Anna J. Thomas, MPH, Deputy Public Health Director for the City of Manchester, NH created this presentation in order to convey the highlights of the Neighborhood Health Improvement Strategy, and presented it at NeighborWorks® Southern New Hampshire's 2015 Annual Breakfast. This slideshow gives some of the highlights from that presentation. If you have any questions, or would like to incorporate any of this presentation into any of your own materials, please contact Anna Thomas at athomas@manchesternh.gov or (603) 628-6003 ext. 341.

1. Anna J. Thomas, MPH
Deputy Public Health Director
athomas@manchesternh.gov
(603) 628-6003 ext. 341
City of Manchester Health Department
Neighborhood Health Improvement Strategy:
A Public Health Approach to Improving the
Health of Manchester’s Children and Families

2. Lead
Radon
Chemicals/Pesticides
Combustion
Products
Mold
Insects/Rodents
Fire/Injury
Drinking Water
Well Constructed
Energy Efficiency
Affordable
Ventilated
Maintained
Safe
Disease
and/or Hazard
Approach
Prevention
Intervention
Treatment
HousingHealth
(Adapted)
Structural
Approach
Historically, We’ve Had Different Approaches:

3. “When we think about health, we usually think about
health care and access to care and the quality of care.
But what research clearly shows is that health
is embedded in the larger conditions
in which we live, learn, work, play and thrive.
So, the quality of housing and the quality of a
neighborhood have dramatic effects on health.”
- Dr. David Williams, Harvard School of Public Health,
“Unnatural Causes: Is inequality Making Us Sick?”
The Connection Between Where We Live
and How We Experience Health

4. 4
How Health is Produced in Communities
Adapted from Dr. Anthony Iton’s presentation “Achieving Health Equity:
Advancing Community Health & Moving the Needle on the SDOH”
Risk
Behaviors
Disease
& Injury
Mortality
or
Recovery
Social &
Neighbor-
Hood
Conditions
Societal
Influences
Preventive Health Sick Care
OutcomesSolutions
Health Inequity Health Disparity
PublicHealth
HealthCare
Where We Live, Learn,
Work and Play

5. 5
To “move the dot
on the graph”,
we must also
see and apply
ourselves to
the 80%.

6. 6
Unclear risks to Manchester’s
and New Hampshire’s Future …
 Growth in aging, every-changing community diversity and family
structure.
 Significant increases in local poverty levels (especially among children)
compounded with a high cost of living.
 Unstable rates of uninsured and reliance on siloed social service
providers, public assistance programs, etc.
 Inappropriate and/or untimely use of care (at the wrong time and in the
wrong place, or not at all).
 Some community and neighborhood vulnerabilities exist (violence,
crime, unhealthy living and housing conditions).

7.  Nearly 8000 or 54% of Manchester school children were
enrolled in free and reduced meals. Of this total, 90% were
enrolled in free meals which means that the total family income for
these children were below 130% of the federal poverty guidelines
(MSD, March 2014).
 Over 40% of the City’s children under the age of 18 were living
in single-parent households (ACS, 2007-2011).
 On average, the MSD identifies nearly 800 students as being
displaced or homeless during a school year. In the City’s most
impoverished elementary schools, one in 15 children will live with
severe housing instability at least once in their lifetime.
 Of the 600 students who attended Beech St. Elementary School
last year, 400 of these children moved in and out of the school
during the academic calendar (SY 2013).
Our Community’s Children Are Living
With Instability and Vulnerability

8.  Manchester had 2,852 “habitually truant” students (NH DOE,
SY 2013). Over one in five of Title I elementary school children
experienced 10 or more half days of unexcused absences during
the school year. In total, it is estimated that nearly 7,000 children
of all ages are in need of some level of school attendance
intervention (MSD, SY 2011).
 Only 57% of Manchester’s third graders are reading
proficiently compared to 77% statewide. Variation in subgroups
(i.e.. FRL, LEP, minorities) is significant (NH DOE, SY 2013).
 16% four-year cumulative drop out rate compared to 5%
throughout the State of New Hampshire (NH DOE, SY 2013).
Our Children Are Struggling to Function
and/or Thrive Which, Unfortunately,
Serves as Our Barometer for the Change Needed

9. 9
Students Enrolled in Free/Reduced Meal Plans
(Living Below 185% of Federal Poverty Level)
Manchester School District vs. All Other New Hampshire,
School Years 03-04 to 11-12
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
SY 03-
04
SY 04-
05
SY 05-
06
SY 06-
07
SY 07-
08
SY 08-
09
SY 09-
10
SY 10-
11
SY 11-
12
%ofStudentsinGrades1-12
City of Manchester All Other NH
March 2014
Total 54.0%

10. 10
Vulnerable Population Footprint
One American
Journal of Public
Health study
determined that
graduation rate
improvements could
positively affect
health more than
medical advances
by an 8:1 ratio.

11. 11

12. When Community Violence Occurs Within
Its Safety Net Institutions, Neighborhood Trauma
Can Take Years, Even Decades, to Overcome

13. 13
Mapping Maternal and Child Health Risk of Lifetime Poverty
in Manchester, NH (Fredenburg, et. al.), 2014

15. Not everyone
experiences
health equally or
in the same way.

16. “In almost all urban areas,
serious health problems and unstable social
conditions are highly concentrated
in a fairly small number
of distressed neighborhoods.”

17.  Stressful events that are chronic, uncontrollable, and/or
experienced without the child having access to support
from caring adults disrupts the architecture of a young
person’s developing brain which can alter—in a lasting way
—the child's capacity to learn and to adapt to challenging
situations throughout their lifetime.
 Young children who experience toxic stress are at high
risk for a number of poor health effects in adulthood,
including cardiovascular disease, cancers, asthma, and
depression.
 The research has shown that even in the most extreme cases
of adversity, well-timed changes to children's environments
can improve outcomes.
The Directive to Act
With a “Clear, Unrelenting Focus”
- Dr. Michael McAfee, Director of the Promise Neighborhoods Institute at PolicyLink

18. There is a
Dose-Response
Relationship With
Adverse Childhood
Experiences (ACEs)
and Negative
Health Outcomes
Over the Lifespan

19. The Critical Connection:
Healthy Homes and Neighborhoods Matter
in the Development of Children and Families

20.  Policy, Systems, and Environmental (PSE) changes are
“interventions that modify environments to provide healthy
options and to make healthy choices easy for everyone”.
 If we focus on adapting policies, systems, and environments,
we can maximize resources by extending our impact to reach
more people.
 We must do this by harnessing convergent strategies, even if
the goals of the collaborating organizations are divergent.
 By modifying the environmental context, we can support healthy
choices across a population vs. an individual.
Meredith Truss, MPP Maryland Department of Health and Mental Hygiene
Health Policy Analyst Center for Cancer Prevention and Control, Prevention and Health Promotion Administration

21. 21
When population-based measures,
such as violent crime, high school
incompletion and inpatient asthma
visits occur at elevated rates,
a community-level, place-based
response is required in order to
reverse and prevent these trends.
This must be a shared responsibility
by all those who have the opportunity
to impact the lives of residents.
In fact, the current and future health
of our City depends on it.
Our Call to Action …

22. 22
Educational
Achievement
Economic
Wellbeing
Supportive
Living
Environments
Access to
Appropriate
Care
Healthier
Behaviors
Individual & Family Health Status
Social Capital – Networks –
Neighborhood Social Construct
Neighborhood Socio-Economic
& Physical Environment Social
Connectedness
and Safety
City of Manchester Health Department
www.manchesternh.gov/health

23. 23

24. Moving from Generational Poverty
To Generational Success

25. 25
NHIS Goals and Guiding Principles
 Prevent toxic stress and adverse childhood experiences.
 Attain health equity.
 Achieve environmental justice.

26. 26
Community Organizing Around Healthy
Neighborhoods and Healthy Kids …
Who Has The Power To Get Us There
and at What Level is it
Most Efficient for Them to Work?

27.  A community school is both place and
partnerships between the school and other
community resources.
 Using public schools as hubs, enduring
relationships are built among educators,
families and community members.
 This means:
Manchester’s Community
Schools Model
 Listening to our neighbors.
 Improving access to health care.
 Increasing social capital by coordinating
and organizing community-based events.
 Focusing on neighborhood improvement
efforts.

28. 28
Current Investment Portfolio
 Community care coordination (CHW’s).
 Healthy start with maternal and child health home
visiting.
 Proactive healthy home visits.
 Neighborhood and school-based events, family gyms and
fitness programming.
 Co-location of mental/behavioral health in the schools.
 Strengthening childhood resiliency.
 Building adult capacities.
 Pro-attendance case management (SW’s).

29. 29
Private-Public Partnerships Are Key …
And Provide An Opportunity to Reinforce
Community Values (Philanthropy, Art, Environment,
Neighborhood Pride, Healthy Living, etc.)

31. No crosswalks/ no walk
buttons
Local Park crosses the
street, but no way to cross
safely
Near local elementary
School
Speed of traffic

32. 32
Focus on Evaluation
Are we seeing the expected/anticipated outcomes?
 Continuous Quality Improvement to demonstrate small tests of
change for scalability and replication.
 Example: Decrease the % of habitually-truant students to 20% or less
by the end of SY2015
 Utilizing Promise/Results Scorecard to set up a centralized
database for monitoring process and outcome indicators.
 Developing a “MyManchester” Website to mutually share
neighborhood-relevant information as one step towards
authentically engaging residents in problem solving.

33. Where Do You See Yourself
in Community Change for the Better?

35. A Special Thanks to Our Supporters for Helping Us Build a
Collective Impact Model and More Strategic and Integrated Ways
to Plan/Fund/Foster the Change We, and the Residents,
Want to See in Our Neighborhoods
 Robert Wood Johnson
Foundation
 Granite United Way
 Endowment for Health
 NH Charitable Foundation
 Cogswell Benevolent Trust
 Norwin S. and Elizabeth
N. Bean Foundation
 The Dartmouth Institute
 HNH Foundation
 Corporate Sponsors
 Convergence Innovation Fund
 EPA
 New England Asthma
Regional Council
 NH Department of
Transportation
 US HUD Community
Improvement Program
 PolicyLink
 St. Mary’s Bank
 US DHHS

36. 36
Thank You !!!
QUESTIONS???
Great Links:
http://www.manchesternh.gov/Departments/Health/PublicHealthD
ata/ReportsandDocuments.aspx
https://www.youtube.com/watch?v=QN7VpIdtDpE
http://nhpr.org/topic/queen-city-crime
“Like” the MHD on Facebook:
https://www.facebook.com/CityOfManchesterNHHealth