The Challenge: Help a Maryland county target health disparities with its first-ever health equity assessment.
The Background: Far from the busy Baltimore-Washington corridor and cut off by the mighty Chesapeake Bay, Somerset County has experienced a long, slow population decline as job seekers look elsewhere for work. Though rich in history, agricultural resources, and natural beauty, Somerset ranks in the bottom third of Maryland’s counties by median household income, and nearly a quarter of residents fall below the poverty line.
In the fall of 2023, the County engaged Ascendient to conduct its first-ever health equity assessment. Serving a population that is 52% White, 38% Black, 4% Hispanic, and 3% mixed race, the Somerset County Health Department (SCHD) wanted us to create a data-informed plan for reducing health disparities discovered in previous studies, including a 2022 Community Health Needs Assessment that covered four counties in Southern Maryland and Delaware.
Our Work: Using the regional CHNA as a starting point, Ascendient spent several weeks diving into additional secondary data to get a more granular understanding of health disparities and their drivers. Using six different national, state, and local databases, we examined 110 separate health indicators for physical health, access to care, social & economic status, and more. We also included statewide numbers (both aggregated and disaggregated) to show how Somerset compared to other counties in Maryland.
After creating a county-level view of health drivers and outcomes, we next disaggregated the data by race. (As with many other small jurisdictions, only the numbers for Black and White residents of Somerset County were statistically significant; other populations were too small for reliable analysis.)
For 25 of the most important indicators, we started with a countywide baseline and then broke out separate measures for Black and White residents. If either group was at least 5% worse than the county baseline, that indicator was flagged as a “high need” disparity.
Beyond parsing the secondary data in new ways, we also wanted to measure perceptions of public health needs and assets in the County. We did that with a community survey available in English, Spanish, and Arabic, plus extensive interviews with department employees.
Our Findings: Our analysis of health indicators disaggregated by race showed multiple disparities that the County might want to target in its planning. For instance, the countywide mortality rate for heart disease is 291 deaths per 100,000, but Black residents fare significantly worse, with a mortality rate of 337.
We also found county-level disparities that varied from the state-level data. For instance, across Maryland we found that asthma sent White people to the ED at a higher rate than Black people, but those numbers were reversed in Somerset County, where Black residents were far more likely to report to the ED with asthma issues. On the flip side, Black residents across Maryland are disproportionately affected by premature death, but that pattern is flipped in Somerset County.
Meanwhile, survey results showed that residents’ top three concerns were mental health, behavioral health (including substance use), and cancer. Residents said that gender discrimination was slightly more prevalent than racial or ethnic discrimination, and they cited five groups that needed greater access to community resources: people living in poverty, people with mental health conditions, single parents, people living with addiction, and children/youth.
The Outcome: Rather than simply cataloging disparities, Ascendient delivered a detailed action plan to support improvement in the priority areas identified by the County. With resources limited (as they always are), we took two additional steps to ensure that any recommended changes were feasible and actionable.
First, we analyzed needs and disparities within small geographic areas to allow for better targeting of resources. In many cases, pockets of geographic disparity were highly correlated with racial disparities. By limiting the geographic scope of some interventions – for instance, targeting three schools for a new program instead of the entire school system – Somerset County is able to invest resources where they will make the biggest difference.
Secondly, given the resource limitations, SCHD asked us to develop an action plan that merged our recommendations with existing programs, work groups, and partners. By working closely with SCHD leadership, we delivered a plan that was both targeted and feasible as opposed to something overly aspirational or unrealistic.
“Collaboration” and "synergy" are often buzzwords that get thrown around in public health, but Somerset County showed rare intentionality in those areas. We salute SCHD for its vision and leadership.
The Takeaway: Healthcare is a lot like politics – it’s always local. Just because a state publishes detailed data on health disparities, county health departments can’t assume they will see the same disparities in their jurisdiction. Health equity starts at the community level; it’s a bottom-up affair.
