Health Equity Data Analysis

State: MN Type: Promising Practice Year: 2019

  • Carver County Public Health (CCPH) is a small to medium size LPH agency with a staff of 19 people located in Chaska, Minnesota approximately 30 miles west of Minneapolis/St. Paul. The county is a unique blend of urban and rural populations with two distinct demographic regions. The eastern region is more urban and characterized by younger, more affluent families, and it supports a broad base of industry and economic development. The western region is more rural and is primarily comprised of small agricultural communities. Carver County is one of the fastest growing counties in Minnesota with rapidly changing demographics. Its current population is over 102,000 with a median age of 38 years. The percentage of non-white residents has grown from 2.1 percent in 1990 to 10.6% in 2016 and is expected to grow to nearly 19% by 2035. Carver County is considered one of the healthiest counties in Minnesota (RWJF County Rankings), but significant health disparities exist depending on race/ethnicity, income, and/or place of residence.
  • County-specific data clearly identifies mental health as a critical public health issue, particularly among those living on little. Quantitative data identified a ratio of one mental health provider per 880 people, which is significantly below the national average of 1:330. Additional data found that residents living under 200% of the Federal Poverty Level (FPL) were over two times more likely to report being told by a health professional that they had depression, almost two times more likely that they had anxiety, and two times more likely to experience frequent mental distress. Information and personal life experiences gathered from focus groups and key informant interviews provided tangible examples of individuals struggling with mental health, and these experiences were exasperated by those with less income.
  • The over goal for HEDA was to identify and address the health disparities and inequities that exist within Carver County. The following objectives were developed in accordance with Minnesota Department of Health to accomplish this goal: 1) expand understanding of health; 2) strengthen community capacity; 3) inform future Statewide Health Improvement Partnership (SHIP) work plans; 4) identify new and strengthen existing partnerships; and 5) build community engagement and facilitation skills of public health staff.
  • HEDA is part of the Community Health Assessment (CHA), which provides critical information to inform the Community Health Improvement Plan (CHIP). The HEDA process focused on gathering qualitative information from county residents with lived experiences” with mental illness and/or other mental health issues. Three focus groups were conducted. Participants included members of a faith community, clients from the county's mental health clinic, and individuals who utilize the county's workforce center. Responses were recorded, transcribed and analyzed according to a thematic coding process. Analysis of the information was drafted into a nine-page academic report, a one-page Executive Summary, PowerPoint presentation, and an infographic responsive to a variety of different audiences. Public health staff presented the findings from the HEDA project at the 2018 Minnesota Community Health Services Conference.  
  • HEDA enabled public health staff to strengthen existing and develop new partnerships with local and statewide organizations and community advocates for mental health. Staff expanded their skills on conducting and analyzing focus groups. Information learned from the project provided greater understanding of challenges in the mental health care delivery system and opportunities for improvement; thereby, expanding CCPH's capacity to address health disparities and initiate strategies to promote health equity.
  • HEDA was successful in meeting all its intended objects according to both internal staff evaluation and feedback from community members, collaborative partners, and other public health professionals. It was instrumental in qualifying CCPH to be selected as one of six agencies across Minnesota for the Health Equity Learning Community Grant.
  • The success of HEDA was based in large part by the rigorous action research process utilized, and the quality of engagement with the Community Leadership Team (CLT), collaborating partners, and the focus group participants themselves.  
  • HEDA made a significant impact on the scope and quality of practice for CCPH and its collaborating partners. It led to the selection and participation in the Minnesota Health Equity Learning Community Grant. It provided the catalyst to enhance and modify the use of the M.A.P.P. Model in conducting the community health assessment. It greatly expanded the quantity and quality of collaborating partners and increased the participation of community residents most affected by the services provided. It also provided new and innovative strategies to improve access and utilization of primary, secondary and tertiary prevention approaches for mental health.

Carver County Public Health is online at

Carver County Public Health (CCHP) integrated the Health Equity Data Analysis (HEDA) project to serve as an integral part of the M.A.P.P. community health assessment. This provided a creative and new process to enhance CCPH's capacity to better understand and respond to the unique health disparities among low-income residents struggling with mental health challenges. It also led to significant changes in how CCHP engaged community members at risk for health disparities and served as a catalyst to launch the "Trauma-Informed Care Model" across the entire Health & Human Services Division.

Mental health related problems were identified as one of the main concerns in Carver County through the previous community health assessment, and these problems were exacerbated in people who live on little. Compared to residents who live above the 200% of Federal Poverty Level (FPL), those living under 200% of FPL are twice as likely to report having depression, and almost three times more likely to experience anxiety and/or psychological distress. This translates to over 2,700 low-income residents experiencing some form of mental health problems in Carver County. The ability to respond to this need is also complicated by the fact that the ratio of mental health providers in Carver County is nearly half (1:880) the Minnesota state average (1:470). While these statistics clearly identified mental health as a real concern in Carver County, and especially for those residents who live on little, it did not provide information on the functional causes of these problems. CCPH needed an alternative process to better understand the "real life" experiences of low-income residents struggling with mental illness and how to respond. Furthermore, CCPH realized that meaningful and sustainable changes would only occur through community wide participation and ownership of both the problem and their solutions.

The HEDA was designed from health equity literature, including the World Health Organization's conceptual framework for action on the social determinates of health and the Sudbury and District Health Unit's, 10 promising practices to guide local public health practice to reduce social inequities in health. Addressing health inequities requires local public health to work differently than in the past. This includes adopting a new approach to community health assessment that will expand the understanding of what creates health. This new approach to community health assessment moves beyond individual determinants of health (e.g. health behaviors and access to health care) to also identify larger structural conditions (e.g. living and working environments, social class, policies and systems) that affect health. A Health Equity Data Analysis (HEDA) is a health assessment process that incorporates this new approach. Specifically, a HEDA calls for:

  • Looking not only at overall health outcomes but also at how health varies between population groups within a jurisdiction such as a county.
  • Looking not only at individual behavior but also at social and economic conditions that impact health.
  • Examining the policies and systems that influence health through those social and economic conditions.
  • Engaging populations that experience health inequities in the assessment process.

A HEDA identifies differences in health outcomes between population groups (as defined by social and economic conditions), and describes the broader policy and systems factors that are significant contributors to those health inequities. The results of a HEDA will in turn provide direction for action to eliminate health inequities. Analyzing health inequities requires a process that actively engages community members (including those experiencing health inequities) and uses data to identify health differences between population groups instead of only examining the population as a whole. The process continues by identifying and examining the causes of these population differences in health. Identifying the causes of health inequities requires the use of both quantitative and qualitative data collection and analysis methods. This is not an entirely new approach to data, but rather an enhancement of the data activities traditionally completed by public health. It is a reframing of data activities to include all of the determinants of health. It incorporates voices from the community who can speak to the social forces that shape opportunities in the community to be healthy.

Reframing data activities starts with questions about the health of populations. The traditional approach to public health data analysis might include initial questions such as:

  • What is the overall diabetes rate in the jurisdiction?
  • How has this rate been changing over time?
  • What behaviors contribute to or reduce the risk of diabetes?

These familiar questions focus on individual lifestyle behaviors; based on the answers, directions for action to reduce health disparities will also tend to be focused on individual lifestyle behaviors (e.g., diet and exercise programs). But in a HEDA, the questions asked about the health of a population must be broader than simply asking what actions individuals are or are not taking with regard to their health (e.g., What behaviors contribute to or reduce the risk of diabetes?”).

To uncover the structural conditions that influence health, additional questions needed to be asked about the systems, structures and policies that create conditions in which some groups of people have higher rates of diabetes than other groups. These new questions focus on living and working conditions, social class, and policies and systems as health determinants, and provided an enhancement to the traditional public health assessment process.

The goal of the HEDA was to identify and address the health disparities and inequities that exist within the community. Objectives: 1) expand understanding of health; 2) strengthen community capacity; 3) inform future Statewide Health Improvement Partnership (SHIP) work plans; 4) identify new and strengthen existing partnerships, 5) build community engagement and facilitation skills of public health staff.

To achieve these goals, CCHP implemented a Health Equity Data Analysis (HEDA) process. As stated in previous sections, the process started by analyzed quantitative data to identify health disparities in the county. The next step was to analyze qualitative data.  Even at this early stage, community partnerships and collaborations were part of the process and key to its success. Utilizing existing relationships, CCHP conducted several key informant interviews with collaborating partners who had face-to-face interactions with people with mental health lived experiences” in the community on a regular basis. These key informant interviews enabled us to specifically target our focus group participants. Through this process, it became evident that CCHP needed to expand its outreach to identify participants who were living on little. This included reaching out to the mental health providers in the county, specifically the Adult Mental Health Initiative, as well as reaching out to our service providers that were working with people who were living on little (e.g. Work Force Center). By building these partnerships, CCHP were able to recruit hard to reach” focus group participants, who would have otherwise gone unrecognized. The next step was to develop a focus group question guide and interviewing process. The guide was developed based on best practices for conducting focus groups, but it also incorporated specific considerations based on previous key informant interviews that were more culturally responsive to this targeted population. The initial draft of the Focus Group Guide was reviewed by our mental health collaborating partners, and modifications were made to the Guide based on their recommendations.

The whole timeframe of the HEDA spanned around a year and a half, with the bulk of the work being done towards the last five months of the project. Key informant interviews were conducted approximately six months into the project. CCHP staff analyzed the data and reflected on the information gained from these interviews. This required a slight modification to the process to optimize success (which is part of the action research cycle). With the involvement and guidance from key stakeholders, the project came together fairly quickly. The Community Leadership Team (CLT) (originally formed as part of the State Health Improvement Partnership) served as a valuable resource for the HEDA team. They shared their perspective and provided access to their connections. The HEDA team utilized some of their connections during the process either as a key informant interview or to assist bringing focus groups together.

CCHP invests heavily into collaboration with stakeholders. CCHP understands that health doesn't happen in isolation. It also appreciates the fact that discovering and implementing solutions requires involvement from a diverse team across multiple sectors of the community including residents and recipients of those services as well. Therefore, CCHP collaborates with both internal and external partners.  There are several committees and teams that CCPH hosts where stakeholders are sought out for their involvement, and several committees that CCPH is asked to be a part of. These include, but are not limited to: Community Leadership Team, Public Health Advisory Council, SHIP partnerships, Mental Health Local Advisory Committee, Local Senior Commissions, All's Well Coalition, Waconia HERO Coalition, Carver County Health Partners, and others. CCHP has a commitment to working on several focus areas in addition to mental health and poverty. Sitting at the table with this diverse population of stakeholders only broadens the understanding of health and all the areas it affects.

The HEDA was supported by a Statewide Health Improvement Partnership (SHIP) grant through the Minnesota Department of Health (MDH). It is challenging to determine all of the in-kind costs but the HEDA team (consisting of five core members and two members of leadership) met bi-monthly for almost six months. The three focus groups took roughly two and a half hours with set-up and clean-up. The analysis and reporting took 10-20 hours for multiple staff members, and presentations totaled roughly 10 hours. The direct costs associated with the HEDA work were fairly minimal. We spent $600 on Target gift cards as incentives for the participants. We spent roughly $200 on food during the focus groups. We spent $253 dollars on having the audio files of the focus groups professionally transcribed. We spent $722.50 on the development of an infographic. Additionally, there were costs associated with travel to the focus groups and other events that were minimal.

CCPH utilized both process and outcome evaluation criteria as part of their participant action research model to measure both the effectiveness of their activities and provide meaningful data to inform staff and collaborating partners on how to modify practices to improve outcomes (i.e., quality improvement). As stated in earlier sections, the goal and objectives of the HEDA project were developed in consultation with the Minnesota Department of Health. The specified goal for the HEDA project was to identify and address the health disparities and inequities that exist within the community. In order to both accurately identify and effectively address the health disparities and inequities with communities of Carver County, CCPH and it collaborating partners needed to: 1) better understanding the concept of health and the conditions that create health; 2) strengthen community capacity to provide the needed services and mindset” to effective address mental health concerns; 3) utilize information learned from this process to inform future Statewide Health Improvement Partnership (SHIP) work plans (AKA data-informed decision making); 4) identify new and strengthen existing partnerships; and 5) build community engagement and facilitation skills of public health staff (this is also tied to organizational capacity). The primary purpose of the Carver County HEDA project was to answer the question, What contributes to the differences in mental health outcomes between people with lower incomes compared to those with higher incomes?”

CCPH were able to meet all of HEDA program objectives. CCPH gained insights into the differences in mental health outcomes between people with lower incomes compared to those with higher incomes and expanded our understanding of health. The project strengthened both the LPH and the community's capacity to identify and respond to health disparities. Community partners were informed of the project's findings. CCPH 2018-2019 SHIP work plan had significant changes from the previous years and included aspects of mental health in every strategy. CCPH strengthened its partnerships with CLT members and others, and they developed new partnerships with Carver County Workforce Center and the AMHI. Lastly, three different LPH agency staff members enhanced their focus groups facilitation, action research, and presentation skills.

In addition to the extensive review of existing quantitative data, CCHP obtained primary data from a series of key informant interviews and three focus groups. The focus groups were recorded and responses were transcribed using a transcription service. Comments from key informant interviews were recorded directly by CCHP staff conducting the interviews. Transcriptions of the focus groups removed filler words such as um”, uh”, so”, and like”. The transcriptions also did not include stutters, stammers, false starts, or repetitions. Once transcribed, each focus group was coded. At least two members of the HEDA Team coded each focus group transcription. Codes were revised throughout the process and constant communication between the HEDA Team led to the development of over thirty different codes. Coded focus group transcriptions were reviewed for consistency and differences in coding were discussed at HEDA Team meetings. The input gathered from participants in the three focus groups was wide-ranging.  They provided many insights into issues related to mental health, low income, and connections between the two.  The most frequently voiced comments were categorized in four overarching themes; 1) The Mental Health System; 2) Social Determinants of Health; 3) Family and Social Supports, and 4) Knowledge and Awareness. Within the Mental Health System, themes that emerged included navigating the system, insurance, and services. One participant stated, If you make too much money, you can't get insurance… what I'm trying to say is, if you're rich, you're fine because you can afford to take yourself to therapy. If you are poor, you can get insurance help through the county. If you're right in that middle, you eat, or you go to therapy.” Within the Social Determinates of Health, themes that emerged included transportation and employment. One participant stated, There are people who can't get to court; people can't get to their—if they live out here [rural areas], they can't get to their county meetings with their reps. They can't get to the food shelf. They can't go to job interviews. They're going to make you feel more hopeless.” Within the Family and Social Supports, themes that emerged included social connections/isolation and life events. One participant stated, They [Hennepin County] would have the AA and the NA group and the Overeaters Anonymous, sexual abuse [support groups]. Like you were talking, the gay, lesbians, transgender [support groups]. Every night there would be different groups that you could go to. Out here [in Carver County], besides the CSP   and the Cedar House, I haven't seen support groups.” Lastly, within Knowledge and Awareness, themes that emerged included stigma, training, and education. One participant stated, I think part of the stigma, is, Oh you're depressed? You're just not taking care of yourself; like you just aren't eating right.” Yeah, Suck it up”. Get tough.”

The HEDA project greatly increased the knowledge and capability of Carver County Public Health staff and its collaborating partners to understand the critical issues associated with health disparity and inequities pertaining to mental health among people who live on little. This information can and will be applied to understanding health disparity and inequities as it pertains to other health conditions. The lessons learned from this project were also shared with a variety of stakeholders, including the focus group participants, internal county departments, and external partners. This information expands their awareness of these critical issues and provides feasible strategies they can apply to their practice or life situation.

To support an equity model, findings were developed into four different tools for different audiences. This included an academic report, a one-page summary, a PowerPoint presentation, and an infographic. All materials were made available online and shared with other Statewide Health Improvement Partnership (SHIP) grantees on Basecamp. Presentations were made internally with Carver County Public Health (CCPH) and workforce center staff. Externally, presentations were made with the Adult Mental Health Initiative (AMHI) (which includes numerous mental health providers and community members) and with the Statewide Health Improvement Partnership (SHIP) Community Leadership Team (CLT) (which includes school staff, medical partners, and healthy eating partners). CCPH staff were invited to present the HEDA project at the Minnesota Community Health Conference in October of 2018. This presentation was very well received, and it led to the recommendation by the President of the Minnesota Public Health Association to apply for the NACCHO Program Model Award.

Dissemination of information from the HEDA project was just one step of the sustainability plan. Carver County Public Health (CCPH) and our stakeholders are invested in sustaining work to address the public health problem and inequities around mental health. After the conclusion of the HEDA project, CCPH and Ridgeview Medical Center partnered on a community health survey to gain more insights around mental health. The survey included questions about not good mental health days,” help-seeking behaviors, and opinions on mental health as a problem in the community. The survey also incorporated questions from the Mental Health Continuum-Short Form to assess measures of emotional well-being. Findings from the survey will support the development of our Community Health Improvement Plan, thus sustaining the work for at least the next five years. Another avenue for us to sustain the project is through the Health Equity Learning Community (HELC) Grant. Based on the work CCPH did with the HEDA project, they were selected through a competitive process as one of six agencies across Minnesota to participate in this opportunity administered by the Minnesota Department of Health. CCPH was awarded $4,500 to enable CCPH to explore ways that they can develop systems to address health equity on a broader scale. The HEDA project also provided justification to contract with Marnita's Table™ to conduct a series of three intentional social interactions. These events are centered around a community meal bringing people together across race, class, and other means of self-identity to find common ground on important policy issues.

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