Community-Level Strategies for Addressing Disparities in Healthy People 2030 Leading Health Indicators

Abstract

Context:

The Healthy People 2030 Leading Health Indicators (LHIs) offer a select set of measurable objectives to help community-based organizations focus their efforts to improve health equity and reduce health disparities across the lifespan within the populations they serve. Disparities are observed across LHIs, including infant mortality, maternal mortality, and food insecurity, and reducing these disparities is a key strategy for improving health and well-being for all.

Objective:

This study was designed to answer the following research questions: (1) What programs and initiatives are organizations implementing to address the LHIs of focus - infant mortality, maternal mortality, and food insecurity? (2) How do organizations determine which programs and initiatives they will implement?

Design:

NORC conducted 9 qualitative interviews with Healthy People 2030 Champions, organizations dedicated to furthering Healthy People goals and objectives, who are working to address disparities within infant mortality, maternal mortality, and food insecurity through a variety of strategies, interventions, and programs.

Results:

Wraparound services, doula programs, and education and advocacy emerged as common strategies for addressing disparities in maternal and infant mortality. Organizations that are working to reduce household food insecurity and hunger implemented food pharmacies and support participant enrollment in federal food assistance programs. Interviewees shared strategies for determining programs to implement and continued program improvement including assessing community needs, leveraging partnerships, and measuring program success.

Conclusions:

Healthy People Champion organizations are using several multidimensional strategies to address infant mortality, maternal mortality, and food insecurity in their communities. These strategies, and the community-based organizations that implement them, are critical for addressing disparities in priority health outcomes among the people who have the greatest need. These findings offer insights into how local communities are tackling national priorities and underscore opportunities for more rigorous evaluation to demonstrate progress toward addressing disparities in the LHIs.

Introduction

The US Department of Health and Human Services Healthy People initiative sets data-driven national objectives to improve health and well-being. Healthy People offers practical tools for communities, states, and organizations to assess needs, identify priorities, use data to set targets, and monitor progress toward these benchmarks.1 The Healthy People 2030 Leading Health Indicators (LHIs) offer a select set of measurable objectives to help public health officials and community-based organizations focus their efforts to improve health equity and reduce health disparities within the populations they serve.2 LHIs track and promote action on national, high-priority health issues, including infant mortality, maternal mortality, and food insecurity, which are Healthy People objectives MICH-02, MICH-04, and NWS-01, respectively. To impact these major causes of morbidity and mortality, the LHIs address the social determinants of health (SDOH) and upstream risk factors and behaviors.3

Healthy People provides data and evidence-based resources for objectives, including the LHIs. Organizations can use these data to examine disparities within the populations they serve and inform programs and initiatives in their communities.4 Disparities are observed across LHIs, including infant mortality, maternal mortality, and food insecurity. In 2021, infants with non-Hispanic Black or African American mothers had the highest rate of infant mortality compared to other racial/ethnic groups with 10.5 infant deaths per 1000 live births.5 Infants with non-Hispanic Asian mothers had the lowest group rate for this objective, 3.7 per 1000 live births. This suggests that Black or African American mothers have more than 2.5 times the rate of infant deaths compared to Asian mothers.

For maternal mortality, in 2022, non-Hispanic Black or African American mothers had the highest rate compared to other racial/ethnic groups with 49.5 maternal deaths per 100 000 live births.6 Non-Hispanic Asian mothers had the lowest group rate for this objective, 13.2 maternal deaths per 100 000 live births. The rate for non-Hispanic Black or African American mothers was more than 3.5 times the lowest group rate.

Lastly, in 2022, non-Hispanic American Indian or Alaska Native persons had the highest rate of food insecurity and hunger compared to other racial/ethnic groups with 23.0% of households reporting food insecurity in the past 12 months.7 Non-Hispanic Asian households had the lowest group rate for this objective, 5.7% of households with food insecurity in the past 12 months. The rate for American Indian or Alaska Native-only households was 4 times the lowest group rate. For more detailed data tables that show disparities within each LHI for demographics other than race/ethnicity, such as by educational attainment and geographic location, see the Supplemental Digital Content, available at http://links.lww.com/JPHMP/B476.

Reducing health disparities is critical for improving health and well-being for all. Programs, interventions, and policies at the federal, state, tribal, and local levels help make progress toward achieving the Healthy People 2030 LHIs and closing the gaps in observed disparities. The Healthy People Champions program consists of organizations nationwide dedicated to furthering Healthy People goals and objectives, such as addressing LHI disparities.8 Currently, there are over 200 Champions, with a range of organization types, including non-profits, philanthropies, universities, health care organizations, community-based organizations, and businesses. The Champions do not receive funding for their participation in the program. The program is grounded in information sharing and the exchange of resources, tools, and knowledge from the Office of Disease Prevention and Health Promotion and fellow Champions to progress their work related to Healthy People. Champion organizations are selected based on demonstrated interest in the Champion program and organizational missions that align with the Healthy People framework.

Due to their commitment to health equity, their focus on impacting the root drivers of health, and their alignment with the Healthy People 2030 framework and objectives, Champions are well-positioned to address disparities to improve health and well-being. Examining how Healthy People Champions are addressing LHI disparities can increase awareness of existing disparities within the LHIs and offer examples of how organizations can address these disparities.

Methods

This study was designed to answer the following research questions: (1) What programs and initiatives are organizations implementing to address the LHIs of focus—infant mortality, maternal mortality, and food insecurity? and (2) How do organizations determine which programs and initiatives they will implement? To answer these research questions, NORC conducted 9 qualitative interviews with Healthy People 2030 Champions who are working to address disparities within these LHIs through a variety of strategies, interventions, and programs.

The NORC research team obtained approval for the study from NORC’s Institutional Review Board. Following Institutional Review Board approval, the study team began recruiting for the interviews by email. To identify respondent organizations, NORC sent an email to all Champions of record, as of November 2023, requesting information about their work related to the LHIs of focus.

The email included an information sheet in Qualtrics in which the Champions could select which LHI(s) their organization addresses, what specific programs or initiatives they implement, and what disparities the organizations address with these initiatives. Based on those responses, the team purposively selected organizations that demonstrated strategies to address health disparities related to the selected LHIs and reported the availability of data showing outcomes for the initiative. In collaboration with the Office of Disease Prevention and Health Promotion, NORC identified 9 organizations; the selected Champion organizations included a mix of state and local government offices, nonprofit organizations, and health care providers from across the country. NORC then recruited selected organizations by email to participate in an interview.

In November and December 2023, NORC conducted 9, 45-minute Zoom interviews with selected organizations to learn more about the strategies Champions are using to address disparities in maternal mortality, infant mortality, and food insecurity in their communities. A semi-structured interview protocol was used to allow for relevant questions to be adapted to fit the initiatives and disparities the organizations shared with the team. To read more about each interviewed Champion organization, see Table 1.

TABLE 1.

Interviewed Organization Characteristics

Champion Organization	Organization Type	Location	LHIs of Focus			Populations Served
			Maternal Mortality	Infant Mortality	Food Insecurity
Alliance Community Healthcare	Health care provider	Jersey City, New Jersey	X	X	X	Pregnant women, women who have recently delivered a baby, people from racial and ethnic minority groups, and households with lower incomes
Buffalo Prenatal Perinatal Network, Inc	Nonprofit organization	Buffalo, New York	X	X		African American and Hispanic pregnant/parenting women
Clay County Public Health Center	Local health department	Liberty, Missouri			X	People experiencing poverty, people from racial and ethnic minority groups, and people who are underserved by food equity programs
Family Planning Council of Iowa	Community-based organization	Iowa	X			Teens through middle-aged adults, especially people with lower incomes, people from racial and ethnic minority groups, and other populations with systemic disadvantages
Maternal and Child Health Consortium	Community-based organization	West Chester, Pennsylvania	X	X	X	Women, children, and families with lower incomes
National Recreation and Park Association	Nonprofit organization	Nationwide			X	Rural, Black, Latino, LGBTQ+, and American Indian or Alaska Native persons, and people experiencing poverty
Northern Manhattan Perinatal Partnership	Community-based organization	New York, New York	X	X		Hispanic, African American, and West African women and families
Novant Health	Health care provider	North Carolina	X	X	X	All birthing persons, children 0 to 1 years old, and other patients screened for food insecurity during primary care visits
Sentara Health	Health care provider	Norfolk, Virginia			X	Older adults, children, and people with lower incomes

Abbreviation: LHIs, Leading Health Indicators.

The data were analyzed using rapid thematic analysis.9 The team identified key themes across the interviews including strategies to address LHIs and associated disparities, implementation challenges, evaluation measures, program outcomes, and sustainability.

Results

This section shares findings from interviews with selected Champion organizations. First, we answer the question: what programs and initiatives are organizations implementing to address the LHIs of focus—infant mortality, maternal mortality, and food insecurity? To do so, we share examples of how organizations are implementing programs to address disparities within these LHIs. Next, we discuss how these organizations determine what programs to implement and how these strategies can be applied more broadly to other LHIs, disparities, and programs.

Implementing programs to address disparities in maternal mortality, infant mortality, and food insecurity

Interviewees shared strategies they use to address the LHIs of focus with their programs and initiatives. Wraparound services, doula programs, and education and advocacy emerged as common strategies for addressing disparities in maternal and infant mortality. Organizations that are working to reduce household food insecurity and hunger implemented food pharmacies and support participant enrollment in federal food assistance programs.

Programs aiming to reduce the rate of maternal and infant deaths

Wraparound services

Wraparound services focus on addressing an individual’s SDOH to increase quality of life and allow for better treatment of the patient’s medical needs. All organizations prioritized assessing and addressing the SDOH needs of their audiences and agreed that to sustain healthy mothers and children, individuals must have safe housing, a support system, transportation, and safe neighborhoods. Given the importance of addressing SDOH needs to reduce disparities, it was critical for programs to put social needs and holistic screening at the forefront of patient engagement.

By implementing programs that address these social determinants, organizations are mitigating barriers to accessing health care for mothers and their babies. For example, during the intake process, the Alliance for Community Health (ACH) assesses the mother’s poverty level and access to stable housing. ACH has a comprehensive program with the county and partnerships that enable them to provide immediate housing to their patients who need it. The program offers temporary housing assistance, like arranging short-term accommodations for a patient, and long-term support, such as helping patients apply for a Temporary Assistance for Needy Families program voucher to pay for rent. The Buffalo Prenatal Perinatal Network (BPPN) often works with housing organizations to ensure mothers and families served through the organization have stable housing and can focus on safer pregnancies and post-natal care. BPPN said, “It’s hard to talk to people about health goals when they don’t know where they’re sleeping that night.” BPPN has also helped the populations they serve obtain driver's licenses, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) coverage, and doula services covered under Medicaid.

Ongoing support for mothers and babies

Interviewees emphasized the importance of ongoing care for mothers throughout their pregnancies, during labor, and postpartum. A few organizations implemented doula programs to provide continued support to mothers and their babies. Doulas are trained medical professionals who serve as advocates for the needs of mothers during pregnancy, labor, and postpartum. All interviewees mentioned that providing support after the birth is a necessary step for ensuring mom and baby stay healthy. When doulas maintain a relationship with mothers and their children well into postpartum, this allows them to continue to build trust and offer additional support via wraparound services and provider referrals. Some programs use community health workers (CHWs) to conduct home visits and connect families to resources to support positive outcomes for mothers and their babies. To garner patient and participant trust, these organizations employed doulas, CHWs, and other staff who reflect the communities they serve. Northern Manhattan Perinatal Partnership (NMPP) runs 3 CHW programs to ensure new mothers have support across a variety of newborn health needs. NMPP highlighted how their CHW programs support mothers and babies, stating,

One CHW program deals with making sure infants get their hearing tested when they’re born and if there is any indication that there are hearing issues, the CHW makes sure that mom comes back for a follow-up visit. Another program focuses on children with special needs … making sure mom is connected to services and is going to all her appointments and has the support she needs at home.

Education and advocacy

A few organizations also rely on education and advocacy to reduce disparities in medically underserved populations. Organizations educate local, state, and federal government offices and advocate within their communities for better health access and treatment for all populations. Organizations focus on educating their staff and governmental offices on implicit bias and health disparities among racial and ethnic groups. They also educate their target populations on best practices for keeping themselves healthy at home and in their communities. For example, the Family Planning Council of Iowa (FPCI) offers reproductive health kits that include emergency contraception, pregnancy test strips, and health education pamphlets that teach recipients about contraception, sexually transmitted infection (STI) testing, and resources available in the community for a variety of needs.

Programs aiming to reduce household food insecurity and hunger

Food pharmacies

Food pharmacies serve as sites within a community where individuals experiencing food insecurity can get healthy, nutrient-dense food. Often coined “food farmacies,” this is an umbrella term to describe practices like food banks, Supplemental Nutrition Assistance Program (SNAP)-backed farmers markets, and mobile food clinics. For example, Sentara Health expanded their food pharmacy program to reach 29,000 people across 50 locations in Virginia and North Carolina. Sentara Health not only works to ensure access to healthy foods within these communities but also emphasizes the necessity to move families from food bank-only reliance to being supported by SNAP benefits.

Benefit enrollment

Food assistance programs, like SNAP, can help reduce food insecurity and mitigate the long-term effects. All interviewed organizations that focus on addressing food insecurity use these federal nutrition programs to improve food access for their communities. For example, the Clay County Public Health Center encourages enrollment in SNAP and WIC by posting weekly lobby displays to provide information to families and individuals, supporting application submission, managing eligibility, and answering questions individuals may have about the programs. In addition, the agency participates in the Farmers Market Nutrition program within WIC to provide clients with funds to spend at approved farmers markets and the Harvesters program to offer food at the health center once a month. The Harvesters program is open to all community members and offers food for pick up at the Health Center. This program has seen success with decreasing food insecurity within the Kansas City northland area, even despite challenges:

Harvester is open to anyone to participate. We partner with Meals on Wheels to organize groups of volunteers to pick up food and distribute to homes. We encourage families to pick up for multiple households to combat transportation barriers. The Harvester program started in 2019, then COVID hit, so we are just now dedicating time to consider program evaluation and changes.

Determining programs to implement, leveraging partners, and measuring program success

Before implementing a program to address disparities, it is important to assess a community’s needs. Interviewees shared how they determine what programs to implement and strategies for continued program evaluation and improvement. Some of the common strategies that emerged across organizations include assessing community needs, leveraging partnerships, and measuring program success. This section illustrates how these recommendations can be broadly applied to address other LHIs and disparities.

Assess your community’s needs to determine what programs will have the most impact

Organizations determined which programs to implement, with which populations, and in which neighborhoods by utilizing gap analyses, asset mapping, community needs assessments, community canvassing, and analyzing data from sources such as the Centers for Disease Control and Prevention’s Social Vulnerability Index10 and other state-level public health data and mapping tools. For example, Novant Health conducted gap analyses within their hospital system and found that non-Hispanic Black and African American birthing persons had lower prenatal care rates and higher cesarean birth rates than non-Hispanic White and Caucasian counterparts. Novant Health then created a strategy to address the underlying causes for the identified disparities and launched a system-wide, long-term goal. Interventions included CHWs, obstetric nurse navigators program, mental health providers, and community resources to address SDOH.

Some organizations described how they conduct community needs assessments and analyze data trends to reveal disparities in the community, identify priorities, and set their agendas.11 Community needs assessments help organizations identify gaps to inform how and where they spend time and resources to reduce disparities. Building a strong database over time allows for comparison to previous time points in which organizations can see their progress in addressing disparities or rework their initiatives if data suggest that they are not having their intended impact as currently implemented. Emphasizing the constantly changing needs of the community, NMPP said,

You have to be on the ground, walking within the community. When CHWs come on board, I want them to do community canvasing. Walk the community, see what services are there and what they are doing. At least a couple of times throughout the year we’ll do community canvasing because things change, today a service is here tomorrow it’s gone.

Leverage partnerships to inform, implement, and sustain community programs

Most interviewees emphasized the importance of partnerships, regardless of which LHIs their programs addressed. Partners help the organizations implement and sustain programs to address health disparities and reach priority populations for these initiatives. Organizations work with community and grassroots organizations that represent and hail from the communities they serve to build community trust and comfort in accessing and using resources provided by health organizations. When implementing a community program, interviewees encouraged others to speak directly with the communities they are serving and ensure they have their trust. Interviewees also emphasized the power of storytelling and elevating community voices to garner support for this work and highlight its importance. For example, the Maternal and Child Health Consortium leverages partnerships with CHWs to run their Healthy Start program, an initiative that focuses on home visits for pregnant women. This program connects expecting mothers to other community resources, while also screening for depression, adverse childhood experiences, and other risk factors that could impact pregnancy. FPCI relies on partnerships with clinics and health centers across Iowa to ensure health care needs for women and children are being met statewide, saying,

We partner with clinics, health care organizations, for the Title X grant. We’re looking to partner with other organizations that are focused on maternal health. Some are family planning clinics, county health departments, or federally qualified health centers. We are also figuring out the best ways to collaborate with the Iowa Department of Health and Human Services because they receive Title X funding and are primarily responsible for WIC and other county-level public health programs.

Monitor progress toward achieving goals to support continued programmatic improvement and replication

Programs and strategic efforts to address health disparities can only be effectively assessed and replicated when measures and outcomes are tracked and evaluated. Evaluating the reach and outcome of a program allows for a better understanding of the program’s successes and challenges in addressing the needs of their priority populations, as well as opportunities to potentially expand the program into other communities.

The programs addressing maternal and infant mortality reported improved access to care for mothers and their children, a decrease in emergency department visits, and an increase in preventative care for postpartum women. The organizations delivering hospital and clinic-based services utilize their electronic medical records to analyze trends and changes in client data. For example, ACH focuses on metrics such as birth weight, delivery type, discharge date, postpartum health, complications, and breastfeeding/bottle feeding. ACH sets targets each year and has monthly staff meetings to discuss progress toward meeting their goals. ACH shared that their program has not had any maternal or fetal deaths within the last 10 years. As another example, FPCI tracks teen birth rates and STI incidence to identify areas of need, such as reproductive health care deserts, and priority populations in the state. By supporting Title X clinics in these areas, FPCI hopes to see a decrease in STIs and unintended pregnancies in the communities they serve. Through a multi-pronged approach, Novant Health successfully increased prenatal care, reduced the disparity in cesarean births, and established food programs to support birthing persons during pregnancy and 6 weeks postpartum.

For outcomes related to food insecurity, the National Recreation and Park Association (NRPA) has a dedicated research and evaluation team that conducts process evaluations and systems of change evaluations to assess the fidelity of their initiatives. NRPA cited focus groups and community interviews as important methods for receiving feedback on the benefits of their programs. NRPA shared that their greatest success was seeing the innovative strategies implemented by their members, saying,

We’ve seen parks and recreation agencies use grant funds to turn old school buses into mobile units that can take meal programs into communities and be those trusted faces for neighbors to have access to these foods. One of our grantees piloted a mobile WIC program so folks can have farmers market food delivered right to their doorstep. A lot of really innovative work from our members, really working to ensure that they’re meeting their community members where they are and helping them have the access that they need.

Limitations

Several limitations must be acknowledged as they may affect the interpretation of the findings. This research was exploratory in nature and organizations self-reported program outcomes. NORC did not conduct an independent evaluation or review of program data, meaning that the findings are primarily descriptive rather than definitive. Additionally, purposively selecting Champion organizations to participate in the study introduces potential selection bias and reduces the generalizability of findings. However, selecting organizations in this way enabled us the ability to showcase a variety of implementation examples from organizations across the country addressing and experiencing different physical, social, and built environments.

Discussion

Healthy People Champion organizations are using multidimensional strategies to address maternal mortality, infant mortality, and food insecurity in their communities. These strategies and the community-based organizations that implement them are critical for addressing disparities in priority health outcomes among the people who have the greatest need.

These programs highlighted the importance of assessing the community’s needs and addressing SDOH to impact health disparities. Interviewees emphasized the importance of data for identifying disparities by race/ethnicity and socioeconomic status in their communities and informing the strategies and target populations for their programs. Establishing and maintaining partnerships can be resource-intensive and challenging, but partners are critical to garnering community support and reaching populations that experience disparate health outcomes. These strategies closely align with Healthy People’s recommendations for communities, states, and organizations across the country, which include identifying needs and priority populations, setting targets, finding inspiration and practical tools, and monitoring progress.1

The qualitative data in this study highlight the dynamic work of organizations mobilizing to address the root drivers of health and builds the evidence base for strategies that address the upstream causes of health disparities. These findings offer preliminary insights into how local communities are tackling national priorities. More rigorous evaluation of program outcomes and further documentation of lessons learned from programs addressing LHIs and other Healthy People objectives can offer implementation strategies and examples for other organizations looking to address these issues.

Implications for Policy & Practice

• Addressing disparities at the community level with the buy-in and partnership of organizations that are integrated into their communities is critical for improving key health outcomes.

• Organizations implementing programs to address maternal mortality, infant mortality, and food insecurity rely on data to determine which strategies to implement and in which neighborhoods. Healthy People will continue to provide national data to serve as a benchmark.

• Improving SDOH, including access to housing, transportation, nutritious foods, and health care, is a key strategy for reducing disparities in LHIs.