2019 San Francisco Community Health Needs Assessment
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San Francisco Community Health Needs Assessment 2019
Table of Contents
A Message from SFHIP............................................3
Message from the Director of Health
A
for the City and County of San Francisco..................... 4
Acknowledgments..................................................5
Executive Summary................................................6
HE 2019 COMMUNITY
T
HEALTH NEEDS ASSESSMENT ................8
Purpose and Collaborators.......................................9
Approach............................................................ 10
Community Health Status Assessment................. 10
Assessment of Prior Assessments........................ 11
Community Engagement................................... 11
Health Need Identification................................. 12
San Francisco Snapshot......................................... 13
Major Findings..................................................... 15
Foundational Issues.............................................. 16
Poverty........................................................... 16
Racial and Ethnic Inequality............................... 17
Health Needs....................................................... 20
ccess to Coordinated, Culturally, and
A
Linguistically Appropriate Care and Services........ 20
Food Security, Healthy Eating,
and Active Living.............................................. 21
Housing Security and an
end to Homelessness........................................ 24
Safety from Violence and Trauma........................ 26
Social, Emotional, and Behavioral Health............. 30
References.......................................................... 35
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San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 2
A Message from SFHIP
It is our pleasure to share with you the 2019 San Francisco Community
Health Needs Assessment. On behalf of the members of San Francisco Health
Improvement Partnership (SFHIP), we hope you find this information useful
in planning and responding to the needs of our community.
We would like to thank the many individuals including Many health needs were identified through this
community residents, community-based organizations, assessment including: access to coordinated, culturally
and health care partners that contributed to this and linguistically appropriate care and services; food
assessment. A special thank you goes out to the security, healthy eating and active living; housing security
Community Health Needs Assessment and Impact Unit and an end to homelessness; safety from violence and
of the San Francisco Department of Public Health for trauma; and social, emotional, and behavioral Health.
their work on the data analysis and overall project Additionally, poverty and racial health inequities were
management, and to the Backbone of SFHIP, staffed by identified as structural and overarching issues which must
the Department of Public Health, the Hospital Council, be addressed to ensure a healthy San Francisco for all.
and the University of California at San Francisco, for
their support for the project. SFHIP recognizes that all San Franciscans do not have
equal opportunity for good health, and we are committed
This Community Health Needs Assessment (CHNA) is to eliminating health disparities and inequities by
part of an ongoing community health improvement working together across sectors to achieve health equity
process. The CHNA provides data enabling identification for all. We hope you find this assessment useful and we
of priority issues affecting health and is the foundation welcome any suggestions you may have for assisting us
for citywide health planning processes including the in improving the health of San Francisco.
Community Health Improvement Plan, the San
Francisco’s Health Care Services Master Plan, the San
Francisco Department of Public Health’s Population
Health Division’s Strategic Plan, and each San Francisco
non-profit hospital’s Community Health Needs
Assessment and Implementation Strategy.
A Community Health Improvement Plan (CHIP) is being
developed as a companion to this document and will
detail goals, objectives and action plans for each of the
focus areas identified.
SFHIP Co-Chairs
Jim Illig,
Kaiser Permanente San Francisco
Amor Santiago,
Asian and Pacific Islander Health Parity Coalition
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 3
A Message from the
Director of Health
PHOTOGRAPH: MIKE HOFFMAN
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 4
Acknowledgments
San Francisco Health Improvement Partnership Steering Committee San Francisco Department of Public Health
AMOR SANTIAGO ESTELA R. GARCIA KEVIN GRUMBACH MONIQUE LESARRE Nora Anderson Mary Hansel Sharon Pipkin
Asian and Pacific Islander Chicano/Latino/Indigena Clinical & Translational African American Community Laura Braining-Rodriguez Ling Hsu Uzziel Prado
Health Parity Coalition Health Equity Coalition Science Institute’s Health Equity Council Brandon Ivory Priti Rane
Katie Burk
Community Engagement
ANGELA SUN FLOYD TRAMMELL SAEEDA HAFIZ Curtis Chan Karen Kohn Chris Rowe
& Health Policy Program,
Chinese Hospital SF Interfaith Council San Francisco Unified Mia Lei Veronica Shepard
UCSF Carol Chapman
School District
KATE WEILAND JENNIFER VARANO Shrimati Data Dedriana Lomaz Maryna Spiegel
KIM SHINE
Sutter Health California Saint Francis Memorial SHALINI IYER Zea Malawa Marianna Szeto
San Francisco Health Derek Smith
Pacific Medical Center Hospital Metta Fund
Services Network Cristy Dieterich Devan Morris Mimi Tam
DEENA LAHN JIM ILLIG TOMAS ARAGON Shivaun Nestor Ana Validzic
ALEXANDER MITRA Patricia Erwin
San Francisco Community Kaiser Permanente Population Health Division,
St. Mary’s Medical Center Margaret Fisher Rita Nguyen Megan Wier
Clinic Consortium San Francisco San Francisco Dept of Public
Health Patrick Fosdahl Trang Nguyen Tiffany Yim
Joanna Fraguli Israel Nieves Janine Young
Jenna Gaarde Amy Nishimura
Community Health Needs Assessment Hospital Council of
Leadership and Major Contributors Northern & Central Dale Gluth Melissa Ongpin
California Christina Goette Prasanthi Patel
Ameerah Thomas, San Francisco Michelle Kirian, San Francisco
Department of Public Health Department of Public Health David Serrano Sewell Sneha Patil
Laura Goria Susan Philip
Ayanna Bennett, San Francisco Paula Fleisher, Department
Department of Public Health University of California at San
Jason Xu, San Francisco Department
Francisco University of California
at San Francisco Community Partners
of Public Health Paula Jones, San Francisco
Department of Public Health Mory Chhom, Vietnamese Youth Development Center
Jodi Stookey, San Francisco Kaya Balke Alex Rutherford
Department of Public Health Priscilla Chu, San Francisco Mollie Belinski Ma Somsouk Debbie Lerman, San Francisco Human Services Network
Department of Public Health Nicholas Evans Roberto Vargas Ellen Moffatt, San Francisco Office of the Chief Medical Examiner
Lauren Swain,
University of San Francisco Victor Kong, San Francisco Laura Fejerman Priyanica Vyas Stefan Nilsen, University of San Francisco
Department of Public Health Stan Glanz Susan Wang
Matt Wolff, San Francisco Karma Smart, Rafiki Coalition for Health and Wellness
Department of Public Health Wylie Liu, University of California Robert Hiatte Erica Wong Pedro Vidal Torres, Center for Open Recovery
at San Francisco
Max Gara, San Francisco Carmela Aileen Xu
Karen Zeigler, San Francisco Office of the Chief Medical Examiner
Department of Public Health Lamonaco
Meg Wall-Shui, San Francisco James Rouse
Department of Public Health Iñiguez
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 5
Executive Summary
Welcome to the Community Health Assessment (CHNA). The CHNA takes a broad view of health
conditions and status in San Francisco. In addition to providing local disease and death rates, this CHNA also
provides data and information on social determinants of health —social structures and economic systems which
include the social environment, physical environment, health services, and structural and societal factors.
The CHNA involves four steps: The CHNA identifies two foundational issues contributing to
• Community health status assessment local health needs:
•R acial health inequities
• Assessment of prior assessments
•P overty
• Community engagement
• Health need identification and prioritization The CHNA identifies five health needs that heavily impact
disease and death in San Francisco:
The CHNA is the foundation for each San Francisco non-profit •A
ccess to coordinated, culturally and linguistically
hospital’s Community Health Needs Assessment and is one of the appropriate care and services
requirements for Public Health Accreditation. While the CHNA •F
ood security, healthy eating and active living
informs large-scale city planning processes such as San Francisco’s
•H
ousing security and an end to homelessness
Health Care Services Master Plan, the intent of this document is to
•S
afety from violence and trauma
inform the work of all organizations, teams and projects that impact
•S
ocial, emotional, and behavioral health
the people of San Francisco. Gaining an understanding of why health
outcomes exist here in San Francisco can help gear our efforts
towards addressing root causes and developing better interventions, Foundational Issues
policies and infrastructure. SFDPH’s mission to protect and promote Racial Health Inequities
the health of all San Franciscans, we all have a contribution to
Health inequities are avoidable differences in health outcomes
achieving this goal, no matter the scale or scope of our work.
between population groups. Health inequities result from both
the actions of individuals (health behaviors, biased treatment by
Overall, the CHNA finds that health has improved in
health professionals), and from the structural and institutional
San Francisco:
behaviors that confer health opportunities or burdens based on
• More San Franciscans have insurance.
status. For example, the uneven distribution of wealth and
•T he estimated rate of new HIV infection in San Francisco
resources determines the level of health those getting the least
continues to decrease.
of these resources can achieve. Pages 17–19 include data on a
•L ife expectancy increased for all San Francisco with the
few improvements to health and determinants of health and
biggest gains seen by Black/African Americans.
point to where more work needs to be done to address the
•M ortality rates due to lung, colon, and breast cancers and
structural and institutional racism in San Francisco. Additional
influenza and pneumonia continue to decline.
data on health inequities are found throughout the Community
•T he availability of tobacco products has decreased. At 11%,
Health Data pages.
rates of smoking are lower than the HP2020 goal of 12%.
•2 017 had the lowest number of traffic-related fatalities
since record keeping began in 1915.
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 6
Executive Summary
Poverty Housing Security and an End to Homelessness
Enough income generally confers access to resources that Housing is a key social determinant of health.1 Housing stability, quality,
promote health — like good schools, health care, healthy food, safety, and affordability all have very direct and significant impacts on
safe neighborhoods, and time for self-care — and the ability to individual and community health. Much of California, and especially the
avoid health hazards — like air pollution and poor quality housing Bay Area, is currently experiencing an acute shortage in housing, leading
conditions. Page 16 focuses on the economic barriers to health to unaffordable housing costs, overcrowding, homelessness and other
that many San Franciscans face. Find additional data on associated negative health impacts. Between 2011 and 2015, the Bay
economics and health in the Economic Environment data page. Area added 501,000 new jobs — but only 65,000 new homes. An
estimated 24,000 people in San Francisco live in crowded conditions
Health Needs and about 7,500 homeless persons were counted in San Francisco.
Pages 24 – 25 provide an overview of the housing stressors in
Access to Coordinated, Culturally and Linguistically
San Francisco. Additional information on housing and health is found
Appropriate Care and Services
in the Housing data page.
San Francisco continued to see gains in access to health care
with 10,000 fewer residents uninsured in 2017 than in 2015. Safety from Violence and Trauma
However, an estimated 3.6% of the population, or 31,480 Violence not only leads to serious mental, physical and emotional injuries
residents, still do not have health insurance. Furthermore, and, potentially, death for the victim, but also negatively impacts the
access to services is influenced by location, affordability, hours family and friends of the victim and their community. Persons of color are
of operation, and cultural and linguistic appropriateness of more likely to be victims of violence, to live in neighborhoods not
health care services. Page 20 presents perceived to be safe and to inequitable treatment through the criminal
San Francisco statistics on health care use, barriers to use, and justice system. Pages 26 – 29 focus on violence and trauma, their
consequences of not having access to quality care. Additional determinants and health impacts in San Francisco. Additional data on
information on health care quality and access is located in the violence and trauma in the City are presented in the Crime and Safety
Health Care Access and Quality data page. data page.
Food Security, Healthy Eating and Active Living Social, Emotional, and Behavioral Health
Inadequate nutrition and a lack of physical activity contribute to Mental health is an important part of community health. In San
9 of the leading 15 causes of premature death in San Francisco
Francisco the number of hospitalizations among adults due to major
— heart failure, stroke, hypertension, diabetes, prostate cancer,
depression exceed that of asthma or hypertension. Presence of mental
colon cancer, Alzheimer’s, breast cancer, and lung cancer.
illness can adversely impact the ability to perform across various facets of
Studies have shown that just 2.5 hours of moderate intensity life — work, home, social settings. It also impacts the families,
physical activity each week is associated with a gain of caregivers, and communities of those affected. Substance Abuse
approximately three years of life. Data on physical activity and including drugs, alcohol and tobacco, contributes to 14 of the top causes
healthy eating and barriers to each are presented on pages of premature death in the City — lung cancer, COPD, HIV, drug overdose,
21–23. Additional data are available in the Physical Activity, assault, suicide, breast cancer, heart failure, stroke, hypertensive heart
Transportation, Crime and Safety, Overweight and Obesity, and disease, colon cancer, liver cancer, prostate cancer, and Alzheimer’s.
Nutrition data pages. Pages 30 – 34 focus on psychological distress, major depression, and
substance abuse in San Francisco. Find additional data on social,
emotional and behavioral health in the City in the Mental Health,
Substance Abuse, and Tobacco Use and Exposure pages.
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 7
The 2019
Community
Health Needs
Assessment
Purpose and Collaborators 9
Approach 10
San Francisco Snapshot 13
Major Findings 15
References 35
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 8
Purpose & Collaborators
The 2019 Community Health Needs Assessment (CHNA) takes a comprehensive
look at the health of San Francisco residents by presenting data on demographics, socioeconomic
characteristics, quality of life, behavioral factors, the built environment, morbidity and mortality,
and other determinants of health status.
Health Care
Services
Master Plan
CHNA Public Health
Accreditation
Hospitals’
Community Community Health
Benefits Plans Improvement Plan
Hospitals’
Community Health Other Planning
Needs Assessments Processes
The CHNA is the foundation for each of San Francisco’s The San Francisco Health Improvement Partnership
non-profit hospitals’ Community Health Needs Assessments (SFHIP) guided CHNA development. SFHIP is a collaborative
and is one of the requirements for Public Health Accreditation, body whose mission is to embrace collective impact and to
which includes: a CHNA, a community health improvement improve community health and wellness in San Francisco.
plan, and a strategic plan for population health. The CHNA Membership in SFHIP includes the San Francisco Depart-
also informs city planning processes such as San Francisco’s ment of Public Health, San Francisco’s non-profit hospitals,
Health Care Services Master Plan. the Clinical and Translational Science Institute’s Community
Engagement and Health Policy Program at UCSF, the San
While the CHNA informs large-scale city planning pro- Francisco Unified School District, The Office of the Mayor,
cesses, the intent of this document is to inform the work of community representatives from the Asian and Pacific
all organizations, teams and projects that impact the people Islander Health Parity Coalition, Human Service Network,
of San Francisco. Gaining an understanding of why health Chicano/Latino/Indigena Health Equity Coalition, and African
outcomes exist here in San Francisco can help gear our American Community Health Council, Community Clinic
efforts towards addressing root causes and developing Consortium, Faith based and philanthropic partners. SFHIP
better interventions, policies and infrastructure. completes a CHNA once every three years.
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 9
Approach
The Community Health Needs Assessment SAN FRANCISCO FRAMEWORK FOR ASSESSING POPULATION HEALTH AND EQUITY
takes a life course approach when exploring and
presenting the health needs of San Franciscans. UPSTREAM Root Causes DOWNSTREAM Consequences
A life course approach considers one’s lived experience and health
throughout the lifespan, within the context of their history, environment,
family, community, society, and culture. Certain events and exposures
(i.e. trauma, racism, poverty, environmental factors, etc.) during sensitive
time periods in early life can have long-term impacts on development and
health.1 Belief Living Health Health
Systems Conditions Behaviors & Well-Being
Cultural/ PHYSICAL ENVIRONMENT Nutrition QUALITY OF LIFE
In addition to impacting one’s own future health status, early life Societal Values Land Use Physical Activity FUNCTIONING
experiences can have intergenerational health outcomes. One’s Discrimination/ Transportation Tobacco Use CLINICAL HEALTH
Stigma
wellness during the prenatal or pregnancy periods impacts the health of Housing Alcohol and Other Drugs Communicable Disease
Natural Environment Oral Health Chronic Disease
one’s children. Investing in pregnancy, early childhood, and family Sexual Health
SOCIAL ENVIRONMENT Injury
wellbeing through policies, interventions and systems can support our Preventive Care Mental Health
Social Cohesion
society and address the root causes of health inequities. Safety
Sleep
ECONOMIC ENVIRONMENT
Data Collection Educational Attainment
Institutional Employment
The CHNA collected information on the health of San Franciscans via Income
Policies &
three methods: Practices Occupational Safety
SERVICE ENVIRONMENT Psychosocial
• Community Health Status Assessment Public Policies Health Care Factors
Organizational
• Assessment of Prior Assessments, and Practices
Social Services
Stress
Education Lack of Control
• Community Inclusion. Reactive Responding
Resilience Death
Through review of the information provided by these sources, SFHIP
identified San Francisco’s health needs.
Community Health Status Assessment
Health is a state of complete physical, mental, and social well-being and
not merely the absence of disease or infirmity.2 While biology, genetics, Community Health
INTERVENTIONS
Strategic Capacity Building Promotion &
and access to medical services are largely understood to play an Partnerships Prevention Medical
Community Care
important role in health, social-economic and physical environmental Advocacy Organizing Civic Case
conditions are now known to be major, if not primary, drivers of health.2-4 Engagement Management
These conditions are known as the Social Determinants of Health and are
shaped by the distribution of money, power, and resources throughout
local communities, nations, and the world.5
EVIDENCE BASED POLICY MAKING
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 10Approach
Recognizing the essential role social determinants of health play in three health equity/parity coalitions, UCSF health SFHIP Key Informant Group Interview
the health of San Franciscans, the Community Health Status professions students, and UCSF Clinical and Translational One focus group was comprised of SFHIP members who
Assessment examined population level health determinant and Research staff began conducting online searches for are all subject matter experts. Two series of questions
outcome variables. We used the San Francisco Framework for published assessment reports for the 2019 CHNA. were asked, “What are the healthiest characteristics of
Assessing Population Health and Equity, which is a modified this community? What supports people to live healthier
version of the Public Health Framework for Reducing Health For this assessment, the San Francisco Framework lives?” and “What are the biggest health issues and/or
Inequities published by the Bay Area Regional Health Inequities for Assessing Population Health and Equity was used conditions your community struggles with? What do you
Initiative to guide variable selection.3 We ranked and selected to define “Root Causes” that reflect social determinants. think creates those issues?”.
available variables based on the Results Based Accountability Additionally, the Working Group decided to add
criteria for indicator selection — communication power (ability to incarceration, experience with law enforcement, and Equity Coalition focus groups
communicate to broad and diverse audiences), proxy power (says community development/investment to the framework. Three focus groups were conducted with each of the three
something of central significance), and data power (available health equity coalitions in San Francisco: The Chicano /
regularly and reliably), as well as the ability to examine health Further details on methods used and findings are pre- Latino / Indigena Health Equity Coalition, The Asian
inequities and current use by stakeholders. Furthermore, we sented in the Assessment of Prior Assessments page. Pacific Islander Healthy Parity Coalition, and The African
hosted meetings throughout 2017 to gather feedback on American Health Equity Coalition. Using the Technology
indicators from experts and community representatives. In all, Community Engagement of Participation (ToP) Consensus Method, the question
171 variables were analyzed. We present the results from all posed to each focus group was, “What actions can we
The goals of the community engagement component of the
analyses in 30 Community Health Data pages. take to improve health?”
CHNA are to:
Assessment of Prior Assessments • Identify San Franciscan’s health priorities, Food Insecure Pregnant Women focus groups
especially those of vulnerable populations Four focus groups were conducted with women who
San Francisco’s community-based organizations, healthcare
service providers, public agencies and task forces conduct health • Obtain data on populations and issues for which experienced food insecurity while pregnant. Each focus
we have little quantitative data group focused on a different group of women: Spanish,
needs assessments and publish reports of their activities for
• Build relationships between the community Chinese, multi-ethnic English speakers, and African
planning and evaluation purposes and to be accountable to
and SFHIP American. The question to respond to was, “What actions
those they serve. Our aim in conducting an assessment of these
can we take to improve your food needs?”
assessments and reports is to augment what we know from • Meet the regulatory requirements including the IRS
routinely collected secondary health data and primary data rules for Charitable 501c3 Charitable Hospitals,
collection through CHNA community engagement activities. We Public Health Accreditation Board requirements for Kaiser led focus groups
hope thereby to gain a better understanding of which communities/ the San Francisco Health Department, and the San Kaiser conducted four focus groups, one each with
populations in San Francisco have been engaged in health needs Francisco’s Planning Code requirements for a Health Kaiser Permanente leadership, Kaiser Permanente staff,
assessment activities; what topics are of concern and interest to Care Service Master Plan Spanish-speaking parents on youth healthy eating and
these communities/populations; and learn about promising and active living, and homeless and/or HIV positive youth.
effective approaches to eliciting and addressing these concerns. The 2019 CHNA includes 4 categories of focus groups:
We included both needs assessments and service reports in our SFHIP key informant group interview, Equity Coalition Further details on the methods and findings are available
definition of “assessments” for this assessment. focus groups, food insecure pregnant women focus in the Community Engagement page.
groups, and Kaiser focus groups.
Beginning in January 2017, CHNA administrative leads from
the SF Department of Public Health and UCSF and a small
Working Group consisting of members of San Francisco’s
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 11Approach
Health Need Identification Figure A: Consensus development steps
To identify the most significant health needs in San Francisco
the SFHIP steering committee met on October 18th, 2018. 1 Individually listing of top health needs
Participants identified health needs through a multistep
Small group discussions on the top health needs to identify
process. First participants reviewed data and information 2
similarities and differences
from the Community Health Status Assessment, the
Assessment of Prior Assessments, and the Community 3 Sharing all the health needs identified by the individuals
Engagement, as well as the health priorities from the 2016
Community Health Improvement Plan. Then, using the 4 Clustering the similar health needs into themes
Technology of Participation approach to consensus
development, participants engaged in a focused discussion 5 Determining a name for the theme, which is the health need
about the data. Finally, participants developed consensus on
the health needs. (Figure A) Throughout the process needs Comparing and discussing new needs with those
6
from 2012 Community Health Improvement Plan
were screened using pre-established criteria (Figure B).
Thisprocess yielded two foundational issues and five
health needs.
Figure B: Health need screening criteria
Foundational issues are needs which affect health at
Health need is confirmed by more than one indicator and/or data source
every level and must be addressed to improve health in
San Francisco. Need performs poorly against a defined benchmark(s)
Health needs include health outcomes of morbidity and mortality as well as
The two foundational issues identified were: behavioral, environmental, clinical care, social and economic factors that impact
health and well-being.
• Poverty
• Racial health inequities
The five health needs identified were:
• Access to coordinated, culturally and linguistically
appropriate care and services
• Food security, healthy eating, and active living
• Housing security and an end to homelessness
• Safety from violence and trauma
• Social, emotional, and behavioral health
Data describing part of each of the foundational issues and
health needs are located in the Major Findings pages and in
the various Community Health Data pages.
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San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 12San Francisco Snapshot
Population Growth growth in California (6 percent).2 By 2030, San Francisco’s children is projected to rise.2,5 As of 2017, San Francisco is
San Francisco is the cultural and commercial center of the population is expected to total more than 980,000. home to 67,740 families with children, 26 percent of which
Bay Area and is the only consolidated city and county are headed by single parents.5 There are approximately
jurisdiction in California. At roughly 47 square miles, it is An Aging Population 132,330 children under the age of 18.2 The number of
the smallest county in the state, but is the most densely The proportion of San Francisco’s population that is 65 school-aged children is projected to rise by 24 percent by
populated large city in California (with a population density years and older is expected to increase from 17 percent in 2030.2 The neighborhoods with the greatest proportion of
of 17,352 residents per square mile) and the second most 2018 to 21% in 2030; persons 75 and over will make up households with children are: Seacliff, Bayview Hunters
densely populated major city in the US, after New York City.1 about 11% of the population.2 At the same time, it is Point, Visitacion Valley, Outer Mission, Excelsior, Treasure
estimated that the proportion of working age residents (25 Island, and Portola (all over 30%).1
Between 2011 and 2018 the population in San Francisco
grew by almost 8 percent to 888,817 outpacing population to 64 years old) will decrease from 61 percent in 2018 to
56 percent in 2030. This shift could have implications for Ethnic composition by percentage of
the provision of social services. population, SF, 2010 – 30
Population by age group as a percentage of
the total population projections, SF, 2010 – 30
Ethnic Shifts 3.1 3.5 3.9
Population growth is expected for all races and ethnicities
15.1 15.1 14.8
14 17
except for Black/African Americans who are projected to 0.3 0.3
21 drop from 4.9 percent of the population in 2018 to 4
percent in 2030.3 Asians and Whites will remain the 0.3
most populous groups and will grow as a percentage
of the overall population. Population growth is expected 33.2 33.7 34
to be lower for Latinx and Pacific Islanders and Latinx
are expected to drop from 15.1 to 14.8 percent of
63 the population.
61 56 5.8 0.2 4.9 0.2 4 0.2
Currently, 35 percent of San Francisco’s population is
foreign born and 20 percent of residents speak a
language other than English at home and speak English
less than “very well.”1,4 The majority of the foreign born 42.3 41.9 42.5
population comes from Asia (65 percent), while 18
10 7 8 percent were born in Latin America, making Chinese
(Mandarin, Cantonese, and other) (43 percent) and
9 10 11
Spanish (26 percent) the most common non-English
4 5 4 languages spoken in the City.4 2010 2018 2030
2010 2018 2030
Multi-ethnic, Latinx, Pacific Islander, Asian, Native
Families and Children American, Black/African American, White.
Groups by age range in years: Seniors (65+), Working Adults
(25 – 64), College Age (18 – 25), School Age (5 –17),
Although San Francisco has a relatively small proportion of
Preschool Age (0 – 4). households with children (19 percent) compared to the
state overall (34 percent), the number of school-aged
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 13San Francisco Snapshot
San Francisco Neighborhoods and Zip Codes, 2014
94130
Treasure
Island
94111
94108
94123 94133 94104
94129
North
Beach
Chinatown 94109
Marina Russian 94105
Presidio Hill 94115
Seacliff
94118
Pacific Heights 94121 2
Nob Hill Financial 10
Presidio
District/ 94
South Beach 94103
Lincoln Park Inner Heights Japantown Tenderloin 94117
Richmond Western
Outer Richmond Lone Addition
Mountain South of 94107
/USF Hayes Valley 94122 94114
Market
Golden Gate Park Haight
Mission Bay 94110
Ashbury
Castro/
Upper 94116
Market Mission 94131
Inner Sunset
Potrero Hill 94127
Sunset/Parkside Twin 94124
Peaks
Noe Valley
94132
Bernal 94112 94134
Heights
West of Twin Peaks Glen Park
Bayview Hunters Point
Portola
ion
Lakeshore
iss
M
Oceanview/
ter
McLaren
Merced/
Ou
Park
Ingleside
Excelsior
Visitacion
Valley
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 14Major Findings
The 2019 Community Health Needs Assessment identified
two foundational issues and five health needs.
The following infographics highlight aspects of each issue
and need.
Foundational Issues
Poverty...................................................................16
Racial and Ethnic Inequality......................................17
Health Needs
Access to Coordinated, Culturally, and Linguistically
Appropriate Care and Services....................................20
Food Security, Healthy Eating, and Active Living...........21
Housing Security and an End to Homelessness.............24
Safety from Violence and Trauma................................26
Social, Emotional, and Behavioral Health....................30
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 15Major Findings Poverty
Foundational Issues
Income generally confers Household Income Income Inequality
access to resources that and Health
promote health — like San Francisco has the
good schools, health highest income inequality
care, healthy food, safe in California.
neighborhoods, and time The wealthiest 5% of households
for self care — and the in SF earn 16 times more than the
ability to avoid health poorest 20% of households.9
hazards — like air
pollution and poor Low income impacts
lifetime health, beginning
quality housing. with pregnancy and birth.
Low income groups are at greater Lower-income children in San
risk of a wide range of health Francisco experience higher rates
of asthma, hospitalization,
conditions than higher income Almost 1 in 4 (22%) San Franciscans live below 200% of the federal poverty level.3 obesity, and dental caries.10-12
groups, and have a shorter
life expectancy.1 For a family of four, A family of four in 40% of new jobs in 18% of children Low-birth weight is highest among
200% of the San Francisco, requires San Francisco are under 6 years of age low-income mothers.13
People who live in communities Federal Poverty an income of greater expected to be low in San Francisco live
with higher income disparity are Level is $50,200.4 than $120,000 to meet wage (Major Findings Racial and Ethnic
Foundational Issues Inequality
Two types of racialized social Improvements
interaction, interpersonal and For Black/African Americans improvements are seen in some social determinants and some health conditions.
structural racism, play a role the However, the improvements do not always impact the inequity as other groups may experience greater gains.
racial health disparities seen in
San Francisco.
Indicator Who Better for...
Racial discrimination in interpersonal Between 2007 and 2016 the teen birth rate for first time moms decreased from 34% to 10% among Black/African
behavior, often called everyday racism or bias, Teen Birth American women in San Francisco.2 In that same time, the proportion of mothers who had a college education
when they delivered their first baby increased by 16 percentage points.2
sets the kind of experiences that make up the
social lives of people of color. The accumulation Mortality rates decreased for all in San Francisco. However, rates decreased the most for Black/African Americans
of those experiences has been associated with (15%) (vs. 11% for Pacific Islanders, 12% for Whites, 14% for Asians and Latinx). Decreased rates among Black/African
increased hypertension, preterm birth and other Mortality Americans were primarily due to decreases in ischemic heart disease, lung cancer, Assault, and HIV..17
conditions mediated by stress. Life Expectancy also grew for all San Francisco with the largest gains seen by Black/African Americans. (+3 years
between 2005 s–2007 and 2015 –2017 vs +2 years for others).
Long-standing social and institutional
rules, both historic and current, High School Graduation rates increased for all between 2012 and 2017. The biggest gains were seen among Black/African Americans
determine which spaces and resources Graduation (8%), and Pacific Islanders (12%) while rates for Latinx (4%), Whites (3%) and Asians (4%) were more modest.3
are available to marginalized groups. The
disparate treatment of children based on race in Childhood Between 2007–2012 and 2012–2017, rates of untreated tooth decay among kindergarteners decreased the
schools and courts is an example of these forces. Caries most for Black/African Americans (26% to 19%).8
So are the historic differences in family wealth
that stem from government housing policy and
private banking rules. These forces are often
Population Loss
intertwined and reinforcing as they occur over the
life-course. Between 1990 Between 1990 and 2005,
and 2005, the the proportion of very low
Black/African income households
Racial inequities are not just a American increased from 55%
matter of unfortunate history, population to 68%.18
but of on-going, correctable decreased by
injustice. 41% from
almost 79,000
The strong association between poverty
to less than and health would suggest that the poorer
47,000. remaining Black/African American population
is more likely to have poor health than the
previous more mixed-income population.
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 17Major Findings Racial and Ethnic
Foundational Issues Inequality
Prebirth/Infancy Childhood Adolescence
Basic
Requirements Adequate income, Engaged with school, Mistakes corrected
for a healthy Healthy Diet
Social network, Adequate housing, Schools well-resourced
life span Prenatal care
Healthy diet, Safety School success
Student Proficiency
Children 0 –18 Living in Poverty3
Black/African American Students
50
Black/African 13% are proficient or above in mathematics,
American 46% 19% in English language arts.5
45
40 Latinx students
35 Pacific 22% of are proficient in math,
30 Islander 28% in English language arts.
27%
25
Latinx K–3 Suspensions Pacifica Islander Students
20 19% of are proficient in math,
15
15% 2.4% 25% in English in Mathematics.
Asian
suspension rate for Black/African Americans
10 10%
5
White vs 0.1% White Students
3% for White SFUSD Students 4 70% are proficient in Mathematics,
0 77% in English language arts.
Hurdles to a healthy life start early in San Francisco
Nutrition 5th Grade Obesity4
Food insecurity among Black/African American
75%
pregnant women in 80 Filipino
San Francisco1 70 Latinx
Pacific
50% 65 66
26.5% among Latinx women 60 Islander
86% 19.5% a mong Black/African
Black/African American and 50
40
52 52 White
American women Latinx SFUSD students are 25% Asian
2–3 times more likely to 30
6.6% a mong Asian and consume fast food (64%, 20
22 23
Full-Term Birth Pacific Islander women 73%), or soda (44%, 36%) 10
Full term birth more likely for Whites (93%) 0%
Almost no White women in at least weekly, as compared 0
than Black/African Americans (86%).2 San Francisco report food to White students (fast food ■ Black/African American ■ Filipino ■ Latinx
insecurity during pregnancy. (35%) and soda (17%). 6 ■ Pacific Islander ■ White ■ Asian
San Francisco Health Improvement Partnership Community Health Assessment & Profile 2019 | 18Major Findings Racial and Ethnic
Foundational Issues Inequality
Adolescence Adulthood Old Age
Basic
Requirements Mistakes corrected Employment, Stable housing Active lifestyle
for a healthy Schools well-resourced Active, Healthy childbearing Independence
life span School success Freedom Long life
Juvenile Detentions Unduplicated Educational Attainment 2012 –20163 ■B
achelor’s Degree
200 Account of Juvenile 80
or higher.
Black/African American youth make up
Hall Bookings
over 57% of bookings at juvenile hall 70 ■ S ome College
150 — Criminal Offenses 60 or Associates
even though they make up only 6% of by Ethnicity, 2017 50 Degree.
the population.9
100 40
■H
igh School
Together Black/African American and 30
Diploma or GED.
Latinx youth comprise 86% of all 50 20
juvenile bookings. Samoan youth are 10 ■ L ess than a High
0 School Diploma
also over-represented and make up 3% 0
of the bookings, but only account for ■ Black/African American ■ Latinx ■ Samoan SF Whites Latinx Black/ Asian Native Pacific
African American Islander
less than 1% of the youth population. ■ Pacific Islander ■ White ■ Chinese American
The starkest inequities are seen between Black/African American residents and all other groups, and occur across the lifespan.
Median Household Income Homelessness Heart
The median income in San Francisco varies greatly by Black/African Americans are Disease 2005-2007 2015-2017
race/ethnicity. Typically, Whites earn 4x more than over-represented among the Heart Disease
Black/African Americans in San Francisco.3 homeless in San Francisco. impacts
All All
Black/African
$120,000
Americans at younger
$100,000 ages. Rates of heart All 80.8 84.0 77.6 83.1 86.1 80.3
$80,000 35% disease related
Asian 85.1 87.5 82.4 87.0 89.6 83.9
of the homeless persons are hospitalizations among
$60,000
Black/ African American Black/African Americans B/AA 68.5 73.7 64.2 72.1 76.5 68.3
$40,000 in their 40s and 50s
$20,000
22% are comparable Latinx 82.7 85.8 79.4 85.1 87.9 82.5
are Latinx compared to to those seen in
0
5% and 15%, other races/ PI 73.4 77.0 76.0 76.8 75.5
■ SF ■ White ■ Latinx ■ Black/African American respectively, ethnicities over White 79.7 83.1 76.9 81.7 84.2 79.6
■ Native American ■ Asian ■ Pacific Islander of the city overall. 3,10 75 years of age.7
San Francisco Health Improvement Partnership Community Health Assessment & Profile 2019 | 19Major Findings Access to Coordinated, Culturally
and Linguistically Appropriate
Health Needs Care and Services
Healthy People Many San Franciscans do not access health care Language barriers
2020 defines access and cultural competency
San Francisco’s population now numbers over 850,000 people.
to health care as of services are serious
“the timely use of Fewer insured
barriers to receiving
personal health Over 10,000 fewer
quality care.
services to achieve San Franciscans were Increased cultural competence requires
the best possible uninsured in 2017 com- structural and systemic improvements,
health outcomes.”1 pared to 2015.However, and can be linked toimprovements in
Access is influenced by and estimated... 3.6% of healthcareaccess, participation, and
residents (31,480) still patient satisfaction.10-11
availability of providers,
do not have health
location, affordability, hours,
insurance.3-4
From the community
and cultural and linguistic we heard…
appropriateness of health 8% 24% 51% 54% 15% 27% 82% “Cultural competency doesn’t happen
care services. Accessible do not have of adults have not of women ages of women with of adults of Denti-Cal with just a class or a one-day training.”
a usual place have not had had a flu 18 – 44 have not public safety have not eligible infants
health care can prevent to go for a routine shot in the received counseling or net insurance seen a aged 2 years “Healthcare professionals need to be
disease and disability, detect medical check-up in past year.5 information about birth do not receive dentist in or less do from the community and actually know
care.5 the past control from a doctor timely the past not access
and treat illnesses, maintain year.5 or medical provider prenatal care.6 year.5 dental care.7 the culture of the community.”
quality of life, and extend in the past year.5
“Community-based organizations serve
life expectancy.2 a critical role in small, datasparce
From a population health Young cohorts, by informing public health
adults are Young adults 18 to 34 years of age and people efforts and bringing resources to
perspective, regular access
at risk. of color are less likely to be covered by insurance.4 multicultural communities.”
to quality health care and
primary care services also
reduces the number of
unnecessary emergency Different Levels Preventable Hospitalizations and Emergency Room Visits
room visits and hospitaliza- of Prenatal Care
While preventable hospitalizations for most causes have
tions and can save public
In 2013-15, > 99% of mothers
decreased over time, preventable hospitalizations for hyperten-
and private dollars. with private insurance received sion and diabetes have respectively increased 45% and 50%
prenatal care in the first trimester.6 between 2011 and 2016 — potentially indicating these
While access to health care conditions are not being well managed at the population level.8
in San Francisco is better Only 86% of those with Medi-Cal
received early prenatal care.6
than many other places, Preventable hospitalizations and ER visits are
significant disparities exist Residents covered by public significantly higher among Black/African
by race, age, and income. safety net insurance do not Americans and Pacific Islanders compared to
receive preventative care at all other ethnicities in San Francisco.9
the same rate as those with
private insurance.
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 20Food Insecurity,
Major Findings Healthy Eating,
Health Needs and Active Living
Many in San Francisco are food insecure Many in
San Francisco do
50% 20 –30% 50% not eat and drink
of low income residents of Black/African American of SFUSD students healthily
surveyed in SF report and Latinx pregnant women qualify for free or
food insecurity.6 are food insecure.5 reduced-price meals.9
Over 100,000 food insecure adults and seniors
Good nutrition means
are eligible to receive meals, groceries or eating vouchers.
getting the right
amount of nutrients Services to ameliorate food insecurity
from healthy foods are not meeting need 2 out of 3 pregnant women in the WIC
and drinks. Good
nutrition is essential Eat SF program and 2 out of 3 youth do not
70% -7% 1,969 eat 5 or more servings of fruits or vegetables daily.5
from infancy to Percentage of eligible Decrease in the number The number of meals
old age. students not participating of food vendors denied Seniors and
in the Summer Lunch authorized to acccept persons with disabilities Some San Franciscans do
The USDA’s MyPlate.org not drink enough water
Program. food stamps.14 at congregate meal sites.6
recommends that fruits and
vegetables make up at least half
of our plate, or approximately
21 days/187 days The number of days seniors/persons with 614
disabilities must wait to start getting home delivered meals.6 people were
five servings a day.1
616 The number of persons waiting for enrollment at a food pantry. 33
hospitalized for
“potentially preventable”
Leading medical and health
associations recommend dehydration in 2016.7
drinking water instead of sugary
The USDA has designated the Oceanview, Merced,
drinks.2 The institute of Many do drink sugary drinks.Two thirds
Ingleside, Bayview Hunters Point, Visitation Valley
Medicine recommends 13 cups of high school students and one third
and Treasure Island neighborhoods as areas of low
of liquids per for men and 9 of young adults regularly consume soda.8
food access.10
cups for women who live in
temperate climates.3
Facilities Barriers to drinking enough water include limited access to Not all have
A healthy diet promotes health necessary to bathroom facilities. 31-32 San Francisco operates 28 public a kitchen to
and reduces chronic disease eat and drink restrooms that are open all day, which amounts cook in. Over
risk. It is critical for growth, healthily are to 3.3 restrooms per 100,000 residents.13 21,000 occupied
development, physical and not available housing units in
cognitive function, reproduc- for all San Francisco do
tion, mental health, immunity, The Mission, Bayview Hunters Point and Treasure not have complete
stamina, and long-term Island districts each have only one public kitchen facilities.
good health.4 access drinking water fountain.12
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 21Food Insecurity,
Major Findings Healthy Eating,
Health Needs and Active Living
Regular exercise Many San Franciscans don’t spend Many San Franciscans don’t meet activity standards
extends lives. the recommended amount of time In San Francisco about 30% of 5th and 7th graders
doing physical activity
The World Health Organization and 40% of high school students do not meet the
(WHO) recommends that 1 out of 2 Fitnessgram standard for aerobic capacity, which is
children and adolescents, age (56%) adults does not walk at least 150 min ability to run one mile or pass a PACER test.
5 to 17 years, should do at per week for transportation or leisure.18
least one hour of moderate-to- 60 percent of Black/African American
vigorous physical activity daily, 1 out of 2 and Latinx 9th graders, do not meet the
while adults, age 18 years and (47%) children ages 3–5 years in child care fitness standards, compared to 30% of White
above, should do at least 150 centers are not physically active for and Asian students. 27
minutes of moderate-intensity 90 min per school day.19
physical activity, 75 minutes of
vigorous-intensity physical 2 out of 3
(67%) middle schoolers do not spend
activity, or an equivalent
60 min per day each day of the week doing Aerobic fitness is
combination of moderate and
physical activity.20 10 percentage points
vigorous activity throughout lower for economically
the week.15 4 out of 5 disadvantaged students 27
Just 2.5 hours of (83%) high schoolers do not spend
moderate intensity 60 min per day each day of the week
aerobic physical doing physical activity.20
activity each week is
Each day,
associated with a gain of 4.5 million
approximately three transportation trips are
years of life.16 made in San Francisco.
Walking is a simple, affordable
way for people to get around.
Of these, only about 37% are walking trips
A walkable city provides a free
or public transit trips which include walking.21
and easy way for people to
14% percent of adults ages
incorporate physical activity
65-75 and 37% of adults
into their daily lives as they
walk to work, to school, over age 75 have difficulty
to the market, to transit or walking or climbing stairs.28
other nearby services, or
just for fun.17
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 22Major Findings Food Insecurity, 59% of adults do not
Healthy Eating, feel safe walking alone
Health Needs and Active Living in their neighborhood
at night. 25
Safety, and a lack Every day, on average 2 people
of resources and walking are hit by cars
other supports Cars violating a pedestrian’s right-of-way is the
are barriers to top risk factor for injuries to people walking.
physical activity In 2018, there were 15 pedestrian
in San Francisco deaths and 3 cyclist deaths.22-23
There are gaps There are gaps in school and
Vision Zero High Injury Network in neighborhood workplace supports for
2017 Update San Francisco California 21 resources for physical activity
physical activity
2 out of 3 (67%) child care
Sidewalk networks centers do not use physical activity
support walkers to curriculum.29
varying degrees.
Downtown and in All of our students, regardless of
Chinatown, the blocks which neighborhood they live in or
are short and provide which school they attend, should
many pedestrian be able to safely walk or bike to
connections. In other school. We are adding crossing
neighborhoods, guards across the City and I am
pedestrians have to walk pushing the SFMTA to expedite
Vision Zero projects because we do
further to make less
not have time to waste. We need
direct connections.34
safer, more livable streets now.”
35% of San Francisco — mayor london breed 23
playgrounds do not
score an A or B for Although each April, more than
infrastructure quality, 10,000 people participate in Walk to
cleanliness and Work Day, including San Francisco’s
upkeep.26 Mayor and Supervisors, over
200,000 workers drive to
work on a daily basis.30
SF has 0.18 miles of bike lane for every 1 mile of streets.24
San Francisco Health Improvement Partnership Community Health Assessment & Profile 2019 | 23Housing Security
Major Findings and an End to
Health Needs Homelessness
Shelter is a basic human need Homelessness
In 2017, about 7,500 homeless persons were
Housing is foundational to meeting people’s most basic counted in San Francisco.7 Despite making up
needs. Quality housing provides a place to prepare and store only 6 percent of the general population, 35%
food, access to water and sanitation facilities, protection of the homeless persons counted
from the elements, and a safe place to rest. Stable/ were Black/African American.
permanent housing can also provide individuals with a sense
Among the many challenges homeless persons
of security. Unfortunately, California, and especially the Bay face, including those in temporary housing, are: 8-9
Area, suffers from an acute housing shortage which has been
driving housing costs to unaffordable levels, leading an •Safely storing medications
increasing number of residents to become homeless.1 •Eating healthfully
•Finding a job
Housing production has declined in the Bay Area
•Maintaining relationships
Between 2011 and 2015, the Bay Area added 501,000 new jobs — but only 65,000 new homes.2 •Going to the doctor
Housing Production Decline in the Bay Area, 1970 – 2015
500,000
450,000
400,000
350,000 Overcrowding
300,000 San Francisco An estimated 24,000 people
usually exceeds in San Francisco live in crowded
250,000
requirements for conditions.4
200,000 development of
150,000 above moderate- Living in
100,000 income housing overcrowded
(120% AMI), but conditions can
50,000 increase risk
builds less than a for infectious
0 third of the units disease.5
1970 –1980 1980 –1990 1990 –2000 2000 – 2010 2010 – 2015 allocated for
Rest of Bay Area San Mateo & Santa Clara (except San Jose) San Jose Marin & Napa moderate and
Outer East Bay, Solano, Sonoma Inner East Bay San Francisco city Bay Area 2020 low-income
Source: SF Planning Analysis of US Census and ACS Data residents.3
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 24Housing Security
Major Findings and an End to
Health Needs Homelessness
Housing Affordability Percent of 0 –14.2%
Between 2010 and renter
households 14.3 –18.3%
2018, the median
market rate rent for +48% whose rent is
50% or more
18.4 – 22.9%
23 – 29.5%
a 2–bedroom unit of their
29.6 – 61.1%
increased 48% household
income Excluded due
to $4,725.10 to small sample
size
It
would
take
4 full-time minimum wage jobs to afford a
“fair market rate” ($3,121) 2–bedroom unit 11 Nearly one-third of
Chinatown residents
6 full-time minimum wage jobs to afford a live in overcrowded
“median market rate” ($4,725) 2–bedroom unit 10 conditions.12
Evictions
There had been a steady increase in the number of all-cause eviction notices between
2011–2016; however, in 2017 there was a 27% decrease in the number
of eviction notices filed.6 This rapid change may be attributable to the implementation
of Eviction Protection 2.0 in November 2015, as well as economic shifts and other factors.
27%
Moving can result in: 5
The median percent of income paid to gross rent in
San Francisco was 30% in 2017.
•Loss of employment
17% of renter households spend 50% or more •Difficult school transitions
of their income on rent.4 •Increased transportation costs
•Loss of health protective social networks
San Francisco Health Improvement Partnership Community Health Assessment & Profile 2019 | 25You can also read
