CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 16 • Number 2/3 • Winter/Spring/Summer 2004

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Hennepin County, Minnesota

County-Level Data Key to Effective Public Health Practice

Comprehensive county-level health assessments are uncommon. Hennepin County, Minnesota, is one of four counties in the United States identified by CDC for their exemplary reports on local health-related quality of life (HRQOL) data. Most counties lack the resources to do their own surveys. Mostly larger entities such as cities or states conduct them. The advantage of communities doing their own survey is that they can look at their population subgroups, both geographic and demographic, and identify unmet health needs.

Hennepin County is thoroughly researching and reporting on community health not only to determine the health status of its residents and assess their health needs, but also to identify community factors (e.g., access to care, social support, social connectedness, economic distress) that affect the physical and mental health of the population. The goal is to obtain information for program planning and policy development.

The largest of Minnesota’s 87 counties, Hennepin comprises urban, suburban, and rural communities. It is home to about one-fourth of the state’s population (more than 1 million people) and half of the state’s racial/ethnic minority population.

Hennepin County recently published data from its Survey of the Health of Adults, the Population, and the Environment (SHAPE) for 2002. The SHAPE project is a collaborative effort of the Hennepin County Community Health Department, the Minneapolis Department of Health and Family Support, and the Bloomington Division of Public Health. SHAPE uses the core Healthy Days measures to rate overall health in Hennepin County. An initial survey conducted in 1998, SHAPE 2002, and future surveys will allow Hennepin County to assess the health status of residents, track health indicators and other measures, and identify trends in the population.

SHAPE 2002 data are also used to compare county health rates with those of Minneapolis, the state, and the nation (see figure). “It’s important to us to track and meet the national Healthy People 2010 goals, especially the HRQOL goals, at the county level,” explained Margaret Hargreaves, MPP, SHAPE project director. Hennepin County has gathered solid baseline data and is poised to develop appropriate and targeted interventions because of its clear understanding of where problems exist.

Percentage of adults who reported health as good, very good, or excellent

[A text description of this graph is also available.]

Sources: SHAPE 2002, Minnesota BRFSS 2002, CDC Health-Related Quality of Life Prevalence Data

General Findings and Specific Results
According to SHAPE 2002 data, Hennepin County residents rate their health as being better than that of other adults in the general U.S. population. More than 90% consider their health good, very good, or excellent, compared with the national rate of 85%. SHAPE 2002 documented some encouraging findings, including a dramatic decrease in the smoking rate for adults aged 18–24 years, from more than 36% in 1998, to 23% in 2002.

 
“This is the only group to show a decrease,” noted Ms. Hargreaves, who suggests the decline may be due to increased state and county efforts to reduce tobacco use among young people during the 3 years prior to the survey.

Also, seniors (aged 65 or older) reported surprisingly good health. Ms. Hargreaves noted that the self-reported rate of good to excellent health was roughly the same for residents aged 65–84 years as for those aged 84 years or older. “We are not sure why we do not see the same sharp decline in health among older adults that is seen nationwide,” she said.

Although Hennepin County residents reported generally better health than other U.S. residents, SHAPE 2002 data did identify health disparities associated with race/ethnicity and place of residence. Not only did SHAPE 2002 gather data on five racial and ethnic groups (American Indians, Asians/Pacific Islanders, African Americans/blacks, Hispanics/Latinos, and whites), but the survey also distinguished between U.S.-born blacks and African-born blacks and looked at Southeast Asians as a distinct group.

Ms. Hargreaves pointed out one finding unique to a specific subgroup when looking at which residents obtained recommended health screenings. “We found that among nonimmigrant groups, the differences among racial/ethnic populations were surprisingly small; however, among immigrants (e.g., foreign-born Latinos, African-born blacks), particularly new immigrants, there were large differences in getting preventive health care services.” Ms. Hargreaves explained the importance of not lumping members of various races and ethnic groups into the same category. “Generic racial/ethnic rates mask significant differences in [rates among] racial/ethnic subgroups,” she said.

Investments in Local Data Charged by County Support and Community Needs
The county’s extensive focus on gathering, analyzing, and reporting local data can be partially attributed to local support including that of community health boards, community organizations, and county commissioners. The missions and strategic plans of these local entities prioritize health, safety, and quality of life for their constituents. The concept of quality of life is well received by local and business communities. Mayors and other local officials take pride in the fact that their community is identified as a good place in which to live and where residents feel good about their health and well-being.

In addition to receiving civic backing, including state-appropriated funds and core public health grants, Hennepin County receives technical support for public health surveillance from the Minnesota Department of Health, the University of Minnesota School of Public Health, and local and national health experts. “We have a highly rated hospital—the Hennepin County Medical Center—which is an anchor to our local health efforts,” explained Ms. Hargreaves. “SHAPE data are also extremely helpful because we are coordinating the efforts of three health departments and five community health boards to collect consistent data throughout Hennepin County.”

Distributing the Data and Reaching Out
By sharing its data and methods with other counties and on state and national levels, Hennepin County is serving as a model for others who want to conduct comprehensive local public health assessments. SHAPE 2002 data were presented to more than 600 attendees at the Health Disparities Summit held in January 2003. “We presented SHAPE data at health services research, local, and statewide conferences, including recent diabetes and cancer conferences,” said Ms. Hargreaves. “In fact, SHAPE data were featured at the Hennepin County SHAPE Up Conference in October 2003 that focused on exercise, nutrition, and obesity.”

Although Hennepin County is in the early stages of applying the findings of SHAPE 2002, many in the public health community have taken notice. The SHAPE survey questionnaire is being used in the development of other health surveys by the Winnipeg Regional Health Authority; by counties in Michigan, Ohio, and Connecticut; and by other counties in Minnesota. “The six other counties in the metropolitan area are preparing to conduct surveys and are working on getting funding,” Ms. Hargreaves said.

In addition, Hennepin County provides data and technical assistance to other county programs. Hennepin County helps county public health workers prepare grant applications, obtain other types of funding, and plan evaluations for projects designed to improve public health or reduce racial/ethnic health disparities. “We also work with community groups to analyze data and answer questions,” said Ms. Hargreaves. “For example, we are working on an analysis of mental health among African American men, asthma among adults, and data for an American Indian family project,” she said. Other county projects include looking at how traditional and complementary health care varies among different populations and how alternative medicine affects quality of life. The county is also working with a health committee in North Minneapolis to identify ways to improve the health of high-risk populations.

Key Approaches to Collecting Local Data
When asked what advice she would give to other local health departments in collecting data, Ms. Hargreaves recommended some key strategies. “It is important to involve many partners to shoulder the load and get buyin,” she said. She also emphasized the collaborative approach as a way to pool resources (e.g., expertise, funding, staff) and avoid duplication of efforts. Ms. Hargreaves advised conducting one thorough survey instead of over-researching certain racial/ethnic communities with limited, disjointed studies and suggested investing more time upfront on survey development and planning before gathering data.

“Engage community members and get their input on what needs to be researched or added to your survey,” she said. “It is important to listen to your target audience and to be flexible.” After hearing that getting phone interviews might be difficult in some communities, SHAPE researchers arranged to speak with respondents in person. “We conducted 9,782 telephone surveys and did 178 face-to-face interviews, and it was a great help to be prepared to conduct in-person surveys,” said Ms. Hargreaves.

To get statistically reliable data for certain racial/ethnic populations, researchers oversampled some neighborhoods with large racial/ethnic minority populations and conducted the survey in five languages (English, Spanish, Somali, Hmong, and Vietnamese). “Translating the survey into other languages was extremely beneficial,” said Ms. Hargreaves. Before translated versions of the survey were finalized, back-translations were done and members of the target communities reviewed the translations to be sure they were understandable. “Don’t skip this step,” Ms. Hargraeves warned. “The survey firm hired bilingual and bicultural interviewers, and it helped when the interviewer began the conversation in the language of the respondent.”

Finally, Ms. Hargreaves emphasized that although gathering local public health data is time-consuming and expensive, it is well worth the effort. “It’s difficult, but it’s not impossible,” she said. “Local data are not the same as national data, and it’s important to look at what’s going on locally.”

Building on the Foundation
SHAPE is an ongoing survey, which Hennepin County plans to conduct every 4 to 5 years. “Our goal is to look at trends over time,” said Ms. Hargreaves. The county will use a core set of surveillance questions and incorporate new questions as needed to identify emerging health issues and gather information of special interest to specific populations. After evaluating the SHAPE questionnaire conducted in 1998, Hennepin County made strategic changes to the next survey. “For example, some key differences between our 1998 and 2002 questionnaires are that in 2002, we had more questions about men’s health, mental health, and cultural factors and their influence on health,” she said. Hennepin County also plans to conduct additional surveillance to fill gaps in information on the health of its children. “Before we conduct the next adult survey [SHAPE in 2006], we hope to do an assessment of the health of our population that is under 18,” Ms. Hargreaves said.

National Support for Local Public Health Assessments
Because of its size and its racial/ethnic and geographic diversity, Hennepin County needs the sort of local stratified data that SHAPE provides to identify health problems within specific population subgroups. The Behavioral Risk Factor Surveillance System (BRFSS) provides state data; however, public health planning differs across states. Ms. Hargreaves noted, “Some states administer services predominantly at the county level, and this is especially true for states in the Midwest.”

Recognizing the need for local data, the National Association of County and City Health Officials (NACCHO) developed an initiative called Mobilizing for Action through Planning and Partnerships (MAPP) that outlines a comprehensive approach to community health by assessing four community components: community themes and strengths, the local public health system, community health status, and the forces of change. (For more information, visit http://www.naccho.org/PROJECT77.cfm.*) The MAPP strategy is to identify positive assets as well as public health problems and outline a comprehensive and systematic plan to improve community health.

CDC supports NACCHO’s initiative and is promoting the collection of local HRQOL data. These data are critical to public health because they give a broader and more timely measure of health than has been used in the past and are specific to the community. Data collected directly in a survey can be used to identify and prioritize current problems, develop a strategy, and make improvements.

Hennepin County is establishing a wealth of useful data that can be applied to improving the physical and mental health of its residents, as well as their overall quality of life. “Communities don’t do enough community health assessment, and that is the most fundamental role of public health—to track the health of the population,” stated Ms. Hargreaves. “You need local data to effectively improve public health.”

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