Indicators within Access to Health Care

• Race & Health Insurance

  What is Measured?
  Ratio between the percentages of Hispanics and whites who do not have health insurance.

  What’s the Backstory?
  Lack of insurance and the high costs of medical care can prevent people from receiving needed treatment. Racial and ethnic minorities are more likely than whites to be uninsured and to have less access to medical care, with disparities particularly pronounced for Hispanics.

  What Did We Find?
  Hispanics continued to be the most likely not to have health insurance (8.2%), compared to whites (6.3%), although a decrease among Hispanics (from 13.2% in the baseline year) and almost no change among whites (from 5.7%) led to a large improvement in the disparity between these two groups. Uninsurance rates for blacks (6.0%) and Asians (4.0%) were both lower than those for whites in the current year. There were also inequalities by immigration and citizenship status: 9.2% of immigrants did not have health insurance, compared to 4.6% of those born in the US. Among immigrants, non-citizens were much more likely to be uninsured (16.6%), compared to naturalized citizens (4.1%), who had a rate even lower than that for US-born individuals.
• Race & Medical Care

  What is Measured?
  Ratio between the percentages of Hispanics and whites who did not receive medical care they needed in the past year.

  What’s the Backstory?
  Barriers to receiving needed medical care include lack of access to health facilities and services, and lack of language and cultural competence among healthcare providers. In the US, Hispanics and blacks are more likely not to have a regular source of medical care compared to whites.

  What Did We Find?
  A somewhat higher percentage of Hispanics reported that they had not received needed medical care in the past year (12.5%) than blacks (11.2%) and whites (9.2%), though the difference between Hispanics and blacks did not reach statistical significance. Asians/Pacific Islanders had the highest percentage in the current year (14.7%), and both they and Hispanics differed significantly from whites. Data from the baseline year suggest that racial and ethnic differences are decreasing: 13.7% of Hispanics and 6.6% of whites reported not receiving needed medical care during that time period. People with private insurance were least likely to have gone without care in the past year (7.8%), while people with Medicaid (13.6%) and the uninsured (17.5%) were most likely.
• Income & Senior Flu Vaccination

  What is Measured?
  Ratio between the influenza non-vaccination rates for people 65 and older in the bottom and top income groups.

  What’s the Backstory?
  Influenza is a serious contagious disease that can lead to hospitalization and even death, especially among people age 65 and older. Yearly vaccination can protect against many forms of the flu, and among seniors, vaccination rates are lower among people with lower incomes.

  What Did We Find?
  Among people 65 and older, large income-based differences were found in flu vaccination rates, with those living in poverty [<100% of the Federal Poverty Level (FPL)] markedly more likely to report not having been vaccinated (36.5%) than those from more affluent households (≥ 600% of the FPL; 24.1%). There were also racial and ethnic differences within this age group, with blacks the least likely to get a flu vaccination (49.7% unvaccinated) compared to Hispanics (32.8%), whites (31.1%), and Asians (26.9%). Since the baseline year, reported non-vaccination rates among New Yorkers 65 and older from low-income (40.8% unvaccinated) and from high-income (25.3% unvaccinated) households decreased, and the disparity also decreased.
• Immigration Status/Gender & Personal Doctor

  What is Measured?
  Ratio between the percentages of foreign-born men and US-born women without a personal doctor or health care provider.

  What’s the Backstory?
  People who have a regular doctor typically receive higher quality care and are less likely to be hospitalized for preventable conditions. Immigrants are less likely to have a regular doctor, and so are men regardless of their immigration status.

  What Did We Find?
  The likelihood of having a regular doctor was influenced by both gender and immigration status: foreign-born men were more likely to report not having a regular doctor (27.7%) than US-born women (9.9%), although there was almost no difference between foreign-born women (16.2%) and US-born men (15.2%). These differences seem to persist, as similar disparities were found in the baseline year. In the current year, racial and ethnic disparities were also large: Hispanics were two times as likely (24.8%) as whites (12.2%) not to have a regular doctor, while blacks and Asians fell in between the two (13.4% and 18.1%, respectively).
• Scores in Context: Local Initiatives

  Some of the policy initiatives under the umbrella of Access to Health Care have clear parallels to the four indicators in this topic. Some speak directly to the disparities measured by the indicators, while others are aimed at increasing access to and awareness of health services more broadly. Most of these initiatives are City policies, but a federal policy—the Patient Protection and Affordable Care Act (ACA)—should also be taken into consideration.

  Since health insurance coverage under the ACA began in 2014, the number of people enrolling in health insurance through the exchange has increased (from 8 million people in 2014 to 12.7 million people in 2016); the percentage of uninsured adults has decreased; and racial and ethnic minorities have seen greater decreases in uninsured rates than whites. All of this is consistent with the substantial improvement we saw in the race and health insurance indicator this year. Even in 2017, with the possibility that the ACA may be changed or repealed, enrollment has increased: during the first half of November 2017, enrollment was 46% higher than the same period in 2016.

  At the city level, the opening of three Neighborhood Action Health Centers in April 2017 (see Box 6) may help to reduce disparities in race and medical care in the future. DOHMH’s Center for Health Equity opened these facilities in East Harlem, Brownsville, and Tremont, all of which are predominantly Hispanic and black neighborhoods. The Neighborhood Action Health Centers have replaced the District Public Health Offices in these neighborhoods, bringing a new model of health care that includes co-located services, data-driven practices, and a focus on reducing health disparities. They provide primary care as well as referrals to other services, health education, and spaces dedicated to community organizing. This new model aims to bring high-quality, comprehensive, and efficient care to underserved neighborhoods.

  More targeted initiatives include the 2016 version of the annual flu shot ad campaign, which may have been related to the small increase in equality we saw in income and senior flu vaccination. Although the campaign did not target low-income senior citizens in particular, adults 65 and older were among the groups highlighted by the campaign as at greater risk. In addition, the 2016-2017 season was the first time that a new flu vaccine designed specifically for seniors, called FLUAD, was available in the United States. Given that varying vaccine effectiveness is one reason some adults do not get immunized, the availability of this more effective vaccine may lead to higher rates of immunization for seniors of all income levels.

  In June 2017, the Mayor’s Office of Immigrant Affairs also completed a one-year demonstration of ActionHealthNYC (formerly Direct Access), which provided low-cost health care to more than 1,200 individuals who were not eligible for public health insurance. Although the program has ended, the pilot may have benefited many people, including new immigrants, who are reflected in the immigration status/gender and personal doctor indicator.

Indicators within Quality of Health Care

• Race & Asthma Hospitalization

  What is Measured?
  Ratio between blacks’ and whites’ hospitalization rates due to asthma.

  What’s the Backstory?
  Large disparities among racial and ethnic groups exist in asthma rates and control of the condition, and hospitalization may be required when it is not adequately managed through treatment and preventive care. Blacks have the highest asthma rates and are most likely to be hospitalized for the disease.

  What Did We Find?
  Blacks were more than five times more likely (382.161 per 100,000) than whites (70.339) to be hospitalized for asthma; the rate for Hispanics was also high (237.493). Asthma hospitalization rates decreased from baseline for both blacks (476.328 per 100,000) and whites (91.744), although the disparity remained largely the same. In the current year, Hispanics (98.5%), blacks (98.3%), and whites (97.3%) were similarly likely to be admitted through the emergency room. However, on average, whites end up staying in the hospital longer: 4.0 days, as compared to 3.0 days for blacks and 2.9 days for Hispanics. Across all racial and ethnic groups, women (257.793 per 100,000) had higher asthma hospitalization rates than men (193.890).
• Race & Diabetes Hospitalization

  What is Measured?
  Ratio between blacks’ and whites’ hospitalization rates due to diabetes.

  What’s the Backstory?
  Diabetes is the seventh-leading cause of death in the US, and uncontrolled diabetes often leads to avoidable hospitalizations. Blacks are more likely to be hospitalized and to have longer stays than whites, in addition to having higher costs related to their hospitalization.

  What Did We Find?
  Out of 17,613 individuals hospitalized for diabetes, 37.6% were black, 21.7% were Hispanic, 17.8% were white, and 17.5% represented other racial and ethnic groups. While hospitalization rates across racial and ethnic groups decreased, the hospitalization rate of 351.954 (per 100,000) for blacks was still three times higher than the rate for whites (114.411), similar to the baseline year. Hispanics and blacks (96.8%) were also more likely than whites (91.1%) to be admitted to the hospital through the emergency room for diabetes complications. Length of stay, however, was higher for whites (6.4 days) than it was for blacks (5.7 days) and Hispanics (5.4 days).
• Race & Sexually Transmitted Diseases

  What is Measured?
  Ratio between blacks’ and Asians’ chlamydia rates.

  What’s the Backstory?
  Although chlamydia is preventable and easily cured, if left untreated this sexually transmitted disease can cause infertility and chronic pelvic pain, as well as potentially fatal ectopic pregnancies. Blacks have been shown to have higher rates of chlamydia and some other STDs than Asians.

  What Did We Find?
  Racial and ethnic differences in STD rates were considerable, with blacks more than six times more likely to be diagnosed with chlamydia (779.21 per 100,000) than Asians (124.38), five times more likely than whites (156.00), and 1.8 times more likely than Hispanics (429.56). The differences in gonorrhea rates were also large: 273.47 for blacks, 126.79 for Hispanics, 106.63 for whites, and 31.59 for Asians. Chlamydia rates have increased from baseline for all racial and ethnic groups, but less so for blacks, which contributed to the small improvement in the indicator.
• Income & Chronic Hepatitis B

  What is Measured?
  Ratio between the rates of newly diagnosed chronic hepatitis B in the highest and lowest poverty areas.

  What’s the Backstory?
  Hepatitis B is a preventable and curable disease, but left untreated it can cause liver damage or failure, or death. The rates of hepatitis B infection is much higher among individuals born in foreign countries; and these populations are more likely to live in neighborhoods with higher levels of poverty.

  What Did We Find?
  Considerable income-based differences were found in the prevalence of newly diagnosed chronic hepatitis B, with the likelihood increasing as poverty increases. Residents living in very high poverty areas (≥30% of people below the FPL) had the highest new chronic hepatitis B rate (126.8 per 100,000) compared to individuals from high poverty (110.7), medium poverty (78.7) and low poverty (35.7) areas (<10 below the FPL). Rates increased from baseline for all income groups, and as a result, the disparity remained largely the same. When broken down by borough, Brooklyn residents had the highest chronic hepatitis B rate (105.8) and Staten Island residents had the lowest rate (35.6). Chronic hepatitis B rates for residents from the other three boroughs fell between the two (Queens: 101.6; Bronx: 80.2; and Manhattan: 67.8).
• Scores in Context: Local Initiatives

  Policy initiatives related to Quality of Health Care include both citywide efforts and more targeted efforts to address specific disparities and groups.

  At the citywide level, in 2015 and 2016 DOHMH launched a series of ad campaigns to encourage New Yorkers to get tested and treated for STDs. The department announced expanded hours for the City’s Sexual Health Clinics for the first time in 10 years in February 2016, and in August 2016 began offering HIV and STD testing at the clinics for all patients 12 years or older. The clinics also distribute #PlaySure kits at no cost to promote condom use.

  In more targeted efforts, in November 2016 DOHMH launched a targeted ad campaign for parents of children with asthma. The campaign focused on the importance of managing asthma by taking medication and avoiding triggers that can exacerbate symptoms. DOHMH located the ads in areas with high rates of asthma hospitalizations: Northern Manhattan, the Bronx, and Central Brooklyn. These are majority black and Hispanic areas of the city, so continuing these types of ad campaigns may contribute to future changes in the racial and ethnic disparities reflected in the race and asthma hospitalization indicator.

  Two other DOHMH initiatives focus on the disparities reflected in the race and diabetes hospitalization indicator. The first is Harlem Health Advocacy Partners, launched in 2014 as a partnership among the Center for Health Equity, the Community Service Society of New York, the New York City Housing Authority (NYCHA), the CUNY Graduate School of Public Health and Health Policy, and the NYU School of Medicine. This program trains residents of five NYCHA developments in East and Central Harlem (majority black and Hispanic neighborhoods) to become community health workers and health advocates, with the broader goal of reducing disparities in chronic diseases, especially diabetes. DOHMH’s Shop Healthy NYC program also aims to address disparities in diabetes rates by providing access to healthy and affordable food in underserved neighborhoods. In November 2016, DOHMH recognized 19 bodegas in East New York (a majority black neighborhood) for participating in the program.

  Finally, in April 2017 several City Council members partnered with the Charles B. Wang Community Health Center and the Chinese American Medical Society to launch NYC Hepatitis B Awareness Week. This effort aimed to educate Asian communities about the disease and how to get tested and/or vaccinated. It was launched in response to a 2016 DOHMH report that found hepatitis B to be most common among foreign-born New Yorkers, especially immigrants from China. The DOHMH report also found that many of the foreign-born New Yorkers who are most susceptible to the disease live in high-poverty neighborhoods, so this initiative may contribute to future changes in the disparities highlighted in the income and chronic hepatitis B indicator.

Indicators within Mortality

• Race & Cardiovascular Deaths

  What is Measured?
  Ratio between blacks’ and Asians’ heart disease mortality rates.

  What’s the Back Story?
  Cardiovascular disease (CVD) is the leading cause of death globally as well as in the US. In the US, disparities in CVD-related death rates across racial and ethnic groups are large, and blacks in particular are at increased risk of CVD-related mortality.

  What Did We Find?
  Across all racial and ethnic groups, blacks were most likely to die from heart disease (213.8 per 100,000, age adjusted), followed by whites (197.5), Hispanics (142.1), and Asians/Pacific Islanders (101.0). Rates have remained almost unchanged from baseline, as has the disparity. When looking at race/ethnicity and gender combined, the rate for black men (265.9) was highest and the rate for Asian/Pacific Islander women (81.6) was lowest. Men generally, regardless of their race or ethnicity, died from heart disease at a markedly higher rate than women (222.4 and 149.3, respectively). When broken down by borough, Staten Island residents were most likely to die from heart disease (231.6 per 100,000), compared to Brooklyn (190.0), the Bronx (184.6), Queens (159.8), and Manhattan (135.0).
• Race & Infant Mortality

  What is Measured?
  Ratio between the infant mortality rates for black and white mothers.

  What’s the Backstory?
  Infant mortality refers to babies who die before their first birthday, and this rate may reflect the general state of a country’s health and well-being. In the US, the infant mortality rate is highest among babies born to black mothers.

  What Did We Find?
  While rates decreased very slightly from baseline overall, the racial and ethnic gap in the infant mortality rate was substantial with black infants almost three times more likely to die in infancy (8.0 per 1,000 live births) than whites (2.7) and Asians (2.6), and nearly twice as likely as Hispanics other than Puerto Ricans (Puerto Ricans: 6.1; other Hispanics: 4.3). Mortality was higher among infants with US-born mothers (4.7) than those with foreign-born mothers (3.5), although when looking at maternal birthplace, those from Haiti, Peru, and Trinidad and Tobago had the highest rates of infant mortality (7.4, 7.0, and 6.7, respectively). Maternal education also tended to be associated with infant mortality: infant mortality rates for those with less than a bachelor’s degree (4.8) were more than twice the rate for those with a bachelor’s degree or above (2.7).
• Race & HIV-Related Deaths

  What is Measured?
  Ratio between blacks’ and whites’ HIV-related death rates.

  What’s the Backstory?
  HIV infection leads to the weakening of the immune system and eventually to AIDS, which can be fatal. Although it is preventable, HIV currently has no cure. In the US, blacks and Latinos have a disproportionately high rate of HIV infection and HIV-related death.

  What Did We Find?
  There were 483 HIV-related deaths in NYC during the current year. Broken down by race and ethnicity, blacks died due to HIV/AIDS at a rate more than eight times higher (13.2 per 100,000) than whites (1.6), and 2.4 times higher than Hispanics (5.5). Rates decreased for both blacks (14.8 per 100,000 in the baseline year) and whites (2.3), but whites saw a larger improvement and the disparity increased. In the current year, the death rate for men was considerably higher than the rate for women (7.8 versus 3.1). Additionally, residents from the poorest neighborhoods (12.0 per 100,000) were 10 times more likely to die from HIV than the residents of the wealthiest (1.2).
• Income & Heroin Deaths

  What is Measured?
  Ratio between the rate of heroin overdose deaths in the highest and lowest poverty areas.

  What’s the Backstory?
  Heroin overdoses are often fatal, and deaths related to this opiate drug have increased greatly in the US in recent years. Deaths due to heroin overdose in NYC are consistently highest in poor neighborhoods.

  What Did We Find?
  Among the 1,374 drug overdose deaths in NYC during the current year, 751 (54.7%) involved heroin. The heroin-related death rate in the city’s poorest areas (≥30% living below the poverty level) during the current year was nearly two times that of its most affluent areas (<10% living below the poverty level), with rates of 15.0 versus 7.7, respectively. While there was a slight improvement in the disparity between these groups, mortality rates have increased from baseline for all income groups. There were also disparities by borough, with rates among Staten Island (18.8) and Bronx (16.1) residents roughly twice those of Brooklyn (7.7), Manhattan (8.6), and Queens (6.2) residents. Looking at racial and ethnic groups, whites (14.3) and Hispanics (13.7) were at greater risk than blacks (8.7).
• Scores in Context: Local Initiatives

  The mortality outcomes measured by the indicators in this topic have received increased attention from the City in recent years, and there are policies that aim to address citywide issues as well as specific disparities within each of these areas. The City’s strategy to combat HIV-related mortality stems from efforts at the state level and is being implemented citywide. A new initiative to address the opioid crisis citywide also includes a place-based targeted initiative that may help to alleviate disparities. In addition, a number of DOHMH programs speak directly to disparities in infant mortality and cardiovascular death rates.

  In an effort to address HIV transmission rates and mortality, the City has partnered with New York State on the Ending the Epidemic strategy, which may be reflected in the race and HIV-related deaths indicator over time. The City’s goal is to see fewer than 600 new HIV infections in the year 2020, down from an estimated 1,696 new infections in 2015. To achieve this goal, DOHMH aims to boost HIV prevention services (including pre-exposure prophylaxis and post-exposure prophylaxis medication to reduce HIV transmission), enhance the treatment and care of those that are HIV-positive, update the HIV testing equipment of the New York Public Health Laboratory, and provide educational programming in partnership with community organizations that serve vulnerable populations, including the LGBTQ community. In addition to these efforts, the City has also increased the hours of its Sexual Health Clinics and expanded HIV screenings, as noted previously in Quality of Health Care.

  Rising rates of opioid-related deaths and the disparities in these deaths, which are the focus of the income and heroin deaths indicator, have prompted the City to take a series of other policy actions. In 2015, for example, it expanded the availability of naloxone, an overdose-reversing medication, by eliminating the need for a prescription. In 2016, DOHMH launched the “Save a Life, Carry Naloxone” ad campaign to educate the public about the medication and where to learn more information. Finally, in 2017 the City launched HealingNYC an initiative that aims to reduce opioid overdose deaths by 35% by 2022, through a range of strategies that include distributing 100,000 naloxone kits through DOHMH, the New York City Police Department, and NYC Health + Hospitals; connecting an additional 20,000 people to medication-assisted treatment; and reducing the opioid supply though a range of efforts including the creation of new Overdose Response Squads targeting dealers in high-risk neighborhoods. The City’s efforts have thus far been concentrated in the neighborhoods with the highest rates of opioid overdose deaths, including four low-income neighborhoods in the Bronx and one on Staten Island. Increasing access to prevention and treatment in low-income neighborhoods may help to reduce income-based disparities over time.

  When DOHMH created the Center for Health Equity, it cited the same disparities that we highlight in the race and infant mortality indicator as a primary area of focus. Alongside the DOHMH Bureau of Maternal, Infant and Reproductive Health, the Center for Health Equity operates several programs to support women before, during, and after pregnancy with targeted services that have been shown to reduce infant mortality: the Newborn Home Visiting program provides breastfeeding support for new mothers in North and Central Brooklyn, East and Central Harlem, and the South Bronx; Healthy Start Brooklyn provides a range of support services for pregnant women, including prenatal exercise and infant safety classes, in Central and Eastern Brooklyn; the Nurse Family Partnership Targeted Citywide Initiative supports pregnant teens and women in foster care, homeless shelters, and at Rikers Island with nurse visits; and the Infant Mortality Reduction Initiative provides case management and education in neighborhoods with high rates of infant mortality. These programs target specific neighborhoods and populations in an effort to reduce racial and ethnic disparities.

  Finally, cardiovascular health is linked to other health outcomes, including diabetes, exercise, and sugary beverage consumption. In addition to the policies described above, the policy initiatives outlined in the Quality of Health Care and Wellbeing topics may contribute to changes in disparities in the race and cardiovascular deaths indicator.

Indicators within Wellbeing

• Race & Low Birthweight

  What is Measured?
  Ratio between the percentages of black and white children born with low birthweight.

  What’s the Backstory?
  Low birthweight can lead to health and developmental complications and even death, in addition to other serious health-related consequences later in life. In the US, black mothers are more likely than mothers from other racial or ethnic groups to deliver low birthweight babies.

  What Did We Find?
  Black infants were nearly two times as likely as whites to be born with low birthweight (11.9% and 6.2%, respectively), defined as weighing less than 2,500 grams. The disparity remained unchanged from baseline, when 12.6% of black infants and 6.6% of white infants were born with low birthweight. The percentages for Hispanics (8.0%) and Asians/Pacific Islanders (8.4%) were more comparable to that for whites than for blacks, but still higher. Black women were also more likely to have a preterm birth (<37 weeks; 12.1%), compared to white women (6.8%), which may account for some differences in low birthweight. There were also differences by nativity, with foreign-born women less likely to have low birthweight babies (7.7%) than US-born mothers (8.8%).
• Race & Sugary Drink Consumption

  What is Measured?
  Ratio between the percentages of Hispanics and whites who consume one or more sugary drinks a day.

  What’s the Backstory?
  Consumption of sugary drinks contributes to obesity in the US and can increase the risk of weight gain, type 2 diabetes, heart disease, and gout. Nationwide, blacks report consuming more sugar-sweetened beverages on average than people from other racial or ethnic groups.

  What Did We Find?
  Almost a quarter (22.8%) of New Yorkers said they consumed at least one sugary drink a day in the past year, which is similar to the baseline (22.5%). Blacks surpassed Hispanics as the most likely to consume at least one sugary drink a day (32.4% and 28.4%, respectively) and were two times more likely to do so than whites (15.8%) and Asian/Pacific Islanders (14.2%). A small decrease from baseline for Hispanics contributed to the small improvement in the score for this indicator, although the numerical difference was not statistically significant. Large income-based differences were also found in sugary drink consumption: those living in poverty (<100% of the FPL) were more likely to consume at least one sugary drink a day (26.3%) than those from more affluent households (≥600% of the FPL; 11.4%).
• Income & Smoking

  What is Measured?
  Ratio between the percentages of people in the bottom and top income groups who smoke.

  What’s the Backstory?
  Cigarette smoking is the leading preventable cause of death in the US. It greatly increases the risk of lung cancer, coronary heart disease, and stroke, in addition to a host of other health problems. Nationwide, adults who live in poverty are more likely to smoke than those with higher incomes.

  What Did We Find?
  Smoking rates overall were similar to the baseline; however, this year the smoking rate among those in the bottom income group decreased significantly, while remaining relatively steady in the top income group. For that reason, we saw an increase in score, although the numerically the difference was only marginally statistically significant. In the current year, those in the highest poverty group (<100% of the FPL) were about a third more likely to smoke (13.0%) compared to those in the lowest poverty group (≥600% of the FPL; 9.3%). Education was also related to smoking: individuals with a bachelor’s degree were less likely to smoke (8.9%) than those with less than a bachelor’s degree (15.5%).
• Income & Exercise

  What is Measured?
  Ratio between the percentages of people in the bottom and top income groups who do not exercise.

  What’s the Backstory?
  Regular physical activity has a number of health benefits including reducing the risk of cardiovascular diseases, diabetes, colon and breast cancer, and depression. People with low income are less likely to exercise and disproportionately likely to have health problems related to physical inactivity.

  What Did We Find?
  Citywide, a smaller percentage of New Yorkers exercised this year (71.7%) than in the baseline year (76.0%), and individuals in both the highest poverty (<100% of the FPL) and lowest poverty (≥600% of the FPL) levels were more likely not to exercise than in the baseline year. Generally speaking, the percentage of New Yorkers not exercising decreases gradually as household poverty levels decrease: in the current year, 36.1% of those in the highest, 33.6% in high, 27.7% in medium, 23.4% in low, and 15.6 % in the lowest poverty levels did not exercise, with the medium, low, and lowest poverty groups significantly different from the highest poverty group. Perhaps related to differences in income, there was also a noticeable difference in exercise by educational level: individuals with a bachelor’s degree were markedly more likely to exercise (19.1% did not exercise) than those with some college education (28.0% did not exercise), those with a high school diploma (33.7% did not exercise), and those with less than a high school education (38.3% did not exercise).
• Scores in Context: Local Initiatives

  There are a number of policy initiatives that speak to the four indicators within this topic. Some policies are citywide efforts to change health behaviors, including drinking sugary beverages and smoking. Other policies aim to reduce specific disparities, including racial and ethnic disparities in birth outcomes and increasing access to exercise opportunities in high poverty neighborhoods. Most of these initiatives are ongoing, while the efforts to reduce sugary drink consumption are more recent.

  Several citywide or location-based initiatives may contribute to future changes in disparities in race and sugary drink consumption. In April 2017, for example, DOHMH, in partnership with the Union Community Health Center, Bronx Health REACH, and the #Not 62 Campaign for a Healthy Bronx, launched the Bronx Healthy Beverage Zone. The goal of this initiative is to encourage Bronx residents to make healthier drink choices and avoid sugary drinks in particular, and as part of this effort, CUNY’s Hostos Community College installed new water refill stations on campus. In the summer of 2017, in turn, DOHMH released a NYC Vital Signs data brief focused on sugary drink consumption and “The Sour Side of Sweet” ad campaign to educate the public about the health hazards of these beverages. At the same time, NYC Health + Hospitals announced plans to stop selling sugary drinks from its vending machines.

  In April 2017, Mayor de Blasio announced five legislative bills aimed at reducing the number of smokers citywide by 160,000 in three years, all of which may contribute to the income and smoking indicator. These bills include raising minimum prices on tobacco products, reducing the number of tobacco retailers, setting restrictions on the retail of e-cigarettes, requiring a smoking policy for all residential buildings, and banning tobacco products from being sold at pharmacies. Some of these bills still need to be approved by the City Council, however, and others may need more robust plans for enforcement.

  The policies highlighted earlier in the Mortality topic may contribute to changes in disparities in the Wellbeing indicator of race and low birthweight, as low birthweight is closely tied to infant mortality. Among the policies that seek to address disparities in both of these health outcomes are Healthy Start Brooklyn, the Nurse Family Partnership Targeted Citywide Initiative, and the Infant Mortality Reduction Initiative. Additionally, priorities of the Bureau of Maternal, Infant and Reproductive Health include reducing unintended pregnancy and focusing on women’s health and wellbeing even before pregnancy, which have been shown to improve pregnancy outcomes.

  Finally, Shape Up NYC may also contribute to changes in disparities in the income and exercise indicator. Shape Up NYC is a program led by the NYC Department of Parks and Recreation (Parks) that provides fitness classes that are free and do not require registration or membership. In 2016, Parks announced the addition of more than 100 new classes, bringing the total to 370 classes provided weekly at more than 225 locations throughout the city. Many of these new classes are located in neighborhoods identified through the Community Parks Initiative, which aims to increase the quality of parks in high-poverty areas of the city.