San Francisco Department of Public Health
Developing policies, plans and partnerships to protect and support Housing Security and Healthy Homes for Pregnant Women and Families Served by Public Health
Population 840,391 (2014); Asian 33.3%, Latino/Hispanic 15.7%, Black 5.5%,White non-Hispanic 41.5%
SF Births/year: 8,813 (2011);
o Ages 0-4 (2010): 35,203:
o WIC (Fed SNAP) average monthly cases with children (2010): 10,344
o Reached by Model Practice: 2.2 %
Public health issue:
The Bay Area's accelerating housing crisis relative to growth in jobs and population means that low-income families are disproportionately impacted by housing insecurity stressors. These in turn impact maternal, fetal and early child health and health/developmental outcomes over the life course. While San Francisco has many progressive housing policies, it has not prioritized housing for these populations which could generate the greatest life course return on investment.
Public agencies often operate in silos, serving clients in isolated ways. Conversely, collaboration across programs within Public Health and with community partners is integral to this model practice.
Goal1: Health departments must normalize and operationalize health equity work, integrating health equity practices into everyday client interactions to benefit clients experiencing housing insecurity.
Obj1 (achieved): The Maternal, Child & Adolescent Health Section (MCAH) Women, Infants and Children Supplemental Nutrition Program (WIC) and partner, Children's Environmental Health Promotion Program (CEHP), will collaborate to offer WIC-enrolled families a comprehensive home environmental assessment that integrates a social determinants of healthâ€ framework.
Goal2: Organizational capacity is needed to advance health equity practices, to address housing access, housing rights and housing conditions.
Obj2 (achieved): MCAH will be better trained and resourced to help clients address housing insecurity. Organizational capacity on housing issues must be inclusive of all populations served, respectful of different staff perspectives, and allow staff to share their lived experiences of housing inequities and vicarious trauma.
Goal3: The Health Department will become an advocate for family housing policy that addresses housing as a social determinant of health and an indicator of health equity.
Obj3 (in progress): MCAH will become significantly involved in citywide housing policy development and resource allocation, to discuss housing as a health equity practice, prioritizing investment in pregnant women and families with young children experiencing housing insecurity.
Goal4: Community partners as key informants and Public Health will develop alliances to collectively advance housing as a health equity issue.
Obj4 (in progress): MCAH and CEHP will create a baseâ€ of community support that will advocate to elected officials or other leaders to demonstrate wide demand from the affected public, helping the health department to expand the boundaries of its work beyond traditional public health activities.
January 2013: CEHP initiates 2-year collaboration offering WIC families comprehensive environmental home assessment with code enforcement follow up, healthy homes teaching, social determinants of health screening and resource provision.
July 2014: MCAH strategic planning and community needs assessment leads to formulation of Housing Action Plan.
June 2016: CEHP provides capacity building training and resource guide to MCAH staff to increase client referrals to resources for housing access, housing rights and housing conditions.
June 2016: CEHP institutionalizes WIC referral mechanism for CEHP services to all MCAH programs.
January-July 2016: MCAH, CEHP and community partner MEDA implement Photo Voice project for community mothers to research and document housing insecurity impact on their families.
July 2017: CEHP issues findings of home assessment project; frequency of housing insecurity and overcrowding is most significant finding.
October-December 2017: CEHP speaking engagements share findings with internal/external audiences.
November 2017: MCAH programs adopt housing insecurity client screening questions to generate dataset for analysis.
CEHP corrected Health Code violations in homes of 173 WIC client families and 56 additional MCAH client families after assessment extended to all MCAH programs/clients. As MCAH programs implement housing screening questions, additional impact anticipated.
MCAH/CEHP and community partner MEDA used Photo Voice exhibit for their advocacy work on housing policy and resource allocation. As exhibit travels, additional advocacy impact anticipated.
CEHP report of project disseminated and housing insecurity findings inform wider circle and engage additional partners for policy change.
Specific factors leading to success:
Strong upper management support by MCAH Leadership and Population Health Director/Health Officer.
Strong collaborative relationship between MCAH and CEHP facilitates evolution of joint Housing Action Plan objectives and activities.
Housing-experienced community partner MEDA was critical to success of Photo Voice community-based participatory research project.
Public health impact:
173 WIC and 56 additional MCAH (total 229) clients benefitted from CEHP-provided code enforcement and social determinants resource provision.
MCAH engaged to further their understanding and quantify the scope of housing insecurity's impact as a toxic stress for their clients, to then inform City policy makers.
Statement of the problem/public health issue:
The Bay Area has an accelerating housing crisis relative to growth in jobs and population. Low-income families are disproportionately impacted by housing insecurity stressors, which impact maternal, fetal and early child health, as well as health and developmental outcomes over the life course. Housing insecurity includes living with threats and illegal rent increases from landlords, having unaffordable, overcrowded and substandard housing units, or units not licensed for occupancy.
While San Francisco has many progressive housing policies, the City has not yet prioritized housing investments for these early life populations that could generate the greatest life course return on investment. Investment in affordable housing for families and pregnant women promotes health and educational equity. The political prioritization of affordable housing for families and pregnant women can positively influence children's birth and life course outcomes, including the reduction of educational, behavioral and physical health disparities.
What target population affected by problem, include relevant demographics:
SF Births per year: 8,813 (2011)
Population of SF children 0-4 (2010): 35,203 or 4.4% of total population:
o 12,143 White, 9,144 Asian, 7,959 Latino, 1,954 Black, 4,003 Mixed and Other
o WIC (Federal SNAP) average monthly number of cases with children (2010): 10,344
o Percentage reached by Model Practice collaboration: 2.2
What has been done in past to address the problem:
MCAH routinely serves and provides home visiting to families living in overcrowded and substandard housing conditions and unlicensed for occupancy living spaces. Yet MCAH personnel are rarely included in City-designated discussions or task forces addressing family housing policy, strategy or resource allocation.
In the past, MCAH staff were not trained as to how to help clients with housing issues, and were not able to offer adequate resources. Some who were knowledgeable gave referral to one or two overwhelmed community agencies assisting families to gain shelter. Home visiting public health nurses in particular have nowhere to bear witness to the overcrowded, unsafe and illegal living spaces that they witness daily and thus experience vicarious trauma in serving these clients.
Numerous City agencies have published reports, including findings from community focus groups and statistical analysis of American Community Survey housing data, that quantify and emphasize the scope of San Francisco's housing crisis and in particular its impact on low income families.
The cost of housing in San Francisco continues to rise, with the median cost of monthly rent in August 2015 of $2,722 for a studio, $3,452 for a one-bedroom, and $4.400 for a 2-bedroom apartment, which is prohibitive for low and moderate wage workers (those earning less than $18/hour), who comprise 36% of the labor market.
Of the 529 affordable housing units built between 2011 and 2015, 53% (280) were family units with two or more bedrooms, quite insufficient to meet demand.
Due to this lack of supply and exorbitant costs for housing of sufficient size for families, the City has promoted a Rapid Rehousing strategy which frequently places and case manages homeless and marginally housed families outside of San Francisco. This policy has continued for several years without evaluation of its impact on family social support.
The SF Planning Department reported in 2017 that more families are living in overcrowded conditions (making up at least 50% of the total households that are overcrowded) and an increasing number of families are in Single Resident Occupancy (SRO) Hotels. In 2014, 699 families with children were living in SROs, a 55% increase since the initial 2001 count of families in SROs.
A $30 million initiative to house 800 SFUSD-enrolled homeless families by 2019, was created in 2016 by the Mayor, the public school district, a non-profit family serving agency and private philanthropists as part of an effort to end long-term family homelessness in San Francisco. When The Heading Home Campaign was announced, SFUSD had established that 1,1,45 public school families were without stable housing, including 1,800 students identified as homeless.
Additionally, the City's Department of Homelessness and Supportive Housing has recently launched a system for Family Coordinated Entry into receiving homeless support services. It has yet to be evaluated as to its criteria, prioritization scheme or results. Some stakeholders assert that San Francisco has reverted to an overly narrow definition of homelessness that puts pregnant women and families with young children at risk. They cite data that clients of a partner agency serving homeless families and those marginally housed had 15% of their clients self-identify as homeless, yet failed to meet the City's newly created definition of homelessness.
Why is the current Model Practice better?:
The Model Practice establishes the scope of housing insecurity and affordable housing need for pregnant women and families with young children in San Francisco. The Model Practice findings have coalesced additional partners who also wish to inform and advocate for housing resources that can foster healthy pregnancies, maternal and child health, prevent preterm birth and foster health child development. By conducting housing screening of its clients, MCAH further builds capacity to act as a key informant for housing policy decision making and resource allocation.
Steps of Model Practice:
CEHP will implement comprehensive environmental home assessment, code enforcement, teaching, social determinants of health survey and associated resources for WIC-enrolled families, and analyze findings for report that provides context of housing insecurity and overcrowding impacts on families.
MCAH will create Housing Action Plan as part of state-required Strategic Plan objectives.
MCAH will schedule all-staff training on resources for housing access, housing rights and improved housing conditions and CEHP to provide training and resources.
MCAH will create literature review and briefing paper on the impact of housing insecurity on health outcomes of pregnant women, fetal development and children ages 0-5.
MCAH will create partnership with community agency to create community-based participatory research Photo Voice project focused on community women researching and illustrating how housing insecurity impacts the health and wellbeing of their families and their community.
MCAH will screen clients for housing insecurity and refer clients to resources for accessing affordable quality housing, housing rights and improved housing conditions.
MCAH will track screening-associated referrals and publish analysis of findings.
Anticipated Outcomes of Model Practice:
MCAH will screen clients for issues of housing access, housing rights and housing conditions, and identify ways to overcome client barriers to using code enforcement services to address housing habitability. As a result, clients experiencing housing insecurity and homelessness are supported to remain in San Francisco, by increasing their capacity to use resources for housing access, housing rights and improved housing conditions.
CEHP will provide MCAH-referred clients with comprehensive healthy homes assessment and code enforcement follow up, along with healthy homes teaching, social determinants of health screening and associated resource provision. Clients will gain improved housing conditions and improved access to social determinant of health resources.
Model Practice dissemination of findings will attract additional agency and community partners. Their voices will have impact on City housing policy, planning and resource allocation for low-income pregnant women and families.
Is current Model Practice innovative? How so/explain:
Collaboration between these disparate branches of the Public Health Department, programs of the Maternal, Child and Adolescent Health section and the Environmental Health Branch Children's Environmental Health Program is extremely innovative and provides synergistic impact. In this regard, the San Francisco Department of Public Health is able to work outside of the box and explore the ways these two branches can amplify attention to core issues affecting the wellbeing of their overlapping target populations, via their collaborative Housing Action Plan. The initial intradepartmental activity of this Model Practice has led to a variety of external collaborations, and continues to draw in public, academic and community-based agency partners focused on the urgency of the housing crisis impact on pregnant women, families and children. For example, the project was recently presented as a brown bag to the City's Planning Department staff seeking to learn about family housing insecurity, and resulted in potential collaborative follow up on rezoning recommendations.
Is the current Model Practice a creative use of existing tools or practices?:
Local public health departments do not usually a broadly focused children's environmental health program, and often must confine themselves to narrow mandates funded by State or Federal agencies. The Model Practice is a creative use of existing code enforcement authority by CEHP, a program originally charged to prevent lead hazards to children under six. By this collaboration with MCAH, CEHP is able to prevent lead hazards in the homes of San Francisco's most vulnerable families, those that are often lacking in awareness or not empowered to seek out code enforcement services. With referrals from MCAH programs, CEHP expands its proactive approach to prevent lead exposure to children and no longer solely relies on reported blood lead levels of exposed children to provide code enforcement services.
The Model Practice began with a four-language mail offer made to the entire WIC-enrolled family population. Response to the mail offer was solely by voluntary request of the WIC-enrolled parent or guardian. The mail offer included pictorial representation of ten healthy housing risks (damaged paint, mold or moisture, no heat, garbage problems, mice or rats, cockroaches, bed bugs, noise, black soot (traffic pollution), or standing water), which the client could self-evaluate as a health hazard present in their home, rating the hazard as minor, moderate or severe.
In addition, the home visiting model provides a creative use of existing tools and resources:
o CEHP bilingual phone intake protocol includes informed consent counseling about the potential for code enforcement by CEHP as a result of the home assessment.
o Home visit includes teaching on identified healthy housing issues within the family's control, as distinguished from issues within the property owner's control.
o Home visit includes identification of Health Code violations and Notice of Violation to property owner; subsequent resolution of all violations through code enforcement process.
o Home visit includes screening for Social Determinants of Health through using survey questionnaire in person, and provision of associated resources.
This model practice began as an intra-divisional collaboration within the City and County's local health district, the San Francisco Department of Public Health (DPH). Maternal, Child and Adolescent Health Section (MCAH) is part of DPH's health care services division, The San Francisco Health Network. Children's Environmental Health Promotion (CEHP) is within the Environmental Health Branch of DPH's Population Health Division.
In engaging a community partner for the Photo Voice community participatory research and action project, Community Assessment for Safe & Affordable Housing (CASAH), the Mission Economic Development Association (MEDA) was a natural choice, based on previous engagement with CEHP in addressing housing insecurity issues. MEDA is a community-based agency that implements numerous economic development strategies within the Mission district, including financial literacy, rental application credit standing, first-time home ownership opportunities, as well as advocating and adopting housing strategies that counter displacement of Latino families from the Mission. Latinos have been increasingly displaced by the rapid rise in the cost of housing, wood structure fires, and a variety of legal and illegal eviction practices.
Other community partners have also been engaged, within the University of California at San Francisco (UCSF) and local agencies, such as First5 San Francisco.
Goals, objectives and activities of the model practice:
Goal 1: Health departments must normalize and operationalize health equity work, integrating health equity practices into everyday client interactions, in this case, regarding clients experiencing housing insecurity.
Objective 1 (achieved): The Maternal, Child & Adolescent Health Section (MCAH) Women, Infants and Children Supplemental Nutrition Program (WIC) and partner, Children's Environmental Health Promotion Program (CEHP), will collaborate to offer WIC-enrolled families a comprehensive home environmental assessment service that integrates a social determinants of healthâ€ framework.
Activities: CEHP will work with WIC to provide:
o Four language mail offer to entire WIC-enrolled family population.
o Bilingual phone intake protocol with informed consent counseling about the potential for code enforcement by CEHP as a result of the home assessment.
o Home visit which includes:
a. Teaching on identified healthy housing issues within the family's control, as distinguished from issues considered as within the property owner's control.
b. Identification of Health Code violations and Notice of Violation to property owner; subsequent resolution of all violations through code enforcement process.
c. Screening for Social Determinants of Health through using survey questionnaire in person, and provide associated resources.
Goal 2: Organizational capacity is needed to advance health equity practices, in particular an understanding of local resources to address housing access, housing rights and housing conditions.
Objective 2 (achieved): MCAH will be better trained and resourced to help clients address housing insecurity issues, with assistance from CEHP. Organizational capacity on housing issues must be inclusive of all populations served, respectful of different staff perspectives, and allow staff to share their lived experiences of housing inequities and vicarious trauma.
Activities: MCAH will create:
o Housing Action Plan as part of state-required Strategic Plan objectives.
o All-staff training on resources for housing access, housing rights and improved housing conditions and CEHP to provide training and resources
o Screening of clients for housing insecurity and refer clients to resources for accessing affordable quality housing, housing rights and improved housing conditions.
o Ways to overcome client barriers to using code enforcement services to address the health and safety conditions of their housing.
Goal 3: The Health Department will become an advocate for family housing policy that addresses housing as a social determinant of health as well as an indicator of health equity.
Objective 3 (in progress): MCAH will become significantly involved in citywide housing policy development and resource allocation, to change the conversation to discuss housing as a health equity practice, prioritizing the life course health outcomes investment in pregnant women and families with young children experiencing housing insecurity.
Activities: MCAH will create:
o Literature review and briefing paper on the impact of housing insecurity on health outcomes of pregnant women, fetal development and children ages 0-5.
o Partnership with community agency to create community-based participatory research Photo Voice project focused on community women researching and illustrating how housing insecurity impacts the health and wellbeing of their families and their community.
o Analysis of housing insecurity screening findings and referrals made.
Goal 4: Community partners and the health department can develop alliances collectively advance housing as a health equity issue, and community partners are key informants in helping the health department to expand the boundaries of its work beyond traditional public health activities.
Objective 4 (in progress): MCAH and CEHP will create a baseâ€ of community support that can advocate on its behalf to elected officials or other leaders to demonstrate wide demand from the affected public, helping the health department to expand the boundaries of its work beyond traditional public health activities.
o MCAH will convene community partners (CBOs, academia, City agencies) to create housing measures for Healthy Places Together (HPT), a child health equity collective impact project.
o The HPT Collective will generate an action plan with measurable goals and objectives which can be tracked and evaluated over time to find out if the health of pregnant women and families with young children has been less impacted by housing insecurity.
Implementation strategy (steps taken to achieve the goals and objectives and put the practice into action within the community):
A. 2013-15 CEHP-WIC collaboration to offer comprehensive home assessment to WIC clients
As a means of promoting healthy housing for families with young children, two San Francisco Department of Public Health (DPH) programs, the Children's Environmental Health Promotion (CEHP) Program and the Women, Infants and Children (WIC) Supplemental Nutrition Program, partnered to offer WIC-enrolled families a comprehensive home environmental assessment service. Response to the mail offer was solely voluntary, with no coercion from WIC, and solely by request of the WIC-enrolled parent or guardian. This protocol included CEHP phone-based informed consent counseling to ensure that the parent or guardian understood how the requested home inspection could result in code enforcement by CEHP.
Overall, CEHP visited the homes of 173 WIC-enrolled families from 2013â€“2015, assessing both the presence of Health Code violations and the family's social determinants of health, including housing security. While many low income families experience the challenges revealed in this report, the families who participated represent a convenience sample of those motivated to respond to the home assessment offer, and as such it cannot be assumed that all WIC-enrolled families, if provided the equivalent services, would generate the same findings.
Each CEHP home visit included these activities:
o A CEHP health educator who was bilingual in English and Spanish, Cantonese or Mandarin administered a survey on social determinants of health and provided families with a wide variety of resources related to their survey responses.
o A CEHP environmental inspector provided home assessment for public health nuisances defined in the San Francisco Health Code, including lead and mold hazards, unsanitary conditions and pest infestations.
o The inspector issued a Notice of Violation to property owner based on their findings, as well as created referrals to another City agency, the Department of Building Inspection (DBI), for violations of the San Francisco Housing Code.
o Both CEHP staff provided the family with healthy homes education on how to prevent environmental hazards that are within their control, as distinguished from those hazards that are the responsibility of the property owner.
B. 2014â€“16: MCAH Health Needs Assessment and Housing Action Plan
The DPH Maternal, Child and Adolescent Health (MCAH) section conducted the Maternal Child & Adolescent Health Needs Assessment (2015â€“2020) to gather key stakeholder input from community representatives, service providers, academic researchers and governmental agency partners to inform MCAH preparation of its State-required Title V Five-Year Action Plan.
MCAH also analyzed client health outcomes data as part of the needs assessment, including which housing types are associated with MCAH client adverse health outcomes such as preterm birth. MCAH needs assessment findings were summarized into three root causes of health disparities and housing insecurity falls within both Toxic Stressâ€ and Poor Living & Work Conditionsâ€ categories.
Stakeholders participating in the MCAH focus groups for strategic planning identified substandard housing, lack of affordable housing and housing insecurity disproportionately affecting the health of low income families.
Consequently, MCAH identified a Housing Action Plan as an objective within their Title V Five-Year Action Plan. The Plan includes MCAH internal capacity building on housing issues as well as collaboration with community partners to implement a Community-Based Participatory Research (CBPR) on how housing insecurity is impacting child, family and community health and wellbeing. Furthermore, MCAH is organizing internal data sources that capture information about housing insecurity or housing type and health access or health outcomes.
The CBPR women researchers used Photo Voice to illustrate the impacts of housing insecurity on maternal and child health and healthcare access, identify and map assets and sources of resiliency, develop their own analysis of community assets and stressors, focusing on the maternal and child health and development impacts of housing insecurity, as well as explore and propose potential resources and solutions.
The Housing Action Plan also committed MCAH to use CRPR outcomes to inform stakeholder agencies and City policymakers.
C. June 2016: MCAH All-Staff Training on Housing Issues
MCAH and CEHP collaboration modeled by the Home Environmental Assessment project for WIC-enrolled families was desired by other MCAH programs and their clients. The first expansion of the service occurred with MCAH Public Health Nurses referring their home visiting clients, primarily mothers with newborns, for CEHP home environmental assessments and Health Code enforcement. This is another group of clients who are unaware of how to access their right for habitable housing and who often live in substandard housing conditions.
To further expand CEHP's environmental home assessment service to all MCAH staff (approximately 200) and their program clients, the CEHP Program Manager provided the MCAH Section June 2016 all-staff meeting an in-service training.
Along with guest speakers, the CEHP Program Manager built MCAH staff capacity on housing issues, including how to refer to CEHP home environmental assessment services as well as an understanding of housing access, housing rights and housing conditions, and related resources.
In the current fiscal year, 2017-18, MCAH is now integrating housing-related screening and referrals within MCAH client services.
Furthermore, MCAH wishes to incorporate many of the social determinants of health survey questions and associated resources into their service framework.
CEHP developed a Housing Resource Guide & Referral Flow Chart for the MCAH all-staff training and is tasked with keeping this Housing Resource Guide and Flow Chart up to date. As an interactive part of the training, CEHP also developed a Housing Case Study which provides a client family scenario prompting MCAH staff how to use the Housing Resource Guide and Referral Flow Chart.
D. Januaryâ€“July 2016: CASAHâ€ Community-Based Photo Voice Research Project
MCAH and CEHP collaborated in 2016 with the Mission Economic Development Agency (MEDA), its Mission Promise Neighborhood (MPN) Program and several Mission District partner agencies on a Photo Voice project titled Community Assessment for Safe & Affordable Housingâ€ (CASAH). In this project, eight women from the Mission community were trained as photo researchers to document the effect of housing insecurity and overcrowding on the wellbeing of their families and to offer guidance to City policymakers on improving the housing situation for families such as theirs.
The women's research culminated in a July 2016 narrated photo exhibit, Â¿An American Dream? The CASAH Photo Voice project is further described on the MEDA and MPN websites. CASAH's July 2016 photo exhibit was covered by multiple media outlets.
MEDA/MPN chose to participate in CASAH because they were already very engaged in advocacy concerning the displacement of Latinos from the Mission District and because community member testimony during two of their Town Hall meetings had overwhelmingly focused on the housing issues faced by long-term Latino residents of the Mission. In their 2015 survey of 1600 Mission families with children, MEDA/MPN found that more than 60% were spending half their income on housing.
This community-based evidence was further substantiated by a San Francisco Budget and Legislative Analyst's Office October 2015 report which stated, If current trends continue, the number of Latinos living in the Mission will decline from the 60 percent of the Mission population they were in 2000 to just 31 percent in 2025.â€ The report found that since 2000, the Mission had lost about 27% of its Latino population, almost 8,000 people.
MEDA's Community Real Estate Department has become increasingly involved in pursuing solutions to the Mission District's housing crisis and the displacement of Latino residents, non-profits and businesses. Their efforts include utilizing the City's Small Sites acquisition program, to help subsidize and rehab smaller private properties and turn them into permanent affordable housing. MEDA has also joined non-profit housing developers to begin planning and construction of several multifamily housing developments with 733 affordable units, to include commercial space for non-profits and small businesses in the Inner Mission.
E. 2016-17 CEHP-WIC Project data analysis and report of findings
CEHP analyzed the program's data from WIC home visiting and published it in their report, Promoting Housing Security and Healthy Homes for Families Served by Maternal, Child and Adolescent Health Programs. The report describes the environmental and social determinants of health findings from those assessments, and advocates for next steps based on those findings. CEHP documented that these families with young children lived with a widespread prevalence of unsafe and unsanitary housing conditions, unaffordable housing costs and resultant over-crowding, high social needs and ongoing stress, particularly the stress of housing insecurity.
CEHP staff discovered that for many families, while their living situations provided a roof over their family members and a floor beneath where they slept, oftentimes that roof and floor cost more than half of the family's income. It's evident that all other family needs (food, heating, transportation and health care) are in competition for scarce resources. As a result, overcrowded multiple family living situations and unlicensed-for-occupancy living spaces are the norm for many low income families who are WIC clients.
Though many of these families meet the City's criteria for being homelessâ€ or at risk of homelessness,â€ their status as such has yet to be counted in any official manner. Parents of young children also report discomfort in living with strangers, in particular adult male strangers, under one roof in these multiple family living situations. There is no hard data as yet to substantiate if some children's behavioral problems may be secondary to exposure to excess alcohol use, abuse or neglect in dwellings with these safety concerns.
The report built the case for how housing insecurity is impacting the health and development of these children and the wellbeing of their families, at a time when City policy and resources are still struggling to attend to those families who are already homeless.
Furthermore, the report demonstrated that housing insecurity itself must be considered a significant source of toxic stress for low income families in San Francisco and an area needing the City's immediate investment.
Any criteria for who was selected to receive the practice?
WIC Program clients represent the largest and most diverse population of MCAH clients, and that was the main criteria for initiating CEHP home investigation with that population.
What was the timeframe for the practice?
Model practice activities have spanned 2013-2017, and will continue indefinitely.
Were other stakeholders involved? What was their role in the planning and implementation process?
Internally, MCAH had multiple stakeholders involved in addition to WIC and Public Health Nursing Programs, including Housing Action Plan lead staff who manage the Reproductive Health Program, Policy & Planning, Quality Improvement, Epidemiology, Deputy Director, Medical Director, Black Infant Health Project and Pre-Term Birth Initiative. Externally, MEDA, the public agency First5 San Francisco, and several University of California at San Francisco (UCSF) programs also have been engaged with and supported the model practice. These are further referenced in the Sustainability section:
1) The Mission Economic Development Agency (MEDA) co-led the Photo Voice research project, also involving several other community-based agencies as sponsors.
2) The First5 San Francisco Agency leads and provides financial support for child development strategic plan activities within San Francisco County. The agency provided support for child care during the Photo Voice research project.
3) The Community Engagement & Health Policy (CE & HP) Program of the UCSF Clinical & Translational Science Institute (CTSI). CTSI provided a nurse practitioner student to help with data analysis and report writing
4) The UCSF Preterm Birth Initiative (PTBi) also had several linkages with our model practice due to the prioritization of housing insecurity as a preterm birth risk factor. Several MCAH staff collaborate with or act in an advisory role with the PTBi.
What does the LHD do to foster collaboration with community stakeholders? Describe the relationships and how it furthers the practice goals.
MCAH is part of a Citywide Our Children, Our Familiesâ€ initiative coordinated through the Mayor's Office and the San Francisco Unified School District. As such, all institutional and community-based partners are networked by this initiative, and are frequent collaborators on a variety of projects. CEHP has also engaged with many child-serving agencies in providing lead hazard assessments, asthma management and prevention teaching, bleach-free disinfection in child care implementation, among other projects.
Any start up or in-kind costs and funding services associated with this practice? Provide actual data if possible or estimate otherwise.
The Photo Voice CASAH Project had start up and in-kind costs for expenses that included in-kind staffing by MCAH, CEHP and MEDA, participant community agency stipends, individual cameras, computers for downloading camera data, projector for group review of photos, professional enlargement and metal prints of 24 images, 24 portable easels, 6 months of group sessions for teaching Photo Voice research technique, and each session's associated participant stipends, childcare and meal costs. An estimated $75K total budget included approximately $24K from CEHP, $39K from MCAH, $9.5K from MEDA and $2.5K from First5 SF.
Various sections in DPH are using results-based accountability to develop performance measures and population health indicators to advance health equity. In this framework, the local health agency can hold itself and other agencies accountable to whether anyone's health is better off as a result of the interventions accomplished.
The Model Practice seeks to mobilize data, research, and evaluation to make the case for, assess, and prioritize housing interventions for the health equity of pregnant women and families with young children. Collecting housing insecurity data among MCAH clients also strengthens our ability to evaluate our efforts overall. These are overall evaluation outcomes for the four goal areas of the Model Practice:
Improvement in health status: 173 WIC-enrolled families received CEHP home environmental assessments that corrected health code violations and provided social determinants of health resources.
Improvement in knowledge/awareness: 200 MCAH staff engaged in the capacity-building housing training
Improvement in community collaboration: 2 DPH branches and 6 community-based agencies engaged in CASAH Photo Voice project
Policy change: 29 MCAH staff completed pilot survey of their client screening on housing issues; additional MCAH staff being engaged this month.
Primary data sources and data collection for three Model Practice components are described next, including the extent to which our objectives were achieved:
A. For CEHP's Home Environmental Assessment Project for WIC-Enrolled Families
The CEHP Home Environmental Assessment Project offered to WIC-enrolled families had two goals: 1) to improve housing conditions for WIC families, both in their control and in the control of the property owner, and 2) to build capacity in families to use available resources to address social determinants of health impacting their families.
Process and outcome evaluation of Inspection component:
From 173 home environmental assessments conducted by CEHP staff, 390 Health Code violations were corrected by property owners. Additionally: 47 Referrals were made to DBI for lack of Carbon monoxide/smoke detectors (N=31) and heat (N=16). Also 165 Family letters were written to describe actions that the family can take to prevent or control hazards. To further focus on actions that families can take on their own, CEHP produced two videos, in English, Spanish and Cantonese versions, to generate discussion during the home visit that would motivate and instruct families on the steps they can take to maintain a healthy home. These videos can be viewed in English, Spanish and Cantonese by searching YouTube for the CEHP SFDPHâ€ channel.
Process and outcome evaluation of Social Determinants of Health Survey component:
100% of participants learned how to use 311 and 211 for phone-based service requests;
100% of participants with email addresses were signed up or referred to MOHCD online affordable housing notification list;
100% of participants were referred to SF Rent Board and tenant rights agencies;
100% of participants not yet having applied were referred to CalFresh enrollment;
100% of participants not yet having applied were referred to Children's Council & Wu Yee for child care subsidy and placement services;
100% of participants not yet having applied were referred to Muni Transportation Lifeline Pass application.
2,445 distinct resource materials were provided to families based on their survey responses.
B. For MCAH Capacity Building Training on Housing Issues
The MCAH Capacity Building Training on Housing Issues had two goals: 1) to increase knowledge and understanding of resources to improve housing access, housing rights and housing conditions; 2) to encourage MCAH programs to build capacity in screening and referring their clients to these resources. The following Manager Assessment was conducted in advance to plan the learning objectives for the June 2016 MCAH All Staff Meeting:
1. Which of the following topics related to housing insecurity would be of use to your staff / clients (please check all that apply):
? The impact of housing insecurity on birth outcomes
? The impact of housing insecurity on early childhood development
? Screening questions / protocols to identify clients with housing insecurity / housing needs
? Housing rights, including fear of retaliation or eviction
? Code enforcement resources
? Rent board and tenant advocacy resources
? How low-income families establish eligibility to gain access to shelter, affordable and/or affordable housing via Human Services / contractors
? Special tips for helping families navigate the above (waiting lists, do's and don'ts, etc.)
? Special considerations / criteria for immigrants who are undocumented
? How SFUSD works with homeless and marginally housed families
? Where to access job training programs that include child care
2. Which of the following presentation methods are most interesting to your staff:
? Case study exercises
? Role plays
3. What is one skill or knowledge set that you would most like your staff to walk away with after the presentation?
4. What are your clients' one or two most pressing housing-related problems?
Based on the MCAH manager assessment, an interactive, case study focused presentation on housing insecurity was developed with the following learning objectives. Each learning objective was then evaluated by a combination of an instant polling tool and post-training written evaluation questionnaire. Evaluation responses indicated that learning objectives were successfully met.
1. Participants will become familiar with housing insecurity vocabulary and resources that will be explained in rest of program.
2. Participants will have access to housing insecurity data that describes the experience of many MCAH clients.
3. Participants will be able to explain how housing insecurity impacts maternal and child health, and child cognitive development.
4. Participants will be able to help clients enroll in MOHCD email alert for affordable housing opportunities, as well as be informed about other databases with housing opportunities and application links.
5. Participants will be knowledgeable about when to refer client families to SF Rent Board to get help on tenant rights issues.
6. Participants will be knowledgeable about when to refer client families to Compass Connecting Point and Hamilton Family Services to get help on immediate housing access issues.
7. Participants will be able to propose screening questions to identify clients needing housing resource referrals and be able to propose actions needed for case study client family.
C. For Photo Voice CBPR Project
As a community-based participatory research project, the CASAH Photo Voice project used qualitative methods and research towards two major goals: 1) Working with community members to generate narratives that engage policymakers to understand the health impacts of housing insecurity, and 2) increasing the capacity of community members themselves affected by housing insecurity to diagnose community problems and assets and to serve as key informants to stakeholder agencies and policymakers. Participants were provided local data and profiles that showed housing challenges and displacement of Latino families, as well as research findings about housing insecurity impacts on child health and pregnancy. They were then supported to use this data in their own efforts to advance housing equity.
The participant learning objectives are embedded in the post- training written evaluation questionnaire shown below. Responses indicated that learning objectives were successfully met.
This survey is anonymous. Your answers will help us determine how effective the training has been.
PART 1: Mark how much you agree or disagree with each statement after being in the project.
Agree Agree Neutral Disagree Strongly Disagree
1. I can describe how to use a camera.
2. I know where to go in San Francisco to get help with a housing issue.
3. I feel comfortable sharing my opinion in a group.
4. My opinion is listened to in a group.
5. People in my community can influence decisions that affect our community.
PART 2a: How confident were you about your ability to take a good photo?
Not at All Confident Somewhat Confident Confident Very Confident Extremely Confident
Before the project: ? ? ? ? ?
After the project: ? ? ? ? ?
PART 2b: How confident were you about your ability to advocate for your community?
Not at All Confident Somewhat Confident Confident Very Confident Extremely Confident
Before the project: ? ? ? ? ?
After the project: ? ? ? ? ?
PART 3: For each statement, please select the best answer. Don't worry! This is not a test.
1. The biggest influence on a person's health is:
? Health care access
2. True or false: if a woman experiences a lot of stress during pregnancy, it can increase her risk of having a baby that is born too soon or too small.
? Not sure
3. Living in poor quality housing can affect the following in a child under the age of 5:
? Physical health
? Brain development
? All of the above
? None of the above
? Not sure
PART 4: Think of this ladder as showing where people stand in their community.
At the top of the ladder are the people who have the most power
to make changes in their community.
At the bottom are the people who have the least power to make changes
in their community.
Please mark where you would place yourself on this ladder.
List any secondary data sources used: The Photo Voice project was accompanied by a literature search that referenced published research on the impacts of housing insecurity on pregnancy and child health and development.
Were any modifications made to the practice as a result of the data findings?
For CEHP's WIC Home Visiting Project, Social Determinants of Health survey questions were modified four times during the course of the project to strengthen participant comprehension and ability to answer questions as they were intended to be understood.
For MCAH Capacity Building Training, participant evaluation was gathered and analyzed by MCAH staff. It has been used to advance internal capacity building to the next stage, which is creating client screening per program about housing insecurity.
For Photo Voice CBPR Project, participant evaluation was gathered and analyzed by MCAH lead staff. Based on evaluation findings and flow of CBPR project, the curriculum has been modified and annotated for future use, based on findings of first cycle.
San Francisco has been losing many families due to the high cost of living. Many agencies have been affected by the loss of their client base, just as the families have been affected by the loss of their familiar support services and community. For this reason, we are also mapping out existing efforts to address family housing insecurity housing instability and homelessness both in San Francisco and regionally, and attempting to align our Housing Action Plan efforts. It is essential to create synergy between agencies that serve the same population, and to coalesce as housing policy informants and advocates.
Sustainability is determined by the availability of adequate resources: Health departments must allocate resources to advance health equity as a primary focus/mission of their organization, with an expectation that every branch and section will strategically direct staff resources to implement policies and practices that advance equity. No specific resources to date have been allocated to address family housing insecurity as a public health issue. Thus, one aspect of our sustainability has been our leveraging of existing roles and programs to do this work, so that in-kind support is built in. By providing environmental health support to housing insecure families served by MCAH, substandard housing situations can be made safer, healthier and code-compliant. Both sets of services are funded by ongoing State and Federal contractual work to local health jurisdictions.
Another resource strategy has been to partner with the University of California at San Francisco Clinical and Translational Science Institute (CTSI) and their Center for Community Engagement to gain the support of graduate student interns to assist in our work. The Center for Community Engagement facilitates relationships between UCSF and academic/health care entities in the greater community that build on each other's strengths to foster civic engagement, health and wellbeing. The Center leverages UCSF's role as an anchor institution with the goals of creating opportunity, advancing equity and improving health outcomes.
In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development: Because of the severity of this public health issue, housing insecurity and homelessness of pregnant women and families with young children is a clear priority for many public and community-based agencies, including MCAH and CEHP programs, as well as many other child and family-serving agencies who are our partners and allies on this topic. Furthermore, San Francisco's affordable housing crisis disproportionately affects African American and Latino children, the same children who bear the burden of an achievement gap in our public schools.
Research points to negative consequences that housing instability has on children's long-term cognitive development, and no period is more critical for children's brain development than that of their first five years of life. Maternal housing insecurity stress also contributes to dangerous and costly preterm birth outcomes. We have created a literature review establishing the justification for addressing housing insecurity as a public health issue, and plan to publish that lit review within an informational housing policy brief. This future brief can also address a cost benefit analysis comparing prioritization of pregnant women and families with young children in housing policy to status quo prioritization.
Another stakeholder public agency, First 5 San Francisco, also known as the San Francisco Children and Families Commission, invests in comprehensive programs for early childhood development, family strengthening and other support services. First 5 San Francisco regularly interacts with preschool teachers, pediatricians, social workers, and a range of other service providers who have their finger on the pulse of families of young children in San Francisco. Their deep engagement with issues affecting children 0-5 years old provides ample evidence to inform their Commission's commitment to speaking out regarding the current housing distress of families with young children. This partner agency is exploring ways to be on record regarding how housing insecurity substantially interferes with and puts at risk the healthy development and well-being of infants and children in their target population, and to request the City's prioritization of pregnant women and families with young children in the allocation of affordable housing resources.
Lessons learned in relation to practice:
Lessons learned in relation to partner collaboration: MEDA's experience countering housing insecurity and displacement has been a great opportunity for DPH partner programs to learn more about housing strategies and community organizing. MEDA has developed a Real Estate department to use many of the progressive housing strategies advanced by City policy. These include HUD-funded RAD green rehab projects of former Housing Authority public housing sites and the City's Small Sites Program, which subsidizes non-profits to acquire and rehab private properties and turn them into permanently affordable units.
An additional partner, the University of California at San Francisco Preterm Birth Initiative-California (PTBi-California), uses precision health and interventions research strategies and the collective impact process to achieve breakthroughs that will reduce preterm birth and its related adverse life course health outcomes. PTBi-California focuses on those at highest risk of preterm birthâ€”women of color and lower incomeâ€”within three communities, including San Francisco, where one in six preterm births occurs in the City's most impoverished neighborhoods. In one such neighborhood, Bayview Hunters Point, a woman is nearly three times more likely to have a preterm birth than a woman living in one of the wealthiest neighborhoods, the Presidio. MCAH has program managers and physicians who participate in the advisory committee of the PTBi.
For this reason, the Initiative includes a community-based participatory research and advocacy strategy, the Benioff Community Innovators (BCI) Program, which recruits and trains a cadre of community members with a passion for improving health for mothers and babies. It provides opportunities for them to develop skills in project leadership and human-centered design so that they can work with researchers, health care providers, and community groups to prototype innovative approaches to improve health and social service delivery that can ultimately reduce preterm birth. BCI advocates are currently focusing on affordable housing access as a means to reduce the maternal stress that contributes to preterm birth. BCI's team of community women researchers are meeting with City policymakers to advocate for substantial changes in the City's housing and emergency shelter policies regarding the eligibility of homeless pregnant women for housing and emergency shelter, both bleakly insufficient to promote healthy birth outcomes. The MCAH Black Infant Health Program is part of the BCI research and advocacy project.
Is there sufficient stakeholder commitment to sustain the practice? An additional stakeholder sustaining commitment to our work on family housing insecurity is the Bay Area Regional Health Inequities Initiative (BARHII), a key partner pulling together regional Public Health Departments and other stakeholders in addressing health inequities, with a current emphasis on the Bay Area's housing crisis. BARHII has provided several key framework references for public use, including an index of progressive housing policies and a regional gentrification and displacement analysis. BARHII is now developing a regional Housing & Young Families Brief, to which our Model Practice collaboration will be a contributor.
Our collaboration is also connected to Healthy Communities Together: Collective Impact Initiatives to Promote a Life Course of Health, co-led by DPH and the University of California at San Francisco's Child Health Equity Collective, involving many stakeholders in the family and child arena. The goal of this inter-agency collective impact initiative is to implement change in social environments, service systems and policies, particularly affecting stressful living and working conditions that impact family health. One component of the work, Healthy Places Together, uses collective impact to implement place-based policies. Healthy Places Together will sustain the work of our Model Practice, using our findings to formulate and implement their housing advocacy focus.
I am a previous Model Practices applicant