Where to Start with Transformative Health Equity Work: Lessons Learned from Minnesota

By Megan Gaydos

One of the questions we frequently receive at HIP from health departments wanting to advance health equity is:

Where do I start?

Three years ago, the Minnesota Department of Health (MDH) started to develop an action tool to help local health departments answer that question.

I had the opportunity to talk with some MDH team members recently about this work. We discussed their takeaways from creating and implementing a tailored data analysis process, in collaboration with community members, to shift the narrative on what creates health at the local level.

This blog post compiles the experiences and lessons learned by the Minnesota Department of Health team with their Health Equity Data Analysis action tool (HEDA).

What is HEDA?

HEDA, or the Health Equity Data Analysis Action Tool, is based upon a framework for understanding health equity. Our team from the State Department of Health developed HEDA in 2015 for local public health departments in Minnesota. For many of our local health departments, it served as a starting point for understanding how to advance health equity in their communities.

We started with data because that is our area of expertise. The HEDA is based upon the fact that health is created by multiple conditions, not just health care, behaviors and genetics. Our goal was to create a health equity assessment process that is doable, builds capacity at the local level and transforms data practices.

A depiction of the information sources for each of the HEDA steps.

Community engagement is essential in all steps of the HEDA. Specifically, when you conduct a HEDA you will: 1) analyze health differences between population groups (not just examine the population as a whole), 2) identify and examine the causes of these population differences in health, and share the findings back with the community.

How does HEDA transform local health department practice?

For our local health departments, HEDA was a concrete health equity activity that helped them better understand health equity concepts and how inequities impact their communities. Many of our local public health agencies had “ah-ha moments” while conducting their HEDAs. They realized that:

• There’s a lot more to know about their communities than they thought
• They receive very different answers and perspectives when they engage directly with people with lived experiences of health inequities, rather than just their service providers
• They observed the impact of power dynamics and exclusion/othering on health

These “ah-ha moments” occurred when meeting with their community members to find out what conditions in their lives impacted their opportunities for good health.

Community members had questions or observations like:

• Employers do not allow time off to pump breast milk
• Community members are under-represented in the decision making process
• There are no places for my kids to exercise that don’t cost money
• At the food shelf, fresh food is only available once per month.
• At that time in my life, there were stressors with no way out other than to smoke.

Out of these interactions come ideas and potential solutions of how to address the existing barriers to health. In addition, new or strengthened relationships were built leading community members to seek out local health department staff as trusted resources.

Health department staff begin to see their roles in facilitating dialogues about what’s needed to be healthy — and how they work with their communities to advance short-term/smaller and long-term/larger improvements. Collectively, these steps are critically important to transforming individual and subsequently organizational health department practice.

What’s your favorite example of how people have used the HEDA?

We have so many examples of how local health departments have used HEDA to change policies, systems and programs, facilitate cross-sector collaboration and strengthen relationship with their communities, that it’s hard to choose a favorite!

But to list a few, some impacts of HEDA use include:

• Building relationships with the Latinx community in their jurisdiction.
• Working with housing advocates and having HEDA findings be used to hold a landlord accountable for improving housing conditions in his city-subsidized apartment building.
• Prioritizing the needs of East African seniors and serving culturally appropriate food at the senior center.
• Adding an on-site social worker at a food shelf to connect people to resources.
• Changing a parking ordinance so that the mobile market can park on city streets, making it more accessible.
• Forming new partnerships with community organizations and other county agencies.
• Incorporating HEDA findings into the 2040 Comprehensive Plan.
• Creating a Health Equity Coalition consisting of community members and cross-sector organizations to start moving upstream to address socio-economic factors.

What are your recommendations for other health departments?

We are still learning and evolving, as is the nature of this work, but we do have some lessons to share with other health departments.

• Tri-directional learning — Our learning is ongoing/continual and intentional. We learn from our local health departments, they learn from us and they learn from each other through the HEDA learning community. This tri-directional learning supports all of us in this work. And at the same time, we are all learning from our communities as well.
• Require HEDA — After piloting the HEDA with 10 local health departments, we tied our grant-making process to HEDA. Specifically, all applicants for our State Health Improvement Partnership grant must use HEDA. We’ve heard “if you did not require us to do this, we would never have done it. But thank you for requiring this.” Similarly, health departments facing opposition to their health equity work can point to the state statute requiring all Minnesota health departments to address health disparities.
• Training is NOT enough — All the trainings in the world won’t matter if you don’t do something with the training. Actually doing a project, even if small, helps practice the concepts of health equity, builds relationships and starts to change conversations and connections. HEDA provides that initial first project.
• Framing/reframing is important — We have found that it’s critically important to change the “narrative” about what causes health. We offer webinars to our local health departments about how to frame health as not just health care, genetics and behaviors but also the community conditions needed for health. HEDA helps elevate why that’s important to do, while the framing webinars help provide TA/skills on how.
• Engage local health leadership — We developed a Health Equity Learning Community for health directors/leadership of local health departments to help them understand health equity concepts, discover opportunities and learn from each other. In developing this Learning Community, we hope that leadership will be supportive of staff health equity initiatives.
• Be flexible — We originally envisioned that success would be measured in policy and system changes. But we’ve realized that we need to be flexible with timelines (e.g. to account for community priorities) and that some of the successes are more discrete (e.g. strengthening of relationships, changing the understanding of what’s needed for health, cultivating buy-in from leadership, etc.). This work is time-consuming but it is worth the investment of time and resources because it begins to transform how the health department partners with the community and where it focuses its efforts.

Visit the MDH HEDA page for more information about the HEDA, including quantitative and qualitative data resources and recent applications.

Read our case study on Minnesota’s work to change the narrative around health equity.

Many thanks to Jeanne Ayers, former Assistant Commissioner of Health; Jeanette Raymond, Community Engagement Unit Supervisor, Kim Edelman, Senior Research Scientist; and Ann Zukoski, Evaluation Supervisor for their time and insights!

Megan Gaydos works as a part-time consultant with Human Impact Partners, managing the Health Equity Guide website and related programming and supporting various research projects. A former epidemiologist, she is incredibly inspired by the work that health departments and communities are doing to advance health equity around the US.