The document discusses Rhode Island's Health Equity Zones (HEZ) initiative. The HEZ initiative aims to address social and environmental determinants of health by investing in community collaboratives across 10 zones. The collaboratives work to improve community health through strategies like improving housing, education, community gardens, and reducing inequalities. Impact to date includes over $1 million in additional community-raised funds and collaboration between over 200 organizations. Next steps include developing community health indicators and expanding the HEZ program statewide.

1. Green & Healthy Planning:
Livability and Equal Access for All!
SNEAPA 2016
Friday, October 21 2016
2:20 – 3:35 PM

2. Health Equity Zones (HEZ)
The Rhode Island Department of
Health’s Collective Impact
Approach to Community
Development
Christopher Ausura

3. What Determines Population Health?
Determinants of Health
Social Supports
Safe Housing &
Neighborhoods
Education &
Employment
Seeking
Medical Care
Diet &
Exercise
Substance
Use
Genetics
[30%]
Healthcare
[10%]
Social &
Environmental
[20%]
Individual
Behavior
[40%]
Affordability Health
Literacy
Access to
Care Adapted from Schroeder, SA. (2007).

4. Health Equity Framework - Equity Pyramid
This pyramid is adapted from Thomas Frieden, MD, MPH, Health Impact Pyramid
presentation at the Weight of the Nation conference, Washington D.C., July 27, 2009
1. Education &
Counseling
e.g. Eat Right
2. Clinical Interventions
e.g. diabetes control; pediatric
weight management counseling
3. Long Lasting Protective Public Health
Interventions
e.g. immunizations; HIV testing; BMI screening?
4. Changing the Context-Healthy Choices as Default Options
e.g. smoke free laws; healthy food in schools law
5. Social and Environmental Determinants of Health
e.g. housing, education, inequalities; community garden
Lowest
Impact
(1)
Highest
Impact (5)
Collaboration, Integration, Partnerships
Most
Individual
Effort
Least
Individual
Effort

5. Health Equity Zones (HEZ)
• In 2015 RIDOH issued an RFP for community led projects called “Health
Equity Zones” that would address the social and environmental drivers
of health disparities
• HEZ are contiguous geographic areas that have measurable and
documented health disparities, poor health outcomes, and identifiable
social and environmental conditions to be improved
• A 4 year, $13 million, investment of state and federal grant dollars by
the RI Department of Health spread across 10 health equity zones
• Focuses on the development of sustainable community collaboratives
who will work to improve the health of their communities using a
collective impact approach to address the social and environmental
determinants of health

6. The Composite of
Health Equity
Zones
for Rhode Island

7. Health Equity Zone (HEZ) –
Implementation
 Build/expand local collaborative
 Evidence of meaningful, true engagement of key
stakeholders
 Should include: Community residents, local housing
authority, Local planning department, local education
agency, city or town leaders, FQCHC and mental health
community centers, other health care providers (e.g.
hospitals. PCPs insurers…), CBO’s, youth organizations
 Identify backbone organization
 Collectively identify and prioritize local health issues
 Conduct community health needs assessment
(needs/assets)
 Review these findings with the community
 Develop and implement local plans of action
 Community-based, evidence-based strategies and programs
 Address multiple health impact domains
 Focused on the elimination of disparities

8. Health Equity Zone (HEZ) Implementation
• Build/expand local collaborative
• Collectively identify and prioritize local health issues
• Develop and implement local plans of action

9. Strong communities infrastructure begins
with genuine community engagement,
and the establishment of strong
community partnerships. Each
community should:
• Understand the community
infrastructure, assets, needs and
opportunities for development
• Understand the social and
environmental determinants of
health
• Develop diverse community
reflective collaboratives
• Ensure community decision making
is fair and equitable, and inclusive of
vulnerable community members
• Understand and take ownership of
the health and development of their
community
• Reach collective agreement on a
vision for improved community
health, functioning, and prosperity
• Invest in the development of
community leaders who reflect the
community
• Leverage investments to achieve
the highest possible positive impact
on the community
To sustain development of resilient, healthy
communities and improve population
health, resources and policies must be
aligned. Multi-sector funders and policy
makers should:
• Invest collaboratively to increase the
effectiveness of investments while
reducing redundant reporting
• Target investments to strategies proven
to eliminate disparities of all kinds while
growing local economies
• Develop investments that link
community development to health
improvement
• Listen actively to community needs and
be responsive to reinforce genuine
commitment
• Prioritize investments that support
sustainable community development
projects, policies, and strategies
• Support projects and policies aimed at
social and environmental determinants
of health
• Seek out and engage non-traditional
partners
• Utilize health improvement outcomes
and costs savings to guide future policy
changes and investments
• Implement sustainable design strategies
By responding to community needs, and
investing in sustainable community
development, Rhode Island communities will
demonstrate improvements. Communities
will:
• Be more livable places that attract and
retain both residents and businesses
• Consist of residents who civically engaged
• Have exemplary health and social
services
• Collectively improve the safety net
needed for healthy human development
• Have stronger and healthier economies
driven by the strengths of the
communities
• Eliminate or be working to eliminate
health, education, and other disparities
• Reduce healthcare costs and
expenditures by improving both physical
and behavioral health outcomes
• Be stronger, more disaster ready, and
adaptable to unforeseen changes
• Have developed sustainable strategies for
community development
• Be able to demonstrate returns on
investments
• Demonstrate increased self-sufficiency
and community pride
Health Equity Zone Theory of Change
IF Rhode Island collaboratively invests together in defined geographic areas to develop sustainable infrastructure, and aligns a diverse set of resources to support
community-identified needs, THEN positive impacts on the social and environmental conditions driving disparities and poor health outcomes will be demonstrated.
Community
Development
Sustained Investment Positive Impact

10. Health Impact Domains
• Integrated Healthcare Domain
This domain focuses on the system of healthcare and social services,
including quality, affordability, and access to physical and behavioral
health and the connection to individual biological and psychological
behaviors, attitudes, and beliefs that affect patient health.
• Community Functioning and Social Domain
This domain focuses on factors that influence the health of individuals
in the community. This may include social, cultural, and spiritual
aspects, economic drivers, and civic and community engagement.
• Physical and Environmental Determinants Domain
This domain focuses on the physical conditions of the environment in
which people are born, live, learn, play, work, and age. This may
include the natural environment, build environment, critical
infrastructure, and hazards and risks.
• Socio-Economic and Demographic Domain
This domain focuses on the social standing of an individual or group in
relationship to the combination of education, income, and occupation
attainment.

11. Health Impact Domains
• Integrated Healthcare Domain
• Community Functioning and Social Domain
• Physical and Environmental Determinants Domain
• Socio-Economic and Demographic Domain

12. Community Development and
Health
• Using the Theory of Change to invest in the Health
Impact Domains we envision better connections
between the sectors that affect the social and
environmental determinants of health
• The alignment of community development sectors with
health improvement sectors provides significant
opportunities for both to leverage existing work to
increase effectiveness and better document impacts
• Collaboration between these sectors already occurs,
but the outcomes are frequently not reported
collectively and leads to outcome reporting that is
undervalued compared to their actual impact

13. Impact to Date
• More than $1,000,000 of additional funding has been
leveraged by HEZ collaboratives to support
sustainability, these are dollars the communities have
raised for themselves
• Over 200 different community organizations,
businesses, and community agencies have come
together across the 10 HEZ to collectively improve the
health of their communities
• HEZ collaboratives are working with town and city
leaders across the state to improve their communities
from within by re-designating buildings for community
use, creating new policies and regulations, and holding
community events to increase civic engagement

14. Impact to Date
• More than $1,000,000 of additional funding raised
• Collaboration of over 200 different community organizations
• Collaboratives are working with local governments to get things done!

15. Next Steps
• We are currently meeting with partners across the
state to establish indicators of community health
based on the Health Impact Domains that will
inform community health index scores reflective of
the diverse set of factors that affect health in a
community
• RIDOH wants to create a Health Equity Zone in
every city and town in Rhode Island; to support a
HEZ in every city and town RIDOH, in partnership
with other private and public funders, plans to raise
and invest $70 million in capital into
comprehensive community development

16. Bristol, RI Health Equity Zone
Craig Pereira
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

17. What will the Health Equity Zone
result in for the Bristol community?
1. A comprehensive baseline assessment of the factors that drive
poor health outcomes across the community.
2. Development of innovative place-based approaches to prevent
chronic diseases, improve birth outcomes, and improve the social
and environmental conditions of Bristol’s neighborhoods.
3. Implementation of a community Work Plan of action by
municipal leaders, residents, businesses, transportation and
community planners, law enforcement, education systems and
health systems, among others over a three to four year period, to
improve the overall health and quality of life for Bristol’s residents.
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

18. Why does Bristol need a HEZ?
1. Despite the overall increasing household wealth of Bristol
residents from 2000 to 2012, there still remains a population living in
Bristol with very limited financial means.
2. 32.1% of all Bristol households have what public agencies define
as extremely low income levels, (incomes at or below 30% of the
area’s median income) - a significant amount that will affect the
general housing, nutrition, and educational needs of the community.
3. The Bristol HEZ will provide the structure for bringing the
numerous social services and community-based organizations
currently working independently together in a collaborative
framework so that more can be accomplished in the area of public
health.
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

19. Five Primary Partners
Bristol Warren Thrive by Five and Beyond
East Bay Food Pantry
East Bay Community Action Program (EBCAP)
Bristol - Warren Regional School District
Mosaico Community Development Corporation.
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

20. Three Target
Demographics
Low to Moderate Income Residents
Elderly Population
Portuguese Population
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
Three Primary
Deliverables
Establish a Collaborative
Baseline Assessment of Health Needs
in the Community
Development of a Work Plan

21. Looking Back on Year One...
Establish a Collaborative
1. Reached out to existing programs, services and leaders in the community
2. Conducted in-person interviews and on-line survey
3. Identified individual strengths and personal interests
4. Provided training to the Collaborative
5. Developed Year 1 scope of work with newly-established Collaborative
6. Encouraged Collaborative members to engage with the community
7. Structured Collaborative ‘levels of participation’ based on their role in the
community, their interest level, and their capacity to participate.
8. Community Partners Outreach Survey employed to better understand the
community stories related to health issues, community strengths and
weaknesses, and health indicators related to at-risk populations.
9. Developed list serve/constant contact list of Collaborative member’s
constituents.
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

22. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
Looking Back on Year
One...
Establish a Collaborative

23. Looking Back on Year One...
Baseline Assessment of Health Needs in the Community
1. Utilized Collaborative outreach data to identify general ‘topic areas’
2. Researched National public health/health equity assessment models
3. Identified range of implementation methods
4. Implemented on-line and hard copy surveys
5. Conducted Focus Groups
6. Participated in and organized community events
7. Gained a snapshot of the community centered around general ‘topic
areas’ by understanding the gaps in services and needs of the community
8. Identified feasible alternatives for programming and delivery of services
9. Created ‘institutional awareness’ of the Bristol Healthy Equity Zone
initiative
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

24. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
Looking Back on Year One...
Baseline Assessment of Health
Needs in the Community

25. Looking Back on Year One...
Development of a Work Plan
1. Adhered to ‘Guidance’ provided by CDC via RI DOH.
2. Solicited Collaborative for strategies
3. Utilized findings from the Baseline Assessment
4. Prioritized submitted strategies with Collaborative
5. Refined the details on each strategy
6. Approved Work Plan submission with Steering Committee
7. Strategy to address the identified gaps in services and needs of the
community
8. Realization of the strength of the community and desire for
improved quality of life
9. Celebrated our award of $321,225 towards implementation of
strategies for Year 2 at week-long community celebration
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

26. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
Looking Back on Year One...
Development of a Work Plan

27. Lessons learned...
Successful endeavors…
1. Building on the strength of an already-existing
organization/network
2. Hitting the streets for public outreach/Listening
3. Leveraging community resources
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

28. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
Lessons Learned

29. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
Lessons Learned

30. Lessons learned...
Not so successful endeavors…
1. Time
2. Communications
3. Flexibility
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

31. What’s Happening in Year 2...
Shift towards a ‘sustainable model’
1. Collaborative’s transition to Working Groups and Champions
2. Higher engagement of Primary Partners
3. Reconstitution of Steering Committee
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

32. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
What’s Happening in Year 2...

33. What’s Happening in Year 2...
Comprehensive integration into the
community
1. Bristol Warren Regional School District
2. Roger Williams University
3. Engagement of Primary Care Providers
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

34. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
What’s Happening in Year 2...

35. What’s Happening in Year 2...
Implementation of new programs and services
1. Personal Health and Wellness
2. Physical Activity
3. Food and Nutrition
4. Substance Abuse Awareness and Prevention
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

36. This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
What’s Happening in Year 2...

37. What’s Really
Happening in Year 2...
Implementation…
Evaluation…
Revision…
Implementation…
Evaluation…
Revision…
Implementation…
Evaluation…
Revision…
Implementation…
Evaluation…
Revision…
This project is supported by the grant or cooperative agreement number DP005511, funded by the Centers for
Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).

38. Public Health Considerations
in City Planning
Patrice Barrett, MPH
https://nextcity.org/daily/entry/visual-primer-social-impact-design.

39. Presentation
• My background
• CDC/ATSDR
• Grant with Horsley Witten Group
• Public health considerations in city
planning projects
• Brownfields and public health
 ID needs of the population
 Link health data to specific environment
 Public engagement & education both
important

40. Public Health in City Planning
• Good partners & advocates
• Provide insight and expertise
• Consider: Health Impact Assessment (HIA) -
assessing health impacts of policies, plans
and projects in diverse economic sectors
using quantitative, qualitative and
participatory techniques.
• Public health practice a very broad discipline

41. CDC/ATSDR Grant & Horsley Witten
• City Middletown, CT
• One year CDC
planning & outreach
only brownfield
revitalization grant
from ATSDR
• People recognized
important to be part
of a transparent city
project
• Learn needs of
population
• Ask citizens what they
want for community
green space
• First learn who they are
• 3 census tracts centrally

42. Our Project
• Approx. 47,000
population
• Small university
• SES portrait different
from whole city (much
lower income, poorer
housing quality)
• Densely populated tracts
• Mixed business and
residential use
• Minimal green space
• Infrastructure issues
(prevent safe pedestrian
use)
• SO – little physical
activity or interest

43. Quality of life neighborhood survey results at grant start
Insightful and set the stage

44. Grant Areas & Properties

45. Brownfield Work
• Grant for where
abundance of properties
• Portrait of the population
living there:
 Socioeconomic
characteristics
 Number of children vs.
adults
 Quality of life issues
 Health status – obesity,
asthma, child lead issues,
other exposures leading to
illness

46. Public Health Education
While planners are doing property
research and planning – Public health
educates in the community:
• What is a brownfield ? (huge task)
• Exposures & pathways
• Exposure = possible disease. Little
physical activity = obesity, diabetes.
OR risky exposure (kids and lead, hands
in mouth with soil)
• Chronic health disease impacts
• How to advocate for issues important to
you and your neighborhood peers….

47. Education Takes Many Forms

48. Stakeholders are important
They fill in the blanks
• Include all
community
sectors
• Provide valuable
insight and
wisdom
• Help you
navigate the
rough spots
• Know what the
data do not
show

49. Engagement: a Multi-Headed Friendly Beast
Public Service Announcement
on local Public Radio

50. Photo Voice: A Common Public Health Technique
Litter on the
streets . . .
Favorite Things about Middletown:
Nice atmosphere ∙ Restaurants ∙
Town keeps developing and that helps everyone ∙
Any development by the water is good ∙
Teachers are great and dedicated, and always push
students
Things they would change:
Generally feel safe ∙ Cleaner would always be nice ∙
A dog park would be nice
We need new
sidewalks

51. People and things otherwise not heard or seen
What happened?
Favorite Things about Middletown:
Like Middletown, nice family town
Happy with soup kitchen and that it’s open every day
Like that there are women businesses owners up and down
main street, woman taking the lead
Things about Middletown that they would change:
Parking is hard to find
A familiar North End sight

52. Some of the Results
• Many residents
got their soil
tested
• Planner site
designs took
into account
what people felt
• Some residents
saw areas of the
city they never
knew (you live
where ?)

53. Thanks & Contact Info
• Thanks for listening
today
• Group activity planned
• Can ask questions
during that time
• Patrice Barrett, MPH
• PatriceBarrettMPH@gm
ail.com
• LinkedIn profile

54. Scenario Activity
• Spilt into groups of no more than 8 people
• Take 5 minutes to read the scenario
• Take 15 minutes to answer the questions with your
group
Greetings
from
CaboSanLobstah
Snappyand
Delectable
since1737