Improving Health Equity With Data

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: advancing health equity through data and the need to reflect equity in the numbers.

NICOLE ALEXANDER-SCOTT:
Well, we want data to be a normal association with our conversations on health equity. We want to continue to make sure we are incorporating demographics that reflect diverse populations in assessing health equity.

HARRY CHEN:
I think we have a lot of data about where the disparities or inequities are, and we have to be able to be kind of nimble in terms of how we react. We also know that the data in terms of performance management can sometimes be slow, but we also have to build it into our systems.

ANNA BRADLEY:
I think that we've had a lot of interesting conversations around measuring health disparities and moving beyond measuring health disparities to really capture the context around those health disparities, to capture the circumstances around those health disparities.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: measuring health equity, how Rhode Island does it, and the challenges with evolving data to provide a more accurate picture of public health across the nation.

Anna Bradley is the state health improvement plan coordinator with the Montana Department of Public Health and Human Services. She's working every day to incorporate equity into the state's plans. Dr. Harry Chan was Vermont's Health Commissioner until 2017. He's thinking about the quality and the availability of health equity data. Both are along later in the podcast.

But first, we hear from Dr. Nicole Alexander-Scott, most recently director of the Rhode Island Department of Health, today a senior consultant at ASTHO. She tells us how Rhode Island incorporates health equity metrics into its process.

ALEXANDER-SCOTT:
So, what we did in Rhode Island was we engaged a diverse group that had already been partners with the department of health in Rhode Island, our community health assessment group. It consisted of representatives from government, from academia, from philanthropy, community-based organizations, our health equity zones in Rhode Island, our private sector, healthcare, and also nonprofit, policy, and advocacy organizations.

Those members came together and, over the course of at least two years, we really worked to develop a set of measures through an extensive community engagement process that helped us better capture those health equity measures that are not your traditional healthcare-related measures.

JOHNSON:
So, how does an agency go about incorporating health equity metrics into their work?

ALEXANDER-SCOTT:
Well, first is to make the decision that this is an important journey to embark on, to recognize that measures of health equity are needed to continue to track our progress and hold ourselves accountable to the investment that we know is needed to move the needle.

Second, we are believers in not reinventing the wheel if you don't have to. What we did was, taking some of that information, we created five domains to make sure that we were covering the best of the health equity measures we could think of. And so, that included integrated healthcare, community resiliency, physical environment, social economics, and community trauma. And you'll find the variety of categories that are out there.

So, you can pick—you know, replicate what we've done, you can replicate what you've seen in other resources nationally or internationally, or choose a similar approach that works for your jurisdiction. And then, you have to look at the data sources that are available to be able to gather that information. And, with time, there are more and more national data sources available.

We had to be creative on how we could use the available data to help answer what we wanted to accomplish with the domains, and the determinants that we looked at within each of those domains.

JOHNSON:
If an agency has decided to include health equity metrics in its planning process, what tips or suggestions would you have for your colleagues regarding the communication of that intention to the people in the department?

ALEXANDER-SCOTT:
Well, we want data to be a normal association with our conversations on health equity. We want to continue to make sure we are incorporating demographics that reflect diverse populations in assessing health equity. And we want to continue to be forward-thinking in determining ways to measure our progress with advancing health equity, as we described.

So, I strongly encourage leaders in public health to take a look at this, embrace it, encourage your teams to dig in and do some of the research needed to see how you can apply some of those measures to the work that you're doing.

There's still a ways to go. There's still going to be many years of continuing to refine this or even see movement. But starting now, to build that. And hopefully, we can have more of a national platform so that we can start to see consistency across jurisdictions, of how we are moving the needle effectively with health equity. But at its baseline, it's something that I strongly encourage doing, for public health leaders who are out there listening to this.

JOHNSON:
What about communicating this direction outside the organization?

ALEXANDER-SCOTT:
There's always the recognition that—particularly when you're looking to do something that hasn't been done before, or there are differences in opinion in what's important or what's not, or it's going against the systems that have been in place to really not accommodate that—there are going to be challenges. There may be pushback, there may be resistance, there may be someone's own personal feelings about it.

But it's understanding that this is core to our discipline of public health, of really ensuring that we are setting up systems that are reflecting the voices of those that may not have a voice for themselves. How is the data being demonstrated or being displayed in a way that is showing the strengths of communities as opposed to always talking about the negatives, much of which has been designed that way, oftentimes.

So, really being purposeful, intentional, about shifting how we approach the work that we do, regardless of someone's own, you know, personal beliefs. It's a critical component to being a successful and effective public health leader and practitioner. And there's more that we need to do within government, and help people understand better outside of government, to move that needle.

JOHNSON:
If any of your colleagues are thinking about doing this, what advice do you have for them?

ALEXANDER-SCOTT:
I strongly encourage it. There was certainly more I could have done to be able to support that, and to me that connects back to taking these words and understanding about health equity and building it into the everyday fibers of the work that's being done in our health departments and in our communities.

So, build it into our performance improvement, build it into our continuous quality improvement work, build it into how we are issuing grant awards to the community. There are resources that are available out there, and I'm hoping to help contribute to that as well so that we can really ensure that we are equipped within public health to support those communities that we know need the assistance the most, and help them build back the power that they can have to thrive and be healthy and resilient communities.

JOHNSON:
Dr. Harry Chen is a public health consultant. He also was Vermont's health commissioner. He says there are challenges and opportunities with health equity data available today.

CHEN:
I think we have a ways to go in terms of our data. But at the same time, you know, there's some very, very basic things.

The data needs to be complete, needs to be up to date, I think. You know, one of the things we learned during the pandemic was, in many places, we weren't even collecting the race and ethnicity data. If that was incomplete, how are we going to use that data to help us define on a granular level where the disparities are? So, that's all so important, to get that important race and ethnicity data.

We have to ensure that's, again, up to date—we need to get as close to real time as we can, understanding there are challenges there. You know, I think one of the things I remember as the commissioner is that it would take a long time to get the data, and it's because they wanted to get it right. And I have absolute confidence that they did the best they could, but it just took too long. And so, how do we get that turnaround on a quicker basis?

I think we had some good experience with COVID on that in terms of the dashboards—in terms of whether they be case dashboards, death dashboards, hospitalizations, or even the vaccination dashboard. So, I think we learned that we have to step up our game there.

JOHNSON:
What would you say are some performance improvement lessons that agencies could use to anticipate, address, or mitigate disparities going forward, whether it's related to COVID-19 or something else?

CHEN:
In your question, there's a very important word and that's anticipate. Because we don't want to be caught perennially in reacting, we want to be able to anticipate. And I think we have a lot of data about where the disparities or inequities are, and we have to be able to be kind of nimble in terms of how we react.

We also know that the data in terms of performance management can sometimes be slow, but we also have to build it into our systems. We have to be able to anticipate, we have to engage community members. Because data is quantitative, but we also need that qualitative information because that will help us with an answer that question of why, and that will help us determine what action we need to take.

JOHNSON:
A lot of time has been spent thinking about how to rethink the notion of messengers and messaging in public health. Does data need an overhaul as well?

CHEN:
Again, the thing—some of the places where we could work a little better with the data is to make it more relevant to the actual today. We did learn some lessons in the pandemic in terms of trying to upgrade our visualizations of data and to upgrade the kind of the cycling of the data, so I think that's important.

JOHNSON:
So much of the data that we see reported as new is actually two or three years old. How do we get to the point where data is more current?

CHEN:
Well, I think you know that we did learn some lessons with the dashboards created by HHS. So, the HHS Protect, you know, basically they were able to take hospital data and automatically download it into their data sets. And they were able to project this almost on a daily basis. So, I think there are ways of connecting data systems so it's not a person having to enter the data every day but it's a system that is able to glean the data from already existing systems.

So, that's what we did with hospitalizations. I think that we could do a lot more in terms of the field of informatics to make it automatic, to make it quicker, more reliable, and virtually automatic.

JOHNSON:
If you were advising others in your field about how to communicate equity using data, what would be your advice?

CHEN:
Well, I think, obviously, you have to tailor your presentation for the audience. But I think for the most part, it needs to be simple. You need to know the science, you need to communicate it simply, you need to lay out the data, and walk them through some clearly articulated goals to tie it to the data.

And then, from there you can actually help guide them to the conclusion in terms of how you want to deal with those goals. What's the action you need? What is it that you're asking of them? Because you know, I never left a presentation without some ask of somebody, whether it be a Vermonter about what I wanted them to do with those drugs in the drug cabinet or with the Appropriations Committee, the legislature, about how I wanted them to view our budget and what we were able to achieve on behalf of Vermonters.

JOHNSON:
If your colleagues are listening to this thinking about how they could improve their data so that they could better address health equity, what would you tell them to think about right now?

CHEN:
I mean, I think it's looking at it in terms of the criteria I mentioned: in terms of correctness, in terms of completeness, in terms of timeliness, looking at how you visualize it.

I think we learned a lot from the pandemic about how important it was to be able to visualize the data. Some people, you can talk all day about numbers, and they just glaze right over. But if you show them a graph, it's a different way for them to learn and to understand.

JOHNSON:
Are there any pitfalls they ought to be aware of as they pursue this approach?

CHEN:
Well, I think the pitfall is to spend too much time on the data and to try to get it perfect. I think that, at some point, you have to just say, you know, the data is good enough.

So, when we saw that COVID-19 disproportionately affected Black and brown Americans, we knew that that would also likely be the same case with vaccines. So we didn't need a lot of data, although in Vermont we watched kind of the gap between BIPOC Vermonters and non-BIPOC Vermonters in terms of vaccinations. We jumped on that quickly and, I think, effectively using some pretty unique strategies that really employed the trusted community partners.

JOHNSON:
Even though we've established the data needs a little help, are you excited about the direction public health is going related to health equity and the way it uses data?

CHEN:
You know, through the pandemic, I think we've gotten a lot more reliant on the data and looking at the data in helping guide our action. And so, I think we need to continue the work based on the progress we've made. And I know that there's a tremendous move afoot to improve our informatics capacity in public health agencies. Because traditionally, it's always been, you know, the people who had the most skills oftentimes end up at Google, right, or Apple and not in a public health agency.

And so, I think we have to ensure that we have the appropriate resources, both in terms of data, we need to have the appropriate resources in terms of the health equity team that we've, for many years, have neglected in terms of personnel and FTEs.

So, just as an example, in Vermont we had a half-time FTE for health equity for many years. We now have eight FTEs. Acknowledging and understanding that somebody's got to do the work, somebody has to translate the data into action, and then work with the community partners that are really vital to getting the job done.

JOHNSON:
Last question for you. What are the stakes? How important is it, in the end, to get the data right? And how much of an impact does that have, or can that have, on closing health disparities in this country?

CHEN:
Well, I think the data is vitally important, because without the data you can't identify the disparities and you can't quantitate them. So, the data becomes a vital piece of it. Not your whole answer, but it really leads you where you need to go.

In any performance management system, you have to have the data that guide you, that tells you are you're on track, are you off track, and then lead you to take that next step, which is asking the question why aren't you making progress? And then, guiding you based on community input with what's the next step? How do I change my strategy at this point?

But the data really starts it all off, starts the conversation off, so you have to have that data. So important to have that data, do the best you can with it, but don't forget that you can't just exist there by itself.

JOHNSON:
Anna Bradley coordinates Montana's state health improvement plan. She's leading the work to bring health equity into the planning process.

BRADLEY:
Montana's Public Health and Safety Division is an accredited public health agency. The Public Health Accreditation Board standards and measures certainly capture concepts related to health equity, how to incorporate health equity into our work, so we definitely use that for guidance. A lot of our programs also work with federal money, and a lot of federal grants—especially from the CDC—are coming down with more and more requirements related to health equity.

But to an extent, I think, you know, the public health profession has always been rooted in addressing health disparities and advocating for equity. But I think right now we're seeing a lot of maybe confusion and disagreement on the language of that work, right. So, I think Montana and for a lot of the states in the country, that right now a lot of the conversations are is around the language of the work. How do we establish a shared vocabulary that captures the agency's goal, which is to advance the health and wellbeing of all Montanans regardless of their life circumstances, in a way that feels like that makes sense to everybody?

And so, that's a lot of the learning and the conversation right now, is how do we focus on the work that's the most important without worrying too much about what the vocabulary is, or what the language is around that. But really just doing creative problem solving to continue to do the work that we've always done.

JOHNSON:
Is it accurate, then, to assume that all of this has affected Montana's health assessment and improvement plan?

BRADLEY:
Yeah, absolutely. And what's nice about the state health assessment and state health improvement plan are they're really about a continuous cycle of quality improvement, right? They get done every five years, and so there's always the chance to improve them, to make them better, or to ask new questions in a new way to better serve the needs of people who are doing health improvement work across the state. So, they're really an important part of the process.

JOHNSON:
How are you using health equity metrics to impact the process or to make your plans better?

BRADLEY:
Well, we actually are entering into a cycle right now of writing our next state health assessment. And one of the conversations that we've been having is what does a health equity metric look like for Montana.

I think that we've had a lot of interesting conversations around measuring health disparities and moving beyond measuring health disparities to really capture the context around those health disparities, to capture the circumstances around those health disparities. So, really kind of coming to an understanding of what does it look like to have like a suite of metrics to capture the bigger picture so that it's not just about disparities between populations, but you're really kind of focusing on that lived experience and that context of what's going on that creates those disparities.

So, that's where the conversation is right now for the state health assessment. We haven't started writing it yet. But we've pulled together a really great cross-sector group of people from different state agencies, as well as different types of work in the field, just to better capture this idea of what is it beyond measuring just the health disparity.

JOHNSON:
And when you say context, are you referring to the social determinants?

BRADLEY:
Yeah. And so, when we think about what's the context in which people living in rural communities in Montana have access to healthcare, right—I mean, that's a really common one for us to talk about in Montana. Where, you know, it's so much more than just looking at the rates of chronic disease self-management in rural Montana versus urban Montana, and it's really more about what's going on in the context that makes that true, right. Like, how can we address access to care in so many different ways, right? If it's access to health insurance, if it's access to broadband internet for telehealth services, if it's access to health professionals.

And so, there's a lot of different components that go into the status of a person's health, so how do we capture and explain all of those different variables, and you can start to extend that out even further, right? If it's about people's employment status, when it comes to housing issues, when it comes to the built environment of a community, that kind of contributes to their overall health and well-being.

So, I think that that context is just starting to paint that broader picture of what are all of the different things that are going into whether or not a person is able to make the healthiest choices for themselves in their families.

JOHNSON:
Thinking about performance improvement strategies to advance health equity, what are Montana's approaches to that question?

BRADLEY:
You know, we do have an integrated performance management system because we are an accredited public health department. I think that the more important mindset overall with performance improvement is just this idea of continuous quality improvement, right, of continuous cycles of, you know, Plan-Do-Study-Act or whatever framework it is that people use for their performance improvement, for their quality improvement work.

The idea is that public health, in order to be successful, we are continuously evolving, right. Public health started as a profession interested in and involved in health disparities and advocating for equity, and all that we're learning is how to do that better and better as we move forward. And so the frameworks themselves, the specific frameworks, I think, as long as they all include this concept of continuous improvement, continuously striving to serve our communities better, to be better public servants, to apply our energy in better and more strategic ways.

JOHNSON:
Where you sit in the planning chair, does it look to you like things are getting better because of the way Montana is dealing with health equity?

BRADLEY:
It's the ways in which we're showing up every day. I personally, you know, get to engage with a group of people who are really focused on data, increasing access to and communication about data, and working with external partners around communicating public health data. And so, it's that group coming together to really examine the ways in which data are collected, and the ways in which we talk about data, how we engage with it, how we engage external partners, all of that work. And that's not a specific performance improvement framework, right? That's kind of just change management, or it's just people showing up to do the work every day.

JOHNSON:
What's next in this area? Does anything come to mind?

BRADLEY:
Yeah, you know, we're talking a lot about what is modern public health, right? Like, what is the modern public health system in Montana? And that's something that we'll continue to talk about, you know, especially in the context of accreditation. Accreditation is not something that's feasible for every single local health department in Montana. And so, how do we support them to deliver services in approachable ways for their communities in which concepts like health equity are embedded, right. It's just a part of what we do, so how do we do it better?

I think that that's the big conversation for moving forward, is how do we continue to embed this work every day in what we do. And I think that what we've heard so far is if the state can release a state health assessment that really speaks to the whole system of state and local health, then it'll help our local health departments and our tribal health departments communicate and continue to contribute to these type of health improvement strategies that address life circumstances, that address lived context and lived experience that are creating health disparities.

JOHNSON:
Thanks for listening to Public Health Review.

If you liked the show, please share it with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org. You can also follow us using the Follow button on your favorite podcast player.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.