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Community Needs Assessment

CHAMG Report Overview

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In this report you will find:

  • A landscape of resources and services
  • Analysis of 52 high-need census tracts in Delaware
  • Information about chronic health conditions, service shortages, quality of life issues, and relevant contextual factors within the 52 census tracts
  • Information about health disparities and outcomes within the 52 census tracts
  • Policy recommendations and practice changes
  • Plans to enhance overall community engagement

Report Description

The research project to promote health equity through advocacy for data-driven policies and practice changes was undertaken by the Community Health Advocacy Mobilization Group (CHAMG) in partnership with the Delaware Health and Social Services Division of Public Health Bureau of Health Equity and the Delaware State University Interdisciplinary Health Equity Research Center Community Engagement and Dissemination Core. The CHAMG is a Delaware coalition of over 40 community organizations focused on promoting health equity through advocacy and community engagement. This research was undertaken to demonstrate how data at the census tract level and dynamic, continuous community engagement could drive the development of solutions, grounded in social determinants and community assets, that were relevant to the communities intended to be the beneficiaries. The results of the research are presented in the ensuing report, prepared to share with decision-makers, community members, and organizations throughout the state who want to make positive change to reduce health disparities and improve outcomes among community members who have or are at risk of developing chronic health conditions.

In this report, the authors recommended policy and practice changes to improve health outcomes in the chronic health conditions facing Delawareans living in high-need communities across the state, as defined by the Social Vulnerability Index (SVI) of 0.75 or greater. Before that, the most pressing, referred hereafter as priority chronic health conditions, were identified by examining data from reliable sources on the My Healthy Community data platform. The analysis showed that the priority chronic health conditions were obesity, depression, and heart disease. Conditions were examined based on the data and research, and the contextual factors that appeared to influence or drive the prevalence of those conditions. Those contextual factors included access to healthy food, open spaces/parks, transportation, medical professionals, insurance (coverage), health literacy, and DE 211 (resources). The review showed that while many community assets were available to address drivers of the health conditions, they were not always “accessible” to community members in the 52 high-need census tracts that were the focus of this project.

The authors synthesized all the information gathered to help frame the policy and practice changes presented in this report, aimed at improving health equity, including:

  1. Enhancing community engagement in health policy planning and implementation.
  2. Increasing financial support for grassroots organizations that provide health services in high-need areas.
  3. Improving health literacy initiatives across the state.
  4. Expanding the healthcare workforce to be representative of all Delawareans.
  5. Expanding Medicaid coverage to include social determinants of health.