Columbus Public Health (CPH) is the Health Department for the nation's 15th largest city, Columbus, Ohio. Its mission is to protect health and improve lives. With an annual budget of $50 million and 450 staff, CPH serves approximately 864,000 people living in Columbus and the City of Worthington (approximately 70% of Franklin County residents). The population of Franklin County is ethnically diverse with wide variations in socioeconomic level. Franklin County has a large new American population, and is home to the second largest Somali and the largest Bhutanese-Nepali communities in the U.S. Thirteen percent of the Franklin County population ages 5 years and older primarily speak a language other than English at home.
According to the most recent data released by the Ohio Medicaid Assessment Survey, nearly 50,000 low-income (under 200% of FPL) Columbus residents remain uninsured. This is significant among minority populations, as 28% of foreign-born residents in Franklin County remain uninsured. The Columbus neighborhoods most at risk for poor health outcomes and chronic diseases are also most adversely affected by housing, education, hunger and food insecurity, poverty, crime, unemployment, and trauma.
CPH was the second health department in the large” category to earn accreditation status in 2013 by the Public Health Accreditation Board (PHAB). The accreditation status provides a platform that supports staff in expanding innovation to provide high-quality services to the community in an efficient, financially-responsible manner. The department's strategic plan was updated in 2018 to place an emphasis on supporting staff with the resources needed to achieve our vision: to be Columbus' leader in identifying public health priorities and mobilizing resources and community partnerships to address them. Considering mental health, addiction, health equity, and the social determinants of health are cross cutting priority areas for all CPH programs.
Trauma affects individuals differently; their ability to cope in a healthy manner is dependent on many factors, including their level of resilience. Unhealthy coping behaviors are often present when individual resilience is low; the individual may engage in high-risk behaviors, or experience depression, poor mental health, and associated illnesses. Traumatized individuals and are more likely to suffer from depression, chronic diseases, stress, and ultimately commit acts of violence later in life.[1]
At the macro level, multiple factors that are connected to health outcomes have also been linked to trauma that is experienced by an entire community including: [2,3,4,5]
Economic instability and disinvestment in community resources
Limited access to safe, stable housing options
Insufficient community social services
Deteriorating public spaces
Inadequate provision of law enforcement personnel
Low sense of community social connectedness
The combination of conditions that foster individual and community trauma make it difficult for communities to implement strategies that promote health and well-being and prevent violence.
Foundational work for Columbus CARE (Community Action Resilience Empowerment) Coalition was initiated in 2015 after a particularly violent event occurred in the Hilltop neighborhood on Columbus' west side. What started as half-dozen City of Columbus social workers and police doing door-to-door outreach in the affected neighborhood has grown to include 200 individuals representing approximately 100 organizations who are committed to transforming Columbus into a trauma informed and resilient community.
In 2017, the CARE Coalition received pilot funding from 3 sources to support trauma-informed and resilience-building work in the Linden and Hilltop neighborhoods of Columbus over an 18 month period. CAREs focus on the Linden and Hilltop communities is based on the amount of trauma and violence that occur within these communities on daily basis. A logic model was created in order to guide the Coalition's work, define resilience, and determine metrics for measuring impact in the community. Objectives of the coalition include:
increasing community engagement for collective impact in addressing adverse childhood experiences (ACEs) & trauma
increasing community capacity for resiliency
strengthening a community culture of care and support for those actively experiencing trauma.
The coalition leveraged the expertise of a steering committee, six workgroups, and 4.5 full time employees to successfully implement 25 process objectives over the course of the pilot period. CARE members are engaged and passionate about creating a trauma-informed and resilient community. On any given month there are 40-60 members in attendance at the coalition meetings. Meetings are structured to include overall coalition celebrations and updates, workgroup breakouts, and partner agency highlights. The steering committee believes this helps members to stay connected to community-wide efforts, expand their networks with partner agencies, and stay engaged in tangible action items. The work of the coalition has also been integrated into the Mayor of Columbus' Comprehensive Neighborhood Safety Strategy that was created in November 2017 in response to an increase in homicides within the city.
Columbus Public Health Website: www.publichealth.columbus.gov
CARE Coalition Website: https://www.columbus.gov/publichealth/programs/Neighborhood-Services/Community-Resilience-Coalition/
References:
1. Finkelhor, D., & Ormrod, R. (2006). The nature and impact of peer and sibling violence on younger and older children. Child Abuse and Neglect, 30(12), 1401-1421.
2 David-Ferdon, C., & Simon TR. (2012). Striving To Reduce Youth Violence Everywhere (STRYVE) (United States, Centers for Disease Control and Prevention). Retrieved August 3, 2018, from https://www.cdc.gov/violenceprevention/pdf/stryve_foundational_resource-a.pdf
3. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Violence Prevention. (2018, February 20). Retrieved August 3, 2018, from https://www.cdc.gov/violenceprevention/overview/index.html
5. Cohen, L., Davis, R., Lee, V., & Valdovinos, E. (2010, May). Addressing the Intersection: Preventing Violence and Promoting Healthy Eating and Active Living. [Scholarly project]. In The Prevention Institute. Retrieved August 8, 2018, from https://www.preventioninstitute.org/sites/default/files/publications/VNPA_Addressing the Intersection_051810.pdf
Trauma defined in its simplest form is the state of being psychologically overwhelmed or a circumstance that overwhelms an individual's ability to cope. The high prevalence of trauma makes it a substantial public health concern. According to the ACE Study led by Kaiser Permanente- nearly 70% of their study participants indicated they had experienced at least one traumatic experience.[1] These results indicate how common trauma is among the population in general. The study looked at 10 childhood traumas including neglect, family incarceration, and physical and sexual abuse and became a key body of research to make the connection between trauma and subsequent health risks and behaviors. Furthermore, the study unveiled the root cause issues that must be addressed in order to make larger impacts on overall health and wellness. Untreated trauma can lead to risky health behaviors and poor physical and mental health outcomes such as obesity, drug and alcohol use, depression, and injury.[1] Applying a trauma informed care lens to public health programming, policy, system, and environmental changes is critical to create healthy, sustainable communities.
Although the majority of people will experience at least one traumatic event in their lifetime, people who live in underserved and impoverished communities know that when trauma happens to one, it happens to all. While trauma is experienced by the majority of people at some point throughout their lives, community trauma is another component that must be considered. It can be defined as cumulative emotional and psychological wounding as a result of group traumatic experiences that is transmitted across generations within a community. Unresolved grief and anger often accompany this trauma and contribute to physical and behavioral health disorders. This type of trauma is often associated with racial and ethnic population groups in the United States who have suffered major intergenerational losses and assaults on their culture and well-being [3]. Violence, poverty, and systemic racism are examples of community traumas that are experienced by Columbus residents; this was especially relevant in 2017 with the record-high number of homicides it the city. Community violence leaves residents perpetually feeling unsafe, isolated, and without the collective efficacy necessary to make positive change.
Due to unaddressed social determinants of health, the Linden and Hilltop communities of Columbus experience a disproportionate amount of individual and community trauma, which has manifested to a significantly increased rate of homicide and violent events experienced by the neighborhoods. Impactful data for each community include:
Life Expectancy- 73.1 years (Hilltop) and 65.2 years (Linden). The Franklin County average is 77.7.2
Percent of adults (over 25) without a high school diploma/GED- 28.4 (Hilltop), and 23.9 (Linden). The Franklin County percentage is 10.3
Percent of vacant homes: 8 (Hilltop) and 10.8 (Linden). The Franklin County percentage is 1.55
Violent Crime per 1,000 residents: 57.3 (Hilltop) and 47.7 (Linden). The Franklin County rate is 12.2.6
As previously noted, Columbus has experienced a significant increase in community violence and homicides since 2016, with 2017 being recorded as the deadliest year in the city's history. In response, the Mayor created a Comprehensive Neighborhood Safety Strategy (CNSS) in late 2017. The CNSS is an eight-pronged approach to investing in innovative programs and collaborating with partners to build stronger sand safer neighborhoods through a multi-sector approach. In addition to the Violent Crime Review Group, which serves to identify patterns and trends across homicides, the CARE Coalition is one of two CNSS strategies housed at CPH. The CARE Coalition is also represented in the Violent Crime Review Group to offer a trauma informed perspective for details surrounding homicides that the group reviews. The CNSS also prioritizes its efforts in the Linden and Hilltop neighborhoods.
The Hilltop neighborhood was devastated following the tragic deaths of three members of a family living in the community in 2015.CPH social workers, accompanied by officers of the Columbus Division of Police walked a two-block radius around the crime scene to knock on the doors of residents in the midst of tragedy. Coupled with the daily realities of a severely impoverished neighborhood, the grief and trauma experienced by Hilltop residents in the aftermath of this crime created an overwhelmingly urgent situation for the community. From the trauma of that event, CPH's CARE Coalition was born with the mission of creating a trauma informed communities, where community leaders and partner agencies understand the effects of trauma, recognize it when it happens, and are able to support residents in a way that promotes resilience and healing. CARE members are rooted in the belief that when trauma happens to one, it happens to all.' It is important to acknowledge that all individuals experience trauma; mental health, public health, and social service providers must not be ill-equipped to attend to the trauma of others.
Although many realized the need for action in 2015 following the triple homicide in the Hilltop, there was no collective community effort to address trauma in Columbus communities until the CARE Coalition was established in 2016. It has evolved to be an inclusive, collaborative effort to reduce trauma and build community resilience. Upon formation, the coalition agreed on several guiding principles:
Bring services and support to neighborhoods that have experienced trauma
Offer care and support
Create a sense of collective ownership for community trauma
A coalition focused solely on community trauma is not traditionally housed at local health departments. Strategically placing the CARE Coalition under the guidance and support of Columbus Public Health offers both credibility and community visibility to the effort. The coalition benefits from applying systematic, evidence-based, multi-sector public health approaches to impacting trauma. Through its location at CPH, the coalition is able to more efficiently partner with organizations from various health-related disciplines. Thus, CARE applies a cross-cutting lens of trauma informed care and community resiliency that advances the work of the Columbus Community Health Improvement Plan health priorities. Since it falls under the larger governmental umbrella of the City of Columbus, the coalition has the unique benefit of collaboration with other city departments including Parks and Recreation, Public Safety, Development, and Neighborhoods. Finally, it also provides another platform to connect residents with the multitude of medical and wellness services that CPH provides to underserved individuals and communities.
References:
1. Centers for Disease Control and Prevention. Adverse Childhood Experiences Study (2016) https://www.cdc.gov/violenceprevention/acestudy/index.html
2. Substance Abuse and Mental Health Services Administration. SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
3.. Ohio Department of Health Vital Statistics Data, Analyzed by Columbus Public Health
4. Types of Trauma. SAMSHA (2016) https://www.samhsa.gov/trauma-violence/types
5. US Census American Community Survey 5-Year Estimates
6. Ohio Department of Job and Family Services
7. City of Columbus, Department of Development
8. City of Columbus, Division of Police
Since the pivotal homicide mentioned above, the CARE coalition has grown to over 200 individual members representing approximately 100 organizations. In early 2017, the Ohio Attorney General's office and Columbus City Council learned about the mission and promising collaboration of the Coalition. Each organization provided the coalition with grant funding for an 18 month pilot period (June 19, 2017 to December 31, 2018) and tasked the coalition with completing trauma-related activities in the Linden and Hilltop neighborhoods. Managing and facilitating a coalition the size and scope of CARE requires a great deal of commitment from community partners and the home organization. CPH also funded 4.5 full time employees from the general operating fund to aid and support the work of the coalition.
A 10 member steering committee was quickly formed that consists of community social workers, clinicians, trauma-informed trainers, and community planners. These members represent a variety of agencies including one that provides services to new Americans as well as the city's Department of Development, which has deep community roots. The Steering Committee presented the growing coalition with a logic model that considered key drivers, objectives, actions/metrics, and broad goals. Coalition impact goals include:
1. Systematically increase education among Columbus residents and community service providers about psychological trauma and trauma-informed care approaches
2. Build an infrastructure for rapid response to traumatic events that affect an entire community
3. Directly engage residents in high-risk neighborhoods experiencing trauma and inequity from a trauma-informed perspective in order to increase resiliency in individuals, families and Columbus communities
4. Create a strong network of providers and community members to address community trauma
To accomplish the 25 process objectives that accompanied the pilot period funding, the Steering Committee also established six workgroups that are charged with meeting these objectives with assistance from the CPH CARE staff. Workgroups include: Community Outreach; Community Trauma Resource Team; Networking; Outcomes; Trauma Training; and Trauma Resource Guide. Key process objectives from the pilot period included:
Hosting listening sessions to best understand trauma
Relationship building with faith communities to promote intersectionality of faith and resilience
Providing trauma responsive care trainings within the community
Offering proactive community events around mental wellness
Providing crisis response to residents following trauma
Developing neighborhood committee meetings to engage residents around action oriented resilience processes
Developing, administering, and analyzing a community survey that examines trauma and resiliency in both the Linden and Hilltop neighborhoods
Since the start of the pilot period, the coalition has successfully engaged 200 individuals representing approximately 100 organizations from a variety of sectors including healthcare public safety, public and higher education, and local government. These partners attend monthly coalition meetings) and separate monthly workgroup meetings when necessary. In addition attending the general coalition meeting, and facilitating/co-facilitating workgroup meetings, Steering Committee members are expected to attend monthly meetings and an annual retreat. The Steering Committee is also very involved in reporting outcomes, planning celebration events, and determining annual strategic and work plans.
CARE's strength as a coalition is highly attributable to the variety of partners that are committed to the work of community resilience. By nature a resilient community relies on multiple systems to take part to support healing and the Coalition has paved the way for this and worked to uplift existing efforts. CARE's work is community driven through diverse representation and partnerships. Many are serving a wide variety of residents on a daily basis and contribute to a larger perspective. Each and every month, CARE is involved in various community driven programs through partners and by leading activities. Collectively, CARE works dedicates a quarter of the year to specific community oriented issues such as those faced by young men of color.
The CARE pilot period expires on December 31, 2018. The main component of evaluating the work of the coalition was to identify whether or not the 25 process objectives were met. Additional activities and events are happening during the final weeks of December, the CARE team and Steering Committee is proud to stratify its accomplishments, which met the 25 process objectives set for the pilot period, into 3 categories:
Connecting with Residents:
Engaged with 150 residents during 10 listening sessions to best understand how trauma is affecting them
Knocked on 3,189 doors to offer support to community members and build relationships
Attended over 70 community outreach events with a high concentration in the Linden and Hilltop, with goal of seeking key partnerships to increase community recognition of the coalition
Surveyed 305 residents to better understand their perceptions on trauma, resilience, trust, and safety
Hosted a remembrance vigil for 75 families that have been impacted by violence
Responding to Crises and Trauma
Reached 532 homes via community debriefs, and door-to-door canvassing in response to 30 traumatic events
Facilitated an event for 73 individuals to complete NOVA (National Organization for Victims Assistance) crisis response training, including 6 Linden and 2 Hilltop residents
Assisted 26 coalition members to earn certifications in in trauma-responsive care
Served as a subject matter expert in trauma and resilience for the City of Columbus Violent Crime Review Group
Shared strategies to apply trauma informed and responsive principles with 115 sexual assault advocates
Educating Stakeholders:
Trained over 500 community residents in Trauma Responsive Care training- a modality that goes beyond Trauma Informed Care to provide tangible trauma based solutions for everyday practice
Created a Trauma Resource Guide to provide residents with a first step in accessing trauma services
Held 30 community meetings to implement resilience-based interventions at the community level
The process objectives were identified and carried out to maximize community outreach and engagement. Many objectives work to create power structures with community residents and uplift their voice and preferences in healing and increasing awareness around trauma and resilience.
Another component of CARE's evaluation plan is the community survey. CARE Steering Committee members recognized that data on violence and trauma is rare, especially at the local level. Thus, staff and coalition members sought to address this lack of data by developing and administering a community survey on crime, safety, trauma, trust, and resiliency during the pilot period. Three objectives of the survey project were established:
Establish baseline metrics of residents' perceptions of crime, safety, trauma, trust, and personal resiliency in Columbus' Hilltop and Linden neighborhoods
Fill a crucial data gap that public health practitioners and community stakeholders need to better understand the needs of these neighborhoods, and therefore, implement interventions that treat trauma and violence as local public health issues
Use the survey data to inform and guide CARE's activities and programs in Hilltop and Linden
CARE staff and Coalition members reviewed literature of existing approaches and instruments for measuring trauma and resilience at the local level.1 The final survey tool included both newly developed questions and those adapted from existing instruments. Respondents were asked questions across several topic areas: crime, safety, trust and support, trauma, and self-perceived resiliency. Adult (18+) residents of Hilltop and Linden (defined by their ZIP code of residence) were recruited using convenience and snowball sampling, with trained surveyors administering the questionnaire at community events and popular local venues from July to October of 2018. All surveys were collected in person after informed consent was obtained from the respondent. There were no incentives for completing the paper questionnaire. No identifying information was collected and surveys were kept confidential. The study received Institutional Review Board Approval through the Ohio Department of Health, in addition to approval from the CPH Research Review Committee.
Three hundred and five (305) surveys were collected (154 in Hilltop and 151 in Linden). The survey respondents were primarily female and Black/African American. The mean age of respondents was 39 years, and approximately 75% of the respondents had an annual household income less than $40,000. Although this was not a representative sample, the survey respondents do reflect the typical residents of these neighborhoods. Given the high population prevalence of trauma according to the literature, it was not surprising that nearly 80% of survey respondents indicating that they had ever experienced trauma. Additionally, only 15% of respondents were classified as highly resilient. These findings further affirm the need for CARE's work in Hilltop and Linden.
Preliminary findings of the survey revealed several implications for CARE's current practices and ongoing monitoring and evaluation. Respondents from both Hilltop and Linden placed the most trust in individuals from their places of worship as well as healthcare professionals. Thus, CARE will prioritize its partnerships with religious and healthcare organizations in order to best reach those in need of their services. Linden respondents felt police were best suited to deal with crime, while Hilltop respondents felt that community residents were best suited. Thus, the focus of the Coalition's trauma-informed initiatives should differ by neighborhood when considering crime and violence prevention. The results of the survey has provided CARE staff and Coalition members with invaluable resident perspectives to inform the ongoing evaluation of the work of the pilot period. This data has been crucial to modifying the work of the Coalition and planning for the years following the pilot.
The same survey will be conducted in the South Side neighborhood of Columbus, as CARE expands its work to that community. Thus, the same baseline metrics will be collected for each neighborhood, streamlining evaluation processes. Once the coalition is more formally connected within these 3 neighborhoods, brief surveys to measure key outcomes including resiliency and perceptions of community support will be administered. This data will assist CARE in quantifying its capacity to meet its objectives of:
increasing community engagement for collective impact in addressing adverse childhood experiences (ACEs) & trauma
increasing community capacity for resiliency
strengthening a community culture of care and support for those actively experiencing trauma
References:
1. Windle et al. (2011) A methodological review of resilience measurement scales. Health and Quality of Life Outcomes. 9(8).
The composition of CARE's Steering Committee is significantly different than the initial group in 2016. While some partners remain active on the committee, other partners remain active in the general coalition but have transitioned out of a leadership role. Recognizing this shift, the Steering Committee assessed its structure in the fall of 2018 and released an application to solicit replacement steering committee members. They received many applications, indicating a strong interest from members to sustain the coalition's efforts and a willingness to think progressively about expanding CARE's reach into the community.
Columbus Public Health's chief of Neighborhood Social Services will continue to provide high-level management and direction for the Coalition upon the end of the pilot period. This consistent leadership, combined with an increase in funding, will facilitate sustainability for years to come. CPH has committed two additional positions to the CARE coalition in 2019, bringing the total CARE staff to 7 full time employees including:
1 program director/social worker
2 program managers/social workers (both Social Workers)
2 community outreach coordinators
1 administrative assistant
At the Steering Committee annual retreat, members prioritized focus areas for 2019. These to include but are not limited to the following:
Continuing moving toward the creation of a trauma informed and resilient community
Aligning coalition work with state and local policy around trauma informed care in public education settings
Capitalizing on the diversity of partner organizations and leveraging assets for collective impact
Educating local funders about how to apply a trauma informed lens to community building Requests for Proposals ( RFPs) and what it takes to create a culture of community resiliency
Training partner agencies on resiliency within their workforce
Apply lessons learned from the pilot period as the coalition expands efforts to Columbus' Southside neighborhood