Alameda County Source: Center for Disease Control and Preventions (2018-2022) County & City-Speciﬁc Data Community safety issues including gun violence, premature death by injury, and pedestrian accident death present major health barriers in Oakland, especially for Black populations.34 Premature death, particularly due to injuries from gun violence, work- related incidents, and car crashes is higher in Oakland (45.9 per 100,000 people) compared with Alameda County (40.3 per 100,000 people).35 Between 2016 and 2020, the injury death rate was twice as high for Black residents of Oakland (95.5 per 100,000 people) than for Oakland overall (45.9 per 100,000 people).36 The motor vehicle crash death rate is two and a half times higher (12.9 per 100,000 people) for Black residents compared with both Oakland and the rate for Alameda County (both 5.3 per 100,000 people).37 San Leandro experiences higher rates of injury death (for example, death from gunshot or a work-related incident) and motor vehicle crash death compared with Alameda County, with a rate of injury death (44.9 per 100,000 people) 11 percent higher than Alameda County as a whole.38 Black residents experience the highest rates of motor vehicle crash death (12.7 per 100,000) compared with all other ethnic groups in San Leandro for which data are available, and this is higher than San Leandro overall (6.9 per 100,000 people).39 Native Hawaiian / other Paciﬁc Islander residents experience injury death rates (69.5 per 100,000) 72 percent higher than San Leandro overall (44.9 per 100,000).40 Respondent Perspectives Key respondents reported that violence disproportionately affects young, Black men. They noted the connection between mental health (especially trauma, depression, stress, and anxiety) and community safety and that individuals and communities that have experienced trauma (including intergenerational trauma) are more likely to suffer from poor mental health. In addition, the respondents highlighted that criminalization of Black people coupled with over incarceration has increased trauma and fear of the police. Respondents shared stories of how over- policing is making people, especially people of color and LGBTQ communities, afraid to walk down the street. At the same time, other respondents spoke about In Hayward, [students] see their parents being carted off, they hear shootings every night, they see their parents in jail, etc. –School leader “ 38 39 victims of violence not being able to call the police because they cannot speak English (e.g., monolingual Cantonese). Key respondents discussed fear and anxiety surrounding contracting COVID-19 as a threat to community safety. Respondents said that residents had been afraid to send their children to school, visit their doctor to receive care, go into public spaces like the grocery stores, and to take public transportation. Key respondents believed that the fear was subsiding, but trauma from these experiences remained. The respondents shared that during the COVID-19 pandemic, domestic violence increased as there was additional stress, and residents were trapped in the house with their abuser. Also, they spoke about the increase in anti-Asian hate crimes, which caused trauma and left residents afraid to leave their homes. The respondents recommended implementing adverse childhood experiences (ACE) screening to support early detection of risk and intervention, to help interrupt cycles of violence and trauma. They suggested promoting anti-violence messages and policies, continuously and not just after a crisis. Because of the connection between unemployment and violence, respondents suggested investing in education and workforce training to prevent violence. They proposed putting out prevention messages in the community, such as on billboards, to try to change social norms. They also suggested investing in proven violence intervention programs. Alameda County’s Black children (ages 0–20) are at higher risk to be placed in foster care than are California children on average. Many researchers have noted that children placed in foster care are at greater risk of contact with the juvenile justice system.41 These disparities for young people can lead to inequities, not just in their experience of community safety but in their ability to succeed in school and in life.42 Additionally, structural racism was mentioned by key respondents as contributing to concerns of community safety. Comments and incidents of “Asian hate” were speciﬁcally mentioned, as well as students and parents of color not feeling like schools are safe and welcoming places for them. In Livermore, key respondents discussed a lack of safe outdoor spaces to exercise and recreate as primary concerns about community safety. One focus group ranked community safety as a high priority. Several focus group participants believed that many community parks had become places of illicit activities, speciﬁcally alcohol and drug use, that made their neighborhoods less safe. While many community safety statistics are better in the Tri-Valley than the state, the rate of violent crimes is higher. Shootings are up 70 percent. Oakland saw sustained progress over 10 years and that progress is wiped out. Vio- lence is both a symptom and cause of mental health issues. Forty-four percent of people who get shot will get shot again within a year. –Nonproﬁt organization leader “ Mental and Behavioral Health Mental health affects all areas of life, including a person’s physical well-being and ability to work, perform well in school, and participate fully in family and community activities. Anxiety, depression, and suicide ideation are on the rise due to the COVID-19 pandemic, particularly among Black and Hispanic Americans. Those facing challenges related to lower economic opportunity often experience high levels of stress in their daily lives, coupled with fewer resources for coping. Children and youth experiencing stress have an increased likelihood of poorer mental and physical health. Deaths of despair—those due to suicide, drug overdose, and alcoholism—are on the rise, and males, American Indians/ Alaska Natives, and the unemployed are at greater risk. Communities across the country are experiencing a critical lack of capacity to meet the increased demand for mental health services. At the same time, rapid adoption of digital platforms for behavioral health services has helped reduce barriers to in-person mental health care. County & City-Speciﬁc Data Alameda County has 614 (per 100,000 people) mental health providers compared with a rate of 352 (per 100,000 people) for California and 247 (per 100,000) for the nation.43 However, mental health remains a serious issue in the county. One reason for concern is higher suicide rates in Oakland than Alameda County.44 American Indian residents in Oakland experience a rate of deaths of despair— those due to suicide, drug overdose, and alcoholism—ﬁve times higher (151.1 per 100,000 people) than Oakland in general (31.5 per 100,000 people).45 High school-aged youth who are of Black and Asian ethnicities report being bullied at higher rates than youth of other ethnicities.46 The racial disparities around youth connectedness and safety47 coupled with the disparities in suicide, drug overdose, and alcoholism,48 suggest a need to equitably address mental and behavioral health services and programs, especially for youth. Seventh graders in Alameda County report being bullied at school nearly 40 percent more often than seventh graders in the state of California. Over a third of seventh graders (36 percent) report experiencing 40 41 bullying in Alameda County, and the percentage is much higher for the seventh graders who identify as Black or Asian (46 percent) in Alameda County compared with the state average (26 percent).49 Cyberbullying is experienced by greater percentages of Paciﬁc Islander youth in Alameda County than by all youth statewide. Paciﬁc Islander youth in Alameda County also experience depression-related feelings in higher proportions than California youth overall. In Alameda County, the proportion of teens contemplating suicide is higher than teens statewide for Native American, Paciﬁc Islander, multi-ethnic, and “other” youth. Experts note that “racial and ethnic minorities have less access to mental health services than do whites, are less likely to receive needed care and are more likely to receive poor quality care when treated.”50 An expert on the historical context of such disparities suggests that “racism and discrimination,” as well as “fear and mistrust of treatment,” pose barriers to Black, Indigenous, and People of Color (BIPOC) community members seeking help for behavioral health issues.51 Black students in Oakland and Alameda uniﬁed school districts, compared with students of other race and ethnicities, report the lowest rates of schoolconnectedness, which measures feeling close to people, safe, and happy at school. This rate tends to decrease even further as students move from seventh to eleventh grade.52 People in San Leandro, especially Black residents, have a high need for access to mental and behavioral health services that combat opioid overdose and mental health issues resulting in deaths of despair. Opioid overdose death rates are twice as high for Black residents (12.2 per 100,000 people) than San Leandro overall (4.9 per 100,000 people).53 Deaths of despair, those due to suicide, drug overdose, and alcoholism, are higher for Black (53.9 per 100,000 people) and White (46.5 per 100,000 people) San Leandro residents compared with other racial and ethnic groups for which data are available, as well as for San Leandro generally (30.7 per 100,000 people).54 In Fremont, deaths of despair—those due to suicide, drug overdose, and alcoholism—are lower than the state55 and Alameda County.56 Disparities exist, however. White Fremont residents experience rates of deaths of despair (32 per 100,000 people) higher than Fremont in general (18 per 100,000 people) and Alameda County (28 per 100,000 people). This rate is the highest among any ethnic group in Fremont.57 Hispanic residents of Fremont experience the second-highest rate of deaths of despair (25 per 100,000 people).58 Behavioral health, which includes mental health and trauma, as well as consequences such as substance use, ranked high as a health need in Livermore, being prioritized by nearly all key respondents and two out of ﬁve focus groups. Binge drinking is higher in Livermore than it is statewide. The impaired driving mortality rate is higher in the Tri-Valley area than in California. In addition, the rate of visits to emergency departments for substance use has been trending up in Alameda County overall. Respondent Perspectives Key respondents agreed that mental and behavioral health is a critical need. They reported that residents are traumatized due to over-policing, anti-Asian hate crimes, fear of being deported, and intergenerational trauma. Others are suffering from mental health illness due to lack of housing. The respondents explained that because of these stressors, residents are turning to substance use, suicide, and violence. The respondents stated that those particularly affected by mental and behavioral health and trauma are Black and Hispanic persons, smaller ethnic groups like Burmese and Mongolian residents, youth, and LGBTQ communities. They also reported that mental health is worse because many residents’ basic needs are not being met. For example, they are in crisis from being unhoused or losing their job. The respondents noted an increase in rates of suicide and overdosing as a coping mechanism for mental and behavioral health needs. The respondents shared that many residents are deterred from accessing mental and behavioral health services because of the associated stigma; and when people do try to access services, there is a three- to six-month wait list. This wait is longer if someone is seeking counseling in Spanish and even longer for languages such as Arabic, Amharic, and Mam. Respondents shared that many people do not know how to seek help and cannot ﬁnd bilingual or bicultural therapists that understand their experiences. Therefore, the respondents advocated for hiring more mental and behavioral health providers, especially bilingual and bicultural therapists that mirror the population. They also recommended investing in more school therapists able to counsel youth regardless of their insurance and more counselors to support the mental health of students. The respondents noted that the increase in telehealth during the COVID-19 pandemic helped many to access services. However, some residents did not have access to a computer with Internet or a private space for online appointments. Therefore, they suggested continuing to offer in-person visits and to increase Internet access for residents. “African American, Latinx, and Asian American community members are struggling in sharing their stories to people who do not understand their customs, culture, etc. –Nonproﬁt organization leader 42 43 The respondents felt that it was important to get mobile care out to people experiencing homelessness and to homebound older adults. They suggested implementing the ACE screening to detect and prevent additional trauma. Other respondents suggested destigmatizing mental health. They proposed spreading messages that people do not have to manage mental health on their own, and to use community approaches (besides traditional one-on-one therapy) that may resonate more with people of color. According to key respondents, mental health, which was already bad, is now at a critical level after the fear, anxiety, stress, job loss, isolation, and lack of trust that resulted from the COVID-19 pandemic. They noted that not only was there fear around contracting COVID-19, there was also an increase in loneliness and isolation (especially among older adults and youth) due to the stay-at-home orders. There was also stress because many residents lost their jobs and Asian residents were afraid to leave their homes due to the escalating anti-Asian hate crimes. Focus group participants stated that the COVID-19 pandemic negatively impacted mental health due to fear of being out in public, using public transportation, and a stigma about mask-wearing. Key respondents stated that mental health does not discriminate based on age, race, or socioeconomic status. Especially after the trauma of the pandemic, mental health is a crisis across all populations. Focus group participants felt that children faced signiﬁcant stress and anxiety because of the pandemic. According to key respondents, school systems do not adequately support students of color and need to make schools more welcoming, inclusive, and safe places for children. Key respondents stated that the pandemic had a major impact on the mental health of youth, citing an increase in suicide attempts, suspensions, and behavioral issues. Focus group participants in Livermore believed that drug and alcohol users made public spaces less safe for the community. Key respondents mentioned a particular need to address substance use within the unhoused community. Livermore respondents explained that many mental health providers are centralized in Oakland and San Francisco and not in the Tri-Valley area. Participants corroborated this, explaining that there is often a long waiting list to see a mental health provider, speciﬁcally citing a shortage of Spanish-speaking therapists. It [mental health] crosses race, gender, and socioeconomic status. Destigmatize mental health. There is a huge stigma around mental illness; mental health needs should be treat- ed the same as any other medical condition. There are never enough counselors at the school. –School leader “ Next Steps Our next step is to develop a Community Health Improvement Plan (CHIP) using the CHNA ﬁndings. CHNA’s are valuable tools in helping determine where to focus health improvement efforts, targeting speciﬁc demographics or geographic locations experiencing health inequities. The CHIP, or the Community Health Improvement Plan, is a long-term systemic effort to address the public health problems of Alameda County based on the results of the CHNA. This process will start by prioritizing our health needs, gathering data, and convening a group of stakeholders who will develop activities and objectives that will address the health needs ﬁndings from the CHNA. They will also be responsible for tracking the work and measuring its progress. The Community Health Improvement Plan is meant to be community driven, by tapping into existing efforts and developing new efforts needed to address the priority areas. ACPHD will be responsible for engaging community partners who are stakeholders in this work and for creating work groups and a steering committee to help drive the work and oversee the overall process. ACPHD will engage stakeholders that address the root causes of inequity, address the social determinants of health, prioritize health behaviors, and promote behaviors that reduce individual-level risk factors for disease and injury. The intention is to have a clear, equity- centered, community-driven plan with clear measurable objectives and strategies that promote the health of all people in Alameda County. Lastly, the CHIP would align with any other internal or external plans that uplift efforts that contribute to our priority areas. Internal plans include our strategic plan and equity plan. External plans include state-wide initiatives like the State-wide Department of Health Violence Prevention initiative or the national Healthy People 2030. 44 45 Sunset view of residential and industrial areas in East San Francisco Bay Area; green hills visible in the foreground. Photo by Sundry Photography. Hayward, CA. Footnotes 1. California Demographics by Cubit , _ population, accessed December 2, 2022. 2. US Census Bureau, Diversity Index by County 2020, / state-by-state/california-population-change-between-census-decade.html, accessed December 2, 2022. https://www.census.gov/library/stories 3. EdData Education Data Partnership, https://www.california-demographics.com/counties_by http://www.ed-data.org/district/Alameda/Oakland- Uniﬁed, accessed December 8, 2022. 4. US Census Bureau, QuickFacts for Alameda County and California, https://www.census.gov/ quickfacts/fact/table/CA,alamedacountycalifornia/PST045221, accessed November 30, 2022. 5. Esri Demographics, 2020. 6. HUD Policy Development and Research, 2014. 7. National Center for Education Statistics, 2017–2018. 8. American Community Survey, 2015–2019. 9. American Community Survey, 2015–2019. 10. American Community Survey, 2015–2019. 11. Esri Demographics, 2020. 12. American Community Survey, 2015-2019. 13. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 14. Alameda County Public Health, CalREDIE and CAIR, November 2021. 15. American Community Survey, 2015-2019. 16. American Community Survey, 2015-2019. 17. American Community Survey, 2015-2019. 18. American Community Survey, 2015–2019. 19. American Community Survey, 2015–2019. 20. American Community Survey, 2015–2019. 21. American Community Survey, 2015–2019. 22. American Community Survey, 2015–2019. 23. American Community Survey, 2015–2019. 24. American Community Survey, 2015–2019. 25. Esri Demographics, 2020. 26. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 27. American Community Survey, 2015–2019. 28. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 29. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 30. American Community Survey, 2015–2019. 31. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 46 47 49 32. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 33. Alameda County Public Health, CalREDIE and CAIR, November 2021. 34. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 35. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 36. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016-2020. 37. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016-2020. 38. Ibid. 39. Ibid. 40. Ibid. 41. See, for example, Cutuli, J.J. et al., 2016. “From Foster Care to Juvenile Justice: Exploring Characteristics of Youth in Three Cities.” Children and Youth Services Review, 67, pp.84-94. Retrieved from https://www.aisp.upenn.edu/wp-content/uploads/2020/11/From-Foster-Care- to-Juvenile-Justice.pdf. And see Yi, Y., & Wildeman, C. (2018). Can Foster Care Interventions Diminish Justice System Inequality?” The Future of Children, 28(1), 37-58. Retrieved from https://ﬁles.eric.ed.gov/fulltext/EJll 79175.pdf. 42. Gallegos, A. H., & White, C. R. (2013). “Preventing the School-Justice Connection for Youth in Foster Care.” Family Court Review, 51(3), 460-468. And see: Foster, M. & Gifford, E. (2004). “The Transition to Adulthood for Youth Leaving Public Systems: Challenges to Policies and Research,” in On the Frontier of Adulthood: Theory, Research, and Public Policy, eds. Richard A. Settersten, Jr., Frank F. Furstenberg, Jr., & Ruben G. Rumbaut. Chicago: University of Chicago Press. 43. HRSA Area Resource File. Footnotes 44. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 45. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 46. California Health Kids Survey, 2017–2019. 47. California Health Kids Survey, 2017–2019. 48. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 49. California Health Kids Survey, 2017–2019. 50. McGuire, T. G., & Miranda, J. (2008). “New Evidence Regarding Racial and Ethnic Disparities in Mental Health: Policy Implications.” Health Affairs (Project Hope), 27(2), 393-403. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928067/. 51. Perzichilli, T. (2020). “The Historical Roots of Racial Disparities in the Mental Health System.” Counseling Today, American Counseling Association. Retrieved from https://ct.counseling. org/2020/05/the-historical-roots-of racial-disparities-in-the-mental-health-system/. 52. California Health Kids Survey, 2017–2019. 53. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 54. Ibid. 55. American Community Survey, 2015–2019. 56. Alameda County Public Health, California Comprehensive Birth & Death Files, 2016–2020. 57. Ibid. 58. Ibid. Appendix 1. Community Leaders, Representatives, and Members Consulted The list below contains the details of leaders, representatives, and members who were consulted for their expertise in the community. Leaders were identiﬁed based on their professional expertise and knowledge of target groups, including low-income populations, minorities, and the medically underserved. Data collection method Afﬁliation Number Perspectives represented Role Date Older adults and transit-riding adults Residents experiencing or at risk of homelessness, residents with lower incomes Medi-Cal recipients, individuals and families with lower income, Hispanic populations People experiencing homelessness in the Bay Area Asian, Paciﬁc Islander residents and families Pregnant women, families, immigrant populations, uninsuredand underinsured populations Food insecure adults and families Food insecure residents Older adults Transit-reliant and transit-riding populations in Alameda County Communities of color Youth and adults with lower incomes in Alameda County, speciﬁcally residents of San Antonio, Fruitvale, and unincorporated areas (Ashland/Cherryland) Leader Leader Leader Leaders, Representative Leader Representative Leader Leader Leaders Leader Leader Leaders 08.04.21 08.10.21 08.20.21 08.18.21 08.20.21 08.09.21 08.12.21 07.27.21 08.03.21 07.14.21 08.12.21 08.26.21 1 1 1 3 1 1 1 1 2 1 1 2 Association of Bay Area Governments (ABAG) Building Opportunities for Self-Sufﬁciency (BOSS) Abode Services Community Clinic Consortium/Alameda Health Consortium/La Clinica de la Raza Asian Health Services Alameda County Public Health Department (ACPHD) Daily Bowl Alameda County Community Food Bank Day Break Adult Day Center & Alameda County Age-friendly Coalition Alameda County Transportation Commission Greenlining ALL In Alameda County Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview 50 51 52 53 Data collection method Afﬁliation Number 3 1 1 5 1 1 1 1 2 2 1 1 East Bay Asian Local Development Corporation (EBALDC)/Berkeley Food and Housing Project/Bay Area Community Services (BACS) East Oakland Collective Eden Housing Resident Services, Inc. Fred Finch Youth Center & Lincoln HOPE Collaborative Oakland Uniﬁed Paciﬁc Center for Human Growth Family Support Services Health Care Services Agency (HCSA) Homeless and Coordination & Everyone Home NAMI Ombudsman/Empowered Aging Partnership for Trauma Recovery Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview Key Respondent Interview 1 1 Planting Justice Roots Health Center Key Respondent Interview Key Respondent Interview Appendix 1. Community Leaders, Representatives, and Members Consulted Perspectives represented Role Date Residents experiencing or at the risk of homelessness Older adults, people with disabilities, food insecure residents Older adults with lower incomes, families, and persons with disabilities Youth, especially Hispanic and Black youth Residents with lower income, are food insecure, youth School-aged youth (K- 12) Refugees and asylum seekers Residents experiencing homelessness Families and residents impacted by mental illness Older adults in residential care and skilled nursing facilities Residents who were incarcerated, people with lower income Caregivers with children Leaders Leader Representative Leader, Representatives Representative Leader Leader Leader Leader Leaders Leader Leader 08.24.21 08.20.21 08.17.21 07.29.21 07.26.21 08.19.21 08.18.21 08.12.21 08.19.21 07.30.21 08.23.21 07.22.21 Residents who were incarcerated, people with lower income Black residents of East Oakland Leader Representative 07.22.21 07.23.21 Appendix 1. Community Leaders, Representatives, and Members Consulted Data collection method Afﬁliation Number 07.26.21 Perspectives represented Role Date Key Respondent Interview SparkPoint Urban Peace Movement Oakland residents, conducted by Alameda County Public Health Department Oakland residents, conducted by Alameda County Public Health Department Oakland residents, conducted by Alameda County Public Health Department Oakland residents, conducted by Alameda County Public Health Department Oakland residents, conducted by Alameda County Public Health Department Oakland residents, conducted by Alameda County Public Health Department Oakland residents, conducted by Alameda County Public Health Department Side by Side (TAY) Unity Council Youth Alive! Key Respondent Interview Key Respondent Interview Focus Group Focus Group Focus Group Focus Group Key Respondent Interview Key Respondent Interview Key Respondent Interview Focus Group Focus Group Focus Group 1 3 1 8 9 11 8 1 1 1 12 10 13 Rubicon Adults and parents with children experiencing unemployment and underemployment Residents with lower income, especially people of color, including Asian, South Asian, Indian, Hispanic, and women of color Black residents and youth Hispanic women with children LGBTQ adults Indigenous Mam families with young children Vietnamese adults Food insecure or unemployed adults, children, and older adult populations Survivors of community and gun violence, especially youth in Northern Alameda County Older adults (65 and over) Transgender adults Cantonese adults Transitional Age Youth Leader Representatives Representative Members Members Members Members Representative Leader Leader Members Members Members 08.06.21 09.01.21 09.08.21 10.01.21 09.30.21 10.07.21 08.31.21 09.01.21 08.16.21 09.02.21 10.21.21 10.06.21 54 55 Appendix 2. Secondary Data Sources Kaiser Permanente Community Health Data Platform Source Dates American Community Survey Behavioral Risk Factor Surveillance System CDC, Interactive Atlas of Heart Disease and Stroke Center for Medicare & Medicaid Services CMS National Provider Identiﬁcation Dept of Education ED Facts & state data sources EPA National Air Toxics Assessment EPA Smart Location Mapping Esri Business Analyst Esri Demographics FBI Uniform Crime Reports Feeding America FEMA National Risk Index Harvard University Project (UCDA) HRSA Area Resource File HUD Policy Development and Research National Center for Chronic Disease Prevention and Health Promotion National Center for Education Statistics National Center for Health Statistics National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention NCHS National Vital Statistics System NCHS US Small-area Life Expectancy Estimates Project NCI State Cancer Proﬁles NCI United States Cancer Statistics NHTSA Fatality Analysis Reporting System US Geological Survey; National Land Cover Database USDA Food Environment Atlas 2015–2019 2020 2016–2018 2018 2019 Varies 2014 2013 2020 2020 2014–2018 2018 2020 2018 2019 2020 2018 2017–2018 2018 2018 2015–2019 2010–2015 2013–2017 2013–2017 2014–2018 2016 2016 Additional Secondary Data Sources Source Dates Alameda County Public Health California Health Interview Survey (CHIS) California Healthy Kids Survey (CHKS) Bay Area Equity Atlas 2016–2021 2020 2017–2019 2019 56 57 Appendix 3. Alameda County Focus Group Demographics Alameda County Focus Group Demographics La t i n x Wh i t e As i a n Bl a c k o r A f r i c a n A m e r i c a n In d i g e n o u s 28% 11% 30% 10% 23% Race Female Male Other Transgender 63% 28% 1% 9% Gender Ad Lucem Consulting Total Participants 56+ 36 23 13 20 11 46-55 36-45 26-35 18-25 Age 104 58 59 1100 San Leandro Blvd. San Leandro, Ca 94577 P. 510 267-8000 F. 510 267-3212 E. qia@acgov.org www.acphd.org Uptown Neighborhood of Oakland, California. Uptown is the art and entertainment center of Oakland featuring many bars, cafes, restau- rants and live music venues. Photo by Eddie Hernandez. Oakland, CA.