Achieving Health Equity From planning to action Ana Novais, MA Peter Simon, MD, MPH Division of Community, Family Health & Equity Rhode Island Department of Health CityMatCH, September 2011

Situation Review For the first time in modern years, the next generation (our children’s generation) has a lower life expectancy than the previous generation…

Situation Review - Healthy RI 2010 Summary of Changes from 2004 to 2007 Reports Native American:5↑7↔6↓ African American:12↑11↔7↓ Asian & Pacific Islander:9↑11↔4↓ Hispanic Latino:12↑13↔5↓ State Overall:12↑14↔4↓

Health Equity Quiz

CFHE Vision CFHE aims to achieve health equity for all populations, through eliminating health disparities, assuring healthy child development, preventing and controlling disease, (including HIV/AIDS and Viral Hepatitis), preventing disability, and working to make the environment healthy.

Community, Family Health & Equity Community- because all health is local Family- because families are our key partners in health Equity- because our mission is to assure that all Rhode Islanders will achieve optimal health

Community, Family Health & Equity Our values guide us in the work we do internally and with our key partners: – Diversity – Health Equity and social justice – Open communication – Team work – Accountability – Data driven & science based

CFHE Priorities Health Disparities and Access to Care Healthy Homes and Environment Chronic Care and Disease Management Health Promotion and Wellness Perinatal, Early Childhood and Adolescent Health Preventive Services and Community Practices

CFHE Equity Framework Social and environmental determinants of health Lifecourse developmental approach Program integration Social and emotional competency

Social and Environmental Determinants of Health Determinants of health = range of personal, social, economic, and environmental factors that influence health status. – Biology – Genetics – Individual behavior – Access to health services – Environment – Age

Social Determinants of Health Social determinants of health are life- enhancing resources, such as: – food supply, housing, economic and social relationships, transportation, – education, and health care whose distribution across populations and communities effectively determines length and quality of life for the individual, the community and the population.

SDH: Education In Rhode Island in 2009, the median income of adults without a high school diploma or GED certificate was $20, 547 compared to $28, 785 for people with a high school degree, and $48, 845 for those with a bachelor’s degree. Source: Kidscount.org

SDH: Education Dropout rate in RI by race and ethnicity in 2010: RIUS RI vs. National14%8.1% White11%5.2% Asian13%3.4% Black20%9.3% Hispanic22%17.6% Native American18%13.2% Source: 2011 RI KIDS COUNT; U.S. Department of Education, National Center for Education Statistics. (2011). The Condition of Education 2011 (NCES ), Indicator 20.Indicator 20

SDH: Poverty In RI ( American Community Survey 5- Year Estimates) Under 18 years old16.7% years old10.3% 65 years and over 9.4% Live below poverty level…

SDH: Poverty & Race Below poverty level by race, ethnicity and gender White8.8% Black24.4% American Indians23.6% Asian16.4% Hispanic28.6% Gender Male10.5% Female12.7%

Life Course Developmental Approach Today’s experiences and exposures influence tomorrow’s health (Timeline) Health trajectories are particularly affected during critical or sensitive periods (Timing)

Life Course Developmental Approach The broader community environment- biological, physical, and social- strongly affects the capacity to be healthy (Environment) While genetic make-up offers both protective and risk factors for disease conditions, inequality in health reflects more than genetics and personal choice (Equity)

Lifecourse Framework

Example of the Life Course Approach in Obesity Prevention (Source: Mary Haan, DrPH, MPH, University of Michigan. Adapted from: World Health Organization, Life course perspectives on coronary heart disease, stroke and diabetes: Key issues and implications for policy and research. Summary Reports of a Meeting of Experts, 24 May ) Available at:

Integration Projects Umbrella CDC Team Works Project DCFHE Healthy Communities Pilot Project in Olneyville ARRA CDC Communities Putting Prevention to Work Initiatives New (CCD) Coordinated Chronic Disease and CTG Grants Multiple DCFHE Policy and Practice Integration Efforts Division of Community, Family Health & Equity Integration Projects Umbrella

CFHE Integration Initiative Provides for consistency in approaches, data use and evaluation to address common: – Socio-economic determinants of health and health equity issues – Population risk and protective factors – Opportunities in venues like CBOs, FBOs, workplaces and schools, health care and other systems

CFHE Integration Initiative Common vision Joint leadership Joint planning and quality initiatives Common outcomes Common policies Common financing and implementation at the state and local level

Common Vision Creates a common vision of a healthy community that will increase HEALTH’s impact: HEALTH EQUITY FOR ALL

Joint Leadership Joint problem solving and decision making mechanisms (MOUs, policy advisory groups, facilitation, criteria for priority setting, etc.) Weekly leadership meetings Monthly program manager meetings Policy work group meetings

Joint Planning & Quality Assessment, monitoring, technology tools; common assessment tools that address subpopulations across the life span. Community input/feedback Evaluation Dissemination of information

Common Outcomes Performance measures, and/or proxy measures of success - behavioral, risk and protective factors, diseases and conditions, injuries, well-being and health-related Quality of Life and Equity. Categorical data layered by populations across life course, geographic areas, income, race/ethnicity, etc. Different look at surveillance and data analysis: Providence DataHub

Common Policies Common legislative and policy agenda. Common communications messages with integrated information and education activities. Integrated advocacy strategies. Common mechanisms for community input and empowerment, integrated training/TA, and capacity building of community advocates.

Common Financing & Implementation Joint leveraging of funds Integrated initiatives and common strategies by community, population, and/or settings, supported with pooled Federal, state and/or state private categorical funds using integrated RFP’s and contracts Joint management of activities

Hands on Exercise Work plan assessment using Pyramid and four questions

4 Equity Questions 1.What does “achieving health equity” means for your program/team? 2.How comprehensive are your interventions (meaning, are your interventions reaching all five levels of the Equity Pyramid?) 3.If you are not addressing all levels of the pyramid, why not? What else are you doing? 4.What support will your program/team need in order to develop a comprehensive public health program, which addresses all levels of the pyramid?

CFHE Strategic Challenges 1.Build a shared public health equity agenda across the state 2.Adopt a community development frame for our work 3.Transform comprehensive service delivery model and culture of service delivery 4.Build capacity to collaborate internally

CFHE Next Steps Meeting with Teams – 4 Equity questions Grants review Local investments Staff training Equity workgroup Responding to the 4 Strategic Challenges

Strategic challenge #1 - update Building a shared public health equity agenda across the state: On-going effort (presentation at key community events and with key constituencies) CFHE Booklet

Strategic challenge #2 Adopt a community development frame for our work: CFHE has completed several local assessment processes and is working with three communities to develop community driven action plans and activation based on the results from the assessments. CFHE adopted a coordinated approach to community engagement and advocacy training across the division. MCH Block Grant Local Initiative RFP

Strategic challenge #3 Transform comprehensive service delivery model and culture of service delivery: Several initiatives are being implemented across the division with the home visiting program, healthy homes initiative, Chronic Care Collaborative (to name a few) so CFHE presence at the local level is coordinated and we are more effective in our approach. Alignment of CTG proposed strategies/interventions with proposal for CCDHP grant

Strategic challenge #4 Build capacity to collaborate internally: On-going activity. Examples: − Health equity grant checklist − Equity pyramid exercise with Teams − Core competency training − Standardization of local assessment tools − Asset mapping project − MCH Block Venture Capital

Hands on exercise Use of grants check list

Implementation examples Tobacco /Pregnancy Risk Assessment Monitoring Survey (PRAMS) Healthy Living Campaign (Diabetes/Obesity) Healthy Housing (Lead, Asthma, Radon, Asbestos); Healthy Housing Strategic Planning Process; Refugee Housing Workgroup Special Populations Emergency Response (Minority Health and Disabilities )

Implementation examples Olneyville Project (Office of Minority Health, Initiative for Healthy Weight, Healthy Communities, Prevention Block Grant – Community Planning) Community Skills Capacity Building (Office of Minority Health, Tobacco Control Program, Initiative for Healthy Weight, Office of HIV/AIDS) HPV (Immunization Program, Woman’s Cancer Screening Program and Adolescent Health)

Implementation examples Chronic Care Collaborative (Heart Disease & Stroke, Asthma, Cancer, Diabetes) HIV/STD’s (Renew Program) Lead/Refugee Health Workforce Development Project

CFHE Local Investments

Healthy Rhode Island 2010 banners

Questions? Ana P. Novais & Peter Simon (401) Resources:

Social Environments as Determinants of Health

Community and Physical Environments