Middlesex County NAACP, Connecticut

Branch 2018-B

Health Equity Focus Groups for

African Americans and Latinos Project

Middlesex County NAACP

Connecticut Branch 2018-B

November 2019
 A MESSAGE FROM THE HEALTH COMMITTEE of the
MIDDLESEX COUNTY NAACP, CONNECTICUT BRANCH 2018-B

The Health Committee of the Middlesex County NAACP, Connecticut Branch was formed to address
Health Equality for all Americans, one of the six NAACP National Game Changers for the 21st Century.
The NAACP’s national health focus is on healthy lives; equal access to affordable, high-quality health
care; and, an end to racially disparate health outcomes. To align with the national objectives, the Health
Committee of the Middlesex County NAACP, Connecticut Branch developed a mission to promote,
protect and maintain the health and well-being of Black/African Americans, Latino/as and all people of
color in Middlesex County by assessing health needs and advocating for health equity in order to
achieve positive health outcomes. To accomplish its mission and meet its vision – a nation where all
people are free from the racial and ethnic inequities that undermine optimal health and quality of life –
the NAACP Health Committee seeks to better understand how various systems contribute to health
inequity, and, to address disparities in health outcomes and social determinants of health for people of
color in our local community.

To meet our goals, the NAACP Health Committee embarked on a formal, representative focus group
study to gain an understanding of the lived experiences of people of color within the systems that
contribute to their health outcomes. Our project was made possible through the generous funding
provided by the Connecticut Health Foundation, the Middlesex Health Women’s Wellness Fund, and the
Community Foundation of Middlesex County. We gratefully acknowledge the support of our funders.
The NAACP Health Committee also extends its sincere gratitude to Health Equity Solutions (HES) for
conducting the focus groups, collecting and analyzing the data, and preparing this report. We continue
to value our partnership with HES as we move forward with our shared vision of advancing health
equity. In addition, we thank the Cross Street AME Zion Church, the Shiloh Missionary Baptist Church,
and the Russell Library in Middletown, and, the First Congregational Church in Cromwell for graciously
lending their spaces for hosting recruitment sessions and/or focus groups at no cost.

This focus group study presents views on the most pressing health problems and drivers of poorer
health outcomes for people of color in Middlesex County. Participants’ perceptions that diabetes, high
blood pressure/hypertension, and cardiovascular disease are major health problems are consistent with
existing data on the African American community in Middlesex County. Other findings include social
determinants as impacting the ability to realize optimal health and well-being.

The second phase of our project includes conducting community conversations with a broad cross
section of community participants and organizations where the report results will be shared, priorities
will be validated, and strategies that are guided by and in alignment with the needs and preferences of
the African American and Latino/a communities in Middlesex County will be developed. We look
forward to working with community partners and community members in developing and implementing
programs and system enhancements that promote health equity for people of color and all residents of
Middlesex County.

Middlesex County NAACP, Connecticut Branch - Focus Groups Report – Middletown, CT, November 2019 i
 Member Organizations/Sectors of the Health Committee of the
Middlesex County NAACP, Connecticut Branch 2018-B:

City of Middletown

Community Advocates

Middlesex Health

Middletown Schools

Ministerial Health Fellowship

Middlesex County NAACP, Connecticut Branch

Shiloh Missionary Baptist Church

Middlesex County NAACP, Connecticut Branch - Focus Groups Report – Middletown, CT, November 2019
TABLE OF CONTENTS

A Message from the Health Committee of the Middlesex County NAACP, CT Branch …… i
Introduction …………………………………………………………………………………………………………………… 1
Methods ………………………………………………………………………………………………………………………… 2
Project Objectives …………………………………………………………………………………………….. 2
Recruitment ……………………………………………………………………………………………………… 2
Notes on the Project Methodology …………………………………………………………………… 3
Data Collection …………………………………………………………………………………………………. 3
Interview Protocol …………………………………………………………………………………………….. 4
Data Analysis …………………………………………………………………………………………………….. 5
Results …………………………………………………………………………………………………………………………… 5
Study Sample …………………………………………………………………………………………………….. 5
Perceptions of the Biggest Health Problems in Middlesex County ……………………. 6
What are the Main Causes of Disease in Middlesex County? …………………………… 8
Behavior ……………………………………………………………………………………………………………. 8
Socioeconomic Status (SES) ………………………………………………………………………………. 10
Genetics ……………………………………………………………………………………………………………. 11
Knowledge ………………………………………………………………………………………………………… 12
Competing Priorities …………………………………………………………………………………………. 13
Stress ……………………………………………………………………............................................. 13
Mental Health …………………………………………………………………………………………………… 14
What are the Environmental Factors that Contribute to Disease? …………………… 14
Food Outlets ……………………………………………………………………………………………………… 15
Walkability and Transportation ………………………………………………………………………… 15
Housing …………………………………………………………………………………………………………….. 17
Chemical Exposure ……………………………………………………………………………………………. 19
What Would it take to Lower Rates of the Top Health Problems? …………………… 20
YMCA ………………………………………………………………………………………………………………… 20
Kids, Seniors, and Everyone Else ……………………………………………………………………….. 21
So, What it Would Take …………………………………………………………………………………….. 22
Conclusions ……………………………………………………………………………………………………………………. 23
Middlesex County NAACP, Connecticut
Branch 2018-B

Health Equity Focus Groups for

African Americans and Latinos Project

Final Report

Submitted by Health Equity Solutions

INTRODUCTION

This project is directed by a partnership between the Middlesex County NAACP, Connecticut Branch
– a local advocacy group, Middlesex Health – the county’s largest health care system, and the
communities these entities serve, and is overseen by the Health Committee of the Middlesex
County NAACP, Connecticut Branch. The contracted vendor to design and conduct the focus groups,
analyze the data and prepare this report was Health Equity Solutions (HES), a statewide advocacy
organization with researchers on staff and in their network. Through this work, the partners seek to
better understand the most salient social determinants of health and other drivers that negatively
impact health outcomes for people of color; strengthen the connection between people of color,
the health system and community service organizations; and, ultimately create changes in the
larger systems (e.g., health care, housing, food, etc.) to advance health equity.

At the outset of the project, local data from Middlesex Hospital’s most recent Community Health
Needs Assessment (2016) showed clear disparities, when stratified by race and ethnicity, between
residents of color in Middlesex County and white non-Hispanic residents for multiple health
indicators. For example, in Middlesex County:

 The death rate (per 100,000) for high blood pressure among individuals age
≥35 years is 1.5 times higher for black non-Hispanic males (215.5) when
compared to white non-Hispanic males (139.1) (CDC, 2011-2013).

 The avoidable heart disease and stroke rate (per 100,000) among individuals
<75 years is 1.9 times higher for black non-Hispanic males (84.5) when
compared to white non-Hispanic males (45.3) and 1.8 times higher for black
non-Hispanic females (43.2) when compared to white non-Hispanic females
(23.4) (CDC, 2011-2013).

 The stroke death rate (per 100,000) age ≥35 years is 2.5 times higher for
black non-Hispanic males (125.1) when compared to white non-Hispanic
males (50.5) (CDC, 2011-2013).

 The rate of adolescents and adults (≥ages 13) living with HIV (per 100,000) is
8 times higher for the black non-Hispanic population (963.7) and 6 times
higher for the Hispanic or Latino population (729) when compared to the
white non-Hispanic population (120.3) (US DHHS, 2010).

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1
METHODS

Project Objectives

The project team employed a qualitative research design in order to collect qualitative data on the
lived experiences of African Americans and Latinos in Middlesex County as it relates to
understanding the social determinants of health impacting and influencing health and well-being
for these populations in the county. The project aims were as follows:

 Aim 1: Identify the specific social determinants of health (e.g., economic,

education, health and health care systems, neighborhood and the built
environment, and social and community context factors) that impact
health and well-being, according to African Americans and Latinos who
reside in and receive care in Middlesex County.

 Aim 2: Generate a new understanding of how systems and local conditions

are driving racial disparities in health outcomes for people of color in
Middlesex County.

 Aim 3: Uncover entry points and specific community-driven actions for

creating change in the local systems that result in improved and,
ultimately, optimal health for people of color in Middlesex County.

Recruitment

Potential participants for this project were recruited using multiple methods. Information about the
study was posted on the HES Facebook page and paid geo-targeted Facebook ads were used.
Recruitment flyers featured stock photos of African Americans and Latinos of various ages.
Recruitment materials for the Latino sample were created in English and Spanish. NAACP Health
Committee members posted flyers at public locations in Middlesex County (e.g., churches, public
libraries, senior centers), mailed letters and flyers to local organizations, engaged in recruiting
participants in-person at community events and churches as well as through their own personal
networks. Interested residents were asked to call HES in order to determine if they were eligible for
participation. Inclusion criteria for the project were: age 21 years or older, self-identification as
African American/Black race or Latino/Hispanic ethnicity, and self-reported Middlesex County
resident. Exclusion criteria were: inability to participate in a 90-minute English language or Spanish
language focus group, NAACP Health Committee membership, and previous attendance at a focus
group session for this project.

Middlesex County NAACP, Connecticut Branch - Focus Groups Report – Middletown, CT, November 2019
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Notes on the Project Methodology

The original project goal was to conduct five focus groups with African American participants and
one focus group with Latino participants, with at least one group taking place in each of the
following locations: Middletown, Westbrook, Cromwell, and Portland. Due to recruitment
challenges and project deadlines, four focus groups were conducted in Middletown and one focus
group was conducted in Cromwell. At least one focus group solely contained self-identified females
and at least one focus group contained all self-identified men. All focus group participants self-
identified as African American/Black.

While eliminating the Latino focus group was a deviation from the original project goals and the
primary reason for eliminating the Latino focus group was low response to recruitment efforts, one
focus group is not sufficient to achieve data saturation. In qualitative research, “data saturation”
refers to the point in the research process when no new information is discovered in data analysis.
Saturation means that a researcher can be reasonably assured that additional data collection would
not yield new patterns or themes. Collecting qualitative data on the lived experiences of Latinos in
Middlesex County as it relates to understanding the social determinants of health remains a priority
for the NAACP Health Committee. Latino focus groups will be held in the future.

The results presented in this report should be interpreted, taking into consideration some
limitations. First, the participants who agreed to participate in this project may be individuals who
are active in the community and who are already connected to community resources and services.
Nevertheless, their responses to questions suggest that they considered challenges to and
strategies for reaching a wider range of the population, including those who may be most in need of
additional health-promoting resources and services. Second, the number of participants in the
individual focus groups was less than optimal. The ideal number of participants in a focus group is
between eight and 10. Two of the focus groups had more than 10 participants; the other three
focus groups had less than eight. Nevertheless, the total sample included 43 participants, which is
an appropriate number of participants for a community-based qualitative project. Data analysis for
this project yielded similar responses across focus groups; consequently, while the size of the
individual focus groups was less than optimal, the project team is confident that we captured key
data from our Middlesex County sample of African American residents.

Data Collection

Five focus groups were conducted with residents in Middlesex County between May and October
2019. Focus group discussions lasted approximately 1 to 1.5 hours and were held in Middletown at
the Russell Library, deKoven House, and Cross Street AME Zion Church and in Cromwell at the First

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Congregational Church. These locations were accessible via public transportation and featured free
onsite parking for participants. Dinner was provided at every session. Each participant provided
verbal consent prior to beginning the focus group discussion. Participants received a $50-gift card at
the end of the focus group session. Childcare was provided on-site upon request and availability.
Focus groups were audio-recorded.

Interview Protocol

The HES Executive Director who is a trained sociologist and an HES subcontractor, a medical
anthropologist with extensive experience in focus group facilitation, created the focus group
protocol. The focus group protocol was informed by the project objectives of determining specific
social determinants of health factors that are impacting the health and well-being of African
Americans and Latinos in Middlesex County and identifying potential entry points for creating
change and ultimately improving health for people of color in Middlesex County.

The focus group protocol started with an introduction, which included statements about
participants’ rights and guidelines for respectful engagement in focus group discussions. Following
the introduction was an “icebreaker”; participants were asked to introduce themselves and state
one thing they liked about living in their city, town, or county. Following the icebreaker, participants
were asked to list the Top 3 health problems they believed affect local residents, in order of severity
with Problem #1 being the top ranked. The interview protocol was written so that the responses to
the “Top 3 health problems” exercise would be used to guide the remainder of the discussion. The
facilitator reviewed the answers and chose the issues that the majority of participants listed and
inquired about the following:

 Why participants believed so many residents in the county struggled with

those problems?

 What it would take to lower the rates or severity of the problems; what the
community could do to address the problems?

 What resources or services are currently available in the community to

address these problems?

 What resources or services, if made available in the community, would

decrease the rates or severity of these problems or help those affected
manage them better?

Middlesex County NAACP, Connecticut Branch - Focus Groups Report – Middletown, CT, November 2019
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After completing that round of questioning, the facilitator read the following statement: “It has
been said, ‘Where we live determines how long we live.’” Participants were then asked to talk
about the ways in which their community environment impacted their health and longevity. They
were advised that they could talk about positive or negative effects. Finally, participants were asked
if there was anything about the relationship between their local environment/community and their
health that had not been covered but that they wanted to discuss.

Data Analysis

Focus group recordings were transcribed for analysis. An HES subcontractor, a trained medical
anthropologist, developed a codebook to analyze the qualitative data. Informed by HES and the
Middlesex County NAACP Branch Health Committee project objectives, primary categories were
created prior to analysis and were refined during the coding process. The codebook taxonomy
consisted of broad categories and specific codes within the categories. All narrative was manually
coded in order to conduct an unconstrained analysis of the data. Data analysis followed established
qualitative methods of deductive coding—searching for themes guided by the project objectives
and aims—and inductive coding—creating additional domains based on new, often unexpected
themes that organically develop.

RESULTS

Study Sample

The final sample consisted of 43 African American participants from Middlesex County. Only 1
participant self-identified as Latino. 9 of the participants were males and the remaining 34 were
females. Of the 43, 38 lived in Middletown; 2 lived in Cromwell; 2 lived in East Hampton; and 1 lived
in Middlefield. Only 3 participants were born outside of the United States. Participants most
frequently reported as having either had some college, without a degree, or an Associate degree
(28%); or having graduated high school including GED, or equivalent (28%). The majority of
participants were either retired (35%); or had full-time employment (28%). Participants most
frequently reported a level of personal income of less than $25,000 before taxes (35%). Only 1 out
of the 43 participants indicated that they were not covered by any form of health insurance. Tables
1, 2 and 3 provide the complete demographic data from eligibility screeners.

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 Table 1. Educational Attainment Reported by Participants
# of % of Total
Highest Level of Education
Responses Responses
High school graduate (GED, or equivalent) 12 28%
Some college (no degree) or associate degree 12 28%
Bachelor's degree 8 12%
Less than 12th Grade (includes 12th grade with no diploma) 3 7%
Master's Degree (MA, MS, MEng, Med, MBA, MPH, etc.) 2 5%
Doctoral Degree (PhD, EdD, JD, DrPH, etc.) 2 5%
Did not answer 2 5%
Professional School Degree (MD, DDS, DVM, JD) 1 2%

Table 2. Current Employment Status Reported by Participants

# of % of Total
Current Employment Status
Responses Responses
Retired 15 35%
Full-time Employment (37+ hours/week) 12 28%
Part-time Employment (36 or fewer hours/week) 8 19%
Unemployed 6 14%
Semi-retired 1 2%
Stay-at-home Mom 1 2%

Table 3. Annual Personal Income Before Taxes Reported by Participants

# of % of Total
Annual Personal Income
Responses Responses
Less than $25,000 15 35%
$32,000 – $49,999 7 16%
$25,000 - $31,999 7 16%
$50,000 - $75,000 6 14%
Did not answer 6 14%
More than $75,000 2 5%

Perceptions of the Biggest Health Problems in Middlesex County

Participants were asked to list the “Top 3” health problems they thought affected African American
and Latino residents in their town, in order of significance, writing the biggest problem at the top of
the list. Thirty-seven lists were available for analysis. Of the 37 lists, all participants listed at least
one health problem; however, two of the lists were incomplete. Diabetes (30%), high blood
pressure/hypertension (27%), and cardiovascular disease (14%) were the health problems that
participants most often put at the top of their lists, followed by cancer (8%), and substance abuse
(5%). The same three health problems were most frequently listed on participants’ lists of Top 3

Middlesex County NAACP, Connecticut Branch - Focus Groups Report – Middletown, CT, November 2019
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health problems, but the percentage of participants listing these problems anywhere on their list
was slightly different with high blood pressure/hypertension (68%) being the most frequently listed,
followed by diabetes (62%), and cardiovascular disease (38%). Tables 4 and 5 provide complete
data from the lists.

Table 4. Health Issues Ranked as Number 1 in Local Town

# of % of Total
Health Issue
Responses Responses
Diabetes 11 30%
High blood pressure/Hypertension 10 27%
Cardiovascular disease 5 14%
Cancer 3 8%
Substance abuse 2 5%
Insurance (Quality/Accessibility/Affordability) 2 5%
Obesity 1 3%
Asthma 1 3%
Urgent care wait time 1 3%
Prostate disease 1 3%

Table 5. Health Issues Ranked in the Top 3 in Local Town

# of % of Total
Health Issue
Responses Responses
High blood pressure/Hypertension 25 68%
Diabetes 23 62%
Cardiovascular disease 14 38%
Cancer 8 22%
Obesity 4 11%
Preventive care 4 11%
Substance abuse 3 8%
Prostate disease 3 8%
Cholesterol 3 8%
Mental health 3 8%
Insurance (Quality/Accessibility/Affordability) 3 8%
Asthma 2 5%
Arthritis/Joint problems 2 5%
Kidney disease/failure 2 5%
Nutrition 2 5%
Teen pregnancy and care 1 3%
Sexually transmitted infections 1 3%
Stroke 1 3%
Exercise 1 3%
Thyroid disease 1 3%

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In each focus group, the moderator facilitated in-depth discussions on the health topics that were
most commonly listed in that particular group. This resulted in narrative data on diabetes,
hypertension/high blood pressure, obesity, cancer, and mental health. For each health problem,
participants were asked:

 Why participants believed so many residents in the county struggled with

those problems?

 What it would take to lower the rates or severity of the problems; what the
community could do to address the problems?

 What resources or services are currently available in the community to

address these problems?

 What resources or services, if made available in the community, would

decrease the rates or severity of these problems or help those affected
manage them better?

Summaries of the participant thoughts and opinions follow. As participants viewed some factors as
contributing to multiple diseases, their perceptions are summarized by cause, rather than specific
diseases unless otherwise specified. Perceptions about contributors to specific diseases are noted
when applicable.

What are the main causes of disease in Middlesex County?

Participant responses as to why Middlesex County residents struggle with diabetes, high blood
pressure/hypertension, and cardiovascular disease focused on the same risk factors. Before being
prompted to talk about environmental factors relative to disease, participants were most likely to
attribute poor health outcomes among Middlesex County residents to behavior, socioeconomic
status, and genetics.

Behavior. Participants mentioned lifestyle and behavior as contributors to poor health. Specifically,
most of the comments about the type of behavior that contributes to diabetes, high blood
pressure/hypertension, obesity, and cardiovascular disease centered on eating. Underneath the
umbrella of lifestyle and behavior is “culture.” People spoke about African American culture as well
as American culture and how these influenced behaviors. Many of the participants stated that their
families moved to Middlesex County from the Southern part of the United States and believed that
this heritage influences their cooking and eating practices and those of many others in the

Middlesex County NAACP, Connecticut Branch - Focus Groups Report – Middletown, CT, November 2019
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Middlesex County community. They characterized these foods and cooking methods as unhealthy,
but it is their affinity for these foods that makes it difficult to give them up.

“It’s basically the health behaviors of our ancestors and we just never changed.”

“My generation, my parents, a lot of people come from the south and it's like a
learned behavior, the way they cook. And like she (another participant) said, a
lot of things are fried and we haven't really learned a different way of cooking.”

“I think there’s a part of our genetic makeup as African Americans,

unfortunately where we’ve got higher rates of cardiovascular issues, but also
tying it back to what we eat; what we do; what we eat to celebrate. And there’s
no balance; we’re not saying, ‘We’re going to have a pig roast and a 5K.’” (All
laugh.)

Participants also talked about the stressors, competing priorities, and eating habits inherent in 21 st
century American culture. The following quotes are examples of participants’ thoughts on how both
African American culture and mainstream American culture collectively impact eating practices.

“As we moved from the south to the north seeking a better life, financially,
socially, you name it… Most of us continue to eat ‘grandma’s cooking,’ ‘aunty’s
cooking’ and tradition says this is the food that you must eat to sustain life.
Nobody worried about how much weight you had or how it affected your
health. But now, we’ll get into the new millennium where health is a big issue…
now we're trying to play catch up. We gotta start eating the right foods, but we
live in a fast food era. The stuff the restaurants and fast food chains put out
there, it's not healthy food. But, here's where we losing it; we're getting away
from preparing our meals at home because nobody got the time because of the
work habits, social habits or I just don't feel like it.”

“I think it is our culture here because it's not like they don't know. A lot of
people I know that have diabetes, it's not like they don't know what they need
to eat; it's just that those are the foods they like to eat. You will put two
different sets of food there for them and they know that's (which one is) better,
but that's what they grew up with. That's what they like. The taste.”

The same participant added:

“I mean, everywhere you go is food. Everywhere you go. Easter is candy.

Valentine's Day is candy. Halloween is candy. Everything they giving kids is
candy. And it's like, I want to scream sometimes because I have kids and it's
like, ‘Can we find something else?’ But that is part of the culture. What do we
do? I don't know.”

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Socioeconomic Status (SES). Participants listed financial strain as a contributor to poor health in
Middlesex County. This section, in addition to addressing the relationship between SES and the top
three health problems, summarizes everything that participants shared about SES and health.

Financial strain is tied to health and healthcare in a myriad of ways. Participants explained that even
with healthcare insurance, copayments (hereafter referred to as “copays”) can be exorbitant and
the decision to seek preventive or even follow-up care may be weighed against other household or
personal obligations. Two participants reported having to pay $200 copays, one for surgery and
another for an MRI. Exemplary statements follow:

“Insurance is very important. If people don't have it or are under-insured or if

copays are too high, they will not use the system in the way that they need to.”

“When you're a struggling parent, you have to figure it out. You make more
money and you get less help. You try to get the help and then you don't have
enough for your rent… And, you know, and the deductibles for the insurance is
so high when you’re not on state insurance. It's ridiculous.”

One participant stated that a $35-copay may be too high for some, especially, if they are expected
to pay more than one copay. Another participant supported that statement, sharing her own
experience:

“Therapy for my knees is $35 per day, so it is extra money, and on a fixed
income, it adds up.”

One participant stated that she shopped around to find an insurance plan with lower copays, but
she had to drive 35 miles to see some of her doctors in order to use that plan and see their
providers.

SES also impacts one’s access to and ability to buy healthy food. Participants stated that there were
grocery stores in the towns of Middletown and Cromwell; however, grocery stores may be further
away and harder to get to than the corner bodega or fast food outlets. (See section on Walkability
and Transportation.) Even when fresh produce and other foods are available, processed food may
be the more economical choice. Supplemental Nutrition Assistance Program, popularly referred to
as SNAP, benefits and other food subsidies are distributed monthly. Individuals receiving these food
subsidies have to buy food that will last and feed them and/or their families for a month. Quite
often processed foods seem like the most logical choice.

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 “To eat right, it costs money. Fruits and veggies cost more than processed
food.”

“We are robbing Peter to pay Paul. We live in a neighborhood where you can’t
get fresh food, just lots of canned and processed food, and we have to choose
between food and paying rent, to make ends meet.”

In addition, other charitable or subsidized sources of food made available to individuals are also
processed. A few participants talked about the quality of the foods at food pantries and in school
lunches.

“The food pantries are—there is one that I know of that give fruits and
vegetables and healthy stuff to you—but everything else is like a lot of
processed stuff. It's like when you poor, you stuck eating unhealthy food.
When you get food stamps, you have to make it spread, and it's the cheap
stuff that's unhealthy that most people have to buy.”

“School lunches and food pantries all have highly processed, high-sodium
foods.”

Genetics. Participants frequently talked about the genetic or hereditary nature of disease. This was
an issue that was raised in every focus group without prompting. The perception among a large
number of participants was that the likelihood that one will have diabetes, high blood pressure,
heart disease, or cancer is greatly influenced by genetics. In fact, more often than not, participants
talked about disease as being influenced by genetics. There are pros and cons inherent to this
perception. Although none of the participants stated that there was nothing that they could do
about their own health problems, they acknowledged that many individuals, if armed with the
knowledge that a disease (e.g., high blood pressure, diabetes) runs in their family, would believe
that it’s inevitable that they will get the disease. Multi-generational illness was assumed to be
genetic, rather than a result of shared/learned behavior or a result of environmental circumstances,
or it was assumed to be the result of a genetic predisposition ignited by behavior.

“People are overweight and it has to do with genetics.”

“Sometimes it’s environmental. Also, I was reading something that

hypertension has gone as far back as slavery; it’s genetic.”

“I think a lot of this is because they’re not used to the fact that (cardiovascular
disease) is a hereditary disease. And, you might know like a brother or a sister
that has heart disease. The fact that heart disease is hereditary will cause
problems.”

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Nevertheless, participants stated that genetic predisposition can be countered with healthy eating,
exercise, and preventive care. Participants also emphasized the importance of knowing one’s family
history. (Researcher’s Note: The downside of focusing narrowly on genetics, screening, and
behavioral change is it can lead to the perception that because there is no family history, there is no
risk. It also ignores environmental drivers that increase risk regardless of genetic predisposition.)

“People don't get checked out, and because my mother died of congestive
heart failure, I have to get checked out.”

“So, I think black people may have an underlying trait that makes us
susceptible to heart problems, anxiety, … But, again it’s also related to what
people eat; it’s related to drugs and alcohol, smoking, bad habits, too busy
trying to live to focus on how to live. I think that’s a major part.”

“I was going to say, because it's hereditary or my mom, my dad, and my

grandpa [had it], we don't try to nip it in the bud before it gets to us. We just
say, ‘It was hereditary. I [am going to] get it anyway.’ Instead of taking care of
the problem before, and like she (another participant) said, we don't go to the
doctor. And, then it’s just gone too far to do something about it. Watch what
you eat. Exercise. Walk, whatever it takes.”

Knowledge. Adjacent to behavior is knowledge. Participants were divided in their opinions about
whether or not a significant segment of the African American population knows how to eat healthy
or prepare healthy food. Some believed that individuals know which foods and preparation
methods are optimal, but choose to eat less healthy foods because they prefer the taste or
convenience of those foods; “less healthy” or “unhealthy” foods as categorized by participants were
traditional Southern dishes (i.e., soul food) or fast food. Others believed that African Americans
know which foods are healthy and unhealthy, but even when individuals want to make healthier
choices or prepare healthier meals, they don’t know how to, particularly within the limits of their
budgets.

“I think if we get a chance to get out there and educate the community on what
to eat and how to eat, no matter if you have $1,000,000 or $1, just learn how to
maneuver when you go to the grocery store or the health food store knowing
what to eat, that'll make a big, a huge difference. I really believe that lack of
education or lack of not knowing what to eat or, thinking, ‘I'm not sure how to
cook this.’ [contributes to poor eating habits].”

“We were never educated on the proper way to eat… We use a high amount of
salt, sodium, over the years, early, early, early on. No one never said, ‘You
shouldn't use so much salt.’ But, as time went on and you start listening more
about health issues, that was one of the main ingredients they say you should
stay away from when you cook and so forth… Salt was like putting ice in water.”

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Competing Priorities. Expanding on an important issue touched on above, participants talked about
competing priorities. Speaking for themselves and others, they explained that many residents of
Middlesex County are constantly making choices about how they should spend their money, trying
to figure out what the most pressing issues in their lives are at the time. Oftentimes, eating healthy
and preventive care are lower priorities.

Stress. Stress was not initially identified as a leading cause of disease, but in each focus group, once
one participant brought up the impact of stress on health, inevitably, others agreed and added to
the conversations. Sources of stress included worries about money or family, competing priorities,
work, caregiving, and simply being Black in America. Perceptions about the impact of stress on
health included the idea that it simply takes a physical toll on one’s body and it hinders people from
making choices that would improve or at least maintain their health.

“I think one of the major things that's going on. Again, not just here, but
people having a lot of stress and from experiencing so much stress, that's
what's causing some people to become diabetics or having cardiovascular
disease… Probably running from one job to the next; being a single mom and
not getting that financial, or that support period, because it doesn't have to be
financial, at times. It can be, ‘Can you just watch them for the weekend? Let
me just breathe.’”

“Paying your bills every month. Getting to work every day, you know, dealing
with what's going on in society worrying about your kids in school. Just your
average everyday stuff… Economy is going up, gas. Jobs. I was working in
Middletown, in Cromwell. Now I have to go to Glastonbury. That was stressful
alone. You know what I'm saying; so, it's just, I think, me personally, everyday
life making sure the bills are paid and your lights aren’t off, and at least a little
bit of food in the refrigerator. You know, that’s the way I see it.”

“Stress has everything to do with it. We have a tendency not to open up and
talk about issues and we carry around a lot of weight and it eats at you and
really affects your health and is a big factor with high blood pressure.”

“We, as black people, need to find better ways to deal with [stress], family
issues, things going on around us. If we want to be around and maintain
health, not just exist, but be alive, we need to come up with ways to better
deal with the stress we find ourselves under.”

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 “I don't care what age group you in, if you are working, okay, got to get to
work on time, got to make sure the bills are paid. And as your kids get older
you still want the best for your children and your extended family. So, you still
worrying about, ok, my daughter needs this, my son need this. The car broke
down. I can't be late for work… A lot of us don't show that emotion on the
outside, but you know because it's you know I grew up in a southern
environment where men were not supposed to cry. You wasn’t supposed to
show it. You wasn’t supposed to show your pain… But as I got older, I realized
you know to show your emotions your feelings that's normal… It never stops.
So, there's always stress. And one of the big stress factors to me and I'm not
saying this as a racial remark being a black man in America is a serious job you
know 24/7 because you have got to learn how to live within your home, your
community, as well as go downtown, across town where all of a sudden if you
physically large and vocal now here come the threats. So, you know what the
process never stop.”

Mental health. Participants in one group of three women discussed mental health. They believed
that mental health is a big issue in the Black community and one that has only recently been given
the attention it deserves. There is nothing unique about Middletown that makes individuals more
susceptible to mental illness. One participant explained that awareness about mental health issues
in Middletown has always been a bit higher than other communities because of the presence of
Connecticut Valley Hospital. She added that Middletown used to be referred to as “Mental Town.”
Participants believe that Middletown has high quality mental health providers, but perhaps not
enough of them. In addition, they believe that there is still a stigma within the African American
community with regards to seeking professional help for mental illness.

What are some of the environmental factors that contribute to disease in Middlesex County?

As an icebreaker, participants were asked to share one thing that they liked about living in their
hometown. The majority of the participants lived in Middletown. Others lived in Cromwell, East
Hampton, and Middlefield. Middlesex County’s “country” atmosphere was the thing that people
liked most about living in Middlesex County. Quiet, wide-open spaces, and friendly people were
some of the characteristics that people liked about living in the area. In addition, parents thought it
was a good place to raise children because it’s safe; there was “enough” to do; and the school
system is good compared with those in some of the surrounding areas. Quite a few participants
mentioned that Middletown and Cromwell do not have the same level of violence and criminal
activity that can be found in other cities, such as New Haven and Hartford. A few of the Middletown
participants also mentioned that they appreciated the town’s diversity.

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Similarly, near the end of the focus groups, participants were read the following statement and
follow-up question, “It has been said, ‘Where we live determines how long we live.’ In what ways
do you think your community environment impacts how long you live?”. Participants were advised
that they could talk about the positive or negative aspects of their community as it related to its
potential impact on their lifespan. The majority of the respondents focused on the positive aspects
of living in Middlesex County.

“Living in Middletown, your longevity is better here than in places with more
crime and everything else.”

Although participants spoke favorably about their hometowns, they also talked about the
environmental factors that negatively affect health as well as inequities that can be found within
towns.

Food Outlets. Participants stated that there are a lot of full service and fast food restaurants in
Middletown. They did not seem to feel targeted in any way, but viewed it as part of the American
landscape, particularly in a college town. There are grocery stores in all of the participants’ towns,
but the density and convenience of restaurants makes it easy to indulge, particularly if participants
perceive restaurant meals to be less expensive than meals they would prepare at home.

“Middletown has a large volume of restaurants that sell fatty foods, artery-
clogging foods. A lot of the little towns are popular for restaurants with
artery[-clogging] foods that we love to eat. That's not so good for us but we
love to eat them… We're a college town and Main Street Middletown has all
kinds of restaurants everywhere, everywhere.”

“Depending on where you live or work, there are strips of fast food
restaurants.”

Walkability and Transportation. Many of the factors that participants identified as contributors to
disease and poor health were national problems, or at least factors that impacted African
Americans nationwide. One of the neighborhood-level factors that participants identified as being
problematic and specific to Middlesex County was town walkability. It was an issue that was raised
in focus groups in response to open-ended questions about transportation convenience and
environmental factors that impact health and disease. Participants stated that towns in Middlesex
County, specifically Cromwell and Middletown, do not have enough sidewalks. Participants
reported being cautious when visiting some business districts in Middletown and Cromwell because
of the lack of sidewalks; they certainly would not feel comfortable walking in the same areas for
exercise.

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 “I'm just amazed by is the lack of sidewalks in the town, especially like on main
strips, or anywhere where would sidewalks should be; there's no sidewalks. Or,
the sidewalk would start during certain businesses and then once you get past
that business it's like, (Others: Done) it's done. And, it's like how do people
move about? How do they go to the grocery store? Get on like a main strip and
then you'll see people walking in the street and then that makes me nervous of
distracted drivers and then walking to the side… I'm just going, “How does this
happen? … I’m in awe of that…in a bad way.”

Beyond not promoting healthy behaviors (i.e., walking), lack of sidewalks presents a clear safety
risk.

“Well, in Middletown, there are a couple of, a few streets that is very
dangerous because they have no paths, especially streets like George Street,
and there are seniors living there and they have to go across the street to get
their mail. … I get so concerned because that's a street where people go really
fast. And I'm always concerned and I always forget because I go to meetings
sometimes with legislators in the city hall and stuff; I never remember to
mention about that, but it is something that really concerns me. Some of the
streets, mailboxes are not supposed to be on the street. It's supposed to be by
the people's home. I find that, you know, sometimes to save a buck, it's not
worth it because lives are more important.”

Contrary to what was said in the other four focus groups, participants in one group characterized
Middletown as a walkable city; however, probing revealed that participants defined “walkability” as
the availability of places to walk, even if they had to travel to get to those places. Individuals and
walking groups traveled beyond their immediate neighborhood to exercise. Local places where
participants reported walking included paths near Connecticut Valley Hospital, Wesleyan University
tracks (indoor and outdoor), local school tracks (e.g., Woodrow Wilson), and parks. In other words,
although there were free local spaces where individuals could safely walk, residents did not talk
about simply walking outside of their front doors and walking on the sidewalks in their
neighborhoods.

“I think Middletown is walkable because they have walking trails such as by

Wadsworth and Westlake, the whole strip of Westlake, people walk up and
down. They have tracks in front of the schools and away from the schools.
They have nature walks that are preserved for people. They have national
parks.”

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A few participants stated that walking trails are not available in the lower income neighborhoods
and other participants stated that the lack of sidewalks in lower income neighborhoods made it
difficult to access healthier food options or parks.

“There are some walking trails in the town, but generally not in our
communities… Not in low-income communities, but Westlake communities.”

“It’s (Price Rite) accessible, but not the go-to because you’ve got to travel
down a very busy street with no sidewalk access. So, even if you had to walk,
there’s very limited sidewalk, so I think that is an environmental factor.”

“We do have great parks; we do. But again, if you have no sidewalk access to
get to your great park or ride your bike, if you're a kid… those things make it
challenging.“

Participants did not talk about the deficits associated with other modes of transportation as much
as they talked about walkability; however, there were some. Participants stated that the
Middletown public transit system, which also services Cromwell, only has five routes and limited
hours. While it is possible to get to other parts of the county or nearby counties, the commute is
significantly longer than if one drove to the same location by car. Taxicabs as well as Uber and Lyft
are expensive. All of this is relevant to health because it limits residents’ ability to get to
appointments or even, as one participant mentioned, get a second opinion, and to access a wider
range of food options.

Housing. The other social determinant of health that participants discussed, which was specific to
Middlesex County was housing. An examination of the aggregated narrative reveals the full impact
that housing has on health in Middlesex County. Housing impacts health in at least three ways. First,
participants stated that housing—rent, in particular—is expensive in Middletown. Paying rent or a
mortgage each month was a source of stress. Furthermore, participants stated that in some
developments, residents are expected to buy the materials needed for home repairs when
something is broken.

“You know with this rent hike, it’s off the wall (out of control). When you live in
a place and you pay $1,200/month, if something has to be done in the house, I
think they should do it. But, they want you to buy it and they’ll put it in for you.
Then, what’s the rent for?”

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 “I agree with everything everybody said. But what I wanted to say is that most
time these landlords, they will go up on their rent and they haven't did a single
thing in your house. Most time if you got a crack in the wall or there are some
parts needs painting and you got something broken, you got to go fix it
yourself because if you don't, it won’t get it done. And, if you do get it done, it
takes months for them to get there, but when the rent time come, they will be
right there… And I think that is some part of how we get stressed, and high
blood pressures and all these different things. People said to me get out
because of things happening in life, but you can't if you don't have a state job.
You can't afford all of that. You can’t afford a $1,000 apartment that looks like
it should only be $500. That's stress.”

The second issue is that the housing itself is unhealthy, but residents feel powerless.

“I have three minor kids and I did not get child support. So, everything is on me
and I have a slumlord. I have a slumlord, and I know I'm not supposed to be
living there. I know that. But it's difficult. It's difficult to move. It's difficult to
move. It is difficult. I know the place is not healthy for me. So, I don't know. It's
my area [of the home] because the way the place is [set up]. The place where
the kids are is okay. But, there are openings around my area, my room area,
and, I know it's unhealthy. And, I need to do something. I know I need to do
something about it.”

“I think, the housing affects living, like repairs and stuff. Landlords around here
don’t do enough to look out for the residents. Residents have kids, a lot of
people out here have kids… Maybe they might get asthma from all the
asbestos or something in the walls and stuff like that. We take care of their
pockets. If they don’t take care of us, why should we give them money? But at
the same time, you don’t want people to live outside and on the streets.”
(Others agree.)

Third, the cost of housing and the responsibility of repairing and maintaining the structure of the
home contribute to individuals’ list of competing priorities. Participants explained that with limited
income, they are often put in a position where they have to choose between healthier food options
and less expensive, nutrient-poor food options. In addition, the stress of dealing with so many
issues, including housing costs, contributes to a situation where one puts health on the back burner.

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 “So the housing is expense. So the houses are expensive and if it's a single
family or it's a couple making X amount of dollars, then (health is) less
prioritized. ‘Do I buy healthy food to feed us in order to have a healthier
lifestyle or do I pay to keep the roof over our heads?’ So I'm sure a lot of times,
that's a decision they have to make. It's easier for me to go to the dollar store
and do grocery shopping. But, what is the nutritional value?... I'm just saying,
the cost of living is so high. We have to keep the lights on. Alright. We have to
keep food. We have to keep a roof over your head. So instead of buying the
fresh this, fresh that, let's just buy a quick meal for a $1.99 or whatever it may
cost. Right. Five, six dollars or so for a quick meal and let's eat that.”

“You gotta live (have housing); that affects everything. You got to have a roof
over your head, but you have medicine to buy. You can't afford your medicine
because you got to pay your rent. You can't get your vegetables because you
done paid your rent; you got your medicine; and the only thing you can afford
is a can of beans. Alright, they’re two for a dollar. That’s all you can get.”

Some participants talked about disparities in specific neighborhoods. Below are examples.

“I was not happy with the produce at East Hampton Stop & Shop. I like hard
fruit. By the time I got home, they were soft. There is different merchandise in
all stores. We have a McDonald, two gas stations, [and] Walgreens.”

“I think housing's an issue here too. There's a huge issue and then you see its
prevalence again. All the disparities, you tend to be able to identify at one
isolated area, which is the north end of Middletown.”

“I know people who come to Cromwell to shop. Produce is better in Cromwell

than Middletown Stop & Shop.”

Chemical Exposure. The focus group of six male participants was the only group to have an in-depth
discussion about cancer. The men mostly talked about the importance of screening; however, they
also talked about work-related chemical exposure. One participant stated that he previously
worked in a Wallingford, “a big factory town.” He explained that a lot of Middletown residents work
in Wallingford and he believes that they have all been exposed to chemicals (e.g., formaldehyde)
and cancer-causing agents. Another participant said that he worked at a prominent aerospace
manufacturer in the 1960s. A cleaning fluid that they used to degrease parts was later identified as
carcinogenic and was banned by the Occupational Safety and Health Administration.

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What would it take to lower rates of the top health problems in Middlesex County?

Participants were asked to discuss the resources and services that are available in the community to
help alleviate illness and improve health. Participants mostly talked about one event or one service
or one resource at a very specific place. For example, they talked about which school tracks were
open to the public or they mentioned a church Health Day. They also talked about free or low-cost
ways to improve or monitor health such as the blood pressure stations at Walgreens and Walmart
and smoking cessation programs at the Community Health Center, Inc (CHC, Inc). One participant
mentioned a vegan smoothie shop and another talked about a health food store where the
employees have a lot of knowledge about holistic health. The CHC, Inc. was the only organization
that was mentioned as having a variety of resources and services for the community. An important
finding from these groups is that there are gaps in service for residents who are struggling, but not
poor enough to receive hardship benefits, and adults who are not seniors. The next two sections on
the YMCA and “Kids, Seniors, and Everyone Else” provides some support for the previous
statement.

YMCA. Middlesex County residents need access to affordable gyms. The Middletown YMCA was
discussed in four of the five focus groups. The YMCA is the only gym that participants spoke about
by name. According to Middletown and Cromwell participants, the YMCA has nice facilities, classes,
organized recreation, and resources. Participants stated that membership is waived for individuals
with very low incomes; however, the prices and à la carte fees are too high for many of the
residents who are struggling financially, but whose incomes are above that which qualifies an
individual for waived membership. Quotes from two participants follow:

“We have a very expensive Y[MCA] that if you're really poor, you can get a
waiver for. But, if you don't meet that very low minimum, then they charge
you $20 to come in, $3 if you want to go to the pool, $5 extra dollars to play
basketball stuff like that, so if the Y[MCA] I could really think about being more
of a resource to address health disparities in the community things like that
would be very helpful. It's here, but that’s it.”

“I tried going to the Y[MCA]. I didn’t know the Y was so expensive; I can’t
afford the Y for me and my kids. It’s too expensive.”

In talking about affordable ways to exercise, another participant suggested that individuals “split” a
YMCA membership, implicitly suggesting that membership may too expensive for some.

“The park doesn't have to cost anything. Get out there and just walk, or cost
effective, maybe the YMCA. Team up with someone; partner with someone,
‘Hey, do you have a Y [membership]? Let’s split it.’”

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Kids, Seniors, and Everyone Else. According to participants, one of the benefits of living in
Middlesex County is that there are lots of activities for children and seniors. There are parks and
organized sports for children, and parents feel safe raising their children in the area away from the
violence that plagues other cities and towns in Connecticut. Similarly, participants stated that
Middlesex County has a lot of resources and services for seniors, including at least one senior center
in Middletown and one in Middlefield. Participants identified social isolation as a risk factor for poor
health, but felt that Middlesex County’s small-town atmosphere along with the activities and trips
organized through community groups and churches provides seniors in the area with plenty of
opportunities to socialize. In addition, seniors are eligible to take advantage of Silver Sneakers, a
Medicare Advantage benefit that covers gym membership for persons 65 and over. One participant
described the senior community as “thriving.” A quote from another participant follows:

“Well, I think one of the things I’ve seen or heard is that as people get older,
they tend to isolate. And, I haven’t really gone to a whole lot of events, but I
know that there are community events in Cromwell, so opportunities for
people not to isolate and [to] feel like they’re part of something bigger, and it’s
not just them.”

While resources abound for children and seniors, participants reported a dearth of support for
everyone in between. Adults did not know how to access affordable resources and services that
would benefit their health and well-being, or even if such resources and services exist. As discussed
in other sections of this report, many of the adults in the area are struggling to make ends meet and
cannot afford healthier food or to pay for fitness programs and/or gym memberships. Participants
identified stress as a problem but didn’t know how to access professional help or even meditation
classes, for example. This is the segment of the sample that is likely to be caring for children and
elderly parents, possibly even doing so in a one-income household. This is the segment of the
sample that reported having moments of reflection where they knew they were eating poorly or
not exercising but put their health on the back burner in order to give attention to other priorities.
The shock of being diagnosed with high blood pressure or diabetes was still fresh for this segment
of the sample. This gap in resources and services is significant, as interventions at this stage in the
lifecycle may prevent or delay chronic disease. Below is a quote from a Cromwell resident.

“I think for adults, it's a little bit trickier. I mean, for kids you know there's like
town rec[reation center] programs and camps and all that stuff. But I think for
adults, I mean, short of just joining a gym, on your own, it's a little bit more
difficult. But I mean I have seen stuff like I get the flyer for the Middletown
Adult Ed and they offer the Zumba, so there are certain services that kind of
carryover from Middletown. Someone who lives in Cromwell, we fall under
that umbrella so we're able to access those services as well.”

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So, What Would It Take …

Participants were asked what it would take to lower the rates or severity of the top health problems
in Middlesex County. They mentioned some of the fairs, workshops, and programs that already
exist in the county. For example, people talked about health fairs and a “Men’s Health Day” at a
local church. Some of the participants characterized the focus groups for this project as community
outreach and suggested that more events like these would be helpful. Participants thought a good
place to start would be to have these sorts of events quarterly instead of annually. Another
suggestion was simply to increase the advertising and expand the media campaigns for existing
programs. There was a sense that there are a lot of resources for people in the county, but people
are not aware of them. People reported learning about community programs and events from
postings on boards at libraries, grocery stores, health centers, or hospitals. Others reported reading
about events in senior centers and local newsletters. Some people reported learning about events
through social media. The current methods for publicizing events seem to primarily reach people
who are already “connected” or who are looking for something to do and ways to access new
information. In order to lower rates of diabetes, high blood pressure/hypertension, cardiovascular
disease, and other illnesses, more Middlesex County residents need to be reached. The 26-year-old
in one of the focus groups posed the question, “What’s a good way to catch the young crowd’s
attention?”

Beyond increasing the frequency of annual events and improving advertisements, participants
suggested a variety of strategies (e.g., farmers’ markets, workshops, mobile food trucks with fresh
and prepared produce and corresponding recipes) for educating Middlesex County residents on
how to cook healthier foods at home and introducing them to new foods or healthier ways to
prepare foods that they already eat. Participants stated that the appeal of poor food choices is the
taste, cost, and convenience. Strategies for improving diet need to focus on making healthy food
equally tasty, economical, and fast.

“If there was a program of what we should eat, like a group like this one, and
if you get enough people attending to cook differently. But right now, we just
eating what’s on sale and its fattening. And you are what you eat.”

Regardless of the strategy used to reach people, according to participants two conditions would be
important for any intervention. First, interventions must meet people where they are. Those most
in need of resources and services are often too busy to seek help. Second, interventions must be
constant. A “one and done” intervention is not likely to have an impact.

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CONCLUSIONS

This project employed focus group discussions with African Americans in Middlesex County to
identify perceptions of the biggest health problems in the county and factors that contribute to
poor health and well-being. Participants generally liked living in Middlesex County and believed that
living there had a positive, rather than a negative, effect on their health and well-being; however,
they talked about the health problems that are present in their community and that are, in many
cases, affecting them personally. Participants’ perceptions that diabetes, high blood
pressure/hypertension, and cardiovascular disease are major health problems are consistent with
existing data on the African American community in Middlesex County. While participants believed
that behavior, financial hardship, and genetics were the most significant causes of excess morbidity,
they also identified social determinants in the local environment that either contributed to poor
health or made it more difficult to realize optimal health and well-being. In addition, they provided
ideas for change that they felt would assist in eliminating disparities and improving health for
people of color in the county. This input can be used by the Middlesex County NAACP, Connecticut
Branch Health Committee to inform their strategies and future actions towards their goal of health
equity for Middlesex County residents.

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 Middlesex County NAACP
Connecticut Branch 2018-B

Please contact healthcommittee2018@gmail.com with any questions or comments.