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 lifeenhancing 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:
RI
RI vs. National
14%
White
11%
Asian
13%
Black
20%
Hispanic
22%
Native American
18%
Source: 2011 RI KIDS COUNT; U.S. Department of Education, National Center for Education Statistics. (2011). The Condition
US
8.1%
5.2%
3.4%
9.3%
17.6%
13.2%
of Education 2011 (NCES 2011-033), Indicator 20.
SDH: Poverty
In RI (2005-2009 American Community Survey 5Year Estimates)
•Under 18 years old
•18-64 years old
•65 years and over
Live below poverty level…
16.7%
10.3%
9.4%
SDH: Poverty & Race
Below poverty level by race, ethnicity and gender
White
Black
American Indians
Asian
Hispanic
8.8%
24.4%
23.6%
16.4%
28.6%
Gender
Male
Female
10.5%
12.7%
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 environmentbiological, 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
Trajectories of Health and Child Development, and MCH Checkpoints
DOMAINS OF HEALTHY
CHILD AND FAMILY
DEVELOPMENT:
Environmental – Poverty
Employment
Safety
Stress
Toxins
Social – Communication
Education
Social Support
Mobility
[RAISE TRAJECTORY]
Born Wanted and Well
Skilled Parents
Healthy Home
Early Reading
Full Preventive Care
Safe Play Space
Good Schools
Social Capital
Mentors
Physical Activity
Behavioral – Mental Health
Tobacco/EtOH/drugs
-Diet/Fitness
GRADUATIONS
SCHOOL
AGE
MCH
Checkpoints
P
G
Y
O
B
P
G
Y
BIRTH
LOW TRAJECTORY
P
G
Y
BIRTH
LEAVE
SCHOOL
SCHOOL
ENTRY
INFANT
YOUNG
ADULT
YOUNG
ADULT
ADOLESCENT
PRE
SCHOOL
Genetic – Familial Factors
Geo-Ethnic ff
Personal
Medical – Chronic Disease
Infections
Disabilities
HIGH TRAJECTORY
PROTECTIVE
FACTORS:
RISK FACTORS:
[DEPRESS TRAJECTORY]
Poverty
Premature Birth
Isolated Parent
Lead Poisoning
Poor Nutrition
Violence
Obesity
Unaddressed illness
Depression/Isolation
School Failure
Tobacco/EtOH
Unintended Pregnancy
BIRTH
UATIONS
O
B
O
B
MCH Checkpoints are regular and prn times of contact between parents/children and health professionals:
O
B
Pediatric
In a community system of family-centered medical homes, these MCH Checkpoints are organized into a coherent, connected,
longitudinal system. That Family Health system recognizes and address risks and protective factors that will influence childrens’
healthy development, as it responds to acute needs, and offers prevention opportunities for all generations.
Trajectories and MCH Checkpoints
Wm Hollinshead - Sept 2007
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 2001. ) Available at:
http://whqlibdoc.who.int/hq/2001/WHO_NMH_NPH_01.4.
Integration Projects Umbrella
Division of Community, Family Health & Equity
Integration Projects Umbrella
CDC Team Works
Project DCFHE
Healthy Communities
Pilot Project in
Olneyville
New (CCD)
Coordinated
Chronic Disease
and CTG Grants
Multiple DCFHE
Policy and Practice
Integration Efforts
ARRA CDC
Communities
Putting
Prevention to
Work
Initiatives
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
CFHE investments by pyramid level 2008 vs. 2010
60%
50%
40%
30%
38%
27%
28%
27%
26%
18%
20%
16%
15%
10%
5%
2%
0%
Lev 1
Lev 2
Lev 3
% of effort 2008
Lev 4
% of effort 2010
Lev 5
Healthy Rhode Island 2010 banners
Questions?
Ana P. Novais
&
Peter Simon
(401) 222-1171
ana.novais@health.ri.gov
peter.simon@health.ri.gov
Resources:
www.health.ri.gov
Social Environments as Determinants
of Health
Social Environments as Determinants
of Health
Community and Physical
Environments