Health means “living a stress-free life,” says Mirra Tuka, “but it’s not easy. You have to have support.”
As a caseworker at Oakridge Neighborhood and a single mother with three children living on campus, Tuka sees firsthand how residents struggle to access fresh foods and health care. With her own car, she can travel outside of downtown to Wal-Mart to purchase the kale, cabbage, potatoes, okra, and other fresh fruits and vegetables she’s used to cooking from growing up in Ethiopia. Like other residents, she sometimes stops at markets that have more diverse offerings but can be expensive, while others must use a mobile pantry on site that often only has canned or frozen foods.
She and her kids receive routine medical care, but she works with many families who don’t know about the importance of receiving preventive health and dental care – just that they can go to the emergency room when they’re sick – or they miss appointments because they are unable to get transportation.
For her, she has sought care for stress, anxiety, and depression as she juggles work and taking care of her family. At the end of the day, after cooking a meal, she’s too tired to take the kids to the playground and worries about her 11-year-old’s safety if he walks around downtown, even though she desires for her kids to get more exercise.
These are just some of the experiences shared through a community health needs assessment of Oakridge Neighborhood residents, conducted in fall 2021 with a grant from the Centers for Disease Control and Prevention (CDC) to the Iowa Department of Public Health (now known as the Iowa Department of Health and Human Services (HHS)). Stakeholders saw an opportunity to better understand how social determinants of health (like food, health care access, and physical environment) influence people in a diverse pocket of the region and develop strategies that meet those unique needs.
“It’s this notion of getting away from the one-size-fits-all approach,” said Teree Caldwell-Johnson, President and CEO of Oakridge Neighborhood, “to really be much more focused on how we tailor opportunities that meet the needs of a more diverse population that is seeking services and needs access to health care.”
Mid-Iowa Health Foundation President and CEO Dr. Nalo Johnson participated on the leadership team to review the assessment and create a plan to respond. In her previous role as Division Director of Health Promotion and Chronic Disease Prevention at the Iowa Department of Public Health, she helped establish the project with the belief in community-driven approaches to improving health and well-being.
“The goal of the Oakridge CDC project was to establish a strong collaborative model of a state health department engaging with community-based organizations in authentic ways to address the communities’ specific needs,” said Johnson. “Having established meaningful partnerships, this project is an excellent example for other programs regarding community-informed public health practice.”
Oakridge Neighborhood is Iowa’s largest Section 8 housing project, located on a 17-acre campus in Des Moines’ urban core, with nearly 1,000 residents from 26 countries who collectively speak 39 languages. More than half are under age 18, nearly three-fourths are refugees or immigrants, and most have a yearly average household income of less than $20,000.
The idea for a needs assessment spurred from a conversation between Caldwell-Johnson and Johnson in winter 2020. Caldwell-Johnson mentioned wanting to do more to support residents’ health beyond Oakridge's core focus on housing. Johnson was interested in how the state department could better connect with communities to learn and provide support.
Both leaders also are involved in The Director’s Council, focused on improving conditions for Black Polk County residents to address disparities highlighted in the One Economy Report. Many disparities are related to social and economic factors that greatly influence health outcomes.
The ability to do a hyper-local needs assessment and action plan fell into place with CDC funding awarded in summer 2021. The project especially brought Iowa HHS stakeholders focused on nutrition, physical activity, and chronic disease management together to work on the project.
“We are not boots-on-the-ground,” said Hailey Boudreau, who managed the project at HHS. “Getting stakeholder buy-in and community buy-in is sometimes difficult. It was wonderful to have firsthand experiences and think about how we can address needs from a statewide perspective, and also understand what that looks like at a local level.”
The grant required the planning team to focus on two of five areas related to the social determinants of health. Based on conversations with Oakridge, the team zeroed in on food insecurity and community clinical linkages as areas of particular concern.
The timing allowed the planning team to align with the Community Health Needs Assessment that is conducted every three years in Polk, Warren, and Dallas counties as a requirement for nonprofit hospitals, as well as a state requirement to be conducted every five years for local public health departments. PCR, the organization conducting the counties’ assessment, was contracted to allow the team to use the same assessment tool for Oakridge, which led to comparison between the two assessment reports.
The tool was translated into 13 languages and Oakridge staff connected with residents in a variety of ways to encourage participation. Nearly 300 residents participated, a high rate considering half of the 1,000 residents are children. PCR analyzed the data and completed a report that compared results to data gathered in the three-county region, the state, and nationally.
To better understand the health survey findings, the team worked with University of Iowa College of Public Health researchers to conduct focus groups with 50 residents divided based on languages spoken. Researchers analyzed conversations for consistent themes.
Providing translation, meeting with residents when it worked in their schedules, and many other steps were taken to make the assessment as inclusive as possible. Participants received a gift card for their time when they took the survey or attended a focus group, following best practices in community-engaged research.
“Our focus has been on finding ways to include all the voices in the community, knowing all of the diversity that exists at the Oakridge campus,” said Almardi Abdalla, Vice President of Family and Workforce Programs at Oakridge Neighborhood, who managed staff during the project.
“We really extended ourselves to make sure we didn’t leave out those who wanted to participate,” said Caldwell-Johnson. “Given our narrow population that could actually participate, we had to go deeper and wider to make sure people had the ability to access the information.”
Through strong communication and partnership between HHS and Oakridge team members, the data collection was completed in about six months.
While the Oakridge assessment showed similarities as what was uncovered regionally, there were notable differences, along with a deeper understanding of what was driving certain issues.
“The project reinforced our understanding and the importance of having both a quantitative and qualitative look at the needs of the community,” said Jill Lange, Bureau Chief of Nutrition and Physical Activity with Iowa HHS. “Asking and understanding why gets to the root of what's going on and how we can help make changes that are beneficial and driven by the community.”
Food insecurity is a prevalent issue on campus. Oakridge provides access to food in a variety of ways with community partners, such as a mobile food pantry, but these efforts often don’t provide the types of foods residents are used to cooking and eating. Without a grocery store nearby, many residents also struggle being able to purchase food regularly.
Another issue is health care access. Even with a hospital right across from the campus and even with access to health and dental insurance, many residents face limitations in seeking routine and preventive health care services. Some reasons include clinics not being open outside of when they work and not being able to get to their provider. Those who do seek care often travel to visit providers who speak their language or whom they trust because of their culturally relevant approach with patients.
“Just living near a food bank or health care provider does not mean there aren't other barriers in accessing these services,” said Jill Myers Geadelmann, Bureau Chief of Chronic Disease Prevention and Management with HHS.
Physical activity was another concern, with most residents reporting that they were not physically active. For some residents, the issue is not having access to a workout facility but needing facilities that separate men and women. They also wanted more options for activities to stay active, such as a ping pong or fuse ball table.
Mental health was one area that Oakridge residents fared better in, but project researchers and planners noted that cultural differences in understanding the concept of mental health could have influenced results. Simply translating the questions may not have resonated when some cultures don’t recognize the concept of mental health in the ways traditionally described in American culture.
A leadership team comprised of stakeholders involved in local health equity efforts came together to review the assessment data and help develop a plan that prioritizes areas of concern and identifies action steps. Based upon the assessment findings, they set three goals:
“Being able to focus on a geographic area, or in our case, a neighborhood, created an opportunity for us to not get lost in the larger data gathering,” Caldwell-Johnson said. “This allows us to not only be responsive to the needs of people in that area, but also determine how to best create a system of support that meets those needs in ways that you wouldn’t be able to do if all of the data you just looked at was aggregated data.”
HHS submitted the plan to the CDC in August 2022 and is waiting for feedback but has already been informed that the CDC will not release additional grant dollars to implement the plan. Without funding to fully mobilize the action plan, Oakridge is taking initial steps to strengthen existing partnerships, using the data to inform how services are delivered. For example, staff are having conversations on how community partners can help increase access to culturally relevant foods for residents. Another project already in the works—expanding its WIC clinic on campus—will allow Oakridge to consider offering other periodic health services, such as a medical, hearing, or dental clinic.
HHS is using the assessment and subsequent plan to share information about programs and services more effectively and to consider other opportunities, such as supporting a community garden nearby. The data is also informing how the state department looks at serving diverse populations across the region and state, and stakeholders are considering how to help local health departments implement similar engagement models.
“I think local public health and even state-run public health should look at how they engage local communities,” said Boudreau. “It takes a lot of time, but it is very important to do.”
Helen Eddy, Director of the Polk County Health Department, has been involved in the Oakridge planning discussions and is using the information to inform how the department helps address some of the identified needs. The process also aligns with the department’s intentional efforts to go deeper than the regional health assessment by listening to the health needs of diverse communities and collaborating in addressing those needs—work that has always been a part of public health but growing as Iowa HHS provides more funding for it.
“One thing Des Moines does well as a community is that it has the right people around the table who can take information that comes from focus groups and community health assessments and have meaningful conversations about possible solutions,” she said. “An important part of the process is that we must have members from the community who are going to be served by the solution at the table to help craft that solution.”
During the pandemic, the Polk County Health Department formed stronger relationships with ethnic community-based organization leaders to hear what their communities’ needs were for receiving COVID-19 and vaccine information and then working with them to deliver information more effectively. To build on that work with grants from Mid-Iowa Health Foundation and the Community Foundation of Greater Des Moines, the department has been holding focus groups with refugees and immigrants to learn about broader challenges with physical and mental health. These efforts require time to foster trust and resources to pay individuals within the communities for their work, but the investment is leading to tangible ideas that will more effectively meet people’s health needs.
“I think what it highlights to us is when you see, for example, a health disparity in terms of cancer screening rates, don’t stop at that,” Eddy said. “You have to ask why and get that answer and ask why again. Eventually you uncover those barriers that stand in the way of people fulfilling their health and wellness potential. It comes down to things like food access, transportation, language, ability to feel like they can form a close relationship with their doctor. Those are the things we need to focus on.”
As a member of the leadership team, Erin Drinnin, Health and Well-Being Officer at United Way of Central Iowa, said the assessment helped her see where to ask more questions as well. For example, while most residents have dental insurance, a large percentage are still not accessing routine dental care. She would like to know more about why that is.
As co-chair of the One Economy Health Group, she is using the Oakridge assessment and plan to help identify and encourage system-change strategies, including how to support hospital systems in training providers to offer care with cultural humility.
“The assessment elevates where some of the potential challenges are and what some of the unique experiences are of people in our community,” said Drinnin. “So many of these issues that arise go back to those cultural barriers for people. This [assessment] can inform broader strategies around health equity.”
How a needs assessment of Oakridge Neighborhood residents is informing ways to improve health and well-being
Teenagers in jumpsuits lying on yoga mats, their eyes closed, their bodies still. This is the image Megan Hoxhalli describes as remarkable for juvenile detention, a place where youth arrive shaken, dysregulated, and scared about their future.