2023 Health Equity & Diversity Assessment Report

2023 HEALTH EQUITY & DIVERSITY ASSESSMENT REPORT

City of Elizabeth: Health Equity & Diversity Assessment

TABLE OF CONTENTS Table of Contents Acknowledgements

02 03

Executive Summary

04

08 Historical & Present-Day Look A Healthy New Jersey 09 11 Our Approach 13 Community Convenings 14 Insight Interviews 15 Community-Wide Survey 17 Insights Pathways to Decentralize Decision-Making 19 Residents Assessment of Health and Safety 21 Current Services & Perceptions of Services 25 29 Barriers Leading to Health Disparities Impact of Race, Culture, Ethnicity & Language

Recommendations

Create a Community Asset Map

37 37

Form a Community Health Council

38

Build a Multilingual Transmedia Strategy

38

Conduct a Policy Equity Assessment

Develop an Integrated Data System Conduct an Environmental Health Study

Community Reflections Appendices 2

33 35

City of Elizabeth: Health Equity & Diversity Assessment

39 40 43 43

City of Elizabeth: Health Equity & Diversity Assessment

ACKNOWLEDGEMENTS Thank you to the residents of the City of Elizabeth, and the staff of Krishna Garlic, Director of the Department of Health and Human Services, for their partnership, collaboration, vision, and insight. Similarly, thank you to individuals representing the philanthropic, board of education, business, public systems, and not-for-profit organizations striving to achieve a healthy and thriving City of Elizabeth for all.

Iona Concepts, Inc. Team & Authors Maurissa Stone, Founder & CEO Dr. Geri Lynn Peak, Lead Public Health Analyst Dr. Jamilla Ajanku-Willie, Insight Facilitator Nneka N'namdi, Public Health Analyst Lisa Robinson, Evaluator Cara Hairston, RN, Public Health Equity Practitioner Janelle Williams Hughes, Editor/Content Creator Tiffani Truss, Editor/Content Creator 3

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City of Elizabeth: Health Equity & Diversity Assessment City of Elizabeth: Health Equity & Diversity Assessment

City of Elizabeth: Opporutnity - Findings - Solutions

EXECUTIVE SUMMARY In April 2023, the City of Elizabeth (COE) Department of Health and Human Services (DHHS) consulted with Iona Concepts (IOC) to conduct a citywide health equity and diversity assessment that allows city leaders to understand the impact of race and language in accessing care and services; identify barriers leading to health disparities; assess current health and safety conditions amongst residents; and understand the suite of current services provided by stakeholders.

Over a 4-month period, IOC engaged in an action research process in collaboration with city leaders, as well as those who live, work, and play in the city. The result of the assessment conducted between April and July 2023 is this final report, which details findings from IOC's layered action research process and recommendations for creating and sustaining a thriving City of Elizabeth for those who reside, work, and visit the city.

THE OPPORTUNITY To best serve and collaborate with the residents of the City of Elizabeth, leaders can

leverage

the

knowledge

gained

through this action research process to integrate the recommendations while embedding

an

intrapersonal,

interpersonal, institutional, and systemic lens to change. This citywide assessment subsequent

report

provides

an

opportunity for not only city leaders but also service providers to enact systemlevel and policy level changes in the advancement

of

health

equity

in

collaboration with the residents.

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City of Elizabeth: Health Equity & Diversity Assessment

THE FINDINGS Conducting a health equity and diversity assessment provides added value to the City of Elizabeth to gain insight into the necessary steps for achieving “A Thriving City of Elizabeth." The value is that this communityinformed process allows City leaders and service providers to reimagine and create communities that are reflective of the vision, needs, and benefits of those often marginalized and left out.

“Social determinants are not things. Social determinants arise out of the societal relationships of power and particularly power and property.”

Source: Nonprofitquarterly.org

Through an action research process, IOC was able to gather the following four (4) social determinants of health:

1. The top health and safety concerns (70% or more) amongst survey respondents consisted of:

CHRONIC DISEASE BEHAVIORAL HEALTH

COMMUNITY SAFETY SOCIAL WELLBEING 5

Diabetes

77.3

Obesity

70.1

Depression

77.3

Alcohol & Substance Abuse

74.2

Anxiety

72.2

Community Violence

70.1

Homelessness

75.3

Affordable & Safe Housing

73.2

City of Elizabeth: Health Equity & Diversity Assessment

2. Of the 70 providers spanning 16 service areas, a majority of the focuses were on human services, education, and homeless services, which were reported to operationalize in siloed communication and offer redundant services.

3. Various gaps in services that perpetuate the health disparities that exist in the City of Elizabeth were identified as: Quality of care in services provided, such as the availability and wait times of services, and offering culturally informed services rooted in trauma-informed care.

Lack of safe and equitable housing that provides accessibility, affordability, equity, and provisions for people facing homelessness.

Absence and lack of access to public green infrastructures and spaces.

Overall basic-needs insecurities include transportation, mental health food, and access to quality healthcare.

4. The impact and intersection of race and language present critical challenges for residents to access care and services, which include: Immigrant Status (language, deportation fear) - 21%; Community Policing - 9.5%; Absence of services and/or knowledge of accessing them - 9.5%.

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City of Elizabeth: Health Equity & Diversity Assessment

THE PROPOSED SOLUTIONS A healthy and thriving City of Elizabeth is one that considers the health and safety of all who live, work, and play in the city, and one that aims to make health equity a strategic priority. The insight gained via the action research process employed by the IOC team suggests that there are actions that city leaders, employers, and service providers can take to improve access to and quality of care, dismantle barriers that lead to health disparities and inequities, and continually assess health and safety conditions amongst residents.

The IOC team urges city leaders to implement the recommendations towards honoring the vision shared by residents of a thriving city.

7

7

1

Conduct a Policy Equity Assessment

2

Create a Community Asset Map

3

Form a Community Health Council

4

Develop a Multilingual Transmedia Strategy

5

Build an Integrated Data System

6

Conduct an Environmental Health Study

City of Elizabeth: Health Equity & Diversity Assessment City of Elizabeth: Health Equity & Diversity Assessment

A Historical & Present-Day Look

CITY OF ELIZABETH In October 1664, Indigenous nations from present-day Staten Island, NY, sold 500,000 acres of land situated between the Raritan and Passaic Rivers to John Bailey, Daniel Denton and Luke Watson. These acres included what we now know as the City of Elizabeth (Elizabeth Destination Marketing Organization, n.d.).

The city’s waterways, streets, halls, and walls have witnessed a lot of change since the 1600s, including the industrial revolution, which made space for shipbuilding,

automobile

plants,

ironworkers,

breweries,

machinery

manufacturers, and oil refining and the evolution of land around the city into a transportation hub that includes an international airport, bridges, a major interstate highway, and a seaport.

Today, the city has more than 120,000 residents and is the fourth most populous city in the state of New Jersey. As the Union County Seat, Elizabeth has served as a thriving economic center for the state for more than 400 years. But much has changed, including continued industrial industry growth and the diversity of the city’s population. In Union County, 100% of the population lives in an urban area (more than 500 people per square mile or more than 2,500 people) (County Health Rankings & Roadmaps, n.d.). Union County contains neighborhoods that experienced intentional disinvestment through Federal Home Owners Loan Corporation redlining between 1935 and 1940, which institutionalized and further exacerbated health disparities that still exist today. Equity has long been a concern.

The first capital of New Jersey, Elizabeth, houses two New Jersey transit stations connecting New York and the rest of New Jersey. The city’s marine terminal, Port Newark/Elizabeth, is the world’s largest containership port and the largest Foreign Trade Zone in the country.

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City of Elizabeth: Health Equity & Diversity Assessment

Elizabeth comprises six wards, and each ward houses unique districts.

Recent research shows that approximately 30 percent of Union County residents were born outside the United States, 12 percent of households are linguistically isolated, and more than 80 percent of residents represent marginalized communities (NJSHAD, 2020).

A HEALTHY NEW JERSEY Healthy New Jersey (HNJ) is the overarching statebased initiative that focuses on identifying and addressing NJ residents’ priority health needs. This is accomplished using two ongoing statewide collaborative processes -- the State Health Assessment and State Health Improvement Plan, both conducted once per decade (New Jersey Department of Health, n.d.).

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City of Elizabeth: Health Equity & Diversity Assessment

Data

from

Community

the

2022

Planning

Healthy

Report

for

Elizabeth City, Union County, which was developed by NJ Departments of Health (NJDOH) and Environmental Protection (NJDEP) staff working in partnership as part of the New Jersey Environmental

Public

Health

Tracking (NJ EPHT) project, illustrate that 21 percent (21%) of city residents lacked

health

insurance

between

2016 and 2020, compared to 11.2 percent (11.2%) of residents in Union County

and

7

percent

residents

in

the

state

(7%)

of

(Healthy

Community Planning New Jersey, 2022).

Evidence-based research shows a strong correlation between a lack of health insurance and a lack of access to preventative and primary health care services, as well as an increase in delayed medical services. “The uninsured are significantly more likely to be in fair or poor health, to have unmet medical needs or surgical care, not to have had a physician or other health professional visit, and to lack satisfaction in quality of care received” (NJSHAD, 2022).

Furthermore, there are 11 contaminated sites per square mile, compared to 3 contaminated sites per square mile when assessing the state overall (NJSHAD, 2022). Proximity to contaminated sites can impact the quality of life and health of all who live, work, and play in the city.

Community health is more than the absence of illness. It reflects how well individuals of all races, genders, backgrounds, abilities, and legal statuses live and the conditions of the environment, which includes equitable access to care, reduced risks of disease, and a high standard of outcomes at every age and stage of life. Community safety goes beyond crime and violence to consider the reduction of various harms that affect how secure, accepted, included, accommodated, and beloved members feel wherever they live, work, and play. Both contribute to community wellness.

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City of Elizabeth: Health Equity & Diversity Assessment

An Action Research Process

OUR APPROACH The IOC team was engaged by the Department of Health and Human Services (DHHS) to conduct a health equity and diversity assessment of the City of Elizabeth. For the purposes of this assessment report, IOC was consulted to gain insight on the following:

1

Impact of race and language in accessing care and services

3

Assessment of current health and safety conditions amongst residents

2

Identification of barriers leading to health disparities

4

Current services provided by stakeholders

IOC employed an action research process. IOC defines this process as a participatory and collaborative engagement undertaken by individuals with a symbiotic relationship toward addressing community health needs for all residents. The action research process included various forms of transactions:

11

1

Convening focus groups and community convenings with members from each ward

2

Engaging in insight interviews with city leaders and community representatives

3

Disseminating a community-wide survey, and

4

Conducting a review of related literature and research reports specific to the state of the City of Elizabeth's health and health disparities

City of Elizabeth: Health Equity & Diversity Assessment

We engaged in our framework to help city leaders determine to what

extent

Elizabeth

City

residents and those who work and play in the city experience barriers to physical health and well-being. Our assessment was rooted

in

the

following

exploratory questions:

Intrapersonal (INTRA)

1

How do health issues damage one's sense of self, physical health, and economic condition?

Interpersonal (INTRA)

2

How do health issues damage family relationships, social bonds, and community functionality?

3 4

Institutional (I)

How do institutions such as state, local government, private industry, and nonprofits create and maintain health disparity issues?

Systemic (S)

How do systems (local, state, and federal laws and regulations) create and maintain health inequity?

This report documents the findings gleaned through the action research process as the basis for a case statement for strengthening efforts to ensure equitable healthcare access and services, a goal outlined in HNJ2030.

The IOC team intended to dive deeper by

auditing

determine

service

the

providers

level

of

to

services

provided to those who live, work, and play in the City of Elizabeth, service limitations,

and

policy

issues

preventing

service

providers

from

serving certain populations. However, contract time constraints had to be managed

and

considered,

as

the

contract was ratified in April and closed out in June. The following sections provide an overview of IOC's action

research

process

and

outcomes.

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City of Elizabeth: Health Equity & Diversity Assessment

COMMUNITY CONVENINGS IOC scheduled six community convenings to gather input from the City of Elizabeth residents and from those who play and work in the city on 1) what a healthy Elizabeth looks like, 2) what a safe Elizabeth looks like, 3) what efforts exist that thwart race and language equity, and 4) what needs

to

improve

to

help

reinforce

equitable services. Our original intent was to host a controlled focus group with selected city leaders, residents, and those who work and play in the city.

3

The community convenings were not traditional focus groups, as the groups were integrated into pre-planned and scheduled community meetings.

Details of the events are listed below:

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April 3

Virtual kick-off attended by residents and employees

April 4

Virtual convening attended by parents, public school system educator & board of education employees

May 3

In-Person convening attended by residents in 1st Ward

May 4

In-Person convening attended by residents in 2nd Ward

May 4

In-Person convening attended by DHHS employees

May 18

In-Person convening attended by residents in 5th Ward

May 18

In-Person convening attended by DHHS employees

City of Elizabeth: Health Equity & Diversity Assessment

IOC’s community convening moderators guided participants through a conversation, offering the following questions as a foundation:

What harms have been experienced by people within your organization?

What practices within healthcare delivery fields perpetuate harms?

What are other practices within the social services sector that contribute to harm?

Where are there strong examples of equitable health care delivery addressing these INTRA, INTER, Institutional, or Systemic factors?

Gaps, what is not being addressed regarding public health services and policies that should be a priority for COE? Resources: What documents/reports should be included in our review?

Who else should we interview? Who can shed light on the health equity landscape in Elizabeth?

INSIGHT INTERVIEWS Eleven (11) insight interviews were conducted between April and July 2023.

Interviewees were selected based on their role as city leaders or selfnominated. In selecting interviewees, IOC worked to ensure diverse representation regarding race/ethnicity, number of years residing in the city, and service provider types. While interviewees’ length of time residing in the City of Elizabeth ranged from three (3) years to eleven (11) years, a majority of them were working at the director level, and many of them worked at the city-level.

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City of Elizabeth: Health Equity & Diversity Assessment

COMMUNITY-WIDE SURVEY Community members were offered an opportunity to respond to either an English or Spanish-language version community-wide survey between May 14, 2023, and June 30, 2023.

The survey covered the perspectives of those who live, work and play in the City of Elizabeth. Residents were asked to reflect on: What makes Elizabeth a thriving city?

What health and safety challenges are present?

What organizations and systems support are available to assist residents, and which ones are exemplary in providing service support?

How have they experienced barriers and challenges from the intrapersonal, interpersonal, organizational, and systems perspectives?

The IOC team received feedback noting challenges with completing the survey. However, by extending the online window for participation, 191 survey contacts were made, 184 connected to the English survey, and 7 to the Spanish survey. Of those, 95 English surveys and no Spanish surveys were completed. A total of 90 respondents resided within the city of Elizabeth, with an average residence time of 36 years, ranging from less than one (1) year to 83 years. Of those completing the demographic portion of the survey (n=53).

The median age of participants was 59 years, and the average years of residency were 36, reflecting an older population due to gatherings hosted in senior centers and venues where elders were present.

A diverse group of respondents were engaged based on ethnic and racial categories, including those who are American Indian or Alaska Native (8%), Black or African American (42%), Asian (2%), Caucasian or White (32%), and Native Hawaiian or other Pacific Islander (17%) with approximately 26% identifying as Latinx or Hispanic.

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City of Elizabeth: Health Equity & Diversity Assessment

Survey participants resided in all six Wards of the City of Elizabeth, with Ward 5 providing the most number of survey responses. A little more than half of the respondents reside in Ward 5 (29%) and Ward 1 (23%) combined, followed by Ward 3 at 18%, Ward 2 at 13%, Ward 4 at 9%, and the remaining residents, 7% from Ward 6. Their residency ranged between 6 months and 80 years.

Respondents who work in the City of Elizabeth described some of their occupations as administrative, clerical, managerial, and educational. Their educational status ranged across the spectrum from some high school or less to Doctorate/ Professional equivalent, and their salaries ranged from $45,000 to $120,000 for salaried respondents and with those who stated hourly wages earning from $10 to $50 per hour.

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City of Elizabeth: Health Equity & Diversity Assessment

Visioning a Thriving Elizabeth

INSIGHTS Elizabeth's residents described their ideas regarding what would create a thriving city through the survey and statements shared during interviews and convenings. Initially, 180 responses from 95 survey participants provided a broad range of topics, often stating what challenges must be fixed to achieve this bold and impactful outcome. The biggest priority was to achieve a crime-free community with safe streets and no violence and was followed by a quality of life, police presence, program resources, jobs, and a clean environment. Some residents specifically identified services, such as programs for youth and seniors or safety issues, that were not focused on reducing crime and violence. These concerns were fairly balanced across racial/ethnic groups.

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City of Elizabeth: Health Equity & Diversity Assessment

Top priorities that would enable the City of Elizabeth to thrive across the six Wards were identified as: Ward 1 and Ward 6 residents viewed “good quality of life”, Wards 2, 3, and 4 valued “feeling safe”, Ward 5 residents reported “having a police presence/support within the community”.

Consolidating responses, such as general and specific program services, a variety of safety requirements, and quality of life features, as well as consolidating structural and social services, incorporating housing, homelessness, and other services led to a set of eight top priorities, illustrated in the above table, where safety is the overwhelming feature of interest; this is consistent with the discussions at the opening convenings.

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City of Elizabeth: Health Equity & Diversity Assessment

PATHWAYS TO DECENTRATILIZE DECISION-MAKING However, some of the most innovative responses came by way of one or a few comments. They reflect ways that political leaders, city managers, service providers, and other organizations can contribute to a more engaged community and pathways to decentralize decision-making. A sample of survey responses are below: Better communication-relationships between-among services and residents (4) A focus on economic equality.

Organizational collaboration.

Decentralization of power: “Decentralize power from politicians only and create a community council where community workers and leaders also gain voice into Elizabeth’s development.”

Cultivating these types of visionary contributions and taking action to consult with the community about them realistically will build trust and open pathways for vital discourse on transforming Elizabeth’s development.

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City of Elizabeth: Health Equity & Diversity Assessment

RESIDENTS’ ASSESSMENT OF HEALTH & SAFETY Based on a review of several reports, the IOC team identified preexisting sets of health and safety concerns. We identified health and safety priorities to vet during the initial convenings and to use in shaping the insight interviews and community surveys.

Common concerns cited by interviewees included inequitable service delivery related to language and transportation barriers. One interviewee noted that she was the only person in her office able to provide language translation services to patients, and another noted that, at a minimum, resident information should be disseminated to residents in various languages, including Creole and Portuguese. Fear of deportation also thwarts undocumented residents from accessing available services. Other interviewees noted that a lack of public transportation prevents some residents from accessing services within the city.

Housing access, affordability, inequity, and the health concerns of an increasing population of those experiencing homelessness were also a theme that showed up throughout the insight interviews. One interviewee shared the following, “The number one need in their City is affordable housing. One bedroom starts at $1200. Seniors whose income comes by way of SSI can't afford it. There is a seven (7) year waiting list for public housing. Additionally, the Section 8 program wait time is four (4) years.

There are no emergency shelters or housing in the City.”

Mental health was cited as a concern in nearly every insight interview, with many citing little to no services available, especially for inpatient services and city employees. One interviewee noted that the health department has shifted to a first responder role in response to the COVID-19 pandemic, which created mental health issues, including stress and burnout. Staff stress and burnout were also noted as concerns among interviewees and their staff and colleagues. “The people, including me, are stressed. It is very stressful to perform well when you have little support, unfair consequences, and policies and procedures that change day to day.” One interviewee noted that:

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City of Elizabeth: Health Equity & Diversity Assessment

“There is not enough training for community service workers or front-line workers like clerks and receptionists in health care facilities. Workers are overworked, resulting in burnout and vicarious trauma.”

Iona Concepts surveyed 95 Elizabeth residents to determine how their health and safety concerns aligned with issues documented in prior health commissions and collaboratives. The tables below show the percentage of responding residents who were concerned about each health or safety issue in four areas: chronic disease, behavioral health, community safety and, social wellbeing.

We also explored the ethnic-racial breakdown of respondents (n=53) within each category (e.g. showing the proportion of people of different racial/ethnic backgrounds who identified each item as a health or safety concern. Below is the order of chronic disease concerns by Elizabeth residents who participated in the survey. Residents identified top health concerns (over 70% of respondents) as diabetes at 77%, with others being obesity, depression, substance use, and anxiety, while their top safety concerns included community violence, homelessness, and affordable and safe housing.

This next table is a breakdown by race of surveyed Elizabeth residents concerned about each chronic disease listed.

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City of Elizabeth: Health Equity & Diversity Assessment

Elizabeth's residents were asked about priority behavioral health concerns,.

Depression was rated the most concerning behavioral health disease, as 77% of survey participants selected depression as a concern.

The table below is a breakdown by race of surveyed Elizabeth residents who are concerned about specific behavioral health issues.

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City of Elizabeth: Health Equity & Diversity Assessment

The community safety survey table illustrates the concerns participants reported based on safety concerns. Community violence was ranked highest at 70%.

This table displays the concerns of the survey participants about the safety of community members based on their race.

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City of Elizabeth: Health Equity & Diversity Assessment

This table identifies social wellbeing issues of the highest priority for Elizabeth residents who participated in the survey.

Homelessness was distinguished as highest social wellbeing concern at 75%.

This table shows the percentages of members of each racialized group who identified these social wellbeing challenges as an issue for the city of Elizabeth.

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City of Elizabeth: Health Equity & Diversity Assessment

Twenty-five Latinx respondents had top concerns that closely mirrored the overall population; however, the level of concern was elevated for most top items by a factor of 5-10%. Chronic stress also rose into the top three concerns related to behavioral health over substance use, potentially depicting a pattern related to legal insecurity around immigrant status and related safety concerns.

CURRENT SERVICES & PERCEPTION OF SERVICES The Iona Concepts team identified more than 70 providers who provide a myriad of services to city residents. The insight gained during interviews suggests that there is a lack of clarity, as well as redundancy, regarding the services provided by unique providers. Siloed communications were noted as one culprit. As one interviewee articulated,

“There are many organizations that are doing the same thing.

If these entities can come together, it would benefit the COE.”

25

City of Elizabeth: Health Equity & Diversity Assessment

26

City of Elizabeth: Health Equity & Diversity Assessment

The IOC team invited residents to share an impactful health or safety experience and how they sought help. These stories focused on health, violence, homelessness, and other concerns. While residents most frequently reached out to law enforcement, the Health Department, health providers, local state and federal programs, and their City council members, about one-third of respondents felt there was no adequate support available.

Survey respondents listed the Health Department, Office of Aging, hospital (not specified), homeless shelters, and community and senior centers as the top most helpful institutions in the City of Elizabeth.

Listed as the top reasons for those choices included that there was access to resources for essential items, e.g., food, clothing, prescriptions, and electricity (20% of items reported) or providing other assistance that helped prevent problems (12.5%). Support that helped with socialization, selfesteem, and confidence (10%) was reported, followed by helpful services for seniors and rental assistance programs at 7.5%, respectively.

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City of Elizabeth: Health Equity & Diversity Assessment

Stories: Impactful Resident Health/Safety Issues

Number

People working in service organizations within the City of Elizabeth also weighed in on the impact of organizational practices. Their comments were nuanced and understandably cautious, noting that: There is a need for more “Police Walking the Beat in Our Community.”

Services provided are helpful but there is a need to do more.

Despite challenges, if the housingdevelopment organization … did not exist then there would be a negative effect on the whole community.

These organizations both uphold and impact health.

Keeping community safe and helping community with any issues with animals they are having.

All of the things listed have a major impact on people and how they perform their jobs.

Effectively and collaboratively helping to assist individuals and families overcome day-to-day hardships.

Significant impact: policies are applied citywide and are very antiquated.

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When asked to reflect upon the harms, barriers, or challenges (disparity issues) impacting their family, social, and workplace relationships, the following experiences were related: Identity relatability Backlash for not being able to meet all demands Lack of security in my workplace.

We help but need to do more.

Dental office inside the school system has limited service to only school children. Other locations could give benefit to more people.

Having little to no private time with families because being on call often creates interruptions in one's own life.

Lack of funding Could do more to address disparities but communicating with residents is a challenge.

City of Elizabeth: Health Equity & Diversity Assessment

BARRIERS LEADING TO DISPARITIES While state public health and social services policies and programs have been created and partnerships cultivated in the City of Elizabeth over the decades in an effort to respond to health disparities and inequities, city residents still experience challenges with the delivery of equitable health care and social services. There are many gaps to fill.

“As a guiding principle of Healthy New Jersey 2030 (HNJ2030), equity refers to the provision of fair and just opportunities to all community members through the development of systems and policies that address and remove underlying disparities and barriers, while giving special focus to community members who have been historically marginalized and face greater risk based on social, economic, historical, or political conditions.”

Source: HNJ2030

Every ten (10) years, the state leads the Healthy New Jersey initiative, which focuses on identifying and addressing New Jersey residents’ priority health needs and serves as the state’s health improvement plan. While the Union County Health Improvement Plan for 2022 notes a commitment to creating health equity, data from the HNJ2020 report show that health care and insurance access goals were not achieved, and equity has been listed as one of the guiding principles of HNJ2030 (NJSHAD, 2020).

Insights gained from the survey, interviews, and community convenings mirror data collected via health assessments discovered during the literature review phase of IOC’s action research process. It shows that there is still work to be done, particularly as it relates to residents who fall into the categories listed below: Non-English speaking and undocumented residents and displaced refugees Residents experiencing homelessness Residents with special needs Residents lacking transportation Residents with chronic diseases Perhaps more than anything else, public health policy largely impacts health status, access to care, and other social determinants of health.

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City of Elizabeth: Health Equity & Diversity Assessment

When public health policies are lacking or designed without the needs, culture, and experiences of marginalized and vulnerable populations in mind, it is inevitable that residents will experience health and social service gaps.

Concerns expressed by community convening participants ranged from a lack of trust in health care providers, transportation access, and safety issues to housing discrimination and a lack of green spaces in city communities and health issues that aligned with survey feedback.

The IOC research action process identified various health and social services gaps within the City of Elizabeth, including the following: Quality of Care: An expressed need for: A decrease in appointment waitlists and lag times An increase in culturally informed Services and trauma-informed care Safe and Equitable Housing Access: An expressed need for: An increase in green spaces throughout the city A more simplified rental application process A decrease in housing costs and an increase in affordable housing programs for residents of all ages Mental Health Services: An expressed need for: An increase in funding for city employees and residents An increase in equitable access to quality providers An increase in multilingual information dissemination Social Services: An expressed need for: An increase in transportation services and a renewed focus on road safety A decrease in food insecurity While 19% of survey respondents found no barriers/negative impact to services, other respondents listed difficulty in accessing systems/bureaucracy (16%), lack of professionals with needed language skills (14%), lack of needed programs (9%) or insurance (7%) as the top barriers to meet community needs. Barriers reported by survey participants were fairly evenly distributed across ethnic/racial groups.

When asked to identify additional barriers, the top three items presented by survey participants were associated with immigrant status (language, deportation fear) 21%; Community Policing (9.5%); and lack of services or knowledge of how to access them (9.5%).

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City of Elizabeth: Health Equity & Diversity Assessment

The residents surveyed found that the same services most likely to be reported as helpful were also listed as most challenging, including law enforcement, hospitals, and housing. In fact, the same proportion of respondents stated that all agencies, organizations, and institutions were problematic as responses noted that there were no problems or bad agencies. This likely reflects the fact that safety from violence/experiences with violence along with health challenges and needs and social services supporting well-being were repeatedly cited as most important and the center of shared stories. The very agencies that provide the most support are the most exposed to scrutiny and experiences like discrimination or disrespectful treatment may come hand in hand with essential resources, funds, and service supports. Specific examples of challenges with service delivery included: Lack of Funds Understaffed No response. Never received help. Ignored and not heard Lack housing No follow-up Not sufficient training Language barriers Ineffective programs Attempting to help the needy with assistance We cannot assist individual due to lack of documentation [sic] Lack of resources for special needs children Shortage of black teachers Police attempt do their job.

Staff members completing the survey identified a few ways institutions perpetuate challenges with respect to disparity issues: We help to an extent but can do more.

Creating barriers, i.e., too many requirements for programs Challenge is getting documents needed to assist families. They are reluctant to provide personal info COE Health Department needs its own building.

Many challenges in system, i.e., certain agencies making rules-policies without first listening to concerns of those affected State and Federal agencies putting more unfunded demands on the local system Policies that do not consider the poor and marginalized.

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City of Elizabeth: Health Equity & Diversity Assessment

Although it was harder to conceptualize how systems maintain inequity in the context of a survey, respondents noted, “the “them and us” mentality permeates programs and services”. Another stated, “We help to an extent but can do more. Feels like a drop in the bucket with some of the needs that are out.”

Other areas where systems can perpetuate or leave space for harm were shared, including: How rules are made and the ability to communicate with state and federal agencies Too many layers in the chain to actually get quick answers and responses Lack of compliance possibly due to bureaucracy and communications challenges.

Instead, staff began thinking about how to address the challenges, stating: The need for assistance to be more effective The intake of information and follow-up with clients to assure they are receiving the help they need Providing free services for people who cannot afford, housing, clinics visits, dental and vaccinations Implementing policies and procedures for a better community Staff applauded services provided by colleagues at: Health and Human Services Josephine’s Place Free dental program for all of the kids living in city of Elizabeth. This program promotes well-being to families.

Rental assistance relocation services programs for youth and seniors Trinitas Regional Medical Center example of institution that provides care to everyone no matter of religion, race etc.

Social Services Elizabeth Police Department YMCA But throughout, one staff continually repeated this rallying cry:

"We help but need to do more."

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City of Elizabeth: Health Equity & Diversity Assessment

IMPACT OF RACE, CULTURE, ETHNICITY & LANGUAGE The diverse makeup of the City of Elizabeth is one of many things that makes it unique. Recent research shows that approximately thirty percent (30%) of Union County residents were born outside the United States, twelve percent (12%) of households are linguistically isolated, and more than 80 percent (80%) of residents represent marginalized communities.

Unfortunately, insight gained using the action research process shows that race and language negatively impact the quality of healthcare services that city residents receive and their overall ability to access healthcare services.

In addition to race, language was cited as a barrier to accessing care and services in the City of Elizabeth. Community convening and insight interview participants all cited language as a barrier to accessing quality care and services. Several insight interviewees noted a need to hire more bilingual staff and disseminate information in multiple languages in order to increase their agencies’ ability to provide accessible and equitable care to all residents. Others noted many undocumented residents do not attempt to access healthcare services due to fear of deportation.

According to a recent study of health disparities in New Jersey conducted by the Robert Wood Johnson Foundation, “Black residents (56%) are more likely to say racial discrimination affects access to quality healthcare either a “great deal” or “good amount” compared to White (36%), Hispanic (39%), and Asian residents (40%)" (Robert Wood Johnson Foundation, 2022).

Furthermore, a report released this year by the New Jersey Health Care Quality Institute illustrated “that many hospitals that serve predominantly minority communities received lower grades for patient safety” (New Jersey Health Care Quality Institute, 2023).

"Health Justice means…not only looking at who should be doing better, but understanding what the relationships are, the social relationships that lead to some groups being denied resources and other groups keeping the resources that are often accumulated on grounds that are unfair and unethical.”

Source: Nonprofitquarterly.org

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City of Elizabeth: Health Equity & Diversity Assessment

Staff reflected on how to provide information more effectively to the diverse population of the City of Elizabeth. The following are suggestions for ways to more directly engage citizens:

“Resources are provided and available, but just need work in getting it out to the people."

Some specific mentions include: Flyers and websites in multiple languages, not just Spanish and English.

Non-technology-based ways to reach people, i.e., Door-to Door. Reach people in person for community events they are attending.

More access to resources.

Distribution of bilingual material, i.e., visit churches, schools etc.

Use social media or go to schools that can help children and then tell parents or have more surveys up.

More community events.

Regular in-person and virtual meetings with updates about the city.

Newspaper.

Mailers.

Make a calendar and mail them out or put them on the buildings.

Host outreach events outside of City Hall.

Some suggestions were more focused on “inclusion of all”: Police should be more responsive.

COE Board of Education needs to employ more MEN in schools as father figures.

They also suggested a variety of unique approaches that could be transformative for authentic engagement of residents: Must approach different classes of citizens, because they have different values systems-religious-beliefs-customs.

Identity relatability outreach.

Additional activities for the children.

Working fire hydrants- The fire hydrant on Jacques Street and East Street did not work.

The City can be more present in the community by making presentations.

Provide literature to community and faith-based groups.

Form citywide community health committee, health ed and 1 rep from major org with each ward represented.

Offer information on how to start a business in Elizabeth.

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City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth

RECOMMENDATIONS A healthy and thriving City of Elizabeth (COE) is one that considers the health and safety of all who live, work, and play in the city and one that aims to make health equity a strategic priority. The insight gained via the action research process employed by the Iona Concepts (IOC) team suggests that there are actions that city leaders, employers, and service providers can take to improve access to and quality of care, dismantle barriers that lead to health disparities and inequities, and continually assess health and safety conditions amongst residents.

Health equity must be assessed and measured.

SOURCE: Live Well Arizona - Community Safety

Developing a systemic data culture that captures quantitative and qualitative data provides direct feedback to policymakers and providers working within social and public health regarding the pathways to equitable health care, safe, affordable housing, and educational and economic empowerment. Building this framework should begin with creating and integrating inclusive, anti-racist, and anti-oppressive institutional norms. Including creating internal processes that audit and measure equity within policies and practices.n

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City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth The City of Elizabeth Department of Health and Human Services has provided staff with training and, in many instances, coaching on Race, Equity, Diversity & Inclusion. These trainings focused on pillars of unconscious bias and cultural competency. As in almost all American systems, inequity is often baked into service providers' systems, culture, and operating norms. COE and health and human services service providers must create a cohesive strategy examining inequitable practices that may burden those receiving services and staff charged to serve the community.

Compassion fatigue, stress, and staff burnout were all cited as areas of concern as the IOC team engaged those who work in COE in the action research process. We recommend city leaders take the lead in empowering service providers to offer mental wellness resources for direct services staff in municipal government, hospitals, and public and social health sectors. The mental health needs of service providers and those being served should be baked into the personnel policies and protocols.

Addressing the recommendations below will go a long way towards honoring residents' vision of a thriving city during this action research process.

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1

Conduct a Policy Equity Assessment

2

Create a Community Asset Map

3

Form a Community Health Council

4

Build a Multilingual Transmedia Strategy

5

Develop an Integrated Data System

6

Conduct an Environmental Health Study

City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth

1

Conduct a Policy Equity Assessment

2

Create a Community Asset Map

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City of Elizabeth: Health Equity & Diversity Assessment

An equity policy assessment amplifies an essential anti-racism strategy. Auditing the city government and service providers such as hospitals, health, and social services providers, using a race, equity, diversity, and inclusion (REDI) lens will help the COE transform outdated systems. This assessment is critical to dismantling systemic transactions that impede equity and inclusion for staff and residents. This process requires: 1) a thorough review of salaries, pathways to promotion, hiring, and recruitment trends, and 2) conducting an environmental culture assessment that seeks to reveal workplace culture and customer service protocols.

Facilitating community asset mapping, also known as a landscape analysis, is a process that uncovers resources in the community that community residents and stakeholders define.

This recommendation will build upon the action research process to identify available resources and services. This process centers the values of the community voices to communicate resources that are in place and the quality of the resources and promotes cross-sector collaborations. Asset mapping identifies linkages, duplication, and gaps and acts as a springboard for building on the existing capacity and potential within a given area.

Building a Thriving Elizabeth

3

Form a Community Health Council Creating a Community Health Council comprised of residents, public health stakeholders, and direct care providers can help COE leaders and service providers identify challenges that focus on perceived and evidenced-based discrimination and poor quality of services experienced by residents using such services.

While some survey and community convening participants provided positive feedback on the quality of service at local hospitals, including Trinitas Hospital, non-English speaking residents identified perceived racism and discrimination while receiving services at Trinitas Hospital. This council should comprise a cross-section of immigrant community members and public and social health service providers.

Moreover, it is strongly recommended that Trinitas Hospital leadership use the feedback from this council to adjust their organizational wellness and community impact goals to mirror the input from council recommendations. This council's ultimate goal would be to address customer service experiences and develop protocols to promote a stronger relationship between Trinitas Hospital and the community.

4

Build a Multilingual Transmedia Strategy Multilingual transmedia strategy provides the public and multilingual residents with direct access to information regarding resources and services by way of social media, print media, television ads, and public marketing spaces, such as billboards and bus stop ads. This strategy must be driven by community residents who speak underrepresented languages in the City of Elizabeth, such as Portuguese and Creole. This transmedia strategy aims to reduce language isolation and increase all residents' access to services and resources.

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City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth

5

Develop an Integrated Data System Creating a centralized data hub for residents’ and organizations’ information is key to removing the barriers and challenges of service delivery, such as reducing intake time and the duplication and siloing of services. Creating a shared data ecosystem will provide nuanced information about resident and visitor needs in the areas of education, social services, and public health services. By linking data across state and local agencies, the City of Elizabeth and the State of New Jersey can build off of the existing shared data reporting systems.

A data hub will help city leaders and agencies understand the complex, interconnected issues facing communities, identify where system efforts are duplicated or missing, learn how to maximize resource efficiency, and design programs or plan system improvements that better meet the community's specific needs.

The data hub should be grounded in the following guiding principles that emerged through extensive engagement with diverse stakeholders: Focus on improving system-level program efficiencies and service coordination, not on individual participants (i.e., the data hub is not a case management system).

Highlight and eliminate racial disparities and inequities.

Embed ethical and transparent data use Maintain high privacy standards 39

City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth

6

Conduct an Environmental Health Study COE sits in the heart of air and seaports, which increases the communities' exposure to environmental factors that create a health burden for residents. Conducting an environmental study would offer information regarding signs and symptoms of conditions precipitated by environmental toxins, such as asthma and other breathing conditions. Additionally, from an economic health perspective, the COE follows national trends in high rents and a lack of affordable housing inventory. This impacts COE residents, specifically public system employees, as they are mandated to live in the city, yet may experience difficulty affording the housing cost.

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City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth

COMMUNITY REFLECTIONS On August 10, the Department of Health and Human Services gathered staff, partners, and collaborators to review the recommendations and reflect on strategies to address barriers to racial equity, diversity, and inclusion in the experiences residents have, its impact on the health and wellbeing of individuals, families, and communities, opportunities for community, organizational and system collaboration and an overview of the impact of the current policy landscape. A summary of the rich comments shared includes: 1. How can we collectively reduce linguistic isolation?

Engage folks from the community, understanding that trust needs to be built or rebuilt, as some communities want to avoid being engaged based on experiences.

Leverage and honor existing skills of individuals, especially those impacted by policy and practice barriers and requirements, such as collective bargaining agreements.

When hiring consultants for assessments, ensure they recruit and engage community members, so the reach is maximized and skills and bounty are shared back to the community.

Creating opportunities for open discussions allows folks to expand community building which powerfully happened in this group.

Collaborative partnerships between certified translators and a trusted relative/friend.

2. How can we better communicate and collaborate across health and wellness sectors?

Establish a committee or group that meets regularly to discuss and problemsolve around all the social determinants of health and address challenges together.

Seat a coalition to address concerns, including the hospital, which has existed in the past, at one time supported by the Robert Wood Johnson Foundation.

Explore usual and unusual service providers as partners, and engage folks from the community at all levels.

Honor community requests for collaborative power building where everyone’s voice is included and heard.

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City of Elizabeth: Health Equity & Diversity Assessment

Building a Thriving Elizabeth 3. What strategies would you recommend to address the experiences of discrimination and racism operating within public health services?

Find a balance between family and system translation supports, and honor client preferences.

Engage community and staff members in certification to confirm translation accuracy and compensate for this, either with payment or changes in job description and workload.

Build a deeper understanding of community culture and needs.

4. What policies (or practices) are in place or lacking that limit access to health care?

Decisions to prefer translation services over trusted community translators uphold a lack of specificity around language inclusion, e.g., some sites require all information to be shared in any language spoken by a minimum population level (5% was shared as a practical example at one organization).

Expand languages covered beyond English, Spanish, Creole, and Portuguese.

Establish a translation hub that all organizations can look to for excellence and consistency in translations (other localities have received funds for such and could serve as models or take on this function regionally).

Balance privacy and confidentiality and existing regulations with culturally responsive practices.

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City of Elizabeth: Health Equity & Diversity Assessment

Visioning a Thriving Elizabeth

APPENDICES 1. Insight Interview Questions 2. Online Survey Questions for Health Equity and Diversity Assessment a. English Version b. Spanish Version 3. List of Reports Cited

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City of Elizabeth: Health Equity & Diversity Assessment

Iona Concepts, Inc. 703 N. Fremont Ave. Baltimore, MD 21218 redi@ionaconcepts.com maurissa@ionaconcepts.com Iona Concepts Inc. is a training and change management consulting organization with a 27-year history of facilitating an open systems approach in collaboration with social entrepreneurs and social enterprise initiatives to support operational capacity and thought leadership. Our mission is to disrupt, extract, and innovate planned change in organizations' systems and communities. Iona, named by enslaved mothers to denote ownership and agency, is the moniker of this boutique consultancy that centers liberatory practices within organizations, communities, and institutions.

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