Building Health Equity Zones
How Rhode Island’s health equity funding strategy is promoting community power and generating community-level impact.
| TIMEFRAME | 2015 – present |
| COMMUNITY | A diverse mix of urban, rural, and exurban communities across the state |
| GEOGRAPHY | Rhode Island |
| FOCUS | Community-defined |
| CORE PRINCIPLES | Inclusive, Co-created, Culturally-centered |
| COMMUNITY ENGAGEMENT OUTCOMES | Strengthened Partnerships + Alliances Expanded Knowledge Improved Health + Health Care Programs + Policies Thriving Communities |
PROJECT BACKGROUND
The Health Equity Zone (HEZ) initiative is a state-level response to Rhode Island’s persistent health inequities. Historically, state-level health funding and data collection have been organized around diseases and conditions (e.g., asthma, diabetes, and obesity), even as research repeatedly documented the role of the local environment in driving differences and disparities in the health status of residents. Furthermore, notes Ana Novais, Assistant Secretary for the Rhode Island Executive Office of Health and Human Services, “we kept providing services instead of investing in communities to define and solve their own challenges.” Progress was not being made. However, when state agencies began looking at population health data by geography, their approach started to change.
The resulting HEZ initiative is designed to address the role of environmental, social, and economic factors in community health. Operated by Rhode Island’s Department of Health (RIDOH), this initiative directs state dollars to community collaboratives in defined geographic areas whose goals align with RIDOH’s leading priorities: 1) address the social and environmental determinants of health in Rhode Island; 2) eliminate health disparities in Rhode Island and promote health equity; and 3) ensure access to quality health services for Rhode Islanders, including its vulnerable populations. The HEZ initiative is RIDOH’s place-based, community-led approach to improving health.
HEZs are designed to engage the entire community in the creation of solutions to address local priorities. From the beginning of the application process to the creation of each HEZ through implementation, RIDOH partners with community members. Through a four-year structured development process, HEZ funding creates a platform for neighbors and community partners to come together in new ways and address the root causes of inequitable health outcomes in their neighborhood. Community leadership ensures that the actions taken are culturally competent, socially relevant, and sustainable.
Watch an overview of how HEZs work by Ana Novais, Assistant Secretary for the Rhode Island Executive Office of Health and Human Services.
Watch community members and Dr. Nicole Alexander-Scott, MD, MPH, then Director of the Rhode Island Department of Health, talk about the impact of Health Equity Zones on local communities.
KEY ENGAGEMENT ACTIVITIES
Define a Health Equity Zone. HEZs are proposed and defined by community members but must serve at least 5,000 people. Initially, HEZ boundaries were defined by ZIP codes. However, it became clear that for some communities the better boundary was a neighborhood; for others, such as rural communities, it made more sense to expand to a county level.
Identify a backbone organization. Each HEZ collaborative is anchored by a backbone organization that acts as an administrative center and convening body for other members. Backbone organizations have included local community development corporations, anchor institutions, municipal government offices, and community-based organizations or health centers.
Build a collaborative. A next step is to build, expand, and/or maintain a collaborative of diverse partners to drive the project. These can include residents, municipal leaders, businesses, education systems, health systems, law enforcement, and others.
Assign a facilitator. Many communities have ideas for how to address their health needs, but not all have the skill sets or experience to lead lasting change. A key component of the HEZ strategy is to embed facilitators, who are contracted by the state, into community efforts to provide structure and process and promote community readiness for implementation. Facilitators follow core principles of shared power and have no decision-making authority.
Provide training and technical assistance. RIDOH tailors support services to help HEZs at different stages of development. Services can include mentorship by other HEZs, participation in quarterly Learning Community meetings, external trainings, webinars, and other resources.
Perform a community assessment. In year one, each collaborative is asked to use a place-based perspective to inventory the assets and needs of their community. The purpose of the assessment is to identify and describe issues that are of interest to the community, including the socioeconomic and environmental factors that drive health outcomes.
Develop an action plan. Each collaborative leads its community in a prioritization process to identify solutions they want to implement. HEZ collaboratives are encouraged to select strategies that address root causes of their health inequities and to consider the feasibility, effectiveness, and synergy between selected interventions to effect change within the implementation timeframe. Collaboratives should agree that their HEZ action plan builds from their insights and innovations so they are invested in the implementation process—this also builds readiness.
Implement the action plan. Implementation occurs during years two and three. During this time, HEZs must begin to leverage local resources to supplement the seed funding provided by RIDOH. This will set the collaborative on a path to become a standalone, self-sustaining center for community health.
Evaluate and monitor HEZs. HEZs are encouraged to evaluate their work, funding, and collaborative growth on a quarterly basis. RIDOH also conducts various evaluations to improve the capacities and practices of individual collaboratives, as well as to strengthen the overall HEZ initiative. Metrics and indicators vary by HEZ and are chosen to reveal the success and sustainability of its approach, but also include HEZ characteristics such as diversity and community empowerment.
PROJECT OUTCOMES
Since its inception, more than $10.4 million in public health funding has been distributed through the HEZ initiative. As of 2021, there were 15 active HEZs across Rhode Island, with at least one in each of the state’s five counties. The state has also developed and released a HEZ Toolkit for use by other states and communities interested in creating and building HEZ-like initiatives.
ASSESSING COMMUNITY ENGAGEMENT OUTCOMES
Below, the Assessing Community Engagement Conceptual Model is mapped to the Impact Story. This mapping illustrates how CORE PRINCIPLES of engagement lead to impact across the four OUTCOME domains, and to specific measurable indices within those domains.
Working with communities to address their health issues has generated outcomes at all levels of the conceptual model. HEZs engage CORE PRINCIPLES to create engagement that is inclusive (coalitions include partners at all levels in the community) co-created and culturally-centered (communities set the agenda and priorities based on local assets and needs).
While individual HEZs have their own outcome measures, surveys of HEZs in 2017 and 2018 suggest these collaboratives are generating STRENGTHENED PARTNERSHIPS + ALLIANCES through diversity + inclusivity (HEZs reach and include residents from urban, rural, and exurban settings and represent each community’s racial and ethnic makeup and income levels); partnerships + opportunities (partners identify as more connected, some partners have run for elected office, and organizations are stepping forward to join local efforts); shared power (partners are more prepared to create mutually reinforcing activities and shared measurement practices, an objective for collective impact); and trust (partners report trust is high). By design, HEZs offer structural supports for community engagement.
The HEZ initiative has EXPANDED KNOWLEDGE in the form of new curricula, strategies + tools (the HEZ funding and development formula is now a repeatable process that has been tested, refined, and formalized for use by other states in the HEZ Toolkit).
Local HEZs have IMPROVED HEALTH + HEALTH CARE PROGRAMS AND POLICIES with solutions that are community-aligned; actionable, implemented, recognized; and sustainable. Results include: The HEZ in Washington County provided evidence-based mental health first aid and suicide prevention training to more than 1,000 partners; the Central Providence HEZ implemented a Walking School Bus program that boosted school attendance; and multiple HEZs have trained and deployed community health workers to build community-clinical linkages. Sample policy results include a town ordinance banning cigarettes and vaping in parks (Bristol); a Green and Complete Streets ordinance that provides safe access to roads for all users regardless of age, ability, or mode of transportation (Pawtucket/Central Falls); and a Healthy Eating policy at recreation centers (Providence).
Rhode Island HEZs have promoted THRIVING COMMUNITIES by improving physical + mental health, as evidenced by a 44% reduction in childhood lead poisoning (Pawtucket); a 24% reduction in teen pregnancy (Central Falls); a 13% reduction in feelings of loneliness (West End, Elmwood, and Southside Providence); a 63% reduction in elementary school absenteeism (Pawtucket); a 39% increase in Supplemental Nutrition Assistance Program (SNAP) sales and 117% increase in new SNAP customers (West Warwick); a 36% increase in access to fruits and vegetables (Central Providence); and 46 people diverted from the criminal justice system to opioid use disorder treatment and recovery services (West Warwick). HEZ participation across the state has also expanded community capacity + connectivity and community power, as evidenced by a 163% increase in community engagement.
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