Bridging the gap between research, policy, and practice: Lessons learned from academic–public partnerships in the CTSA network

A primary barrier to translation of clinical research discoveries into care delivery and population health is the lack of sustainable infrastructure bringing researchers, policymakers, practitioners, and communities together to reduce silos in knowledge and action. As National Institutes of Healthʼs (NIH) mechanism to advance translational research, Clinical and Translational Science Award (CTSA) awardees are uniquely positioned to bridge this gap. Delivering on this promise requires sustained collaboration and alignment between research institutions and public health and healthcare programs and services. We describe the collaboration of seven CTSA hubs with city, county, and state healthcare and public health organizations striving to realize this vision together. Partnership representatives convened monthly to identify key components, common and unique themes, and barriers in academic–public collaborations. All partnerships aligned the activities of the CTSA programs with the needs of the city/county/state partners, by sharing resources, responding to real-time policy questions and training needs, promoting best practices, and advancing community-engaged research, and dissemination and implementation science to narrow the knowledge-to-practice gap. Barriers included competing priorities, differing timelines, bureaucratic hurdles, and unstable funding. Academic–public health/health system partnerships represent a unique and underutilized model with potential to enhance community and population health.


POSITION DESCRIPTION
The Coordinator of Research and Evaluation position at the Chicago Department of Public Health (CDPH) will lead a range of initiatives that support strong collaboration between academic researchers and institutions and community stakeholders to improve the health of the city of Chicago. This approach will accelerate the impact of research on the health and healthcare of communities, by cultivating diverse partnerships to integrate complementary perspectives, skills, and resources.
Working directly with CDPH and Chicago Consortium for Community Engagement (C3), this position will help engage and serve as a liaison between CDPH and key C3 constituencies to enhance city-wide collaboration and participation in research; develop and implement innovative approaches for assessing and aligning the specific research interests and resources of academic researchers and community stakeholders with Healthy Chicago 2.0 priorities; facilitate effective widespread dissemination of research findings from across Chicago to support evidence-based policymaking and practice; and leverage appropriate services provided across C3 members and partners to support their collective success. This position will build new and reinforce existing relationships with a diverse group of investigators, collaborators, CDPH and community partners. This position will also help develop a system to continuously evaluate and report progress.

ESSENTIAL DUTIES
• In collaboration with academic and community stakeholders, leads the establishment of a new CDPH Office of Research that will ensure equitable design, conduct and use of research to further health equity in Chicago. • Develops and sustains relationships and communication with and among local Clinical and Translational Science Institutes (CTSI), CDPH, community, and other stakeholder partners. Includes online/written communication, convening and attending meetings and conferences. • Reviews, tracks and coordinates Chicago health research, and facilitates evidence-based research findings into policy and practice • Provides development and oversight in disseminating analytic research findings to community partners.
• Leads the development of a city-wide public health research agenda • Directs the preparation of programmatic reports, plans, procedures and protocols based on the analysis of data collected • Directs the identification of potential new funding sources and the completion of applications to obtain same • Works with supervisor in establishing operating policies and procedures for the office • Prepares reports on section's work accomplishments • Provide information to CTSI and CDPH senior staff for inclusion in research and grant proposals.

NOTE:
The list of essential duties is not intended to be inclusive; there may be other duties that are essential to particular positions within the class.
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.
Many health needs were identified through this assessment including: 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; and social, emotional, and behavioral health. Additionally, poverty and racial health inequities were identified as structural and overarching issues which must be addressed to ensure a healthy San Francisco for all.
SFHIP recognizes that all San Franciscans do not have equal opportunity for good health, and we are committed to eliminating health disparities and inequities by working together across sectors to achieve health equity for all. We hope you find this assessment useful and we welcome any suggestions you may have for assisting us in improving the health of San Francisco. In the following pages you will find a very informative, data-rich roadmap for the continued improvement of the health of San Francisco.
The assessment takes a comprehensive look at the health of San Franciscans, through a combination of studying the social determinants of health, as well as specific health outcomes of individuals, neighborhoods and populations.
The CHNA is completed once every three years and is an important tool for informing the community about San Franciscans' health, identifying key priorities for the city and county, and gaining a better understanding of health inequities. This year, we expanded our work to provide more insights regarding homelessness, trauma and violence.
The report paints a compelling and broad picture of health and the challenges to health in San Francisco -from life expectancy, to differences in health status by neighborhoods, and racial and ethnic groups, to the renewed threat of nicotine addiction presented by e-cigarettes. Just to name a few.
The CHNA is also a key part of DPH achieving and maintaining national Public Health Accreditation, which we earned in 2017. Accreditation means that the department is meeting national standards for ensuring essential public health services and improving and protecting the health of the community.
With the CHNA, we demonstrate our ongoing collaboration with the San Francisco Health Improvement Partnership (SFHIP) that includes San  I commend the DPH team for this outstanding report, and extend my gratitude to the numerous community members and SFHIP partners who also contributed. Our enduring efforts are essential to fulfill our mission to protect and promote the health and well-being for all in San Francisco. Best regards, A Message from the Director of Health San  Welcome to the Community Health Needs 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.
Executive Summary San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 6 The CHNA involves four steps: • Community health status assessment The CHNA identifies two foundational issues contributing to local health needs: • Racial health inequities • Poverty The CHNA identifies five health needs that heavily impact disease and death in San Francisco: • 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

Racial Health Inequities
Health inequities are avoidable differences in health outcomes between population groups. Health inequities result from both the actions of individuals (health behaviors, biased treatment by health professionals), and from the structural and institutional behaviors that confer health opportunities or burdens based on status. For example, the uneven distribution of wealth and resources determines the level of health those getting the least of these resources can achieve. Pages 17-19 include data on a few improvements to health and determinants of health and point to where more work needs to be done to address the structural and institutional racism in San Francisco. Additional data on health inequities are found throughout the Community Health Data pages.

Food Security, Healthy Eating and Active Living
Inadequate nutrition and a lack of physical activity contribute to 9 of the leading 15 causes of premature death in San Francisco -heart failure, stroke, hypertension, diabetes, prostate cancer, colon cancer, Alzheimer's, breast cancer, and lung cancer. Studies have shown that just 2.5 hours of moderate intensity physical activity each week is associated with a gain of approximately three years of life. Data on physical activity and healthy eating and barriers to each are presented on pages 21-23. Additional data are available in the Physical Activity, Transportation, Crime and Safety, Overweight and Obesity, and Nutrition data pages.

Housing Security and an End to Homelessness
Housing is a key social determinant of health. 1 Housing stability, quality, safety, and affordability all have very direct and significant impacts on individual and community health. Much of California, and especially the Bay Area, is currently experiencing an acute shortage in housing, leading to unaffordable housing costs, overcrowding, homelessness and other associated negative health impacts. Between 2011 and 2015, the Bay Area added 501,000 new jobs -but only 65,000 new homes. An estimated 24,000 people in San Francisco live in crowded conditions and about 7,500 homeless persons were counted in San Francisco. Pages 24 -25 provide an overview of the housing stressors in San Francisco. Additional information on housing and health is found in the Housing data page.

Safety from Violence and Trauma
Violence not only leads to serious mental, physical and emotional injuries and, potentially, death for the victim, but also negatively impacts the family and friends of the victim and their community. Persons of color are more likely to be victims of violence, to live in neighborhoods not perceived to be safe and to receive inequitable treatment through the criminal justice system. Pages 26 -29 focus on violence and trauma, their determinants and health impacts in San Francisco. Additional data on violence and trauma in the City are presented in the Crime and Safety data page.

Social, Emotional, and Behavioral Health
Mental health is an important part of community health. In San Francisco the number of hospitalizations among adults due to major depression exceed that of asthma or hypertension. Presence of mental illness can adversely impact the ability to perform across various facets of life -work, home, social settings. It also impacts the families, caregivers, and communities of those affected. Substance abuse including drugs, alcohol and tobacco, contributes to 14 of the top causes of premature death in the City -lung cancer, Chronic Obstructuve Pulmonary Disease, HIV, drug overdose, assault, suicide, breast cancer, heart failure, stroke, hypertensive heart disease, colon cancer, liver cancer, prostate cancer, and Alzheimer's. 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.
The CHNA is the foundation for each of San Francisco's non-profit hospitals' Community Health Needs Assessments and is one of the requirements for Public Health Accreditation, which includes: a CHNA, a community health improvement plan, and a strategic plan for population health. The CHNA also informs city planning processes such as San Francisco's Health Care Services Master Plan.
While the CHNA informs large-scale city planning processes, the intent of this document is to inform the work of all organizations, teams and projects that impact 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, policies and infrastructure. The San Francisco Health Improvement Partnership (SFHIP) guided CHNA development. SFHIP is a collaborative body whose mission is to embrace collective impact and to improve community health and wellness in San Francisco In addition to impacting one's own future health status, early life experiences can have intergenerational health outcomes. One's wellness during the prenatal or pregnancy periods impacts the health of one's children. Investing in pregnancy, early childhood, and family wellbeing through policies, interventions and systems can support our society and address the root causes of health inequities.

Data Collection
The CHNA collected information on the health of San Franciscans via three methods: • Community Health Status Assessment • Assessment of Prior Assessments, and • Community Engagement.

Approach
Through review of the information provided by these sources, SFHIP identified San Francisco's health needs. Additionally, following the health needs assessment a Community Asset Assessment was completed.

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, and access to medical services are largely understood to play an important role in health, social-economic and physical environmental conditions are now known to be major, if not primary, drivers of health. [2][3][4] 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 Recognizing the essential role social determinants of health play in the health of San Franciscans, the Community Health Status Assessment examined population level health determinant and outcome variables. We used the San Francisco Framework for Assessing Population Health and Equity, which is a modified version of the Public Health Framework for Reducing Health Inequities published by the Bay Area Regional Health Inequities Initiative to guide variable selection. 3 We ranked and selected available variables based on the Results Based Accountability criteria for indicator selection -communication power (ability to communicate to broad and diverse audiences), proxy power (says something of central significance), and data power (available regularly and reliably), as well as the ability to examine health inequities and current use by stakeholders. Furthermore, we hosted meetings throughout 2017 to gather feedback on indicators from experts and community representatives. In all, 171 variables were analyzed. We present the results from all analyses in 30 Community Health Data pages.
To reveal health disparities, the Community Health Status Assessment analyzed data by age, race/ethnicity, poverty, place, and more. However, available data do not permit analyses for all groups which are known to experience health inequities including Native Americans, people who identify as LGBTQ, transgender persons and persons with disabilities.

Assessment of Prior Assessments
San Francisco's community-based organizations, healthcare service providers, public agencies and task forces conduct health needs assessments and publish reports of their activities for planning and evaluation purposes and to be accountable to those they serve. Our aim in conducting an assessment of these assessments and reports is to augment what we know from routinely collected secondary health data and primary data collection through CHNA community engagement activities. We hope thereby to gain a better understanding of which communities/populations in San Francisco have been engaged in health needs assessment activities; what topics are of concern and interest to these communities/populations; and learn about promising and effective approaches to eliciting and addressing these concerns. We included both needs assessments and service reports in our definition of "assessments" for this assessment. SFHIP key informant group interview, Equity Coalition focus groups, food insecure pregnant women focus groups, and Kaiser focus groups.

SFHIP Key Informant Group Interview
One focus group was comprised of SFHIP members who are all subject matter experts. Two series of questions were asked, "What are the healthiest characteristics of this community? What supports people to live healthier lives?" and "What are the biggest health issues and/or conditions your community struggles with? What do you think creates those issues?".

Equity Coalition focus groups
Three focus groups were conducted with each of the three health equity coalitions in San Francisco: The Chicano / Latino / Indigena Health Equity Coalition, The Asian Pacific Islander Healthy Parity Coalition, and The African American Health Equity Coalition. Using the Technology of Participation (ToP) Consensus Method, the question posed to each focus group was, "What actions can we take to improve health?"

Food Insecure Pregnant Women focus groups
The Homeless Prenatal Program held four focus groups with women who experienced food insecurity while pregnant. Each focus group focused on a different group of women: Spanish, Chinese, multi-ethnic English speakers, and African American. The question to respond to was, "What actions can we take to improve your food needs?"

Kaiser led focus groups
Kaiser conducted four focus groups, one each with Kaiser Permanente leadership, Kaiser Permanente staff, Spanish-speaking parents on youth healthy eating and active living, and homeless and/or HIV positive youth.
Further details on the methods and findings are available in the Community Engagement page.

Approach
San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 12

Health Need Identification
To identify the most significant health needs in San Francisco the SFHIP steering committee met on October 18th, 2018. Participants identified health needs through a multistep process. First participants reviewed data and information from the Community Health Status Assessment, the Assessment of Prior Assessments, and the Community Engagement, as well as the health priorities from the 2016 Community Health Improvement Plan. Then, using the Technology of Participation approach to consensus development, participants engaged in a focused discussion about the data. Finally, participants developed consensus on the health needs. (Figure A) Throughout the process needs were screened using pre-established criteria ( Figure B). This process yielded two foundational issues and five health needs.
Foundational issues are needs which affect health at every level and must be addressed to improve health in San Francisco.
The two foundational issues identified were: • 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.

Community Assets Assessment
To identify the community's resources available to address identified health needs, the San Francisco Department of Public Health reviewed data collected during the Community Engagement activities described above.
Questions asked of the participants relevant to the Community Asset Assessment included , " What are the strengths, resources, and assets of your community?", "What are the barriers that contribute to health issues for your community?", "What are the strengths and resources you and your family have to support your food needs?", and "What makes it hard to address you and your family's food needs?" Further details on the methods and findings are available in the Community Assets Assessment and Community Engagement pages.

San Francisco Health Improvement Partnership
Community Health Needs Assessment 2019 | 13

San Francisco Snapshot Population Growth
San Francisco is the cultural and commercial center of the Bay Area and is the only consolidated city and county jurisdiction in California. At roughly 47 square miles, it is the smallest county in the state, but is the most densely populated large city in California (with a population density of 17,352 residents per square mile) and the second most densely populated major city in the US, after New York City. 1 Between 2011 and 2018 the population in San Francisco grew by almost 8 percent to 888,817 outpacing population growth in California (6 percent). 2 By 2030, San Francisco's population is expected to total more than 980,000.

An Aging Population
The proportion of San Francisco's population that is 65 years and older is expected to increase from 17 percent in 2018 to 21% in 2030; persons 75 and over will make up about 11% of the population. 2 At the same time, it is estimated that the proportion of working age residents (25 to 64 years old) will decrease from 61 percent in 2018 to 56 percent in 2030. This shift could have implications for the provision of social services.

Ethnic Shifts
Population growth is expected for all races and ethnicities except for Black/African Americans who are projected to drop from 4.9 percent of the population in 2018 to 4 percent in 2030. 3 Asians and Whites will remain the most populous groups and will grow as a percentage of the overall population. Population growth is expected to be lower for Latinx and Pacific Islanders and Latinx are expected to drop from 15.1 to 14.8 percent of the population.
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 population comes from Asia (65 percent), while 18 percent were born in Latin America, making Chinese (Mandarin, Cantonese, and other) (43 percent) and Spanish (26 percent) the most common non-English languages spoken in the City. 4

Families and Children
Although San Francisco has a relatively small proportion of households with children (19 percent) compared to the state overall (34 percent), the number of school-aged children is projected to rise. 2

Major 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.

Income Inequality and Health
San Francisco has the highest income inequality in California.
The wealthiest 5% of households in SF earn 16 times more than the poorest 20% of households. 9 Low income impacts lifetime health, beginning with pregnancy and birth.
Lower-income children in San Francisco experience higher rates of asthma, hospitalization, obesity, and dental caries. [10][11][12] Low-birth weight is highest among low-income mothers. 13 Two types of racialized social interaction, interpersonal and structural racism, play a role the racial health disparities seen in San Francisco. Racial discrimination in interpersonal behavior, often called everyday racism or bias, sets the kind of experiences that make up the social lives of people of color. The accumulation of those experiences has been associated with increased hypertension, preterm birth and other conditions mediated by stress.

Employment Disparities Median Income
Long-standing social and institutional rules, both historic and current, determine which spaces and resources are available to marginalized groups. The disparate treatment of children based on race in schools and courts is an example of these forces. So are the historic differences in family wealth that stem from government housing policy and private banking rules. These forces are often intertwined and reinforcing as they occur over the life-course.
Racial inequities are not just a matter of unfortunate history, but of on-going, correctable injustice.

Improvements
For Black/African Americans improvements are seen in some social determinants and some health conditions. However, the improvements do not always impact the inequity as other groups may experience greater gains.
Between 1990 and 2005, the Black/African American population decreased by 41% from almost 79,000 to less than 47,000.
The strong association between poverty and health would suggest that the poorer remaining Black/African American population is more likely to have poor health than the previous more mixed-income population.

Population Loss
Between 1990 and 2005, the proportion of very low income households increased from 55% to 68%. 18

Indicator
Who Better for...

Teen Birth
Between 2007 and 2016 the teen birth rate for first time moms decreased from 34% to 10% among Black/African 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

Major Findings
Foundational Issues From a population health perspective, regular access to quality health care and primary care services also reduces the number of unnecessary emergency room visits and hospitalizations and can save public and private dollars.
While access to health care in San Francisco is better than many other places, significant disparities exist by race, age, and income.

Language barriers and cultural competency of services are serious barriers to receiving quality care.
Increased cultural competence requires structural and systemic improvements, and can be linked to improvements in healthcare access, participation, and patient satisfaction. [10][11] From the community we heard… "Cultural competency doesn't happen with just a class or a one-day training." "Healthcare professionals need to be from the community and actually know the culture of the community." "Community-based organizations serve a critical role in small, datasparce cohorts, by informing public health efforts and bringing resources to multicultural communities." San

-7%
Decrease in the number of food vendors authorized to acccept food stamps. 14

1,969
The number of meals denied Seniors and persons with disabilities at congregate meal sites. 6 Over 100,000 food insecure adults and seniors are eligible to receive meals, groceries or eating vouchers.

-30%
of Black/African American and Latinx pregnant women are food insecure .5

50%
of SFUSD students qualify for free or reduced-price meals. 9 Barriers to drinking enough water include limited access to bathroom facilities to go to the bathroom. 31

Major Findings
Health Needs Food Insecurity, Healthy Eating, and Active Living

Shelter is a basic human need
Housing is foundational to meeting people's most basic needs. Quality housing provides a place to prepare and store food, access to water and sanitation facilities, protection from the elements, and a safe place to rest. Stable/ permanent housing can also provide individuals with a sense of security. Unfortunately, California, and especially the Bay Area, suffers from an acute housing shortage which has been driving housing costs to unaffordable levels, leading an increasing number of residents to become homeless. 1 San Francisco Health Improvement Partnership Community Health Needs Assessment 2019 | 24 An estimated 24,000 people in San Francisco live in crowded conditions. 4

Housing production has declined in the Bay Area
Between 2011 and 2015, the Bay Area added 501,000 new jobs -but only 65,000 new homes. 2

Homelessness
In 2017, about 7,500 homeless persons were counted in San Francisco. 7 Despite making up only 6 percent of the general population, 35% of the homeless persons counted were Black/African American.
Among the many challenges homeless persons face, including those in temporary housing, are: [8][9] • Excluded due to small sample size Nearly one-third of Chinatown residents live in overcrowded conditions. 12 Percent of renter households whose rent is 50% or more of their household income

Housing Security and an End to Homelessness Violent Crime is a Concern in San Francisco.
Violent crime rates in San Francisco are high (712/100,000) and exceed California rates (452/100,000). 12

San Francisco Health Improvement Partnership
Community Health Needs Assessment 2019 | 26 Violence not only leads to serious mental, physical and emotional injuries and, potentially, death for the victim, but also negatively impacts the family and friends of the victim and their community.
Community violence decreases the real and perceived safety of a neighborhood disrupting social networks by inhibiting social interactions, causing chronic stress among residents who are worried about their safety, and acting as a disincentive to engage in physical activity outdoors. [5][6][7][8] Children are particularly vulnerable. Witnessing and experiencing violence disrupts early brain development and causes longer term behavioral, physical, and emotional problems. [1][2][3][4] Violence is rarely caused by a single risk factor but instead by the presence of multiple risk factors. Some risk factors for violence are: poverty, poor housing, illiteracy, alcohol and other drugs, mental illness, community deterioration, discrimination and oppression, and experiencing and witnessing violence. [9][10][11] rates per 100,000

Violent Crime Rate
Violent crime rates and rates of emergency room visits due to assault are highest in the Eastern half of the City. Residents are also less likely to feel safe in these neighborhoods. 13

Social and Social Economic Status Inequality
San Francisco has the 6th highest income disparities in the US. 20

High Residential Instability
According to 2016 data, 2,512 or 4% of SFUSD students are homeless. 21 Less than 25% of Black/African American, Latinx, and Native American residents own their homes. 23  The rate of substantiated maltreatment among Black/African Americans is significantly higher suggesting a need for greater support.

Major Findings
Health Needs

Safety from Violence and Trauma
During the 2016 -17 school year nearly 40% of all SFUSD students who received at least one suspension were Black/African American, despite making up only 11% of the student population.

Suspension rates for Black/African American and Pacific
Islander students are 5x higher than those of Asian students.
Contributors to the school-to-prison pipeline include: Inadequate resources (e.g. overcrowded classes, lack of counselors, special education services)

Police presence at schools
Harsh punishments that result in suspensions and out of class time. 33 An arrest, a court appearance, and even brief detention, especially for minor infractions, increase a minor's risk of dropping out and getting into more serious crime. 34 Once a student enters the juvenile justice system they face barriers to re-entry into traditional schools and many never graduate from school. 33

Major Findings
Health Needs In San Francisco, steps have been taken to combat the school-to-prison pipeline. [35][36][37] However, Black/African American, and Latinx students are still more likely to be suspended or expelled and, with Samoan youth, are more likely to be arrested.
200 150 100 50 0 All All All All All All All All All All A m e r i c a n I n d i a n B l a c k \ A f r i c a n A m e r i c a n C a m b o d i a n C h i n e s e Count O t h e r O t h e r A s i a n P a c i fi c I s l a n d e r

Criminal History has a "ripple effect"
Differences in the severity of charges at booking and the number of times that people of color were previously arrested, convicted, and incarcerated explain almost all of the difference in conviction rates.
Detentions, searches, arrests and % of population each sum to 100%

Major Findings
Health Needs

Social, Emotional, and Behavioral Health
Depression is the most common mental illness. 3 Depressive symptoms are common among San Francisco school-aged youth.5 High School depression 26% of SFUSD high school students reported prolonged sad or hopeless feelings in 2017.
Considering suicide Almost 13% of SFUSD high school students and 20% of middle school students had considered attempting suicide in 2017.

Sexual identification and depression
Bisexual and gay or lesbian high school students are more likely to report prolonged sadness or hopelessness (45%-62%) and suicidal thoughts (32-40%) than heterosexual students (22% and 10%, respectively).
People with lower education, income, and/or social status, and those who experience discrimination on the basis of race, gender, social class, or other characteristics are at a particularly high risk of mental illness.

23.3%
of Women with less than high school education are more than 3 times more likely to report prenatal depressive symptoms than women with a college degree (37.6% vs 9.0%).

Women with Medi-Cal insurance
are more than 2.5 times more likely than women with private insurance to report prenatal depressive symptoms (24.1% vs 8.9%).
Hispanic and Black/African American women are more likely to report prenatal depressive symptoms than White or Asian women. • Poverty 16,17 The effects of drug and alcohol use are cumulative, and significantly contribute to costly social, physical, mental, and public health problems. These problems include: Binge drinking is defined as consuming 5 or more alcoholic drinks for men and 4 or more for women on at least one occasion.
Neighborhoods with higher density of off-sale alcohol outlets coincide with those with higher rates of emergency room visits due to alcohol abuse. Age-adjusted rate per 10,000

Major Findings
Health Needs

15% vs 5%
Men are 3 times more likely to smoke than women.

16% vs 10%
18 to 24 years are more likely to smoke than those 25 and older.

E-cigarette use
In 2017, while 4% of SFUSD high school students reported smoking cigarettes, 7% reported using e-cigaretes or other electronic smoking devices in the last 30 days. 5 25% of SFUSD high school students reported ever using e-cigarretes or other electronic smoking devices. 5 "Vaping" is on the rise, especially among young people, which caused the US Surgeon General to call for aggressive steps to curb the epidemic of teen nicotine use in 2018. 15 To limit e-cigarrette use among youth in San Francisco the following laws have been passed: 2014: prohibition of the use of electronic cigarettes wherever smoking of tobacco products is prohibited.