Rhode Island Targets Social Factors to Achieve Health Equity

While a higher percentage of Rhode Islanders have health insurance compared to the U.S. average, achieving health equity has been a challenge for the state—especially for its infant mortality rate. Now, the Rhode Island Department of Health is targeting key social factors that impact infant mortality in minority groups, including education, income and stress.

“When we look at what’s happening with infant mortality data, we have a clear disparity by race and ethnicity,” says Ana Novais, executive director of health at the Rhode Island Department of Health. “Whether the metric was the percentage of preterm births, delayed neonatal care, tobacco use or insurance status, minority groups were always more likely to be impacted.”

The Rhode Island Commission for Health Advocacy and Equity was created in 2011 to address the inequity, by bringing together state agencies to focus on the social determinants of health—typically defined as the wider set of forces and systems shaping the conditions of daily life. Aligning the efforts of those inside and outside the state is also key. The state is participating in the national Collaborative Improvement and Innovation Network to Reduce Infant Mortality (Infant Mortality CoIIN), led by NICHQ. The state has joined the IM CoIIN’s Social Determinants of Health (SDoH) Learning Network. The learning network adopted the World Health Organization framework for tackling SDoH and developed a set of 20 strategies to foster innovation and advance policies and programs. Rhode Island is focused on the strategy of health equity in all policies. A recent state assessment of Rhode Island’s capacity to do this work made one thing clear: a dedicated staffer is required.

“We have the political interest,” says Novais. “What’s needed is one person coordinating this effort. It’s been 10 percent of everybody’s time and 100 percent of nobody’s time. It’s a huge challenge when you have competing priorities.”

Community-Needs Assessments Underway

Despite the lack of dedicated personnel, the state has already created 11 health equity zones. Health equity zones are geographic areas designed to achieve health equity by eliminating health disparities using location-specific strategies to promote healthy communities. A community collaborative was created for each zone, which was then assessed for gaps in care, disease burden and environmental conditions. Data from the zones is still being collected. The state plans to use it to precisely target services over the next few years.

There are a myriad of possible social determinants to address, notes Angela Ankoma, chief of Rhode Island’s Office of Minority Health. “The key underlying factors that we see over and over with our infant mortality work are income level and education level,” she says.

A range of other frequently discussed issues, such as intimate partner violence and substance abuse, will likely also be considered. But there is another, lesser known issue that the health department hopes to address: toxic stress. Rhode Island is a pioneer in this area, which involves the kind of chronic stress that can come from discrimination. A screening tool for toxic stress is already being piloted by family physicians and OB-GYN’s in the state, so that patients can be referred to mental health services or other support when appropriate.

Ankoma says working in such a small state can make the challenge seem overwhelming, but the small size of Rhode Island is helpful in some ways too. “We have the perfect conditions to pilot initiatives at the state level.”