ONSITE HEALTH AND WELLNESS ASSESSMENT 7-2016 copy

ASSESSMENT OF HOPE SF ONSITE HEALTH AND WELLNESS ACTIVITIES

July

2016

An assessment to inform the continued development of onsite health and wellness activities in HOPE SF communities

Assessment of HOPE SF Onsite Health and Wellness Activit ies

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PREPARED BY SAN FRANCISCO STATE UNIVERSITY MASTER OF PUBLIC HEALTH STUDENTS

Yamelith Aguilar

Julia Custodio

Carla Garcia

Setie Asfaha

Lana Davila

Julie Gardner

Hannah Berchenko

Claire DeLeon

Cindy Hong

Nessia Berner

Kate Ferguson

Joshua Landicho

Kathy Nguyen

Melissa Peters

Melinda Prieto

Andrew Rodriguez

Atziri Rodriguez

Mariah Santiago

Elizabeth Schoyer

Hana Shirriel

Clea Vannet

Justin Wellins

DEPARTMENT OF HEALTH EDUCATION & HEALTH EQUITY INSTITUTE

Jessica Tokunaga, MPH

Jessica Wolin, MPH, MCP

Sarah Wongking, MPH

FOR MORE INFORMATION OR COPIES OF THIS REPORT, PLEASE VISIT:

WWW.HEALTHEQUITYINSTITUTE.ORG


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ACKNOWLEDGEMENTS Our gratitude goes to our key partners: HOPE SF, the San Francisco Foundation and, the San Francisco Department of Public Health.

This project would not have been possible without the dedication and contribution of the Peer Health Leaders across all four HOPE SF sites; Huntersview, Alice Griffith, Potrero Terrace and Annex, and Sunnydale, who provided insight into their work and their communities.

Community-based organizations at each of the four HOPE SF sites played an essential role in data collection and through their support we were able to incorporate community voice in a meaningful way. Thank you to the Bayview YMCA, Mercy Housing, Urban Strategies, and the Healthy Generations Project.

In particular we would like to thank PJ Iose Iulio, Jr. for all of his work to lead and coordinate the health parties at Huntersview and his partnership in data collection and analysis. His work was essential to the success of this effort and we have tremendous gratitude for his partnership.

We have tremendous gratitude and respect for the people we had the honor to interview program staff and community leaders from around the country who provided their knowledge about what works and the challenges of providing health and wellness services onsite in public housing communities.

We would also like to thank the Department of Health Education and the Health Equity Institute at San Francisco State University for their ongoing support of this work and community-academic partnerships.

Finally, our deep thanks to the residents who lent their voices to this assessment. We were honored to hear your stories, which provided us with invaluable experiences and tremendous knowledge to inform the learnings presented in this report.


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ASSESSMENT PARTNERS HOPE SF HOPE SF is the nation’s first large-scale public housing revitalization project to invest in high- quality, sustainable housing and broad scale community development with minimal displacement of current residents. There are four active HOPE SF sites – Alice Griffith, Huntersview, Potrero Terrace & Annex and Sunnydale. HOPE SF is led by the San Francisco Mayor’s Office with dozens of public and private sector partners including The San Francisco Foundation and Enterprise Community Partners. At the time of this report, the HOPE SF Peer Health Leadership programs are run by Urban Strategies, Inc., Health Generations Project, Mercy Housing and the Bayview YMCA.

SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH The San Francisco Department of Public Health (SFDPH) strives to preserve, promote, and protect the health of individuals, families, and communities in San Francisco. SFDPH is an integrated health department with two major divisions: Population Health and the San Francisco Health Network. These divisions work in collaboration to provide and fund medical services, community health programs, and oversight and implementation of prevention activities and programs.

BAYVIEW YMCA IN HUNTERSVIEW As a branch of the San Francisco YMCA, the Bayview YMCA shares its agency's mission to build strong kids, strong families, and strong communities by enriching the lives of all people in spirit, mind, and body. This is accomplished by providing various programs and services, such as family support services, physical activity, nutrition programs, after-school programs, and sports and recreation programming at various locations throughout the Bayview-Hunters Point community. The Huntersview HOPE SF site is one of the affiliate locations for the Bayview YMCA branch where many of these services are offered.

SAN FRANCISCO STATE UNIVERSITY DEPARTMENT OF HEALTH EDUCATION & HEALTH EQUITY INSTITUTE The Department of Health Education currently offers a BS degree in health education with emphases in community-based health, holistic health, and school health. At the graduate level, the Department offers a Master’s of Public Health (MPH) degree in community health education.

THE HEALTH EQUITY INSTITUTE (HEI) HEI is a trans-disciplinary research institute at SF State University that links science to community practice in the pursuit of health equity and justice. HEI is conducts original research and partners with communities to understand and address critical health equity issues.


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Contents

INTRODUCTION ................................................................................................................... 5

BACKGROUND ..................................................................................................................... 5

ASSESSMENT PURPOSE AND KEY QUESTIONS ......................................................... 7

ASSESSMENT METHODS .................................................................................................... 8

LEARNINGS & IMPLICATIONS ....................................................................................... 15

REFERENCES ........................................................................................................................ 57


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INTRODUCTION The Onsite Health and Wellness Services Assessment is the fifth community assessment conducted as through a partnership between San Francisco State University and HOPE SF. It builds on previous projects and seeks to illuminate learnings about current and potential onsite health activities in HOPE SF including existing Peer Health Leadership programs and a future Wellness Center. In addition, the Assessment explores the perspectives of program staff and community leaders from around the Country who are implementing health services onsite in public housing or similar environments. This Assessment is designed to provide meaningful insights and implications to key stakeholders about the continued support and development of the HOPE SF onsite health and wellness activities.

BACKGROUND In November 2011, HOPE SF, the San Francisco Department of Public Health, and San Francisco State University’s Department of Health Education and Health Equity Institute came together in a partnership to further the development of strategies to address health issues facing HOPE SF communities.

From its inception, this partnership has been guided by recommendations developed by the HOPE SF Health Taskforce and has a focus on gathering additional information and best-practice examples for effective implementation of the Taskforce’s recommendations. The collaboration builds on the many community efforts already underway to improve the health of San Francisco communities, including HOPE SF sites, as well as the significant research endeavors that have already and continue to take place with HOPE SF communities.

Goals The partnership’s work seeks to illuminate how the City of San Francisco, private partners and other stakeholders can best support the development and implementation of health strategies at all of the HOPE SF sites in a manner that honors the uniqueness of each community and recognizes commonalities to ensure a coordinated and thoughtful approach.

C o m m i t m e n t to H e a l t h E q u i t y & M e e t i n g U r g e n t H e a l t h N e e d s This partnership and the related projects stem from a commitment to health equity and the urgent need to address the health issues facing the HOPE SF communities today. Actions at all levels – the individual, interpersonal, community and societal levels – are needed to address health inequities in the HOPE SF communities. This work seeks to balance a commitment to both long term changes in social determinants and the more immediate individual, interpersonal and community changes that have an impact on health.


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Assessments

• Peer Health Leadership (2012) • Children and Families Affected by Mental Health Issues (2013) • Youth (age 12-24) Health and Wellness (2014) • Art and Healing (2015) • Onsite Health & Wellness (2016)

Key P a r t n e r s h i p C o m p o n e n t s

Resident and Community Engagement Residents and community representatives of HOPE SF sites play a critical role in partnership activities. Resident leaders and site based HOPE SF staff and community organizations provide guidance for assessment activities (including development of data collection tools, outreach, and data collection), and participate i n the design and lead implementation of new service and community-building strategies.

MPH S tuden t P rac t i ce Based Lea rn ing A key aspect of these projects is that it they are designed to result in meaningful products for the community and City partners as well as serve as a practice-based learning opportunity for San Francisco State University (SFSU) MPH Students. Students and faculty conduct the assessment activities as part of the Community Assessment for Change and Professional Public Health practice courses in the SFSU MPH program, which take place over a 7 month period.

Assessment Timeline

All of the assessments conducted follow a similar timeline.

• Assessment Planning (November – January)

• Literature Review (February –April)

• Data Collection (April – June)

• Data Analysis (July)

• Presentation of Findings and Recommendations (July)


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ASSESSMENT PURPOSE AND KEY QUESTIONS Purpose To examine the opportunities, challenges and experiences of implementation of onsite health and wellness interventions in HOPE SF communities.

Key Questions

I. What health conditions do HOPE SF residents experience that might be addressed by onsite health and wellness services?

II. What health services and wellness activities do residents want onsite? III. How might these services be delivered most effectively? IV. What might improve or hinder resident participation in onsite health services? V. What role do Peer Health Leaders currently play in onsite health and wellness services and

how might their work best be integrated with onsite clinical services? a. To what extent does it matter to participants that activities are run by Peers?

i. Peers as role models ii. Peers as bridges to the community and engagement iii. Trust building iv. Peers as health educators

b. What other things do participants want to happen around health in their community that are run by Peers?

c. What impact has participating in Peer run programs had on participants? d. What difference does it make in the community to have Peer Health Leader

Programs? VI. What is known from work around the country about how to effectively deliver onsite health

services in public housing? VII. What is it like to live on a construction site and be in a community undergoing tremendous

change and transition? a. What are some of the impacts on health? b. What impact is there on the community as a whole? c. How can residents be supported through this change/transition?


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ASSESSMENT METHODS This assessment took place over the 7 month period January through July 2016. Advisors who represented key stakeholders in this work provided guidance throughout the assessment. Assessment methods also included a literature review that was conducted to lay groundwork for primary data collection; a crosswalk of data collection tools used to collect data from HOPE SF residents over the past 7 years; a synthesis of past assessment learnings; and, primary data collection for which 22 MPH students were divided into three data collection teams.

1) The Huntersview Team gathered the voices of residents at Huntersview through “Health Parties” (focus groups) about the upcoming onsite Wellness Center at the site. There were 74 Health Party part ic ipants in 6 Health Part ies conducted.

2) The Peer Health Leadership Team examined the impact of the current HOPE SF Peer Health Leadership programs through a survey of participants, observation, focus groups and a photo story project with with Peer Health Leaders. 51 surveys were col lected across the 4 HOPE SF s i tes and 14 Peer Health Leaders part ic ipated in the 4 focus groups and photo story projects .

3) The Key Informant Assessment Team talked with program staff and community leaders from around the country who implement onsite health services in public housing and other similar environments. 25 interviews with these key informants were conducted.

H O P E SF C o m m u n i t y H e a l t h A s s e s s m e n t S y n t h e s i s As the first step in the Assessment, the assessments that have been done over the past 4 years were reviewed. All of the learnings and recommendations about the delivery of onsite health services at HOPE SF that have already been identified by residents, program staff and HOPE SF key stakeholders were identified. A synthesis of these findings and recommendations are provided in Appendix A.

D a t a C o l l e c t i o n I n s t r u m e n t C r o s s w a l k After completion of the synthesis of previous assessments, the next step involved a review of all of the data collection instruments used to gather data from HOPE SF residents since the inception of the initiative over 7 years ago. All health related questions were identified. In addition, characteristics of the sample, data collection process, time frame and location were laid out for each question in a “crosswalk.” This table illustrates the extent to which data has been gathered from residents about their health and the exact questions that have been asked in surveys. The crosswalk is provided in Appendix B.

Literature Review An essential element of this assessment was a comprehensive review of the literature regarding onsite health and wellness services in public housing and similar environments in the United States. Twenty two MPH students read over 200 articles and reports with the purpose of better understanding what has been learned about the delivery of health and wellness services onsite in public housing around the country. Literature was not restricted to peer reviewed journals and


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included published professional reports and other non-academic work. Ultimately, 85 articles were determined to be relevant and were reviewed for lessons learned. In some areas there was a limited amount of literature specific to public housing and articles about circumstances similar to public housing (affordable housing developments) with similar demographics (e.g. low-income, poverty, impoverished urban communities, minority women and children) were included in this review. However, a full review of this larger body of work was outside the scope of the literature review.

To review the literature on onsite health and wellness services in public housing the MPH students worked in two groups – one focused on clinical interventions and the other focused on non-clinical interventions. Each literature review team used a variety of databases available through the San Francisco State University Library server including: PubMed, PsycARTICLES, PsycEXTRA, JSTOR, ERIC, Web of Science, Academic Search Complete as well as Google Scholar.

H u n t e r s v i e w H e a l t h P a r t i e s In order to understand what residents of Huntersview want from a Wellness Center that will be opening at their site over the next year and what health needs they feel are important to address, focus groups or “Health Parties” were conducted. The MPH students partnered with the Bayview YMCA who provides leadership and oversight for social services at the site. Over the course of 6 weeks, a YMCA staff person, who is also a community resident, worked with the students and SF State University faculty to recruit and coordinate the parties.

Sample The sample consisted of 74 participants in 6 focus groups with 10 to 15 participants for each group (see Table 1.1 and 1.2). A few residents attended more than one focus group bringing the total of unique participants to 69. Forty-two women, 26 men and one person who refused to state comprised the sample. The focus groups were stratified by populations, including: seniors, Pacific Islanders, transitional age youth (TAY) women

Table 1.1 Summary of Resident Demographics

Total Residents* 74

Unique Residents** 69

Average Age** 39.71

Range of Ages** 16-74

Average Years Lived in Huntersview**

20.41

Range of Years Lived in Huntersview**

1-55

Total Men** 26

Total Women** 42

Refused to State Gender 1

Refused to State Age 3

Refused to State Years Lived in Huntersview

4

*Some residents attended more than one focus group and are repeated in the total resident count **Unique residents

and men, Peer Health Leaders, monolingual Cantonese speakers, and Phase III residents (residents who have not moved to new units).


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The lead resident staff of the Bayview YMCA recruited resident to “host” each focus group and the hosts directly recruited people in their social circles to attend each focus group. Although a large number and a diversity of residents participated in the focus groups it cannot be considered a significant representation of the population. A description of demographics of the participants is found in Appendix C. Participants were also given a water bottle and gift bag as a token of appreciation from the collaborative partners.

*Some residents attended more than one focus group

Procedures To increase resident participation, the assessment team promoted the focus groups as “Health Parties.” During each 2 hour Health Party, there was one facilitator and one note- taker. The first half hour was dedicated to establishing a welcoming environment which included a provided meal. The remaining time consisted of the carrying out of our protocol. There was a welcome from the Resident Staff, a representative from the Department of Public Health and the host. Framing of the purpose and goals of the focus group was performed by a representative from the Department of Public Health and from the Senior Director of Family Support Services of the Bayview YMCA. Digital recordings of the discussions were approved by participants through verbal consent, which was obtained at the start of the discussion. On average,

discussions lasted 45 minutes, with the note-taker transcribing observations and thematic notes on a computer. Following the event, the assessment team documented analytic notes and transcription. Verbatim transcriptions were not utilized in this project, but the recordings were used to assist in: completion of notes, discovery of themes and verification of quotes from residents.

Instrument Fifteen questions were grouped into five sections including community context, needs and barriers, service delivery, redevelopment and transition and closing. Key questions focused on specific resident health concerns, current use of health services and programs, and what the health and wellness center should do to address resident health needs. Also included in the interview protocol were questions asking residents about their experience as the first HOPE SF site to undergo construction and relocation. Full protocol is in Appendix D.

Pee r H e a l t h L e a d e r s h i p S u rv e y , F o cu s G r o u p s and P h o t o S t o r y A critical part of this assessment was an exploration of the work of the existing HOPE SF Peer Health Leadership programs. This examination included looking at 1) the role Peers currently play in onsite health and wellness services, 2) the extent to which it matters that activities are run by

Table 1.2 Gender by Focus Group Attendance*

Men Women Refused Total

Pacif ic Is lander

5 12 17

Cantonese

4 8 1 13

Peer Health Leaders

4 4 8

Seniors

2 5 7

Phase I I I (not in new units)

6 10 16

TAY (16-25)

7 6 13

Total 28 45 1 74


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Peers, 3) the impact peer health leadership programs have had on participants and the community, and 4) what more participants want from these programs. In order to get a better understanding of these issues the assessment included three data collection methods:

• Surveys of residents who participated in peer- led health activities at all of the four HOPE SF sites.

• Field observation by the assessment team provided insights into the implementation of Peer Health Leadership programs and interactions between Peer Health Leaders and participants.

• Focus groups and a photo story project with Peer Health Leaders from all of the HOPE SF sites allowed them to share their experiences by taking and discussing photos which spoke to the theme “A Day in the Life of a Peer Health Leader.” The focus groups centered on the impact being a Peer has had on them professionally and personally.

Sample Surveys were collected through interpersonal outreach facilitated in partnership with current Peer Health Leaders. Fifty-one responses were collected across the four HOPE SF communities (Alice Griffith n = 21, Hunter’s View n = 6, Potrero n = 9 and Sunnydale n = 15). Demographics of the sample are outlined in Table 1.3. Purposive sampling was used to identify residents who participated in Peer-led health activities, and an effort was made to reach all residents at each site who participated in health activities during the survey period. Respondents at these sites received a water bottle to incentivize participation. At sites where no current Peer-led health activities were scheduled, researchers worked with Peers to reconvene past participants at an event during which the survey was administered; to encourage participation, respondents at this event received a $20 gift card.

The 15 Peers across HOPE SF sites were invited to participate in the photo story project; 14 submitted final photos, and 14 participated in the photo story

Table 1.3 Demographics of survey respondents

n %

Total respondents 51 100%

Gender

Female 45 88%

Male 6 12%

Race/ethnici ty

Black/African-American 33 65%

Pacific Islander 6 12%

Latina/Latino 4 8%

White 2 4%

Mixed race 3 6%

Other 3 6%

Age

20 to 29 years 4 8%

30 to 39 years 16 31%

40 to 49 years 11 22%

50 or older 16 31%

Missing 4 8%

Length of residence

Less than 5 years 6 12%

5 to 9 years 8 16%

10 to 19 years 10 20%

20 to 29 years 3 6%

30 to 39 years 9 18%

40 years or more 7 14%

Missing 8 16%


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focus group discussions. All four sites were represented in both of these efforts.

Procedures Two assessment team members (MPH students) were assigned to each of the four HOPE SF sites, and recorded field notes after each visit to their site. The pair was in charge of organizing the survey administration methods that best suited the activities of the Peer program at their site, including working with program coordinators and Peers to decide on timing and method of administration. Surveys were administered one of three ways, depending on the format of the Peer program activity and individual respondent preference:

• Individual administration, written. After being read information about the purpose of the survey and informed consent, respondents could choose to take a copy of the survey to read and complete on their own, while a member of the assessment team was available to answer questions as needed.

• Individual administration, spoken. After being read information about the purpose of the survey and informed consent, respondents could choose to have the assessment team member read the survey items aloud while the respondent followed along and circled their own answers, or gave their answers verbally for the assessment team member to write down.

• Group administration. After giving information about the purpose of the survey and informed consent, one assessment team member read the survey items out loud while respondents followed along and circled their responses. A second assessment team member was available to work one-on-one with any respondent who requested assistance.

Once data was collected, research team members entered it into Excel, identified with an ID number. Hard copies of the surveys were destroyed.

To complete the photo story project, each site was given one camera and camera training. Peer Health Leaders met with two assessment team members who provided training on camera use, and Peer Health Leaders were instructed to take photos over a week period and then choose 3-5 photos each which represented their work, lives, and communities. The assessment team facilitated a focus group with Peer Health Leaders at each site to discuss the photos and how the program has had an impact on them. Discussions were recorded and transcribed by a professional transcription service, and were incorporated into qualitative data analysis and coded for recurrent themes.

Instrument The assessment’s key questions were used as a basis to create a primarily quantitative survey to administer at the HOPE SF sites (see Appendix E). The survey asked about which activities respondents attended and how often, if and how they believed their health had changed as a result of attending activities, how they felt about the “peer” part of the Peer Health Leader program, and what more they would like from the program. The survey took approximately ten minutes to complete, and included sixteen baseline questions with some variety by site. Ten questions were scaled choices, two were open-ended, and four collected basic demographic information.


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Photo story focus groups were recorded and transcribed for later data analysis. As part of this discussion, Peer Health Leaders also completed a brief quantitative survey to collect their demographic information. The focus group protocol and quantitative survey can be found in Appendix F.

Key I n f o r m a n t I n t e r v i e w s Key informant interviews were used to examine best practices in the development and

implementation of health and wellness services on site in public housing and similar environments in the United States. Health and wellness was defined broadly to include clinical care services, behavioral health care, and health education provided at public or low-income housing. Semi- structured interviews to capture the perspectives of professionals from around the country who have experience overseeing, developing and implementing health and wellness services in public housing sites.

Sample The sample included program managers, directors, clinicians, and researchers who had previously or currently work with programs providing health and wellness services on-site in public or low-income housing in the United States. Using the literature review, as well as supplemental Internet research, the assessment team identified relevant program and conducted phone and VOIP interviews with those program staff.

In total, the team contacted 67 programs, and conducted interviews with 25 (Table 1.4). Email and phone calls were made to organizations to recruit interview participants.

Procedures Interviews were conducted by a pair of members of the assessment team. In-person interviews took place at the interviewees’ offices. A conference call service was used to conduct the phone and VOIP interviews. In a pair, one person facilitated the interview while the other took notes. All interviews were digitally recorded by either a hand-held digital recorder

Tab le 1 .4 : O rgan iza t iona l Type a n d S ta f f Pos i t i ons of I n t e rv i ew ees Organizati

on Type

# interview

ed

Role

Housing Authority

5 Director, Deputy Administrator, Analyst, Program Manager

Nonprofit Public Health Organization

5 Health Educator, Director, CEO

Department of Public Health

3 Medical Director, Director

Resident Services Organization

3 Director, Manager

Research Institution

3 Research Associate, Core Investigator, Program Manager

Medical/Nursi ng School

3 Director, Professor

Health Education Organization

2 Executive Director, Program Manager

Federal Agency

1 Decline to state


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or the recording function on the conference call service. In addition, detailed notes were taken and after the interview, the note taker created a transcription, using the detailed notes as a guide.

Upon completion of the interview, the pair of students wrote a memo including thoughts about how the interview went, which questions worked, which did not, and any insights gained. These notes were used during data analysis as quick guides to understand the context of each interview, and how the data collected fit into the overall scope of the analysis.

Instrument The interview protocol had eight main content questions, in addition to an icebreaker and two concluding questions. All questions were open-ended, and for each of the main content questions, several probes were developed. Content questions covered two categories: program development strategy and reflection/big picture opinions. The protocol was intended to elicit actual experiences, logistics, and descriptions of programs, as well as the interviewees’ perspectives and opinions. As much as possible, published information about the programs was gathered prior to the interview. Full protocol is in Appendix G.

Observation In addition, to these formal data gathering efforts, all students and faculty who did primary data collection with the HOPE SF communities took field notes.

Data Analysis Over a 6 week period, SFSU students compiled, organized and analyzed survey, interview, focus group and observation data gathered from residents, Peer Health Leaders and key informants. All qualitative data was coded using predetermined and emergent codes. The three data collection teams developed themes and salient quotes were extracted from the transcripts. Each team then developed learnings based on the themes which were then combined into one overarching set of learning and implications that are presented in this report. Quantitative data from the Peer Health Leadership program participant survey and Peer health Leader demographic survey were analyzed in Excel using descriptive statistics to illuminate any patterns across or by site. See Appendices H and I for full results of these surveys.

Limitations Convenience and snowball sampling was used in this assessment allowing for significant recruitment bias. Current Peer Health Leaders conducted much of the survey recruitment, and their personal relationships with participants may have biased responses towards positivity. While residents who tried the activities and disliked them would have been unlikely to continue attending, and would not have been captured by the survey. Due the nature of qualitative data learnings cannot be generalized beyond the individuals who participated in this assessment. English was the only language used for most of the focus groups (with the exception of a monolingual Cantonese focus group at Huntersview) and that may have been a barrier for non- native English speakers. Similarly, the Peer Health Leader program participant survey was only made available in English, excluding participants who did not read or speak English well enough to complete the survey.


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LEARNINGS & IMPLICATIONS The following learnings and implications were developed by the MPH students and the course instructors who guided the data analysis process and have conducted evaluations of the Peer Health Leadership programs over the past 3 years. The learnings reflect themes that were found in the secondary and primary data collection. The Learnings and Implications are grouped by themes including the following:

1. Guiding Principles for Onsite Health and Wellness Activit ies Learning 1a: Resident participation Learning 1b: Multigenerational services Learning 1c: Trauma Informed Approach

2. Context and Social Determinants of Health

Learning 2a: Violence as a barrier to services Learning 2b: Limited access to public space at Huntersview Learning 2c: Social action and polit ical advocacy Learning 2d: Health impact of construction

3. Services Needed at Huntersview

Learning 3a: Complementary Health Services; Sexual Health Services; Mental Health & Substance Use; Food Access and Nutrit ion

4. Outreach and Engagement of Residents

Learning 4a: Lack of participation and outreach challenges Learning 4b: Varied and persistent outreach methods Learning 4c: Incentives

5. Access to

Services Learning 5a: Hours Learning 5b: Location Learning 5c: Home-based services Learning 5d: Language Learning 5e: Services distinct from property management

6. On-site Health Services Delivery

Learning 6a: Seamless connection of on-site and off-site services Learning 6b: Nurse managed on-site health services Learning 6c: Case management role in service navigation Learning 6d: Tailored programs Learning 6e: Confidentiality Learning 6f: Licensed


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providers Learning 6g: Shared information systems


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7. Peer Health Leader Program

BEST PRACTICES Learning 7a: Meaningful roles for peer health leaders

IMPACT Learning 7b: Peer Health Leaders are relatable Learning 7c: Peer Health Leaders create safe spaces Learning 7d: Peer Health Leaders benefit from role

CHALLENGES Learning 7e: Lack of focused health intervention Learning 7f: Variabili ty in program structure Learning 7g: Need for specific health skill training Learning 7h: Lack of resident understanding of program Learning 7i: Peer Health Leaders play dual roles


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Guiding Principles for Onsite Health and Wellness Activities

Learning1a: Meaningful and structured resident participation in HOPE SF onsite health and wellness program development, implementation and evaluation is cri t ical to program success and is not yet fully realized. Health programs implemented at public housing developments around the Country have proven effective when program leaders and researchers work with residents from the beginning of the development and continually through the evaluation phase. Resident involvement is essential to resident investment and utilization. A Huntersview resident stated, “Residents. It should be resident- driven. They should be a part of it, because that will want other residents to come in and utilize it.”

Successful onsite programs begin with resident involvement in the planning process. Resident participation in program development can take a variety of forms, and is essential in ensuring that clinical services meet the community need and will draw resident participation. Programs that engage the community in problem identification and intervention strategy not only report desired outcomes but are enduring and dynamic programs—lasting years instead of months. For example, a study of the Sister-to-Sister smoking cessation support program authored by Andrews, et al. (2011) describes a ten year process of problem identification, developing community advisory boards and proliferating a peer-based smoking cessation program for African American women in fourteen public housing communities. Studies have found that programs were less successful when residents were not engaged with the mission and vision of the program (Bowie & Rocha, 2004) or had different interpretations of “community engagement” (Smallwood et al., 2015) and “shared ownership” (Brown et al., 1998) than program leaders. When working with residents a “participatory [practice] must be fostered to counter the apathy, frustration, and resentment that often arise from feelings of powerlessness and oppression” (Bowie & Rocha, 2004, p. 337).

Once an onsite program has been implemented, it is important for residents to continue to play leadership roles and participate in the implementation and evaluation process. Resident participation on advisory boards is one way residents can stay involved in program operations and be a part of decision-making processes and is an approach common to successful programs around the Country. Resident advisory boards (RABs) create a space for gathering feedback from specific resident leaders and also the larger community. Residents have a sense of ownership when part of a collective that continuously collaborates with health clinic partners on creating and implementing programming for residents, utilizes residents for advocacy efforts, and engages the youth.

Increased trust is an outcome of resident involvement in the governance of onsite health and wellness centers. There are multiple examples in the literature of how trust is built through engagement in programs across the U.S. In addition to including residents on its board of directors, The Grace Hill Neighborhood Health Center (GNHC) operates several health clinics on or near public housing sites and has an active advisory council comprised of residents, tenant managers, representatives from local schools, and other neighborhood providers who furnish


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services to public housing residents (Leifer, Zakheim, Scott, & Vieth, 2007). Community surveys,


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ongoing meetings with resident committees, and exit interviews are also feedback mechanisms found in the literature. Programs that utilize various feedback methods are able to identify what is not working and address the concerns of residents.

Part of continuing to empower and build resident capacity is to hire residents as staff to support the health clinic. Residents are considered a direct connection into the community and are utilized in service delivery, outreach, and planning. Hiring residents creates jobs, learning opportunities, and a strong internal workforce through the clinic. Paid internships have also been made available to support workforce development among residents. Residents in Huntersview spoke specifically about involving community youth, and expressed interest in getting youth to participate by letting them earn volunteer hours that can also be used for school credit. Furthermore, it may be possible to create opportunities for residents to become employed or build their skills through partnerships. A key informant shared that they work with all of their partnering organizations to secure employment and training opportunities for their residents: “with every health partnership, we ask for employment and training opportunities. Out of all of this, we have gotten about a dozen, opportunity to be trained, and be able to assist or provide education...” The programs that make space for learning and engagement opportunities support their residents’ holistic health. Partnerships with Universities with research and/or training programs in relevant areas also have the knowledge base, teaching experience and infrastructure to work with onsite programs in providing professional development services (Gerwitz, 2007; Yaggy et al., 2006).

Implications The lack of an overall resident governance and leadership structure in HOPE SF makes an approach to resident involvement specifically for the onsite health and wellness services necessary. Building a transparent, consistent, and resourced resident leadership structure for the onsite health and wellness activities is essential. Efforts should go beyond relying on the Peer Health Leaders’ input or one-off conversations and data gathering efforts. The development of a process and structure, such as a Resident Health Advisory Board, for ongoing input of residents and governance, would be a new and necessary step in the development of the wellness activities on site in HOPE SF. Furthermore, employing residents or directly or creating access to opportunities in partner organizations would promote engagement and build community investment in services while directly benefitting individuals.


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Learn ing 1b: Mul t igenera t iona l heal th and wel lness approaches a re needed a t HOPE SF s i tes , however , some exis t ing Peer Heal th Leadersh ip wel lness p rograms tha t a im to se rve fami l ies face cha l lenges wi th engagement and paren ta l involvement . There is a lack of consistent programming with a “whole family” or multi-generational approach at scale across the HOPE SF sites. Residents desire to prioritize services for their children and may neglect their own care. One resident stated, “I’m not tripping on checkups, I’d rather worry about my daughter’s health, she’s 3.” Whole-family clinical service models help to improve the health of low-income families living in public housing (Popkin, Scott, Parilla, Falkenburger, & McDaniel, 2012). These programs usually intervene simultaneously with different generations of the family unit. Clinical services that target two generations have seen promising results among public housing residents.

Furthermore, while multi-generational programming is important, there are also challenges in the implementation of such an approach. Current HOPE SF programs targeted for parents and children have great potential to model good parenting practices, but some programs experience low parent/guardian participation, which limits programs’ ability to provide services. Peer Health Leaders who run health programs focused on families are frustrated by the lack of caregiver participation, noting “parents won't interact with their kids.” This lack of participation leads program staff to take on additional roles. Unfortunately, the lack of multigenerational programming and low participation in existing programs result in family-oriented activities showing only limited success.

Multigenerational approaches are well described in the literature and there is much evience about their effectiveness. The Housing Opportunity and Services Together (HOST) program is one model for whole-family service delivery in mixed income communities (Popkin et al., 2012; Popkin & McDaniel, 2013; Scott et al., 2012). Currently being piloted in Chicago, Portland, New York and Washington D.C., the HOST program provides intensive wraparound services to support families in public and mixed income communities. In Chicago, the HOST program provides intensive case management services to heads of household while at the same time providing after school activities and job training to youth in those homes. Implemented in 2011, the HOST programs have seen “unprecedented engagement” (Scott et al., 2012, p. 9) at the sites where services are implemented.

Communication between agencies and family members receiving services has been key to successfully implementing these integrated whole family services. Substance use treatment and case management is another promising area for whole family interventions. Larkin (2003) describes a substance use treatment program in Georgia, which used a family therapy home visiting model in a public housing site with a majority African American population. Rather than work only with the individual with the substance use issue, this intervention involved the family in intensive therapy sessions and workshops, resulting in a self-reported reduction in substance use. Families felt that the program helped them address social issues that compounded the risks for substance use. Both models address the need for services that address the family as a unit. These models “improve the life-chances of some of our most vulnerable children and families” by


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addressing them in context with meaningful services. The health of an individual is often dependent on the health of the entire family. Taking into account not only the health needs of each resident as an individual, but the health needs of their family allows residents to successfully participate in primary care services and make improvements in health and well-being.

Learning 1c: Trauma-informed approaches are needed to effectively deliver health services onsite to HOPE SF residents. For the new on-site health services i t is key to ensure stabili ty of engaging and committed providers, even at the individual staff level, as a legacy of inconsistent and terminated programs has eroded trust in services at the HOPE SF sites. In order to best address the health needs of their communities, many on-site program leaders around the Country call for a trauma-informed model that addresses behavioral health and community building. Key informants interviewed emphasized that staff should be aware of the historical injustices faced by the community: “there's a lot of historical damage, oversight, under- support, under-funding that has to be undone.” The effects of intergenerational poverty were also noted: “Be it their own families, be it violence in the family, in the community, in the neighborhood. Be it their own addiction, mental health issues possibly. Be it three generations of poverty, most people are just really traumatized.” HOPE SF has embraced this approach wholeheartedly and SFDPH has made great strides in training its leadership, workforce and community providers in Trauma Informed practices. There are several key areas where attention should be paid to continuing to strengthen a trauma informed approach in HOPE SF communities.

CONSISTENCY A trauma informed approach considers the importance of consistency and continuity in programming and staff. In Huntersview, residents expressed deep concern for lack of consistency

Implications Engaging a family unit and multiple generations in a family is critical to make a lasting impact on individual and community health in the HOPE SF sites. Programs that take a multi-generation approach are needed. One possibility is to provide combined clinical visits where both child and caregiver can be seen at the same time or provide child care during caregiver appointments in order to address the health needs of not just the child but the caregiver as well. However, real challenges must be addressed and strategies to foster parental engagement is required or programs run the risk of becoming more like child care than family programs. Furthermore, peer-to-peer programming for youth, not just adults, and ultimately having young people take on health leadership roles in youth groups within their community needs to be part of stable programs focused on children and transitional aged youth (TAY).


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in providers and programming that has negatively impacted the community in the past. One resident explained, “You can’t just come out one time and then leave them high and dry, you need to be there constantly.” Informants also emphasized the importance of staying in a community over time and building trust as a way of overcoming the community’s history of trauma, neglect and abandonment by service providers. As one resident stated, “We want to be able to trust these nurses. You know, we want to be able to see them all the time. We don’t want nurses who are going to come up here today and then there’s a different nurse next week.”

Unfortunately, just in the time HOPE SF has been underway and even since some minimal on-site health and wellness activities have been in place, there has been substantial turnover of key staff working on-site. Program coordinators, direct service providers, case managers, community builders have come and gone. While some of this turnover is to be expected and reflects the regular changes in work personnel, the departure of staff is particularly difficult in HOPE SF communities. Ensuring the ongoing and consistent presence of individual staff is essential to providing quality trauma informed care.

EXPERIENCE IN THE COMMUNITY In order to earn trust from, and gain knowledge about residents, providers must incorporate themselves into the community by getting to know residents outside of the clinic. Residents in Huntersview desire health and wellness center staff who are willing to work hands-on with the community and be invested to “really see what we face on a day-to-day” as one resident stated. Key Informants also expressed this as a priority: “they have to go knock door to door and sit down with people and have tea and talk about what life is like, and how they can be part of the community, go to people’s quinceaneras. They have to be part of life, they can’t be outside of it.” Getting a window into residents’ lives and becoming part of the community has helped programs to better address their community’s health issues. Residents in Huntersview focus groups expressed it was important for health and wellness staff, in particular the service providers, to be individuals who are “heartfelt people that want to see the community change for the better. We need people that care.” Engaging with the community is one key element in gaining trust but service providers who mirror the population they serve can be an integral piece to strong service delivery. In a study of 41 primary care health centers in public housing, “[m]any are members of the community they serve, and many are bilingual, so they understand the cultural nuances of their patients,” (Howard-Robinson, 2008, p. 3). These strategies help providers avoid conflict and rejection of services that could have disastrous health repercussions for residents, and address patient perceptions of provider indifference and insensitivity to their health needs.

SUPPORT FOR PROVIDERS Several key informants with program leadership experience in on-site health and wellness programs said that in order to be effective, staff and peer health leaders must also be supported with their own trauma and receive trauma informed training so as not to be re-traumatized or inflict further trauma on the community. To avoid provider burnout, health care staff need appropriate levels of training and emotional support to continuously work with high-need populations. In one expert's words, "some well-meaning lovely, probably young, committed nurse of color will come...and will walk out two years later trashed because the foundation wasn't built and that's so disheartening." In some cases burnout was avoided by having leadership positions


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that could provide their staff with adequate emotional and professional support. Additional methods to mitigate burnout include maintaining manageable caseloads for providers and employing health workers or aids. This learning is echoed in previous assessments done in HOPE SF where the emotional burden of working in violent communities has been detailed. The call for more emotional support for staff working on-site in HOPE SF communities has been made by numerous interviewees across multiple community assessments and has been articulated by current staff working on-site currently.

Implications In order to build trust and create a wellness center grounded in the community, the staff of onsite service providers should be supported to take the time to be at community-wide events outside of traditional operating hours. Job descriptions for these positions should include relationship building a community presence as a key activity. Staff should not be expected to do this work without compensation, but should be have this work built into their work responsibilities. It is essential to program success that providers receive emotional and workload support to avoid burnout. High rates of staff turnover builds distrust within public housing communities. Providers need to be consistent in order to build trust with residents. DPH should continue to build on their commitment that all staff should receive support for their own stress and traumatic experiences. It should be a priority to support staff about their own trauma, whether it is group debriefings, one-on-one supervision, or another method. It is not fair to just assume or demand that a front line staff member has “street smarts” or “common sense.” These skills should be taught and supported for staff.


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2. Context & Social Determinants of Health

Learn ing 2a: Fear of v io lence is an ongoing and major bar r ie r to Peer Heal th Leader ou t reach , res iden t access and , provider implementa t ion o f on-s i te heal th and wel lness se rv ices in HOPE SF s i tes . Whether it be due to past experience with violence or fear for their safety, residents consistently talk about safety issues as a barrier to them taking care of their health. Safety concerns hold people back from attending programs, and keeps them confined to their homes. “There are some people locked in their house because they’ve lost their significant other… and they don’t even want to deal with the community because of this reason [safety], they’re traumatized.” Across different populations, it was observed that residents desire to have safety as an underlying foundation to any programing, before they can attend. The residents who have joined the community more recently voiced concerns of not feeling safe in the Huntersview environment because of their newcomer status. In addition to the cameras already in place, residents requested a security guard or security presence, such as good lighting and heavy staffing, at the health and wellness center in order for them to feel safe enough to go there. Peer Health Leaders and staff have also expressed concerns over safety while doing door-to-door outreach after recent violent events in the community. Peer Health Leaders recalled engagement “…being a safety issue down here sometimes when we’re not able to go out and do outreach, because it’s been crazy outside, you know, the day before we try to do outreach, or even that day getting caught up in the mix of, you know, maybe a shooting or something.”

Learning 2b: Perceived limited access to public space at Huntersview, including in the new development, hinders physical activity, social interaction and negatively impacts individual and community health. Residents in Huntersview expressed feeling restricted and isolated by the public space policy choices in their community. The built environment poses difficult choices for residents. They are located on a hill in a dense, urban environment, which isolates them and impacts the accessibility of open areas and green space. This isolation makes exercise and outdoor play difficult. Observation and the focus groups revealed many Huntersview residents living within the new

Implications The impact of community violence on the successful implementation of program and the wellbeing of residents is profound. Residents have suggested strategies such as a security guard or security presence, such as good lighting and heavy staffing, at the Wellness Centers in order for them to feel safe enough to go there. Clear and realistic protocols to ensure the safety of Peer Health Leaders and staff as they do community outreach is needed as well.


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housing units were concerned about the lack of public space accessible for health activities. Residents said, “the playground is limited, the whole family can’t play with it and John Stewart says they are not allowed to play [and there are] regulations and they are restricting what can be played with.” Since the construction has started, residents have felt confined and “isolated behind big red gates.” Before the construction, “all these dudes would be at my house or we at their house but if I stand in front of his door I feel weird. I feel that was kind of their plan anyway. Well-built jail.” The built environment hinders family quality time in the neighborhood and minimizes community cohesion and opportunities to build trust. Welcoming public space and proper maintenance is of great importance to the health of community members.

Huntersview residents expressed concern with the lack of safety and designated recreational areas for youth to play in due to construction, “We had a little park at the top of the hill, but they tore it down. It was a nice little park for the kids to play in. It was real, real nice. But they tore it down. They should have torn that down last. Now, the kids have nowhere to play. And, this is a community with a whole bunch of kids in it and you took that away from them. So, now where do they have to play at? Nowhere.” The rebuild has consequently led to the deconstruction of children’s parks, leaving sites without adequate recreational areas for families. With regards to the lack of spaces for healthy child activity, one resident states “I see more kids in the house, than I do outside.” Residents feel the shared spaces in the new construction, like the inner courtyards, the park, and the playground are inaccessible. “It kind of diminishes family from what we know, the tightness of, you know you had somewhere to go. You [could] knock on someone's door and not fear being rejected or turned away.”

Learn ing 2c : Rais ing HOPE SF Peer Heal th Leader and program s ta f f consc iousness about soc ia l de te rminan ts of heal th and suppor t ing them to engage res iden ts in soc ia l ac t ion and pol i t i ca l advocacy has the po ten t ia l to be a powerfu l engagement and long te rm heal th improvement s t ra tegy. Currently at the HOPE SF sites, Peer Health Leaders and staff of community organizations are not serving as organizers of social or political action to address community health issues. However, there is great potential in training and supporting Peer Health Leaders or other residents in community organizing, political advocacy and building their knowledge of the social determinants

Implications There is a clear need to address resident concerns about limited access to space for play and socializing at Huntersview. Supporting residents to engage in physical activity in areas with this is possible is essential to their health and wellbeing. Changing perceptions may be needed as much as addressing actual limitations.


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of health. Across the Country, political advocacy is one way public housing residents engage with their communities, as critical conversations emerge about how systematic disparities result in health inequity. These critical conversations allow residents to collectively initiate advocacy with the purpose of campaigning on behalf of the collective. One key informant stated: "Where there may be individuals coming to talk about you know obesity, and obesity rates and how it’s impacting the city, or our county, or our nation, how it's impacting a certain communities more than others, what's contributing to it, sugar...So that's the way we sort of participate in more global, in staying on top of what's happening in our culture and making sure our families are getting that same information awareness access. We also have our Resident Leaders who will participate in lobby days, or various action days as it's related to food security, or whatever's going on up in Sacramento.”

Another key informant suggested the way to best have these critical dialogues is by engaging residents in collective learning, "I mean we like to say we facilitate the classes, we don't teach the classes because it's not us sharing our amazing knowledge with them, it’s like they, what do we know as a community, as a group. What injustices are there and how can we address them? Like how can we inspire ourselves and each other to make little steps to lead healthier lives?"

Peer Health Leaders across the U.S. who learn and examine social determinants of health feel more motivated to address these overarching issues that impact their community’s health. Affecting these social determinants takes strategies grounded in health education theories, political advocacy and ongoing investment in these efforts. One key informant found that engaging residents in policy advocacy allows them to find meaningful ways to be involved in community level changes. It also allowed them to feel that they are part of a team. "Residents wanted to be heard and they wanted to have a voice and they wanted to feel like they were equal partners - that they weren't just part of advisory and they weren't just filling out a survey but that they were really engaged." Political advocacy ultimately empowers residents to take charge of their own health and be leaders for change in their own communities.

Implications The Wellness Centers and Peer Health Leader programs can be a platform for resident advocacy work addressing the determinants of health in their own communities, across all the HOPE SF sites and San Francisco more broadly. Currently, efforts to promote HOPE SF residents to engage in community organizing for social action is limited. Peer Health Leaders could play a critical role as informed leaders in the effort to advocate for community health. Training in health equity and social action skills, and engagement with San Francisco social action efforts to improve health such as the effort to pass a soda tax are opportunities go beyond services delivery. SFDPH has multiple efforts focused on community action for health underway in the south eastern area of San Francisco in particular. Collaboration between these efforts and the Wellness Centers and in particular the Peer Health Leadership program, are a critical way to connect the HOPE SF sites to efforts to address social determinants of health through social action.


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Learning 2d: Huntersview residents perceive a lack of support for their health during construction. At all HOPE SF sites, Peer Health Leaders are viewed by residents as sources of information and about the rebuild process and the physical and emotional health impacts of construction. The rebuild process has been stressful and confusing for both residents and Peer Health Leaders, who feel the emotional and physical effects of the construction and transition to new housing. Residents at all sites hear a mix of false rumors and accurate information that results in tension and anxiety through all stages of the rebuild process. Many Huntersview residents feel that there was little support for their own personal health during on-site construction. Many new health concerns have surfaced and were mentioned as specifically due to construction. Residents mentioned, “we never used to have nosebleeds. But ever since the construction started, we’ve been getting nosebleeds. I was taken to the hospital four times, because it just wouldn’t stop at home.” Residents feel health issues related to construction and transition were not addressed fully and wish that there was more information prior to construction about taking care of their health and health services that specifically address health problems resulting from living on an active construction site.

Peer Health Leaders hear from residents that those living in older units with family members who are off-lease feel anxiety and stress about what will happen to those family members when they move to the new units and the risks they would face for violating their lease to allow their off- lease family members to continue living with them. Off-lease residents are concerned about being rejected and having no place to go if the friends and family they could previously rely on to provide a place to stay become unwilling to risk the lease violation. This type of stress may reduce the strength of important social support networks in this community. In addition, the transition to new housing also results in more of the older units being left empty before they are torn down. Displaced residents with nowhere else to turn are finding refuge in these abandoned units, which are often physically unsafe.

Peer Health Leaders are filling the role of community connector by sharing information about construction with residents, attempting to dispel rumors and encouraging residents to talk with case managers about how to prepare for transition. They occupy leadership positions in the community both through the Peer Health Leader program and because of their own natural roles in the community. While this is not an intended part of their job description, Peer Health Leaders are valuable as a source of information and support for residents and also to the HOPE SF leadership as an existing connection to hear and respond to the voices of residents through this transition. Their leadership and role in these conversations have developed organically, and they are likely to continue to be important voices and resources for residents as the rebuild continues.


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Implications One area in which resident advocacy can be supported is addressing the physical and emotional health impacts of living on an active construction site. Through the Wellness Centers, resident leadership, expertise and advocacy can be fostered in monitoring and advocating for their own health during construction. In partnership with the Wellness Centers and DPH, residents can offer regular check-ups for asthma flare ups on high dust days, construction stress management support, home visits to check in with impacted residents, and communication about the mitigation of health risks as a result of construction. Residents and DPH can work with the construction management to collect health impact reports and data, and distribute the findings to the community to ensure residents are up-to-date on information that may affect their health.


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3. Needed Se rv i c e s

Learning 3a: Huntersview residents desire a range of western and complementary health services that address what they see as their most cri t ical health needs including mental health and substance use, sexual health and nutri t ion. Focus groups in Huntersview elicited requests for specific health services on-site in their community. Although these were mentioned by Huntersview residents they have been mentioned in other assessments by community members of all HOPE SF sites. Following are the most mentioned health services that Huntersview residents expressed a need to have in their community. In Appendix J is a complete list of the services requested by Huntersview focus group participants.

SEXUAL AND REPRODUCTIVE HEALTH SERVICES AND EDUCATION Huntersview residents are interested in improving the sexual and reproductive health status of residents. Residents agreed services around sexual health should be geared towards youth. Residents expressed worry about increased rates of STIs, stating “we also need to give them like sex education. We got a lot of unprotected sex up here, we got a lot of stuff going on here, it’s either pregnancy or STDs, they really are just wild.” Both men and women of all generations asked for reproductive health education for the community as a whole and for youth in particular. Residents also requested “a safe sex class” because “no one really practices that.”

CLINICAL SUBSTANCE USE AND MENTAL HEALTH SERVICES Substance use was repeatedly mentioned by residents as a service the health and wellness center could provide. Methadone distribution was mentioned by residents as a way for the health and wellness center to help overcome transportation barriers to access of off-site services. Residents urged, “we need a methadone distribution site.” Residents felt substance use services are hard to access from Huntersview. “There are people who just can’t make it down Third Street to receive [methadone] at 6 in the morning or by themselves.” Other addiction support services were requested, such as Alcoholics Anonymous and group counseling services.

Mental and behavioral health issues experienced by community residents are a result of trauma. Crime, safety, isolation, poverty, and personal hardships, are all sources of trauma for residents. Residents requested the health and wellness center provide counseling services to help address these issues. One resident stated, “people don’t know how to deal with what they see regarding police and murder, for some it’s just an everyday normal conversation. People here think it’s normal. People are really hurting they don’t know how to deal with their emotions. People need [a] coping mechanism.” A range of residents felt the new health and wellness center should offer much needed access to counseling services to help address their mental health concerns.

ACCESS TO HEALTHY FOOD AND NUTRITION SUPPORT Community members identified a need for resources and knowledge of nutrition and healthy cooking. One resident exclaimed, “I just feel like us living in a food desert, [they] don’t give us healthy fats for our heart and our mind to do the right things.” On-site, there are limited points of access to healthy food. The food pantry is a valuable service residents utilize to supplement their


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nutritional needs. Yet residents feel the food pantry should improve its services by providing healthier food options, such as fresh fruits and vegetables. One resident stated, “a food bank would be good...to bring vegetables and fruits only, would be good”. Community members also requested nutritional classes and cooking classes offered to all members of the community. In the context of nutritional education, residents requested help in the management of their chronic diseases which are affected by their diet: “we need help on how to manage our chronic disease.” One resident spoke about the need for “more informational meetings to show people how to eat healthy and where to access healthy food.”

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) When delivering clinical services to residents experiencing multiple stressors, therapies that target the body, mind, and spirit of individuals have been proven to be effective (Manor et al., 2014; Rollin et al., 1995; Westley & Glick, 1997). Alternative therapy programs for youth that teach the effects of stress on the human physiology and stress-management techniques enabled participants to identify events that caused stress, as well as techniques they could use to manage stress (Rollin et al., 1995). Approaches to alternative therapy can include approaches such as: physical modalities, including tai chi (Chinese martial arts) and yoga; cognitive, including lectures and group discussions; and experiential approaches such as creative movement, guided visualization, and breathing techniques. Comprehensive therapies such as aromatherapy and massage have also been found to support relaxation, improve circulation, and alleviate pain when combined with standard clinical care services. This was seen in a study of elderly and disabled residents who received regular foot care at their public housing complex.

At Huntersview Asian and Pacific Islander community at Huntersview have a cultural connection to non-Western forms of medicine for the treatment of many symptoms. Multiple residents expressed using alternative medicine instead of Western medicine, “my family does not use medicine, we use this tea instead,” and “Polynesians don’t believe in hospitals.” An older resident mentioned, “there’s a lot of natural remedies to cure high blood pressure and stuff like that.”

Implications Meeting the health needs of residents that they have identified will go a long way towards building interest and engagement with services. Focus group participants at Huntersview were clear about the most pressing health issues they would like addressed and at a minimum these services should be provided if possible. Furthermore, recognizing the real limitations and strengths of the environment and its impact on health behaviors is needed to create meaningful health education programming. In addition, community health assessment has been one way of gathering the input of residents and program staff during the development of an overall health strategy for HOPE SF. Building on all of the assessments already done and incorporating the input of residents shared in these assessments is an important way to develop services that reflect their needs and ideas.


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4. Out r each and E n g a g e m e n t

Learn ing 4a: Out reach for on-s i te heal th and wel lness ac t iv i t ies in HOPE SF and across the U.S. is o f ten ex t remely cha l leng ing and the re is a lack of communi ty par t i c ipa t ion in heal th programs, even those tha t a re h igh qual i ty , reques ted or res iden t led . Interviews with key informants illustrated that one of the biggest ongoing challenges in onsite health and wellness work around the Country is lack of resident participation. This lack of engagement is often due to resident distrust, lack of resident interest or availability, and poor recruitment efforts. Struggles with lack of resident participation leads to program closure, funding cuts, and staff frustration and disappointment. Many key informants noted that recruitment is essential, and poor recruitment can contribute to poor utilization of services. As one key informant explained that outreach can help overcome resident misperceptions, “I’ve even seen situations even where there are great, really high quality services available, and people aren’t used to having great high quality services available to them so outreach and really making that connection for folks to see that it is intended for them, for it to be a welcoming environment and for them to feel safe traveling to that location.”

Peer leaders in HOPE SF have also found outreach and engagement extremely challenging across all sites. One Peer Health Leader shared their concerns; “A lot of people don't take advantage of the opportunities… Like people say, ‘I want to lose weight,’ [but] we have Zumba class every Wednesday and Thursday [and only] three or four people come.” A significant portion of the Peer Health Leader’s role is conducting outreach to participants in the form of advertising peer programming in the community and encouraging program participants to attend. In focus groups with Peer Health Leaders across all sites, they expressed that they conduct regular outreach to community members, but see it as one of the greatest challenges in their work. One Peer Health Leader remarked, “getting the people to participate, that is the number one challenge,” and another compared it to pulling teeth. While Peer Health Leaders were confident that they were conducting frequent, in-person outreach, many program participants surveyed said that Peer Health Leaders needed to do more, requesting both door-to-door contact and flyers.

Outreach and engagement is challenging in any environment. Even in the most well designed program, if the targeted audience is unable to attend, the program cannot be effective. When working in a public housing setting, challenges are magnified. Despite a wide range of outreach efforts by Peer Health Leaders across the HOPE SF sites, eliciting engagement and participation in Peer-led activities continues to be a challenge due to the gap in perception of outreach efforts and the often unpredictable and violent environment of public housing.

Inconsistent programming also undermines outreach efforts; irregularity in time, date, location, and types of activities was seen to be confusing to both Peers and participants in Peer Health programs. Changes were often made to logistics of activities to accommodate other site activities or activities were cancelled due to low attendance. The confusion this created contributed to low resident turn-out and and distrust of the longevity of these programs. This impacts outreach and initial recruitment into activities.


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Consistent programming may not be the only factor though in long-term participation. Programs that have regularly scheduled and unchanging activities have experienced changes in participation over the years as well. One program that focuses on parent-child relationships has seen fewer parents attending and more children and youth without adults joining the activities. Peer Health Leaders note that there is a great need for youth programming in their community and they feel that they are filling that void, but that is not the primary goal of their program. While consistency helps to initially bring in participants, the perceived benefits of participation may be a motivating factor in ongoing engagement. Overall, more needs to be understood about participation in Peer Health Leader programs; programs struggle to capture the number of participants and frequency of participation, along with the demographics of who they actually serve. Most participant data is duplicated or counts of the total number of interactions, leading to high numbers in participation; after reading sign-in sheets though, it is clear that many of the participants are the same residents utilizing services multiple times. While this is greatly beneficial to those particular residents, there are few new participants indicating the limited scope or reach of these programs.

Learning 4b: Programs across the Country and in the HOPE SF sites have been most successful when integrating varied and relevant outreach methods that results in multiple “touches” to deliver program information to residents. Multiple outreach strategies are often used to and increase resident participation. Programs that put up flyers, knocked on doors, and made phone calls see better results. As one key informant stated about mailing flyers: “I always say it provides a base and a means for us to demonstrate that we did contact everybody, [but] people often don’t look at the mail...so doing more one-on- one engagement is far more successful.” One Huntersview resident spoke about the impact of multiple communication strategies and stated, “[the] Y is constantly in my head and calling me and reminding me and they leave a lot of flyers and then they call you leaving messages. They are a lot of help.”

Key informants described that program that have recruitment success employ additional techniques to inform residents of the services and activities offered. These include placing flyers in rent statements, monthly newsletters, monthly meetings, orientations for residents, back to school night presentations, and advertising of wellness activities in surrounding community spaces. Engaging multiple avenues of information sharing and including culturally sensitive materials results in reaching a wider audience. One key informant described a resident services on-site in public housing that is looking into getting a mass text messaging system, in order to send mass text messages to residents reminding them of upcoming events. A key informant from a major U.S. City’s Housing Authority agency works with property managers and maintenance staff to be prepared with targeted referrals and resource suggestions for residents, especially for mental health and housing instability services, as that staff also commonly interacts with residents on-site. Programs that provide participants with a variety of educational materials such as recipes, videos, and informational pamphlets prove to enhance self-efficacy and improve outcome expectations as


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well (Ahluwalia et al., 2007). Different residents respond to different techniques, and some need continual nudges, so a multi-method outreach approach may be what they need to actually show up for services.

Implications Current and planned onsite health and wellness programs rely upon effective outreach to engage residents. However, the significant challenges of conducting outreach (violence, limited outreach methods, minimal training for Peer Health Leaders, lack of a coordinated approach) make focused attention on how to effectively engage residents necessary.

Peer Health Leaders are viewed as the individuals who will conduct outreach for the onsite health and wellness activities. Plans for Peer Health Leaders outreach must go beyond assumptions that their role as resident leaders is enough to recruit and engage other residents. In order for them to be successful in this work, safety concerns need to be addressed as well as the development of efficient and varied systems for conducting outreach (i.e. technology to do mass text messaging). Expectations should be that repeated contact and in multiple forms will be needed to engage residents in activities. Ensuring a diversity of Peer Health Leaders who represent the range of ethnic communities at the HOPE SF sites is also critical to engaging the full community in activities.

Finally, data systems to track outreach efforts and the resulting participation rates would help illuminate what methods are most effective at promoting participation. Understanding participant data and trends (unique versus duplicated participants) is important in addressing gaps in outreach and knowing the population that is being served; without a uniform reporting system to monitor participation, little can be learned about how these programs are reaching the community.

Learn ing 4c : Al l of the HOPE SF s i tes provide some form of incen t ives for engagement in many of the heal th and wel lness ac t iv i t ies . I t is not c lear to what extent incen t ives enhance or de t rac t f rom meaningfu l p rogram engagement over t ime . Many health and wellness focused programs implemented in public housing communities provide an incentive (often monetary) to residents to promote participation. Interventions that provide food or entertainment incentives have also been shown to increase participation in health education programs. These types of incentives can increase participation both by offering direct,


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concrete benefits (e.g., providing a meal to members of a population who may have food access issues) and by creating or strengthening social networks within the community through celebration. Childcare is often utilized one form of incentive for participation. Many parents and other caregivers in public housing cannot access services if they have no support system to take care of their children during appointments (Bowie & Rocha, 2004). In the literature, an evaluation of a home-based substance use treatment program that included a child care component for African- American residents in a public housing complex found the program an effective way to help residents deal with their substance use issues; residents “like(d) [it] because [they] don’t have to worry about finding someone to keep their child” (Larkin, 2003).

Common incentives also include food and raffles for small prizes or gift cards. Combining health services with other activities has been another incentive to participation. One key informant from a Housing Authority described combined blood pressure checks with a food pantry: “…we would give incentives for folks to participate and get their blood pressure checked, or go through screening while they were, waiting to get some food on-site. So that has been a, something that's worked really well.” Incentives such as gift cards and food have been successful when used for encouraging the initial participation of residents in health clinic events, yet the continuous use of material incentives can promote disengaged participation in health services. Some key informants thought incentives were “better at getting people to start. I don’t think it’s as good at getting people to continue.” Partners are another source of small incentives, but many informants emphasized that the real value is in the service that is provided: "People want services, usually incentives are more around group and community building."

Implications Incentives should be considered a necessary part of engaging residents in onsite health and and wellness activities. But sustainability and their impact on meaningful engagement needs to be considered. From a past evaluation, it was observed that health activities in which participants also experience tangible health improvement (weight loss, improved medical diagnosis, less stress) naturally encourage ongoing engagement and investment in those activities. While there are merits to having general community building activities, health improvement that can be felt and identified by participants is a tremendous motivator in continuing an activity. Further evaluation of the impact of incentives should be undertaken.


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5. Access

Learning 5a: Huntersview residents desire clinical services that offer both scheduled appointments and drop-in hours on a consistent basis and include evening and weekend availabili ty is reflected in best practices around the Country. Residents in Huntersview and key informants from across the country commonly spoke about the importance of consistent and varied hours of operation. Traditional hours are difficult for families who have competing demands on their time and limited family support. As mentioned by a Huntersvew resident, “I mean like, [I’m a] single mother with two kids and they are involved in this, that and the other.” Services offered only during the day inhibit residents from accessing health and wellness activities. One resident urged, “you got to be accessible, and it has to be open in the evening time.”

Key Informants had differing points of view on the best way to schedule services: some programs felt strongly that the clinic had to be open every day of the week and that limited weekday hours would be ineffective. One Housing Authority Director said, “I think the biggest problem that is continually replicated is this schedule thing, is that the hours that the programs are open are too few and too unpredictable to really be useful.” Other programs run successful clinics that were only open a few days a week, which informants felt served the needs of their communities sufficiently. A nurse practitioner running an on-site clinic noted: "establishing trust was really a key component...you have to be there all the time...On the days off, you can close the clinic, it just has to be open whenever you say it's gonna be open. It can be limited hours, but it has to be open."

It is clear that if a clinic can only be open for limited hours, it is essential that the residents be able to depend on those hours; they have to be consistent and well-advertised. In addition, offering both scheduled appointments, and drop-in hours are crucial, which provides residents with both flexibility and dependability. A Public Health Department Director mentioned, "Access needs to be really easy in very supportive ways. In ways that maybe otherwise in the health world may not be necessarily acceptable. You have to have drop in, you have to have an open door…” Flexible scheduling was also brought up specifically in reference to youth. "For youth in particular, running a medical clinic and only going by appointments is not going to work...Really being able to not create barriers, having hours that work for people, non-traditional hours, non-traditional folks for working those hours."


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Learning 5b: Across the Country, on site health programs benefit from locations in the middle of housing communities, in dedicated service spaces. Having a dedicated service space reinforces for residents that the services provided within that space are for them and leads to more opportunities for interacting and engaging with the community. Having a health and wellness center in the middle of a housing community does raise some concerns regarding the stigma associated with others seeing you access services. To address this, it has been helpful for programs to get input from the community about what services will and will not be utilized. For example, when one program learned from their residents that they would not be likely to seek STI services on-site, they changed their programming plans to accommodate other services their residents were more interested in using on-site. Other programs addressed stigma by knowing their services would not be used by everyone. On the other hand, more than key informant found stigma to not be a barrier at all. They have resident populations that are eager to seek on-site services as they know they will receive a caliber of care not necessarily available at off-site community clinics, and there is “more buy-in from residents when they see their actual neighbors and friends taking advantage of services on-site.” Further, a key informant from a senior development noted: "it became almost a social thing, our waiting room. People would pop in and they'd see a friend, and they'd come down and just sit there." Having a well- positioned health center does not mean that outreach and recruitment activities can cease. More than one key informant noted that, despite a clinic being in the center of the community, they still had to outreach to residents to let them know services were available for them. Said one program director: "Even though we have been there for 30 years and are right in the middle of the community it's surprising how many people don't know it’s there, they don't even know the neighborhood center is there, a whole building they have to drive past everyday."

Implications SFDPH is well versed in meeting the needs of a diverse population with varied needs and the commitment to on-site services reflects that understanding. That being said, simply because services are on-site does not mean they will be well used or that they will be fully accessible to residents. It is paramount that Wellness Center hours include a range of availability including drop in and scheduled appointments, evenings and weekends. Ensuring consistency in hours is critical, particularly if the times the services will be available are limited. Trust is severely undermined when services are provided inconsistently, providers are not on-site when scheduled and they do not have a regular, predictable presence.


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Learning 5c: Nationally, home based care has been demonstrated as an effective strategy to deliver onsite services. At the same time, Huntersview residents were supportive but do have reservations about this approach. At Huntersview, despite being within a short distance of residents home, mobility of residents and the topography of the community create barriers in accessing on site services for residents. A Huntersview resident commented “[seniors] can’t walk down there. [You] fall out [of consciousness] by the time you get to the doctor”. Additionally, many residents feel Huntersview is isolated from the San Francisco mass transit system. This impacts their ability to access the services they need and was often mentioned as a barrier to accessing health services off-site. Literature discusses successful programs focused on meeting residents where they are by delivering services through home visits. Huntersview residents expressed house calls were a “good idea for working with adults, seniors, handicapped, [and] those who can’t walk”.

Home visits are being used in other contexts to deliver many different primary care services, including substance use treatment, psychiatric illness, contemporary health services, and clinical service delivery. Home visits have shown to be a successful strategy in public housing to deliver care to seniors, families, and residents with behavioral health issues (Larkin, 2003; Harahan, Sanders, Aff, & Stone, 2015; Saegert et al., 2003; Rabins et al., 2000; Westley & Glick, 1997). Primary care programs that focused on seniors living in public housing involved nurses who conducted home visits to care for residents in their home when a clinic visit was not possible (Westley & Glick, 1997). In other programs, when psychiatric illness prevented residents from accessing off-site services or treatment, a case worker would visit the home to deliver care (Larkin, 2003; Harahan et al., 2015; Rabins et al., 2000; Westley & Glick, 1997). While home based visits can increase access for specific residents, Huntersview residents expressed discomfort with drop in or unscheduled home visits. Residents said a variety of services would be appropriate to receive at home “but only after the relationship has been established and it will [need to] be consistent.” Establishing connections with the community before house-call implementation is crucial. In this way, home visits address some of the deepest barriers to clinical care on-site in public housing developments including lack of trust in providers and underutilization of services.

Implications Home based services can engage residents with mobility challenges or who are resistant to entering the onsite Wellness Center. They should be considered an essential part of service delivery done through the HOPE SF on-site health and wellness services. However, it is essential that resident concerns about home visits are addressed and that only trusted service providers enter resident homes.


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Learn ing 5d: Wi th in HOPE SF, the re a re growing monol ingual communi t ies tha t exper ience language and cu l tu re bar r ie rs in access ing ons i te se rv ices . Across the Count ry , p rograms tha t success fu l ly reach th is popula t ion inc rease language capac i ty of s ta f f and develop cu l tu ra l ly re levant ou t reach and program s t ra teg ies . Many key informants noted the importance of finding ways to reach non-English speaking residents. Huntersview also has a growing monolingual Cantonese speaking community and members of the community expressed a deep desire for services and materials in Cantonese & Mandarin. Many expressed feeling excluded from services due to the language barrier, and do not feel English only services were created with them in mind. Strategies used for reaching residents who don’t speak English include hiring bilingual residents part-time, using bilingual Peer Health Leaders, bringing in multi-lingual staff, and utilizing staff from across the agency. Other important initiatives in other parts of the Country include advertising services and events in multiple languages, offering classes in some of the major non-English languages, and informing outside providers of local language needs. In addition to language, key informants felt overall that it was important to offer targeted and culturally appropriate services, tailored to the housing community, such as cooking classes that utilize the food options available and relevant to residents. In many cases offering linguistically and culturally appropriate services required sub- contracting with agencies in the community.

Learning 5e: In programs around the U.S., public housing residents are hesitant to seek out health and wellness services closely aligned with property management because they do not feel they can trust the providers. As housing stability is often a concern for residents of public and low-income housing, some programs have found that their residents may be reluctant to seek services if they feel their housing could in any way be compromised. Rather, it needs to be clear to residents that the information that comes up in medical and behavioral health appointments will not be reflected back to the property managers. One key informant described a program that has addressed this by “pretty much hav[ing] a firewall in terms of talking about diagnoses and medical information

Implications Support for Non-English speaking residents is essential to engaging a diverse range of participants. Employing multilingual staff is a way to ensure residents have an opportunity to connect with services and programs however there is danger in relying on one person to connect with a subset of the population. Off site support for material development in multiple languages should be considered and access to a phone translation service is needed.


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so that the health part, the case managers don’t share that with property management.” In this way, residents can be assured that what comes up when they seek health services will not put them at risk for losing their housing. At the same time, it is important that the property management team be compassionate and knowledgeable about the role they serve for the population: “...we work with property management agencies that understand that…they’re there to keep the community healthy and safe and clean and they’re working with a very specific target population.” It is not clear to what extent HOPE SF residents see program delivery as distinct from property management.


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6. Hea l th Se rv i c e De l i ve ry

Learn ing 6a : HOPE SF’s commitment to ons i te heal th se rv i ces as an access po in t to an o f f s i t e , mul t id isc ip l inary , coord ina ted sys tem of ca re is re f lec ted in e f fec t ive e f fo r t s a round the Count ry and in the l i t e ra tu r e . Essent ia l to th is e f fo r t is ensur ing a seamless t rans i t ion be tween se rv i ces and c la r i ty for res iden ts about what se rv i ces can be accessed on s i te and those tha t requ i re t rave l o f f - s i t e . Providing wraparound services reduces barriers to accessing necessary health care for public housing residents (Badger & McArthur, 2003; Gerrity, 2010; Howard-Robinson, 2008; Pynoos, Liebig, Alley, & Nishita, 2005; Rivo & Gray, 1992). “As is often the case with vulnerable populations, residents had multiple diagnoses that required a combination of strategies to achieve symptom management and health goals” (Badger & McArthur, 2003, p. 62). Programs attuned to the multiple dimensions of needs offer a combination of wraparound services including screening, medical referrals, counseling, immunizations, health education, chronic disease management behavioral and mental health services, dental care, case management, nutrition, and alternative medicine (Badger & McArthur, 2003; Gerrity, 2010; Howard-Robinson, 2008; Pynoos, Liebig, Alley, & Nishita, 2005; Rivo & Gray, 1992). Linking behavioral health and primary care increases efficacy of treatment, serves to reduce stigma of participation in mental health treatment, and enables providers to treat patients who do not meet diagnostic criteria but are in need of mental health support (Gerrity, 2010).

While wraparound services are an important component to successfully addressing a diverse range of health needs, on-site clinical services in public housing are consistently used to supplement rather than replace off-site health care (Beigay, 2007; Naparstek, Dooley, & Smith, 1997; Rorie et al., 2010). Supporting residents with continuous care requires strong partnerships between on and off-site health centers. When executed effectively, on-site centers improve use and efficacy of traditional clinical health care, including increased likelihood of residents attending their scheduled off-site appointments and receiving preventive services between office visits (e.g., blood pressure and hypertension checks, glucose monitoring, dental disease screening), all of which support overall health (Beigay, 2007).

This access happens in many ways. For example, one key informant described one on-site clinic that creates agreements with community primary care providers (PCP) in which the on-site clinic makes the referral and shares health information, and then the PCP will confirm if a patient shows up for their appointment. If an appointment is missed, the on-site community health workers can then go out and follow up with the residents; this is all tracked in a database created by the head nurse on-site. Another key informant explained the value in health department-employed nurses having access to their patients’ electronic health records so that they can make off-site appointments and follow up on the services that get people to appointments.

One way to coordinate on- and offsite services is through mobile clinics, which have often been used to bridge the gap between public housing residents and the larger health system


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(Naparstek, Dooley, & Smith, 1997; Rorie et al., 2010). The Boston Public Housing Authority used mobile vans to deliver primary care services to residents on-site, including screenings for hypertension, high glucose levels and dental disease. By offering appointments after business hours and over weekends, and employing Resident Health Advocates (RHAs) to support connection to off-site services for those who screened positive, the mobile service increased screening and subsequent off-site clinic appointments for residents (Rorie et al., 2010). In Boston, RHAs from on- site mobile clinics accompanied residents to off-site appointments, translated, and offered resources and information on uninsured access to care. This made a significant difference in resident care, with an increase of appointments kept from 15% in year one to 55% in year two (Rorie et al., 2010). In this way, on-site clinical services increase access to screening and support the effectiveness of off-site care, supplementing rather than supplanting clinical services for public housing residents.

Key informants did raise a critical challenge facing onsite health services as an entry point to regular medical care outside of the public housing setting -- residents wanting to continue to receive their care on-site. After building up trust in the on-site providers, it can be hard for residents to navigate other services outside the community. The programs that prioritized referring off-site have addressed this by intentionally not offering comprehensive services on-site, in order to support the existing health services.

Furthermore, more than just connecting residents to offsite clinical care through patient referrals, highly effective onsite clinical services use a model in which care is seamlessly coordinated. Programs find it beneficial to residents when providers have the ability to give them a “warm hand off” to other service providers. Logistically, internal referrals among providers are most successful when they are in close proximity. “The primary care providers sees the patient through screening, or even just eye-balling the patient, realizing there might be some kind of behavioral health issue impeding them from moving forward in their wellness...they could literally step out of the room to, BHC is across the hall typically, and have the BHC come into the room, so like two social clinical workers come into the room assess the patient, determine what the next steps need to be, very briefly, and then the patient is able to proceed with their appointment." In Baltimore, MD, health care providers at a public housing complex instituted systems of communication including centralized record keeping and a discharge plan protocol to address limited use of services by residents and lack of care coordination between on- and off-site clinical care (University of Maryland, 2004). More than just connecting residents to off-site clinical care through patient referrals, examples of highly effective, on-site clinical services seamlessly address care through intensive service coordination; established personnel and specific activities to address barriers.


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Learn ing 6b : Similarly DPH’s plan for nursing se rv ices on-s i te in HOPE SF is re f lec ted in bes t p rac t i ces around the Count ry where nu rse -managed heal th p rograms in publ i c and low-income hous ing a re shown to be an e f fec t ive way to provide c l in ica l heal th se rv ices . Key informant interviews with programs around the Country illuminated that many onsite clinics in public housing are led by nurse practitioners and BSNs. Nurses working on-site to deliver several preventative health services, coordinate and refer care off-site, and work to maintain a personal connection with the community. Although nurse-managed health programs are often limited in the extent of the health care they can provide on-site, there are many preventative care services they perform, including chronic disease screening, immunizations, STI diagnosis and treatment, blood pressure checks, and sugar level tests. Some provide pregnancy tests and basic prenatal care as well. Often nurses will work closely with existing nearby hospitals and clinics by communicating with the patient’s primary care provider to ensure continuity of care. Nurses benefit from having access to a network of referrals to provide for patients when off-site care is needed.

Further, several nurse-managed health programs in public and low-income housing found that by building relationships with nursing schools, they are able to use nursing students as a cost effective resource for increasing the service capacity offered on-site. Programs considered this to be a two- way benefit, where at no-cost, they can provide essential clinical health services to the community, and the students receive their hours for school. However, the potentially damaging nature of these rotating staff should be considered and judicious use is of paramount importance.

Implications As planned by SFDPH, HOPE SF Wellness Centers will be connected to offsite services and part of a larger system of care. Creating a seamless system for coordination of care off-site and providing needed but limited on-site services can help support residents accessing off-site services. Systems for tracking patients who are referred off -site with follow up to the on-site services for no-shows and care management could help ensure utilization of the off-site services by HOPE SF residents. Creating a sense of connection between off-site and on-site services is important for residents to value and trust that their needs will be meet through this coordinated system. Furthermore, delivering health services as a continuum from home based to on-site to offsite is a way to engage and serve residents in the most relevant ways. This entire continuum should be seamless and protocols should be well-understood by both providers and residents. The development of strong partnerships and data sharing systems with off site providers is an important step in ensuring this continuum is effective.


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Learn ing 6c : I t has been demons t ra ted tha t the d is t inc t ro le of a case manager and/or res iden t se rv ice coord ina to r is ins t rumenta l in the e f fec t ive de l ive ry of on-s i te heal th se rv ices ensur ing connec t ion be tween on-s i te and o f f - s i t e se rv ices . Many programs successfully utilize case managers or resident service coordinators in part to help run health and wellness programs on-site, and make connections to off-site services. As in the HOPE SF sites, this role tends to have a wider scope than specifically health and wellness, but some of the varied responsibilities include: the coordination of PHL efforts, engaging the community, and providing referrals. Case managers and/or resident service coordinators have also acted as liaisons for incoming residents and residents moving into redeveloped housing. Because they generally have a reach broader than the wellness programming, they have more access to residents. Case managers and/or resident service coordinators are then able to successfully engage in health and wellness outreach efforts via their normal resident interactions: "the case managers that were already going into the homes were able to help us reach those that maybe we weren't able to reach in our initial recruitment processes. So they were able to send over referrals to us, and then we started being able to reach a lot more of the residents, and then word spread from there, and we started being able to reach more. So I think that was, worked really well." Case managers working specifically in on-site health clinics provide referrals, patient care coordination, and engage with residents to remind them about appointments.

Implications It is essential that a case manager and/or resident service coordinator is centered in the Wellness Center to ensure linkage and utilization of off site resources. Having a case manager or service connecter physically housed in the Wellness Center to meet with residents as they visit the Wellness Center provides immediate support for residents to connect to necessary health services and any other needed support. Thoughtful strategy is needed on how to integrate this role so resident linkage to off site and necessary services is effective. There are challenges and barriers to residents linking to care off site and readily available case management or service connector can navigate these barriers. Oftentimes residents express needing support in areas other than health (such as housing, employment, education, childcare) that case managers can link them to resources with. The case manager or service connector needs to be tied into the larger case management system on-site and connected with other CBOs.


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Learning 6d: Across the Country, tailored programming for subsets of a larger population and health education combined with clinical services can foster posit ive health outcomes and increase participation. Efforts that focus on a subset of the larger public housing community is a theme across the majority of public housing health and wellness programs in the Country (Ahluwalia et al., 2007; Dierich, 2007; Greene, Smith, & Peters, 1995; Howard-Robinson, 2008). Tailoring programs can be particularly beneficial for “hard to reach” and isolated groups such as seniors, disabled, and monolingual populations. The Wellness Center for Elderly directed wellness efforts towards a senior population residing in public housing. They actively encouraged seniors to come to the wellness center through providing monthly foot clinics which proved beneficial in addressing their specific health needs (Dierich, 2007). Wellness Information for Senior Empowerment (WISE) is another senior focused program that provided programming to strengthen community cohesion among senior residents. This cohesion led to an increase in social interaction for senior residents who are often an isolated group, thus increasing their participation in wellness programming (Dierich, 2007; Howard-Robinson, 2008). The program “I Have a Future,” specifically focused on African American youth who resided in public housing. By using a culturally relevant self- empowerment model to increase interest and maintain engagement, they were able to foster healthy outcomes for youth (Greene et al., 1995).

Poor health literacy negatively impacts public housing residents’ health outcomes as well as costs of care. (Nardone, Roan, & Trowbridge, 2013). Educational interventions not only work to improve residents’ knowledge of the diseases affecting their communities but also to improve residents’ ability to “make behavior changes that reduce their risk [for disease]” (Sikkema et al., 2000, p. 58). The need for health education curricula paired with clinical services for public housing residents is clear. Other health care models within public housing sites across the country have implemented educational programs connected to clinical care services. Several programs that experienced sizable resident participation contained integrated health education, risk reduction education, or other wellness programs with clinical services such as screening, counseling, immunizations, and medical referrals (Rivo & Gray, 1992; Robbins et al., 2000; Sikkema, 2000). Interventions that utilized culturally appropriate programming integrated with health education geared toward the daily lives of residents has proven to decrease the burden of disease in public housing communities (Ayala, 2011; McNeill et al., 2009; Sikkema et al., 2000).

Implications Trying to meet the needs of all of the population of a HOPE SF site may not be possible or particularly effective. Creating programming that is targeted at specific sub populations in combination with community-wide programming may be a more sustainable and meaningful approach. Residents and HOPE SF want as many people as possible served and expectations are high; but, transparency about priority services and populations is needed. The Wellness Center and the Peer Health Leadership program cannot be all things to all people and advertising for these activities should reflect the limitations along with the opportunities for access to services.


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Learn ing 6e: Main ta in ing conf iden t ia l i ty in ons i te heal th se rv ices can be a chal lenge in re la t ive ly smal l communi t ies l ike the HOPE SF s i tes , but i t is a c r i t i ca l p iece of a t rus t ing re la t ionsh ip wi th res iden ts . Having onsite health services brings up many concerns about confidentiality; not only can community members see each other entering the Wellness Centers, but other residents might also be staff there. Concerns over gossip, rumor, and stigma can be a barrier in residents accessing onsite health services. Residents may also have trust issues with providers due to past experiences and question confidentiality integrity. One resident spoke of the importance of confidentiality; “Technically, if you go to a health care worker and talk about something, it should be, between you, like you and the priest, you and your god.” In addition to distrust of provider confidentiality, there is the fear of residents observing one another accessing services. Residents expressed that Huntersview is a small community and it can be easy to find out each other’s health and personal issues. “When someone’s hurt or someone’s ailing, we know that. So even though we may not want to share with everyone, we still know, because we’re a close knit community.” Although many residents see each other as family and often turn to each other for support, residents need service providers to build a trusting relationship in order to ensure private information stays private. In past assessments, concerns over confidentiality, particularly in accessing mental health support, were stated as a huge barrier by residents across all four sites (Mental Health Assessment, 2013). Working to ensure confidentiality with Peer Health Leaders is an essential piece of building the trust of that program as well.

Learn ing 6f : The status of providers as “licensed” is a critical criteria for Huntersv iew res iden ts to engage wi th on-s i t e heal th se rv ices and in par t i cu la r menta l heal th providers . For residents at Huntersview, the desire for a licensed provider was clear when asked about the services they wanted at the Wellness Center. Licensed providers were viewed as an important component of service delivery. When asked about what services residents wanted at the health and wellness center, “someone licensed” was emphasized across focus groups. Residents urged, “[we need] mental health services. Psychologists, therapists. You know there is so much going on,

Implications Prioritizing confidentiality and transparency with residents on how confidential health services work can reduce the stigma surrounding utilization of services. Peer Health Leaders need training and support to maintain confidentiality. Community- wide strategies to combat stigma in accessing health services should be generated through a collaboration of Wellness Center, resident leaders and local service providers. Efforts to address community norms and provide accurate information to the community can help build trust between providers and residents.


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that you don’t have time to evaluate, or even process, what’s going on.” The multiple requests for licensed providers, child therapists, psychologists, and trauma specialists indicated residents wanted behavioral health services delivered by providers who can adequately handle the level of trauma they face. In addition, they want to feel that they are being seen by a high quality provider and are not being given a sub-standard form of care.

Learn ing 6g: Shared in fo rmat ion sys tems a re necessary for e f fe c t ive par tne rsh ips for implementa t ion , meaningfu l pe r fo rmance management and evaluat ion of ons i te heal th se rv ices in publ i c hous ing . Gaps in data management systems and centralized data banks are barriers to effective health and wellness program implementation and monitoring in HOPE SF sites. Numerous entities onsite offer health and wellness related activities and each have their own data collection and reporting system. There is no systematic way to gather all sets of data from different entities to get a full picture of health activity and status of residents just within one site. The standard of data collected also varies, even if multiple programs are housed together. The one Wellness Center that is currently in operation houses numerous staff (including clinical providers, program coordinators, the Peer Health Leaders, a Peer Leader from DPH) all who provide different services and activities onsite. These activities are also done in partnership with other community organizations both on and off site. There is no systematic or understood effort in collecting participant data from all activities, including health service utilization, so there is no way to get the full-picture of health service delivery onsite. While it is challenging to coordinate data collection across distinct entities and services, without a partnership and system in place, resident health access and activity cannot be fully known.

In examining the literature, other programs share the benefits of shared data systems and best practices on how to achieve an effective shared data system. A shared multi-agency information system is central in providing sound and accurate care (Yaggy et al., 2006; Center for Health Program Development and Management at University of Maryland, Baltimore County, 2004). Initiatives that successfully manage contracts across multiple agencies enable residents to access more robust and diverse clinical services, including mental health services, primary care and case management. A strong administrative structure managing interagency contracts is critical to successful service provision (Yaggy et al., 2006; Theodos et al., 2010). Having sophisticated and centralized patient databases allow clinicians from various agencies to communicate about an

Implications Being clear with residents on who is providing health and wellness support and what their capacity is and their credentials will help build trust. Furthermore, residents experience never-ending cycling in and out of providers, staff, and programs, making accessing and understanding what is available difficult for the community. Having defined and well-articulated roles among onsite partners (community based organizations, resident organizations, city-agencies, etc.) is necessary in ensuring residents understand who to turn to for support.


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individual patient’s health, diagnosis and treatment in an effective and timely manner (Yaggy, 2006) and to better analyze clinical and patient participation data for evaluation and program planning purposes (Gerrity, 2010). Information-sharing among providers increases monitoring of medication compliance and improves provider ability to coordinate care (Badger & McArthur, 2003). Monitoring of medical conditions and medications on-site increases compliance and decreases hospital visits (Oke, 1994).

Currently in HOPE SF, there is no centralized data reporting system in place or systematic way across all four sites to collect resident data. Two of the four sites use the system case management reporting system TAAG, but its effective utilization is limited by staff turnover (causing disruption in use to accommodate training), changes in reporting requirements to funders, and challenges in formatting TAAG to meet the needs of site staff. TAAG in and of itself is not a problematic program, but has not been utilized across all four sites, so comparisons across the sites is not possible. In addition, data entered into TAAG only comes from residents who choose to use onsite services, it is not mandatory, capturing only a fraction of the full population. Much of the data is also self-reported and not shareable across agencies and community based organizations or across all HOPE SF sites.

In addition to collecting programmatic and utilization data about residents, there is a need to understand the health impact on residents over time. TAAG is a case management monitoring program focused on service connection; it is not meant as a longitudinal evaluation data system. HOPE SF’s original theory of change focused on service connection. This has evolved over the past 5 years, but TAAG has not been changed to meet the current data needs of the initiative. To meet the needs of tracking change over time, each site has developed their own methods of collecting resident data. Each site has implemented some form of household survey and depending on their funding source, may have regular intervals of data collection. A “crosswalk” analysis of all questions that have been asked to residents about their health in all four sites has been done as a part of this assessment (see Appendix B). From this, it is clear that there are very few common questions asked in all four sites and no systematic way in which those questions are asked. Household survey efforts take much time, resources, and contribute to survey fatigue of residents, and there is currently no strategy in place for this level of data collection that can speak to longitudinal health change.


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Implications Shared information systems are crucial to supporting residents in navigating through the various health care systems and should be developed between all partners. Resident consent processes and data sharing agreements will be needed to make sharing of health data possible. Similarly, shared and robust information systems will allow for meaningful performance management, quality improvement and evaluation. Current data systems and collection practices in the HOPE SF on- site health services are inadequate and do not allow for analysis and reporting. A plan for development and implementation of data systems for both health services and community health education and wellness activities that are linked to the larger DPH data processes is needed. Furthermore, ongoing evaluation is also needed to monitor the effectiveness of service delivery. A plan for the ongoing performance monitoring and evaluation of the on-site health and wellness activities supported by DPH is needed as Kaiser Permanente’s funding of the Peer Health Leadership evaluation will end in 2017. To understand change in resident health status and health impact over time, there needs to be uniform, systematic, and well-thought out approach in gathering data from residents. Ideally, a household door-to-door survey asking basic questions about health should be implemented at regular intervals over time. Key data points collected by city agencies can also contribute to understanding health impact and can provide comparison between HOPE SF communities and wider San Francisco.


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7. Peer Hea l th Leade r sh ip

BEST PRACTICE

Learning 7a: Across the Country, Peer to peer programs in public housing employ residents to serve in a range of roles to promote health. From conducting outreach to providing in-home services, peer leaders serve the cri t ical role of connecting residents to services, educating residents about health issues, providing social support and advocating for changes in health systems. A variety of terms were used by staff across the country to describe the role of the peer health support person such as health advocate, educator, community health worker, promotora, and lay health worker. The term Peer Health Leader is used here to describe all of these possible support roles. Peer Health Leaders are residents from the communities they serve. Experts found the most effective Peers have been identified as community leaders, had language skills reflective of the resident population, had a strong commitment to community engagement, and had experience in leadership roles. With these skills and qualities, Peer Health Leaders are drivers in resident participation in health and wellness services.

In interviews with staff running peer to peer programs, many program models have effectively utilized Peer Health Leaders to provide in-home health education on topics such as reducing environmental contributors to asthma, safe pest control, self-managed care, and information about smoking cessation classes. In a high intensity Peer Health Leader intervention for asthma, Peer Health Leaders conduct home assessments, create individualized action plans, link families to community resources, and visit multiple times. After a year, findings showed that the use of urgent healthcare services and the number of days with activity limitations were significantly decreased (ICER, 2013).

Peer models have been used as an effective way to address chronic disease prevention among public and low-income housing residents. Peers lead health and fitness events and activities, including walking groups, Zumba, and cycling groups. One successful Peer to peer model, implemented to lower obesity rates and increase safety, hired Peer Health Leaders to teach 10- week long cohort style classes on exercise, healthy eating, family communication and disaster preparedness. In some programs, Peer Health Leaders organize community health and wellness events, often in collaboration with the health center. These activities also served as community building opportunities led by Peers. Peer-led programs that focus on a foundation of building community and interpersonal connections contribute to healthier outcomes among residents (Ayala et al., 2011; Krieger, Rabkin, Sharify, & Song, 2009; McNeill et al., 2009; McNeill & Emmons, 2011; Wolff et al., 2004). As community residents, Peer Health Leaders in the High Point Walking for Health Program served as resident advocates by choosing interventions that were suited for their community (Krieger et al., 2009). Through the leadership and encouragement of the Peers and residents increased their physical activity through walking groups, which fostered a sense of community social support (Krieger et al., 2009; McNeill & Emmons, 2011).


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Outreach is another effective component of peer to peer models. Peer Health Leaders conduct outreach, such as door-to-door advertising, flyering, and word-of mouth. In one example, resident health advocates (RHAs) increased utilization rates of health assessments (hypertension, high cholesterol, diabetes, and dental disease) (Rorie, Smith, Evans, Horsburgh, Brooks, & Goodman et al., 2010). Beyond general community outreach, because of their embedded position within the public housing community, Peers can also identify and reach out to hardest-to-serve residents. In the Psychogeriatric Assessment and Treatment in City Housing (PATCH) program, “case finders,” including residents and housing employees, were trained to identify and refer elderly residents in need of mental health or substance use treatment and alert the program’s clinical nursing staff to the need for in-home psychiatric assessment (Robbins, German, Tlasek-Wolfson, Penrod, Rabins, & Brant, 2000).

Peer Health Leaders have also been integrated into health center coordinated systems of care as health service navigators or advocates. As navigators, PLs accompany residents to their appointments, translate information, and offer information on services for the uninsured (McElmurry et al., 2003; Rorie et al., 2011). Literature on health care also shows that a collaborative nurse and Peer Health Leader team is more effective in fostering community participation than either role is working alone (McElmurry et al., 2003). Trust and credibility among Peer Health Leaders, community members, and partners lead to systemic changes. In the Salishan community of Tacoma, Washington, “an agency partner who worked with the Advocates on a proposed change to the housing authority’s tobacco policy said, ‘I think that they [the Advocates] were critical, a fundamental part of the survey collection. They knew how to communicate with community members’” (FHG, 2013, p. 3).

IMPACT

Learn ing 7b: The percep t ion of Peer Heal th Leaders as r e la tab le , access ib le , and t rus twor thy cont r ibu tes to the i r success as ro le models and sources of suppor t . Peers modeling healthy behaviors can positively impact residents to make behavior changes. A Peer Health Leader shared, “It’s important to be a role model, it makes a difference to how people hear the health classes. If people can see your growth and acknowledge it and then want to change because of you, they say, ‘If you can change, I can change, too.’” This learning is consistent across sites, with 80% of program participants surveyed viewing a Peer Health Leaders as a role model, and 75% reporting that they would seek out a Peer for advice if they were considering a health change (see Appendix G).

Program participants trust Peer Health Leaders and value their relatability. Seventy-three percent of resident program participants surveyed found it important that Peer Health Leaders are from their community, while 84% would be more likely to attend a health event if they were invited by a Peer Health Leader. Participants trust Peer Health Leaders, as evidenced by choosing to share personal information with them and trusting them to watch their children. When asked to explain


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why it was important that a Peer Health Leader was from their community, 65% of respondents said they were more comfortable talking with someone from their community, and more than half reported it was easier to trust someone who understands their situation (see Appendix G).

While some Peer Health Leaders embrace being a role model, others find conflict in their roles and expressed guilt or confusion about their influence. “They see me smoke a cigarette or drinking a beer, oh my god, what are they going to say?” Still others described how since becoming a Peer, Health Leader the influence they already had as informal leaders became more productive. “I'm more of a positive role model instead of a negative role model. And that's a change that I got from the job.” Finally, some program activities are intentionally structured to provide modeling as a means to teach new behaviors to program participants, but with waning participation, aren’t effective.

Learning 7c: HOPE SF Peer Health Leaders create safe spaces where residents can escape stress through emotional support and intentionally nurturing atmospheres. Violence and construction were both significant stressors reported by Peers and participants in Peer Health Leader programs. Peers recognized the negative health effects of living in a chaotic and stressful environment. Across sites, spaces where Peer Health Leadership programs were held had a calming, stress free atmosphere, "I like activities about safety around the neighborhood, especially for kids, I work on Saturdays and when I work, a safe neighborhood environment is important." The Peer Health Leaders cherish their ability to provide a safe space, in which residents can find refuge; one Peer commented “we play…the kids will play. In a safe environment. It's like, they don’t have to worry about anything...We read to them and sometimes we have the older kids to read. And, you know, it's smiling, it's good for the mind.” Peers reported that residents come to Peer Health Leadership programming not just to receive services but also for emotional support and stress reduction. Stress reduction and mindfulness were integrated into many activities across sites, including a program which started every session with a deep breathing exercise.

Some of the programs focused on mitigating stress for children and families, allowing children the chance to play, exert energy and feel safe. Kids play and have fun; their parents/caregivers relax and experience a reprieve from the threats of violence ubiquitous in the community. Peer Health Leaders at one site create an intentional atmosphere of trust and comfort through nurturing actions. Hugs, words of encouragement, and trusted relationships are essential to the emotional support Peer Health Leaders provide. Together, emotionally supportive atmospheres and physical spaces became safe havens.


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Learning 7d: HOPE SF Peer Health Leaders have greatly benefit ted from this professional experience and in many cases improved their physical health, mental health and or developed new skil ls. From focus groups with Peer Health Leaders in HOPE SF, it was found that residents in this role across sites gain professional skills, develop healthier behaviors, and see lasting change both personally and professionally as a result of their role in peer health leader programming. Peer Health Leaders absorb the information they are being given to teach, and as a result, many improve their diet, activity levels, and mental and emotional well-being. One Peer Health Leader reflected “I'm actually physically, mentally, and emotionally healthier being a part of the program. I've lost over 60 pounds in the last year and a half. I've started my own health and wellness business.” Being a Peer Health Leader helps people with specific health goals such as smoking cessation and weight loss, with one Peer Health Leader sharing that because of the health and cooking classes she is no longer a pre-diabetic. They have also advanced their professional skills, such as public speaking, computer skills, job searching, and interview skills. In addition, several Peer Health Leaders have attained a Community Health Worker certification from City College of San Francisco. One Peer Health Leader was so motivated that they attained their driver’s license, achieved a better paying job, and moved out of public housing. Other Peer Health Leaders have had opportunities to travel and network in a professional capacity. They also reported feeling increased confidence and social skills achieved through going out into their communities to do outreach with residents around Peer-led programming.

CHALLENGES

Learn ing 7e: The depth and focus of heal th educa t ion ac t iv i t ies vary ac ross a l l four HOPE SF Peer Heal th leader p rograms wi th many ac t iv i t ies focused on casual soc ia l exper iences wi th no c lear re la t ionsh ip to improving heal th ou tcomes. Through observations of the programs over 2 months, it was seen that each Peer Health Program implemented health education activities differently. These activities varied from cohort style, curriculum based education to soft-touch healthy snack distribution to hosting community building events. Activities were facilitated by Peer Health Leaders, program coordinators, outside contractors, and clinical health providers, with Peer Health Leaders for the most part acting as a bridge between services and the community. For some of these activities, there was no explicit health education component and it was unclear to observers the goal or intended health outcome from these activities. While over half (56%) of all Peer Health Leader survey respondents across sites reported a change in their physical health after beginning to participate in peer-led activities (see Appendix G), not all activities had health education components, potentially lessening the positive health impacts on participants in the program.

In many cases, it was observed that program coordinators and Peer Health Leaders identified a


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great need for safe and fun activities for residents, leading to the implementation of activities


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focused on community building and mutual support, like crochet groups, game nights, family dinners, and monthly community events. The desire for these types of activities was evident in talking with the Peer Health Leaders, but the intended health outcomes of these activities were not clear and the impact on resident health is unknown from participating in these types of activities. Evaluation and progress review of these programs is challenging without concrete health outcomes to track or well-defined activities to evaluate. Without justified activities or measurable outcomes, there can be no understanding of the effectiveness of the program and why they are or are not achieving their outcomes. The activities in all four sites have evolved into four distinct programs, rather than one unified program being implemented in different communities. While variation across all four programs might be seen as responsive to the individual communities, it could also contribute to inequitable health support for residents depending on the health education activities offered by Peer Health Leader programs.

Learning 7f: The HOPE SF Peer Health Leadership programs have much variabili ty in program structures and processes impacting effectiveness and morale. Peer health programs that have regular team meetings, defined roles and consistent programming were observed to have more team cohesion, higher sense of morale and more effective engagement of Peer Health Leaders. It has been observed in all three Peer Leader evaluations (2014 - 2016) that sites where Peer Health Leaders met weekly together with coordinators to plan events and check-in about ongoing activities, there was a strong sense of team cohesion, ownership, and responsibility for program success. In past interviews and focus groups, Peer Health Leaders with these regular check-ins with the entire team, spoke of how supported they felt by coordinators and other Peer Health Leaders. Over the past year, program sites that have discontinued these weekly team check-ins have been seen to have less cohesion, investment, and clear communication about program goals in comparison to previous years. In contrast, in focus groups with Peer Health programs that continue to meet regularly, Peers spoke about strong

Implications A new, centralized contractor that will oversee the four Peer Health programs is an opportunity to strengthen the design and focus of the peer to peer health work at HOPE SF sites. The Peer Health Leader programs need to implement a clearly- defined health intervention with a justified theory of change in order to effect change. Furthermore, the intervention needs to be integrated with the vision and theory of change underlying the larger Wellness Center effort. Planning these two components of the on-site health strategy in tandem is needed. Understanding how the Peer Health Leader program is part of larger strategy, how Peer Health Leaders relate to other on-site health staff and how the program helps advance towards agreed upon health outcomes is needed.


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communication between each other in coordinating activities, feeling supported, and how they help each other out when needed.

At one site in particular, lack of role definition for the HOPE SF Peer Health Leaders, program coordinators, and even the program led to confusion for all involved. This confusion resulted in very low Peer Health Leader engagement and attendance in activities, trainings, and meetings. On the other hand, several sites were very clear on each person’s responsibilities, from program director to program coordinator to Peer Health Leader. It was seen at these sites that Peer Health Leaders were consistent in attendance and understood what they were supposed to do.

As mentioned previously, consistency in programming also varied across all four sites. In some sites, activities were either short-term activities for 1-2 months or ongoing activities that changed time and location. The lack of consistency was seen to cause confusion for residents who did not know when or what activities would be taking place, contributing to low attendance in activities. Peers and coordinators experienced frustration in the low turn-out; some programs responded with more activities or initiatives, but those efforts spread the Peer Health Leaders, coordinators, and resources thin and did not provide any more clarity on what their programs were trying to achieve. In contrast, others sites focused on a few finite activities that occurred regularly and have not changed in three years. It should be noted though that despite having consistent programming, participant attendance still varies and is low in comparison to the total population of each site. Consistency can support program morale and understanding of the program, but may not be the only factor in ensuring higher participation.

Implications Once a theory of change and unified plan for the on-site health and wellness strategy is developed. The role of peer health leaders can be further defined. Currently, Peer Health Leaders largely serve as outreach workers and often are not engaged in clear health related activities. Rather than Peer Health Leaders be “everything”, they need to have clearly defined jobs, roles, and tasks that support the purpose of the on-site health and wellness activities. Focusing the efforts of Peer Health Leaders on achievable and tangible goals can also help prevent burnout while supporting skill development that can support Peers in the future. Operationalizing appropriate, consistent, and effective peer health programming is challenging when Peers Health Leaders are not given context, structure and support for their work. Peer Health Leaders should be supported by their coordinator(s) with dependable leadership and guided by functional program structure - clear roles for Peers and coordinators, consistent and reliable programming, and regular team meetings. It is also essential that programs develop clear goals and consistent messaging, allowing the teams to approach their work and any challenges simultaneously, as a team, and direct their energies towards programming that fits the environment at hand.


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Learn ing 7g: HOPE SF Peer Heal th Leaders’ effective contribution to improving heal th ou tcomes requ i res spec i f i c hea l th sk i l l t ra in ing and i n - depth heal th educa t ion tha t goes beyond genera l leadersh ip development or b road heal th in fo rmat ion . A t ra in - the - t ra ine r approach and the C i ty Co l lege Communi ty Heal th Worker Ce r t i f i ca te P rogram have been essent ia l p ieces of s t reng then ing the sk i l l s and knowledge of some of the most e f fec t ive HOPE SF Peer Heal th Leaders . Effective community health interventions incorporate specialized training for Peer Health Leaders on specific health conditions including asthma, obesity, and HIV/AIDS that have been identified as highly prevalent or at high risk within certain public housing communities across the country (Ayala, 2011; Gutierrez-Kapheim et al., 2015; Sikkema et al., 2005; Sikkema, 2005; Wechsberg, Smith, & Harris-Adeeyo, 1992). Trainers are a combination of specialized health professionals, experienced community health workers and project directors, all of whom shared an interest in improving the health and well-being of the resident community. Nationally, trainings also include leadership development, CPR, confidentiality, including HIPPA agreements, and core skills to effectively work with community members.

Across sites, Peer Health Leaders are both learners and teachers. One site used a “train the trainer” model where residents participated in a health education course first as a student, then some continued on to take the role of teacher for the next cohort of resident-students. In another site that used art to help with healing, a Peer explained how they brought what they learned to their programming: “we, as a team, did a collaboration...whose focus was teaching us about art and healing… [We] decided to incorporate that into the community as a way of introducing art to the community, along with trying to use it as a healing tool.” In addition to their explicit role in leading programming, Peers can be informal teachers in the community with casual conversation and interactions, “...giving to someone else that doesn’t know how to live a healthier life.” Leading exercise groups and conducting nutrition education influenced the behavior and positive health outcomes of peer leaders.

Implications Peer Health Leaders effective contribution to health interventions requires specific health care skill training and in depth health education that goes beyond general leadership development or broad health information. Peer Leaders need to be trained in specific skills that contribute to health change and accomplish specific health goals set by the program. These trainings need to be in-depth and ongoing.


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Learn ing 7h: Mul t ip le se rv i ce providers wi th over lapping purpose and ac t iv i t ies makes i t cha l leng ing for res iden ts to d is t ingu ish be tween Peer - led p rograms and those run by o ther p roviders or agenc ies . Residents who are acquainted with Peer-led activities may be unaware of the connection between the activities and the Peer Health Leader program. Observations and specific questions about Peer Health Leaders revealed residents of Huntersview could not identify the Peer Health Leaders within the community. “Is that like big brother?” Instead, residents identified YMCA staff in association with health programs and activities. The confusion was heard in other sites where participants were sometimes unaware of the full scope or other offerings of Peer Health programs in the community. This could be that because Peer Health Leaders are established leaders in the community and are seen that way individually, without making the connection of their activities to an official program or title of Peer Health Leader.

Learn ing 7i : As res iden ts of the communi ty they se rve , HOPE SF Peer Heal th Leaders occupy dual ro les which lead to cha l lenges in es tab l i sh ing p rofess iona l boundar ies . Being a resident and a Peer Health Leader creates a working environment in which they are not able to completely extract themselves from their role, leading to Peer Health Leaders taking on tasks to support residents beyond their working hours. One Peer Health Leader reflected “Because we live and work here it’s kind of hard...separating those identities, not trying to stretch yourself out.” Examples of this are abundant across sites, and include Peer Health Leaders driving residents to appointments, addressing building needs, and diffusing conflict. Peer Health Leaders gave examples of being called on by residents for support, related to emotional or physical well- being, at all hours. “A lot of people call me, text me whenever there's an issue or a problem. So, I'm constantly involved. This past week has kind of been draining for a lot of us”. Confidentiality and trust related issues between the peer worker and residents created conflict. In some cases, trainings to strengthen communication and conflict resolution skills were needed to help address this (see Davidson, Chinman, Kloos, Weingarten, Stayner, & Tebes, 2006).

Implications Consistent program descriptions and “branding” are needed for the Peer Health Leadership program. Highlighting the role of the program in the community and the work of the Peer Health Leaders helps to reinforce their role as leaders and role models. A logo, tag line, brief description that the staff regularly uses would be helpful to provide residents with a clearer sense of the program and its role in the community.


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Ambiguous roles are often a source of stress for Peers. Their insight as residents into community needs and strengths also provide an invaluable perspective. Many Peer Health Leaders express pride that they are doing whatever is needed to support their community. Across sites, Peer Health Leaders do not distinguish between their defined role as a Peer and their work hours; whatever support is needed, they provide. Their discrete role as a Peer Health Leader and their function in the community as a supportive and active contributor are somewhat indistinguishable to residents and Peers Health Leaders alike. Peer Health Leaders, belonging to the same community they served, face similar stressors to those faced by other residents, at times leaving them without the peer support that they might need.

Implications Intentionally cultivate the personal and professional development of Peer Health Leaders and support them in making their own health changes. Provide supportive resources (such as childcare) for Peer Health Leaders to continue their participation and invest in their professional development by paying for conferences and City College courses, or having flexible schedules to allow them to pursue professional development goals. In addition, it is necessary to provide additional support for Peer Health Leaders in dealing with stress related to work and personal issues. Peers should be supported in creating boundaries between their personal lives and professional role(s). This will not only improve their ability to meet community need, it is an ethical response to the emotional work Peer Health Leaders are asked to engage in.


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