Rhode Island's Health Equity Measures

Generations-long social, economic, and environmental inequities have resulted in adverse health outcomes that have affected communities very differently. For example, segregation in housing and education and racist mortgage lending and zoning policies have historically advantaged white Americans and disadvantaged communities of color. Inequities like these have a greater influence on health outcomes than individual choices. Reducing these inequities can help improve outcomes for every Rhode Islander. To improve surveillance of the socioeconomic and environmental factors that drive health inequities, the Rhode Island Department of Health (RIDOH) collaborated with members of the Community Health Assessment Group (CHAG) to develop the first set of the  Rhode Island Health Equity Measures .

The Rhode Island Health Equity Measures include 15 determinants of health in five domains that affect health equity: integrated healthcare, community resiliency, physical environment, socioeconomics, and community trauma. Data come from various sources. This StoryMap illustrates how this data can be mapped by community. Data are reported by other demographic characteristics such as race/ethnicity, disability status, and income level on the RIDOH website.

There is great work happening across Rhode Island to address the root causes of health and well-being in our communities. For example, RIDOH's  Health Equity Zone  (HEZ) initiative encourages and equips neighbors and community partners to collaborate and create healthy places for people to live, learn, work, and play. Many HEZs are working to improve access to healthcare, address socioeconomic conditions in their communities, build community resiliency, improve the natural environment, and address community trauma - using the Rhode Island Health Equity Measures to help evaluate their work. Some of this work is highlighted throughout this StoryMap using quotes from HEZ partners about how the model is helping them advance health equity in their communities.

Integrated healthcare is an emerging model for treating the whole person. It offers a more efficient and effective way for health professionals to work together by coordinating diagnoses and treatment of all health conditions.

By expanding access to quality care and leveraging limited resources, integrated healthcare can lead to improved overall health for individuals, families, and communities.  More important, it allows for healthcare cost savings by helping to reduce hospital and emergency room utilization rates. 

The Supplemental Nutrition Assistance Program (SNAP) provides low-income families with resources to purchase food. Access to this service can help relieve food insecurity.

This measure looks at how many individuals who are eligible for SNAP benefits based on income are receiving those benefits. For this measure, a higher percentage is favorable. A lower percentage suggests that fewer people are accessing or aware of SNAP, or that more eligible people are experiencing some other barrier to receiving SNAP benefits.

Data Source: SNAP, US Census Bureau

Naloxone is a medicine that can reverse an overdose. Improving access to naloxone helps prevent overdose deaths.

This measure is expressed as the number of naloxone kits distributed per every overdose death by municipality. A higher ratio is considered more favorable, as this suggests greater availability of naloxone kits and relatively fewer overdose deaths. Municipalities with fewer than five overdose deaths during the year will not have valid, reportable data for this measure (in these cases, small numbers are suppressed for purposes of statistical reliability and to protect confidentiality). Thus, data used to compare cities and towns should be interpreted with caution, because valid data only exist for areas with more than five deaths per year.

Data Source: RIDOH, Prevent Overdose RI website

Access to medical and dental care helps a person to live a healthy life and prevents more costly medical conditions from developing. Yet gaps in access to affordable care can limit opportunities for health and well-being for some Rhode Islanders. 

This measure demonstrates the percentage of adults who reported not seeking medical care due to financial costs. For this measure, a lower percentage is favorable. A higher percentage suggests that more people do not have access to affordable healthcare.

Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Community resilience is a process that uses a community’s assets to strengthen public health and healthcare systems to improve the community’s physical, behavioral, and social health. This supports the community to withstand, adapt to, and recover from adversity. Strategies for building community resilience include increasing social connectedness, reducing social vulnerabilities, and making sure everyone in a community is represented in decision making.

Social connectedness relates to the frequency of interactions between people. Social ties exist between family members, close friends, neighbors, and co-workers. People also connect within a variety of social settings including in the workplace or community. Studies show that strong social ties have a positive impact on health.

Through civic engagement, like voting and volunteering, people can promote positive changes that influence health and well-being in their communities.

This measure represents the percentage of registered voters who participated in the most recent presidential election. For this measure, a higher percentage is favorable. A lower percentage serves as an indicator of lower civic engagement. 

Data Source: Rhode Island Board of Elections

According to the CDC, social vulnerability refers to, "the resilience of communities when confronted by external stresses on human health." External stressors may include disease outbreaks, natural disasters, or other events that are detrimental to a whole community.

The Social Vulnerability Index (SVI) uses 15 different variables from US Census data to determine which communities are more socially vulnerable. Some of these variables include poverty, transportation access, and housing and population density. For this measure, a higher value is favorable. A lower value suggests these communities are more socially vulnerable. 

Data Source: Centers for Disease Control and Prevention (CDC) Social Vulnerability Index, Agency for Toxic Substances and Disease Registry (ATSDR)

Housing affordability affects health in many ways. High housing costs can force families to forego other basic needs, such as food and heat. It can also relegate lower-income families to substandard housing in unsafe neighborhoods with fewer resources for health.

This measure combines data from two sources to estimate how many low to moderate-income housing units there are relative to the number of low to moderate-income households in each city and town. The lower the value of the ratio, the fewer low to moderate-income housing units there are relative to the number of households that may be income-eligible for those units.

Data Source: HousingWorks RI, Comprehensive Housing Affordability Strategy

Research shows that the health of individuals and families, in part, is largely determined by the conditions in their environment. In fact, the Centers for Disease Control and Prevention (CDC) have determined that more than 50% of our health stems from our physical and social environment.

Environmental factors that influence health go far beyond biological agents such as air, water, and climate. Public health also considers the types of policies and investments in housing, transportation, safety, public recreational spaces such as parks and playgrounds, and the aesthetics of streets and neighborhoods. Whether in an urban or rural environment, these factors affect large groups that share common living or working spaces. They can also account for vast differences in health status across ZIP codes and geographic locations. 

Trees promote health in many ways, such as providing oxygen, improving air quality, reducing the effects of climate change, conserving water, preserving soil, and supporting wildlife.

This measure shows the percentage of land with tree canopy cover. For this measure, a high percentage of tree canopy cover is considered a more favorable outcome.

Data Source: US Department of Agriculture (USDA) Forest Service i-Tree Tools

Affordable transportation improves the health of people and communities in many ways. Low-cost transportation helps people get to work, school, and doctor’s visits and access healthy foods. 

This measure reports estimated transportation costs. For this measure, a higher value is favorable, as it indicates lower transportation costs.

Data Source: US Department of Housing and Urban Development (HUD) Low-Cost Transportation Index

Lead poisoned children are likely to suffer life-long consequences. Children can be exposed to lead at home, in schools, or from soil contaminated with lead paint chips or dust, which can be found in homes and buildings built before 1978. Lead poisoning can have a negative effect on a child's development and can cause serious health problems, including learning disabilities, loss of IQ, and reduced attention span. 

This measure shows how many children enter kindergarten with toxic levels of lead in their blood. For this measure, a low percentage of lead poisoned children is considered a more favorable outcome.

Data Source: RIDOH Environmental Lead Program

Socioeconomic factors that determine health include education, employment, occupation, and income. The lower the social and economic position of a population or community, the higher their rates of mortality and morbidity. On the other hand, the better the social environment, such as can be found in more economically resourced communities, the more possible and likely it is for people to adopt and sustain healthier behaviors. 

Communities with low socioeconomic status are often characterized as having higher risk factors for violence, increased levels of unemployment, decreased levels of economic opportunity, poor housing conditions, and high emotional distress.

High housing costs have a negative impact on health. Cost-burdened households are often forced to choose between the cost of housing and other essentials, such as food, utilities, and healthcare.

This measure demonstrates the estimated percentage of renters and owners spending more than 30% of annual household income on housing. For this measure, a lower percentage is favorable, as it indicates a lower percentage of cost burdened households.

Data Source: American Community Survey

Food insecurity is defined as the disruption of food intake or eating patterns because of lack of money and other resources. Adults who are food insecure are at an increased risk for a variety of negative health outcomes.

This measure is a measure of food insecurity devised by the US Department of Agriculture (USDA). For this measure, a lower percentage is favorable, because high percentages suggest a larger proportion of people in that area experiencing food insecurity.

Data Source: Feeding America

Education helps ensure that people can live healthy lives in healthy communities. People with more education are more likely to have well-paying jobs and to live in communities with better access to resources, like high-quality schools, transportation, and healthy foods.

This measure shows the percentage of students graduating from high school in four years. For this measure, higher values are favorable. Lower values indicate fewer students graduating from high school in four years.

Data Source: Rhode Island Department of Education (RIDE)

Trauma can affect anyone, regardless of age, gender identity, socioeconomic status, race, ethnicity, sexual orientation, or any other factor. Community trauma, or adverse community experiences such as violence, structural racism, generational poverty, and discrimination have long scarred entire communities.

The persistent presence of community trauma is a major barrier to efforts to improve population health and health equity. When people don’t feel safe in their homes or neighborhoods, they are less likely to walk to the grocery store, use local parks, access public transportation, or let their children play outside. Social cohesion is replaced by social isolation, and factors that contribute to healthy lifestyle behaviors are replaced with unhealthy, undesirable alternatives. 

Involvement with the criminal justice system, including incarceration, probation, and parole, can affect the health and well-being of individuals, families, and communities. People with a history of incarceration have poorer physical and mental health outcomes than the general population. Formerly incarcerated people also often face challenges finding employment and housing, or accessing state and federal benefits.

This measure presents a ratio of the number of non-violent offenders under probation and parole for every 1,000 residents. Higher numbers are less favorable, as they indicate a greater proportion of residents involved with the criminal justice system.

Data Source: Rhode Island Department of Corrections (DOC), US Census Bureau

Crime and violence affect the health of community members in many ways. People may experience injury or death, mental distress, or reduced quality of life. They may also be less likely to engage in physical activity. In addition, children exposed to violence are at higher risk for long-term behavioral and mental health challenges.

This measure reports the violent and non-violent crime rate for every 1,000 residents. Lower values are favorable, as they indicate lower rates of crime.

Data Source: Rhode Island State Police Uniform Crime Reports, Federal Bureau of Investigation (FBI) Uniform Crime Reporting Program

Routine discrimination can be a chronic stressor and increase vulnerability to physical illness. Discrimination can limit opportunities, resources, and well-being of less privileged groups.

This measure demonstrates the percentage of adults reporting racial discrimination in healthcare settings in the past 12 months. Lower percentages are favorable, because higher percentages indicate more discrimination. More information can be found at  https://health.ri.gov/data/healthequity .

Data Source: BRFSS (available in 2020)

Policy makers, State agencies, healthcare providers, and community partners can use the data in this report to collaborate across sectors to address barriers to health and advance health equity. Each of the Rhode Island Health Equity Measures reflects systems and policies that affect the ability of every Rhode Islander to live a healthy life and achieve their full potential. Throughout this work, it is critical to engage the community to better understand how community members’ environments and experiences affect health.

The data available for each Rhode Island Health Equity Measure can help communities establish a baseline, identify gaps, determine policy priorities, and assess the impact of health equity initiatives. They also provide a way for Rhode Island to measure its shared progress towards advancing health equity.

The CHAG includes partners from diverse sectors, including representatives from local and state government, academia, philanthropy, community-based organizations, healthcare, Health Equity Zones, nonprofit policy and advocacy organizations, and the private sector. CHAG members spent more than two years developing this set of indicators through an extensive community engagement process that included the following phases:

Phase 1: Identified policy priorities and reviewed similar work nationally and internationally.

Phase 2: Examined 180+ potential measures.

Phase 3: Selected a core set of measures.

Phase 4: Encouraging use of the measures as the statewide standard to assess progress toward health equity in Rhode Island.

Measures were selected using a set of criteria. For example, data for each indicator must have been publicly available for Rhode Island; updated regularly; reflective of recent (2015 or later) data; able to be broken down by community and/or other demographics; and reflective of upstream factors that affect health. RIDOH and the CHAG continue to work with partners to explore how to build upon these measures, which are designed to complement existing datasets.

For more information about the Rhode Island Health Equity Measures, visit the RIDOH website at  health.ri.gov/data/healthequity .