The Health of Urban Rhode Island:
Assets and Opportunities
Prepared by
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Safer Institute
Table of Contents
Executive Summary ........................................................................................................ 3
Acknowledgements ......................................................................................................... 6
Methods .......................................................................................................................... 7
Defining Urban Rhode Island .......................................................................................... 8
Health Concerns ........................................................................................................... 10
Quantitative Results ...................................................................................................... 11
Assets ........................................................................................................................... 13
Opportunities ................................................................................................................. 15
Challenges .................................................................................................................... 16
Conclusions................................................................................................................... 18
References .................................................................................................................... 19
Appendices ................................................................................................................... 20
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Executive Summary
“Someone once asked me, “What is the number one health issue of Providence Community
Health Center patients?” Poverty. If you don’t have money, you can’t eat as well. You can’t
follow your diabetic diet as well. You don’t have easy access to get around.”
The Health of Urban Rhode Island: Assets and Opportunities is a mixed methods report
in which quantitative data on the health of urban Rhode Island is compared to that of the
entire state, and public health professionals from multiple sectors provide their
perspectives on the discussion of how to achieve gains in public health. We obtained
data on demographics, social determinants of health, and health insurance coverage
from the 2010 U.S. Census. Data on health status indicators, including general health
characteristics of adults, non-communicable disease prevalence, lifestyle indicators,
and healthcare access and utilization were obtained from the 2011 and 2012 Behavior
Risk Factor Surveillance System (BRFSS), a state-based, telephone survey of civilian
adults, conducted in collaboration with the Centers for Disease Control and Prevention
(CDC). We obtained data on child health indicators from the 2011 and 2012 BRFSS, as
well as the 2014 Rhode Island Kids Count Factbook, the latter of which is provided by
Rhode Island KIDS COUNT, an independent nonprofit organization that publishes a
yearly factbook.
The association of social determinants of health such as employment status, income,
educational attainment, with self-reported health status and risk of specific poor health
outcomes has been observed in several U.S.-based and international studies.1-3 The
literature suggests that not only is addressing social determinants important for reducing
the risk of poor health status, upstream factors influence self-management of chronic
diseases such as diabetes.3
With few exceptions, the data reveals disparities in both social determinants and health
outcomes between urban and non-urban Rhode Island. The communities identified as
the urban core of Rhode Island (Providence, Pawtucket, Central Falls, Woonsocket)
have higher rates of poverty than the state as a whole, with Providence’s poverty rate
(27.9%) more than twice that of the state (13.2%). Urban Rhode Island also has higher
rates of unemployment, lower median household incomes, and lower educational
attainment compared to the rest of the state, most notably Central Falls where 48.2% of
adults over the age of 25 have not completed high school.
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The data also reveals disparities in health outcomes. Urban Rhode Island has a higher
proportion of adults reporting that they have ever been diagnosed with diabetes,
obesity, asthma, depression, a heart attack or stroke. Urban Rhode Island also has a
higher proportion of individuals who smoke or lead sedentary lifestyles.
Children in urban Rhode Island also experience disparate health access and outcomes,
Mothers in urban Rhode Island are less likely to have accessed prenatal care early in
their pregnancy, and are more likely to have preterm births. With few exceptions, urban
rates of low birth weight and infant mortality are higher compared to overall state rates.
Children in Providence have higher rates of hospital admissions due to asthma and
higher rates testing positive for exposure to lead. In Central Falls and Woonsocket, the
rate of teen pregnancy is approximately 3 to 4 times the state rate.
Data on healthcare coverage, access and utilization was examined, but must be
interpreted with the understanding that it was collected before the state’s Medicaid
program was expanded in 2014. A greater proportion of adults and children in urban
areas (except Woonsocket) were less likely to have health insurance coverage
compared to the statewide uninsured rate. Individuals in urban Rhode Island are less
likely to have a regular healthcare provider or make use of preventive care services.
The Center for Medicare and Medicaid Services (CMS) reported a 35.1% increase in
enrollment in Medicaid and the Children’s Health Insurance Program,4 which may
influence the proportion of uninsured as well as healthcare access patterns in the future.
The observations from the quantitative data were supplemented with insight from
interviews conducted with individuals in state and local government, higher education,
hospital, community health and primary care organizations. Participants generally
defined urban Rhode Island as the urban core cities (Providence, Pawtucket Central
Falls, Warwick, Woonsocket, Newport), characterized by poverty, ethnic diversity, and
population density, and similar to cities in coastal Connecticut, the suburbs of
Washington, DC, Philadelphia and Pittsburg. Health issues included chronic diseases
such as diabetes, asthma, hypertension, obesity, premature and low birth weight
babies, lead poisoning, crime and safety, concentrated poverty, food security, education
quality, and homelessness, access to primary care and mental health.
Statewide assets that contribute to the health of urban RI include hospital and physician
groups, the community health center network, higher education institutions and their
students, and the Department of Health. There are opportunities to achieve health
gains and reduce health disparities by addressing the social determinants previously
mentioned, developing effective substance abuse and youth smoking interventions,
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using public schools as a platform to teach healthy nutrition (breakfast) and increase
activity (gym/sports), using text messaging, social media and other technologies for
public health campaigns, and shifting the focus from health insurance coverage to
patient centered medical homes (PCMH), where patients have a team of medical
providers collaborating in the provision of their care. Improving the transportation
system represents an opportunity to improve air quality and increase daily walking and
physical activity levels.5
Challenges to realizing these opportunities include a recovering economy and limited
financial resources at all levels of government, requiring new ways to do things;
ensuring the linguistic and cultural appropriateness of public health messaging; the
quality of the public education system as well as the educational attainment of Rhode
Island residents; and inadequate health literacy. Public health interventions or
innovations need to be patient-centered and should take these challenges into
consideration. Taking into consideration the attributes and characteristics of the public
health and health care system, and the people who use them will hopefully minimize the
risk of individuals and groups missing essential health messages,6,7 and maximizing the
efforts to impact upstream determinants of health.
Eliminating disparities in social determinants of health and health outcomes requires an
ongoing dialogue between and coordinated efforts by all stakeholders.8 We hope that
this report and subsequent discussions will provide insight that will help prioritize and
capitalize on opportunities to improve the health of all Rhode Islanders, and eliminate
the disparities between urban RI and the rest of the state.
Larry O. Warner, MPH
Director, Public Health Initiatives
Safer Institute
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for healthier, safer communities.
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Acknowledgements
Special thanks to the following individuals for their contributions to the collection of
qualitative and quantitative data, and preparation of this report.
- Norin Ansari – Intern, Safer Institute; MD/MPH graduate student, Brown University
- Peter Asen, MA – Director, Providence Healthy Communities Office
- Tara Cooper, MPH – Health Surveys Program Administrator, RI BRFSS Coordinator,
Interim YRBS Coordinator, Center for Health Data and Analysis, Rhode Island
Department of Health
- Mary Jean Francis, MS, RN – Vice President, Performance Improvement,
Providence Community Health Centers
- Yongwen Jiang, PhD – Senior Public Health Epidemiologist, Center for Health Data
and Analysis, Rhode Island Department of Health
- E. Paul Larrat, PhD – Interim Dean, College of Pharmacy, University of Rhode Island
- Meryl Moss, MBA – Chief Operating Officer, Coastal Medical, Inc.
- Patricia Nolan, MD – Rhode Island Public Health Institute; Brown University
- Elizabeth Roberts, MBA – Lieutenant Governor, State of Rhode Island and
Providence Plantations
- Terrie “Fox” Wetle, MS, PhD – Dean, School of Public Health, Brown University
- Jennifer Wood, JD – Chief of Staff, Office of Lieutenant Governor Elizabeth Roberts,
State of Rhode Island and Providence Plantations
- Patrick Vivier, MD, PhD – Hasbro Children’s Hospital; Director, MPH Program,
School of Public Health, Brown University
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Methods
DATA SOURCES
Data on health status indicators, including general health characteristics of adults, noncommunicable disease prevalence among adults, and lifestyle indicators, and data on
health care services utilization were gathered from the 2011 and 2012 Behavioral Risk
Factor Surveillance System (BRFSS). The BRFSS is a stated-based, random-digit-dial
telephone survey of non-institutionalized, civilian adults over the age of 18 years. It is
conducted in collaboration with the Centers for Disease Control and Prevention (CDC)
and state health departments and collects information on health conditions and
behaviors. Data specific to Rhode Island were obtained directly from the Health Surveys
Program Administrator and BRFSS Coordinator at the Rhode Island Department of
Health.
Children’s health data were collected from Rhode Island Kids Count, an independent
nonprofit organization that publishes a yearly factbook that examines 67 indicators of
children’s well-being. The 2014 factbook uses data from 2010, gathered from several
sources including the U.S. Census Bureau and the Annie E. Casey Foundation Kids
Count Data Center.
Data on low birth weight infants, infant mortality, preterm births, and births to teenage
mothers also came from the BRFSS but were obtained online from the Rhode Island
Department of Health’s Web Data Query System.
All data on demographics, social determinants of health, child population size, and
health insurance coverage were gathered from the U.S. Census Bureau, which last
collected data in 2010.
In-person interviews were conducted with key persons in Rhode Island representing
higher education, private and safety net healthcare providers, and state and local
government, providing diverse perspectives on the discussion of Rhode Island’s public
health assets and opportunities. The interview guide was developed with the goal of
soliciting participant knowledge, attitudes, definitions, experiences, and suggestions. In
addition, questions were created to help develop a context for discussion on the
quantitative data. Introductory questions were designed to establish the participant’s
public health experience, identify how they defined and characterized urban Rhode
Island, and identify comparable urban areas. Three questions were drawn from an
interview previously published online which aligned with the purpose of this report.
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Defining Urban Rhode Island
“To me urban Rhode Island is the five inner cities (Providence, Woonsocket, Pawtucket, Central
Falls, and Newport) that…are considered the areas most in need of services, high risk, vulnerable.
When you talk about public health, those that have the worst indicators, highest disparities in
healthcare.”
One of the early observations in this project was that no two data sources or interview
respondents defined Urban Rhode Island exactly the same way. Interview participants,
were asked how they would describe Urban Rhode Island in order to contextualize their
subsequent responses. Their responses are summarized in Table 1.
“Clearly density of population. I think in Rhode Island, as in many urban areas in the country,
(there is) a relatively high proportion of ethnic minorities, and of people who live in poverty,
particularly children who live in poverty. (It’s) also defined by higher mass transit penetration.”
Descriptions of urban Rhode Island included densely populated areas of Rhode Island
such as Providence, Pawtucket, and Central Falls, with a concentration of commercial
and/or industrial activities. Some respondents included Woonsocket and Newport in the
list of urban areas. One respondent felt that only Providence was truly urban, while
another felt that the entire state could be considered urban.
In the context of similarities and differences to other urban areas, Boston was described
as being on a different economic pathway than that of urban Rhode Island, and as such
is not a comparator, even though it is a neighboring urban metro area.
“(Boston has) had a different economic transformation pathway than Rhode Island, and they
also have a much a different level of maturity around human service development. Because of
the intense concentration of higher education and the corollary concentration of health and
human service professionals, and the environment, they have a way more built out non-profit
sector than we do.”
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Table 1. Definitions and characteristics of urban Rhode Island from respondents.
Characteristic
Definition of urban RI
Description
- Cities (e.g. Providence, Central Falls, Pawtucket, etc.)
- Urban core and Woonsocket
- From Massachusetts border to Warwick, West Warwick
- Newport due to poverty and ethnic diversity, not population density
- Providence, Central Falls, Pawtucket, Cranston, Warwick
- Rhode Island is almost entirely urban
Similarities to other urban areas
-
Disparities in income, wealth and poverty
Population density
Concentration of poverty, low income
Concentration of commercial and industrial activities
Racial/Ethnic diversity
Similar size (population)
Old housing stock
Lower college education rates
Instability of households (own vs. rent)
Lower access to healthy foods/groceries
Crime, violence, perception of safety
Interaction with and knowing neighbors
Strong family values
Mass transit
Linguistic and cultural minorities
Greater access to the political process
Similar to Baltimore, DC suburbs, coastal Connecticut, Southern New
Jersey, Philadelphia, Pittsburg
Unique characteristics
Accessibility, closeness of venues
Affordability for a greater proportion of people
Greater economic challenges in urban RI
Overlap of leadership and mentorship
Same people in different circles
Number of immigrant populations
Small area
Statewide urban-suburban transportation system
Not strong barriers between communities
Universities and hospitals play a big role
Less crime, livable, drivable, beautiful
Multigenerational stability within communities
Rich history of immigration
More walkable, more open space
Concentration of higher education
-
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Health Concerns
“Concentrated poverty is a problem in our communities, and the challenge of the low income
populations is very significant, because there are issues around food security, and around
education, around access to healthcare. Even though we do remarkably better than a lot of
other communities around the United States in getting people access to care, it’s still a huge
challenge.”
Health concerns for urban Rhode Island fell generally into the following categories:
behavioral risk factors, social determinants, healthcare access, and health outcomes.
These categories and specific health concerns are listed in Table 2.
Table 2. Health concerns in urban Rhode Island from respondents.
Category
Behavioral Risk Factors
Social Determinants
Healthcare Access
Health Outcomes
Concern
- Weight control
- Exercise
- Lifestyle chronic diseases
- Smoking
- Segregation
- Disparities in job opportunities
- Crime / perception of safety
- Disparities in physical and recreational opportunities
- Health insurance coverage
- Linguistic needs of patients
- Concentrated poverty
- Quality of education
- Food Security
- Homelessness
- Access to primary care providers
- Access to mental, behavioral health and addiction services
- Health insurance enrollment
- Healthcare transitions
- Asthma
- Diabetes and comorbidities
- Lifestyle chronic diseases
- Hypertension
- Obesity
- Premature and low birth weight babies
- Lead poisoning
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Quantitative Results
DEMOGRAPHICS & SOCIAL DETERMINANTS OF HEALTH
In 2010, Rhode Island had a population of 1,052,567, with 32% of its residents in the
urban core areas of Providence, Pawtucket, Central Falls, Woonsocket, and Newport.
Compared to the rest of the state, most of these cities have a younger population, with a
greater proportion of their population under the age of 18 years and between the ages
of 18 and 64 years. All of the urban cities have a smaller proportion of elderly in their
populations compared to the entire state.9
Urban Rhode Island is also home to a greater proportion of racial and ethnic minorities.
Fifty percent of the people who live in the City of Providence identify themselves as
white and 16% identify as black. Across the state, 81.4% identify as white and 2.9% as
black. Similarly, urban cities have a greater proportion of Hispanics/Latinos. The
percentages for Central Falls (60%), Providence (38%), and Pawtucket (20%) are
higher than the 12.4% of the state’s total population who identify as Hispanic/Latino.10
Compared to the entire state of Rhode Island, urban core cities (with the exception of
Newport) have higher unemployment rates, lower median household income, and a
greater proportion of its residents living under the federal poverty line.
Urban cities have a greater proportion of adults who did not complete high school.
Providence, Central falls and Newport have a higher proportion of adults whose highest
attainment is a high school graduate, while Pawtucket and Woonsocket have a higher
proportion of high school graduates compared to the entire state. Newport has the
greatest proportion of adults with at least some college (70.3%), Central Falls has the
smallest (24.3%), Providence has 48.7%, and the statewide proportion of adults with at
least some college is 55.5%. Providence and Newport have the greatest proportions of
adults with graduate or professional degrees.
HEALTH STATUS INDICATORS & DISEASE PREVALENCE
Urban core cities have a greater proportion of their residents reporting fair or poor
health compared to all of Rhode Island, and a small proportion of residents reporting
excellent, very good, or good health. People residing in urban cities are also more likely
to report feeling physically unhealthy more than 14 days of the past month, mentally
unhealthy more than 14 days of the past month, and more than 14 days of limited
activity in the past month.
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Disparities between urban Rhode Island and the entire state in rates of noncommunicable diseases are not as clear. Generally, urban Rhode Island has a greater
proportion of people with diabetes, obesity, past history of heart attack, angina, or
stroke, current asthma, and current depression compared to the state. However, there
are exceptions, including Providence’s slightly smaller proportion of adults with a prior
heart attack, angina, or stroke, and Pawtucket’s slightly lower rate of adults with current
depression compared to the statewide rate.
A higher proportion of urban residents report that they are smokers or lead sedentary
lifestyles (reporting no physical activity or exercise in the past 30 days) than residents
across the entire state. Patterns in binge drinking are not clear.
CHILDREN’S HEALTH
Approximately 28% of Rhode Island’s 223,956 children live in the cities of Providence,
Pawtucket, Central Falls, Woonsocket, and Newport. In these cities, women are more
likely to have had delayed prenatal care and infants are more likely to be born preterm.
These cities, with the exception of Central Falls and Newport, are also more likely to
have infants born with low birth weight and, again with the exception of Central Falls,
have a higher infant mortality rate than the entire state. Asthma hospitalization rates
range from 1.4 to 3.7 hospitalizations per 1,000 children in urban cities, compared to 2.1
hospitalizations per 1,000 children statewide. New cases of lead poisoning also vary,
ranging from 5.13% of children in Woonsocket testing positive for lead poisoning to
9.81% in Providence, compared to 6.0% positive cases of those tested across Rhode
Island. Teen (age 15-19 yrs.) birth rates are higher in urban cities compared to that of
the entire state. In Central Falls, the teen birth rate is 78.1 per 1,000 girls, and in
Woonsocket, the rate is 67.3 teen births per 1,000 girls. The rate for the state of Rhode
Island is 23.3 births per 1,000 girls between the ages of 15 and 19.
HEALTH CARE ACCESS & UTILIZATION
With the exception of Woonsocket, the urban core cities had higher proportions of
uninsured coverage than people living throughout Rhode Island in 2010 Census data.
This disparity, including the Woonsocket exception, held true for children in these areas
as well. Among those with health insurance coverage, a greater proportion of adults in
urban RI have public insurance than across Rhode Island and were less likely to have
private insurance than in other communities in Rhode Island. However, across these
cities and in the state of Rhode Island, a greater proportion of the population holds
private health insurance than public health insurance.
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Compared to Rhode Island totals, people in urban cities are less likely to have a regular
health care provider, less likely to have had a routine checkup in the past year, and less
likely to have dental insurance. Women above the age of 40 in these areas are also less
likely to have had a mammogram in the past 2 years and women above the age of 18 in
these areas are also less likely to have had a pap smear in the past 3 years than
women in the same cohorts across Rhode Island. However, Pawtucket did have a
slightly lower percent of its population with no medical checkup in the past year and a
slightly lower percentage of women over 40 without pap smears in the past 2 years
compared to state totals.
Assets
“We have the Public Health (School) at Brown, and we have a medical school close by. We have
the Public Health Institute which helps with policy. We have a small public health association in
Rhode Island…I think they’re an asset. They have policy briefs and white papers that they’ve
written from time to time to inform the larger community, hold forums from time to time. We
have a first lady who’s a nurse. We have the Rhode Island Free Clinic… (which) provides access
for some folks…for people who are uninsured…Once you get in they have a large array of
services. They provide diabetes education. They have yoga classes. They have nutrition classes.
It really surprises me, all the services that they can provide there.”
Several assets were identified relevant to the health of urban Rhode Island, including
the size of the state, which facilitates a level of accessibility and intercommunity
interaction that might not exist in a larger urban area. The statewide transportation is an
undersubscribed resource that not only increases the accessibility of different areas of
the state, but can have a positive environmental impact through the reduction of car
pollution. Additional assets are summarized in Table 3.
Hospital groups such as Lifespan and Care New England and physician groups such as
Coastal Medical were identified as resources, partly due to the quality medical care that
is provided to the community, but also due to the employment opportunities that their
institutions represent. In the context of quality medical care, Rhode Island only has one
children’s hospital, and one hospital that focuses on care for women and infants. As
such, there is little if any hospital segregation. Both the rich and the poor seek are
served by Women & Infants Hospital and Hasbro Children’s Hospital, and have a
chance to receive care from the same institution and the same staff.
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“There is a community health center that serves every single one of the…cities and towns in
Rhode Island. I think that’s an asset, because people who are uninsured can get care at low or
no cost.”
Table 3. Urban Rhode Island public health assets identified by interview respondents.
Category
Urban RI Characteristics
Healthcare
Educational
Other
Assets
- Size
- Accessibility
- Diversity
- Intercommunity interaction
- Sense of connection to the community
- Hospital networks (e.g. Lifespan, Care New England) and doctors
- Less hospital segregation
- Community health center network
- Number of doctors participating in Medicaid
- Hospitals as employers
- 1 medical school
- 1 pharmacy school
- Brown University – heavily involved in health of Rhode Island
- Students engaged in public health services (e.g. Health Leads)
- Universities as employers
- Active Department of Health
Participants also identified the community health center network and the Rhode Island
Free Clinic as valuable assets. Every community in Rhode Island is served by a
community health center, making healthcare obtainable for those who need free or low
cost care. In addition to the community health centers, Rhode Island benefits from a
single medical school, a single school of public health, a single college of pharmacy, a
single new physician assistant program, and a small number of nursing programs.
These institutions and their students are actively engaged in the communities around
them either through research, service, or both. Because of the diversity of racial and
ethnic groups in Rhode Island, students have opportunities to develop cultural
competence over time, which benefits them as a professional, and benefits the
community in which they are employed.
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Opportunities
“I think sustaining and rethinking some of our public transportation would really make a big
difference. We already know that people who use public transportation get more physical
activity. We already know that cars pollute pretty much everything. Our buses have improved.
They’re not perfect, but we’ve really invested in the buses. But we still are essentially driven by
the automobile, and I think there are some real opportunities that would change our health
profiles. Both by increasing activity and improving air quality.”
Respondents provided valuable insight regarding opportunities to achieve gains in
public health in urban Rhode Island. Suggestions ranged from using the state’s
universal school breakfast program as a venue to teach nutrition, to using physical
education classes to improve the health of young people rather than to just fill a
statutory requirement. Table 4 contains a list of these and additional opportunities.
Table 4. Opportunities to achieve health gains in urban RI from interview respondents.
Category
Areas of focus
Strategies
Assets
- Premature births
- Heart disease
- Injury rates
- Mental health and addiction recovery services
- Youth smoking
- Transportation
- Education
- Prevention
- Obesity
- Stop cutting Dept. of Health budget: “It’s not ever pennywise” to cut prevention
- Improve gun control laws…cost of youth violence
- Develop partnerships between academic institutions and healthcare industry
- Make urban areas more pedestrian friendly (e.g. lighting, crime,
road/sidewalks)
- Develop early substance abuse prevention programs, based in schools and
other community resources
- Use public schools as a platform for health: food/nutrition, physical activities,
summer activities
- Promote healthy eating and nutrition through school breakfast and other
venues
- Shift the focus from getting people health insurance coverage to getting people
into patient centered medical homes (PCMH)
- Develop interoperability of Health Information Technology (HIT)
- Use text messaging as a public health campaign tool (80% of Providence
Community Health Center patients have text messaging capabilities)
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Challenges
“Access to food for low income people is a challenge, and access to fast food is of reduced
nutritional value is not a problem, so it escapes me why we can’t do a better job of marketing. I
think there are a number of people who do things with regards to improving access to food.
Whether it’s the community gardens, the farmers markets, the corner store program…it’s
another example of where we have a whole lot of people doing little things, and not an overall
sense of how to make the market work.”
There are challenges at both the 40,000 foot level as well as the ground level in
achieving the aforementioned opportunities. High level challenges include Rhode
Island’s economy, which the American Legislative Exchange Council (ALEC) ranked
47th in the country for economic performance and 41st for economic outlook.11 State
and local programs are expected to do more with fewer resources and less funding, as
has been seen in proposed and actual reductions in funding for safety net services in
recent years. Community mental health organizations and the Women’s Cancer
Screening Program at the RI Department of Health are examples of state-supported
programs that have had funding reduced and eliminated respectively in recent years
while the demand for services was trending upwards.12 13 Research shows an
association between reductions in health department funding and worsening population
health.14 In the words of one interview respondent, “it is not ever pennywise” to cut
public health funding.
Another economic challenge is Rhode Island’s 7.7% unemployment rate according to a
July 2014 report from the Bureau of Labor Statistics, which is only higher than that of
Georgia and Mississippi.15 As seen in 2010 US Census data, the unemployment rate in
urban Rhode Island was higher than that of the entire state, suggesting that a relatively
high unemployment rate does not reflect the even worse urban struggle.
Research studies have suggested that county level socioeconomic indicators are
associated with health related quality of life (HRQOL).16 As shown in the BRFSS data,
urban Rhode Island has a significantly higher number of individuals reporting that they
have been physically or mentally unhealthy for 14 or more out of the last 30 days.
While Rhode Island does not have a county form of government, it is possible that some
of the same characteristics that result in disparities between counties with different
socioeconomic indicators are present in Rhode Island and contribute to the disparate
outcomes observed between urban Rhode Island and rural/suburban Rhode Island.
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Resolving the state’s economic challenges is beyond the scope of this paper. However,
we do hope that policy makers and elected officials recognize that there is an
association between the state’s fiscal health and population health. Socioeconomic
position beyond that of the individual person or household is a predictor of individual or
population health.
Several interview respondents pointed to the diversity of urban Rhode Island as both an
asset and as part of the definition of being urban. As new health campaigns, initiatives
and interventions are developed, care must be taken to ensure that they are
linguistically and culturally appropriate for the target audience: the entire state. Even if
a health message is efficient in its reach and penetration, if it is incompatible with
cultural assumptions or practices, then it may not effect the desired outcome, whether it
is increased awareness, or changes in knowledge, attitudes, beliefs, and behaviors. As
a result of the Affordable Care Act, the Patient Centered Outcomes Research Institute
funds research that emphasizes stakeholder engagement in several areas including but
not limited to the translation and dissemination of research, comparative effectiveness
research, and research to improve healthcare systems. As part of the effort to improved
population health, organizations must engage patients, providers, policy makers, and
payers in public health research, as well as in the development and implementation of
innovative health care delivery initiatives. A patient-centered approach to research and
implementation will increase the appropriateness of interventions, messaging, and a
partnership-based approach to research, rather than an approach where external
assumptions guide research and implementation. This model should be employed at
the local level to ensure that the maximum benefit from research and innovation is
realized for the most people.
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Conclusions
“Statewide…I think we have a great commitment from the state toward providing healthcare to
many folks, and it could be through various different mechanisms. Sometimes it’s community
health centers, sometimes it’s state hospitals. Certainly, the local hospitals, like Lifespan, provide
a great deal of support to the health of various communities in the state, and in particular the
areas of the state that are urban.”
The assets identified in this study and the discussions that already taking place at the
state level and at the local level are steps in the right direction towards achieving gains
in public health. We hope that elected officials, policy makers, thought leaders,
community organizers, researchers, healthcare providers, economists, educators, and
most importantly the residents of Rhode Island lend their voice and share their ideas,
suggestions and concerns to the discussion of how to improve the health of all Rhode
Islands. There are a great number of opportunities for improvement, ideas that have yet
to be identified, and partnerships that have yet to be established. Whether it is a
collaboration between higher education and industry, public schools and athletic
organizations, or communities working together to resolve a common challenge, Rhode
Island is small enough that we can have those discussion and forge those relationships.
Rhode Island is small enough that there should not be large gaps in health outcomes
between urban and rural/suburban Rhode Island. Tough decisions must be made to
address existing public health challenges so that rather than “kicking the can” down the
road and “burdening future generations” with the problems of today, we can face today’s
challenges head on. It can be hard to make the decision to maintain or increase
funding for public health programs, but “when public health happens, costs are averted”.
Let us invest our time, energy, and talents in public health so that we can improve the
health of all Rhode Islanders, improve the access of appropriate care to all Rhode
Islanders, slow the growth of healthcare spending, and reduce or eliminate disparities
between urban Rhode Island and the rest of the state.
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Safer Institute
References
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conceptual frameworks. Advances in life course research 2013;18:150-9.
2. Palomo L, Felix-Redondo FJ, Lozano-Mera L, Perez-Castan JF, Fernandez-Berges D, Buitrago F.
Cardiovascular risk factors, lifestyle, and social determinants: a cross-sectional population study. The
British journal of general practice : the journal of the Royal College of General Practitioners
2014;64:e627-33.
3. Clark ML, Utz SW. Social determinants of type 2 diabetes and health in the United States. World
journal of diabetes 2014;5:296-304.
4. Total Medicaid and CHIP Enrollment, February - July 2014. http://kff.org/health-reform/stateindicator/total-monthly-medicaid-and-chip-enrollment/ Accessed on September 24, 2014.
5. McCormack GR, Virk JS. Driving towards obesity: a systematized literature review on the association
between motor vehicle travel time and distance and weight status in adults. Preventive medicine
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6. Norman N, Bennett C, Cowart S, et al. Boot camp translation: a method for building a community of
solution. Journal of the American Board of Family Medicine : JABFM 2013;26:254-63.
7. Baptist AP, Thompson M, Grossman KS, Mohammed L, Sy A, Sanders GM. Social media, text
messaging, and email-preferences of asthma patients between 12 and 40 years old. The Journal of
asthma : official journal of the Association for the Care of Asthma 2011;48:824-30.
8. Corburn J, Curl S, Arredondo G, Malagon J. Health in All Urban Policy: city services through the prism
of health. Journal of urban health : bulletin of the New York Academy of Medicine 2014;91:623-36.
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May 2014, http://factfinder2.census.gov
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12. Mental-health advocates decry proposed $10-million cut, affecting those not eligible for Medicaid.
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Accessed on June 12, 2014.
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Nation's Health 2010;40:1-16.
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department resources with changes in state-level health outcomes. American journal of public
health 2011;101:609-15.
15. Unemployment rate, state by state. Bureau of Labor Statistics,
http://money.cnn.com/interactive/economy/state-unemployment-rates/ . Accessed on July 7, 2014.
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quality of life among US adults: a multilevel analysis. Journal of community health 2009;34:430-9.
Our Mission: Technology and policy innovation
for healthier, safer communities.
Page | 19
Safer Institute
Public Health in Urban Rhode Island
Appendix
Table A-1. Demographics and Social Determinants of Health
Providence
Pawtucket
Central Falls
Woonsocket
Newport
Total RI
178,042
23.4
67.9
8.7
71,148
23.3
64.1
12.6
19,376
29.1
62.2
8.7
41,187
24.0
62.8
13.2
24,672
16.5
69.2
14.2
1,052,567
21.3
64.3
14.4
RACE AND ETHNICITY (%)
Non-Hispanic White
Black
American Indian or Alaska Native
Asian
Hispanic or Latino, any race
49.8
16.0
1.4
6.4
38.1
66.5
13.4
0.6
1.5
19.7
52.9
10.1
0.9
0.6
60.3
77.7
6.4
0.4
5.4
14.2
82.5
6.9
0.8
1.4
8.4
81.4
5.7
0.6
2.9
12.4
ECONOMIC CHARACTERISTICS
Unemployed rate, age 16 years and over (%)
Median household income ($)
Poverty rate (%)
14.7
38,243
27.9
11.4
40,383
18.7
10.7
29,268
30.4
8.8
38,356
24.5
5.2
57,690
10.8
9.5
56,102
13.2
11.3
13.0
32.4
17.0
7.4
12.6
6.3
30.8
17.4
27.4
13.2
3.8
5.3
2.0
12.1
15.6
34.4
18.7
6.2
8.8
4.1
2.6
7.1
20.0
17.1
5.0
29.1
19.1
7.0
9.5
28.2
17.5
7.6
18.5
11.9
POPULATION
Total population
Percent under 18 years
Percent 18 to 64 years
Percent 65 years and over
EDUCATIONAL ATTAINMENT (% of adults age 25 and older)
Less than 12th grade, no diploma
15.4
th
th
9 to 12 grade, no diploma
12.0
High school graduate
24.0
Some college, no degree
14.7
Associate’s degree
5.0
Bachelor’s degree
15.9
Graduate or professional degree
13.1
Source: 2010 Census, United States Census Bureau / American FactFinder.
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Safer Institute
Table A-2. Health Status Indicators and Disease Prevalence
Providence
Assets and Opportunities
Pawtucket
CF, Newport,
West Warwick,
Woonsocket
Urban Core
Subtotals
Other
rural/suburban
cities/towns
Total RI
75.93
24.07
86.26
13.74
83.13
16.87
16.57
11.73
13.19
16.24
11.87
13.19
11.26
7.59
8.70
10.02
28.92
10.12
26.86
8.73
25.03
9.15
25.58
10.39
9.00
7.95
8.27
2.57
13.84
18.57
12.88
16.28
2.8
2.26
10.72
9.86
2.43
11.37
11.78
21.95
17.60
18.58
6.86
22.77
18.92
18.39
6.50
24.94
SELF REPORTED HEALTH CHARACTERISTICS (% of adults over 18 years of age)
Excellent, very good, or good health
72.12
81.70
77.71
Fair or poor health
27.88
18.30
22.29
Physically unhealthy for 14+ out of past 30
16.59
14.15
18.02
days
Mentally unhealthy for 14+ out of past 30
16.98
14.43
16.34
days
Experienced limited activity for 14+ days in
12.16
9.51
11.09
the past month
NON-COMMUNICABLE DISEASES (% of adults over 18 years of age)
Diabetes
10.63
9.11
Obesity (BMI ≥ 30)
25.85
25.79
Percent who have had a heart attack,
7.87
9.30
angina/coronary heart disease, or stroke
Percent who have had a stroke
2.66
3.50
Currently diagnosed with asthma
11.92
13.49
Currently diagnosed with depression
16.81
11.29
LIFESTYLE (% of adults over 18 years of age)
Current smokers
Binge drinkers
Chronic drinkers
No physical activity in the last 30 days
20.89
19.80
5.72
30.43
21.26
15.33
5.84
29.89
23.85
17.01
5.48
29.40
17.95
5.66
29.97
Source: 2011 and 2012 Behavioral Risk Factor Surveillance System (BRFSS) National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and
Prevention, Atlanta, GA. Analysis performed by the Rhode Island Department of Health.
Note: Bold/underlined/italics denotes statistical significance (p<0.05).
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Safer Institute
Table A-3. Child Health Status Indicators
Public Health in Urban Rhode Island
Providence
Pawtucket
Central Falls
Woonsocket
Newport
Total RI
41,634
19.2
12.8
9.1
8.9
3.7
34.6
16,575
16.2
12.0
8.7
6.8
2.5
44.2
5,644
17.6
11.5
7.4
4.6
2.7
78.1
9,888
16.1
12.5
10.0
7.7
1.9
67.3
4,083
8.6
11.2
7.7
8.6
1.4
23.9
223,956
13.7
10.9
7.8
6.4
2.1
23.3
9.81
5.81
8.33
5.13
7.44
6.0
CHILD HEALTH
Child population
Percent of women with delayed prenatal care
Percent of preterm births
Percent of infants born with low birth weight
Infant mortality rate per 1,000 live births
Asthma hospitalization rate per 1,000 children
Teen birth rate per 1,000 girls ages 15 to 19
Percent new cases of lead poisoning of those tested
(blood lead > 5mcg/dl)
Source: 2014 Rhode Island Kids Count Factbook, Rhode Island KIDS COUNT, Providence, RI.
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Safer Institute
Assets and Opportunities
Table A-4. Healthcare Access, Utilization, and Insurance Coverage
HEALTH INSURANCE COVERAGE
Percent with health insurance coverage
Percent with private health insurance
Percent with public health insurance
Percent with no health insurance coverage
Percent under 18 with no health insurance coverage
Providence
HEALTH CARE ACCESS & UTILIZATION (%)
Do not have a regular care provider
24.23
No routine checkup in the past year
29.18
No dental insurance
41.75
Women over 40 who have not had a
22.51
mammogram in the past 2 years
Women over 18 who have not had a
22.34
pap smear in the past 3 years
Providence
Pawtucket
Central Falls
Woonsocket
Newport
Total RI
79.6
51.3
34.9
20.4
7.8
84.7
58.7
37.2
15.3
7.2
69.6
42.0
36.9
30.4
18.4
89.1
60.5
41.2
10.9
3.3
87.1
69.5
30.5
12.9
5.9
88.9
71.8
29.9
11.1
5.2
Pawtucket
CF, Newport,
West Warwick,
Woonsocket
Urban Core
Subtotal
Other
rural/suburban
cities/towns
Total RI
16.02
22.64
45.28
17.02
25.79
32.65
20.16
26.72
38.96
10.71
21.20
28.76
13.57
22.87
31.58
17.25
20.65
20.86
18.19
18.92
18.80
22.42
21.67
17.20
18.67
Source: 2011 and 2012 Behavioral Risk Factor Surveillance System (BRFSS) National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and
Prevention, Atlanta, GA. Analysis performed by the Rhode Island Department of Health.
Note: CF=Central Falls
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