State and Territorial Efforts 

to Reduce Health Disparities 

Findings of a 2016 Survey by the U.S. Department of Health and Human Services 

Office of Minority Health

 
State and Territorial Efforts 

to Reduce Health Disparities

Findings of a 2016 Survey by the U.S. Department of Health and Human Services 

Office of Minority Health

This document was produced for the Office of Minority Health by Westat under contract 

number HHSP23320095655WC, order number HHSP23337028T. The contributing authors 

were: Sari Siegel, Brenda Leath, Stephanie Fry, Calvin Pierce, Natalie Teixeira, Willow Burns, 

Nina Freed, Paul Weinfurter, Brian Dorsey, and Jennifer Nooney of Westat, and Stacey Williams 

of the Office of Minority Health. The views expressed in this report are those of the authors 

and do not necessarily represent those of the Office of Minority Health, U.S. Department 

of Health and Human Services. 

Suggested citation: U.S. Department of Health and Human Services, Office of Minority Health. 

(2018). State and Territorial Efforts to Reduce Health Disparities: Findings of a 2016 Survey by 

the U.S. Department of Health and Human Services Office of Minority Health. Washington, DC: 

U.S. Department of Health and Human Services.

State and Territorial Efforts to Reduce Health Disparities i
Table of Contents

iii Letter from OMH Director

1 About the Federal Office of Minority Health and State and Territorial Minority Health Entities

1 Background on the Office of Minority Health

2 OMH’s Mission

2 OMH’s Structure and Core Functions

4 Background on State and Territorial Minority Health Entities’ Relationship with the OMH

5 Part I: Executive Summary

7 Part II. Acknowledgements

8 Technical Expert Panel Members

9 Participating States and Territories

9 Data Group Members

10 Part III: Introduction & Background

11 Goals and Structure of the Health Disparities Report

12 Methodology

13 Summary of Findings

15 Conclusions

17 State and Territory Profiles

State and Territorial Efforts to Reduce Health Disparities ii
Letter from OMH Director

July 29, 2018

On behalf of the United States Department of Health and Human Services (HHS) Office 

of Minority Health (OMH), I am delighted to present our special report, State and Territorial 

Efforts to Reduce Health Disparities (Health Disparities Report). This report summarizes 

persistent health disparities in the United States, as well as innovative state-level approaches 

to address them. The strategies used and reported by the states draw upon evidencebased strategies, frameworks, and models proven through decades of independent research 

and practices. 

As you peruse the following pages, you will learn about the OMH’s long-standing history of 

developing and implementing strategies designed to build and strengthen partnerships across 

public and private sectors for the purpose of improving the health status of racial and ethnic 

minority populations. Often the coordination of activities addressing health disparities and 

health equity occur at the state level within the organizational units that focus on minority 

health issues. These organizational units, or state/territory minority health entities (SMHEs), 

have been principal partners in linking the OMH (and other federal agencies) and local efforts 

to address and eliminate racial and ethnic health disparities. 

The Health Disparities Report is the culmination of commitment and hard work from multisector stakeholder entities. Dissemination of this resource, particularly to community-level 

decision-makers, represents an important step toward increasing the accessibility of stateand territory-level data to a wide range of audiences. This data sharing supports opportunities 

to achieve the goals of the 2018–2022 HHS Strategic Plan, such as meaningful health system 

reform. It also supports national health policy that will improve population health. As such, 

this publication will be of great interest to funders, legislators, researchers, and institutional 

administrators, among other stakeholders. 

I encourage all current and emerging OMH partners, organizational networks, community 

coalitions, multidisciplinary professionals, and others working to eliminate health 

disparities to consult and use this report in your ongoing work. The OMH and its constituent 

organizations are energized by our collective successes and are committed to furthering our 

mission to achieve health equity. We hope you will explore this defining report and visit our 

website to learn more about our successes to date and share our vision for the future.

Sincerely,

Matthew Y.C. Lin, MD 

Deputy Assistant Secretary for Minority Health 

and Office of Minority Health Director 

State and Territorial Efforts to Reduce Health Disparities iii
About the Federal Office of Minority 

Health and State and Territorial 

Minority Health Entities

Background on the Office 

of Minority Health

Understanding the background and history of the Office 

of Minority Health (OMH) is critical to a productive 

review of the agency’s body of work, including initiatives 

and resulting impacts. OMH’s portfolio of projects and 

resource materials such as reports, tools, and peer-reviewed literature provides essential context. This background information lends clarity and perspective to its 

vital mission, signature initiatives, stakeholder engagement strategies, and multi-level partnerships. Of particular relevance to this report are the OMH partnerships with state and territorial offices, which align with 

the OMH National Partnership for Action to Eliminate 

Health Disparities (NPA) and the National Stakeholder 

Strategy for Achieving Health Equity. 

The National Institutes of Health defines health 

disparities as “differences that exist among specific 

population groups in the United States in the attainment of full health potential that can be measured by 

differences in incidence, prevalence, mortality, burden 

of disease, and other adverse health conditions.1 Disparities are often used within the context of two social 

constructs—race and ethnicity; however, they can also 

occur within the contexts of gender, sexual orientation, 

age, disability status, socioeconomic status, and geographic location.2 According to Healthy People 2020, 

all of these factors, in addition to race and ethnicity, 

shape an individual’s ability to achieve optimal health.3

OMH’s etiology resulted, in part, from a landmark 1985 

report released by the United States Department of 

Health and Human Services (HHS) entitled “The Secretary’s Task Force Report on Black and Minority Health” 

(Heckler Report). The Heckler Report offered a stark 

and compelling account of the prevalence of health 

disparities among racial and ethnic minorities in the 

United States. This defining work led to the elevation 

of minority health to national priority status and the 

establishment of the OMH in 1986. 

In 2010, the Patient Protection and Affordable Care 

Act (ACA) reauthorized OMH, further solidifying its 

structure within the federal landscape. This statute 

also mandated the establishment of Offices of Minority 

Health within six HHS agencies: Agency for Healthcare 

Research and Quality, Centers for Disease Control and 

Prevention, Centers for Medicare & Medicaid Services, 

Food and Drug Administration, Health Resources and 

Services Administration, and Substance Abuse and 

Mental Health Services Administration. 

These subsequently established federal Offices of 

Minority Health join the HHS Office of Minority Health 

and the National Institute on Minority Health and 

Health Disparities (NIMHD) to lead and coordinate 

activities geared toward improving the health of racial 

and ethnic minority populations and eliminating health 

disparities. This configuration resulted in a formidable 

interagency partnership that supports federal efforts to 

end health disparities and promote health equity.

1 NIH (National Institutes of Health). Health disparities. 2014. [November 2, 2016].http://www.nhlbi.nih.gov/health/educational/healthdisp.

2 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health 

Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Communities in Action: Pathways to 

Health Equity, Baciu A, Negussie Y, Geller A, et al., editors. Washington (DC): National Academies Press (US); 2017 Jan 11.

3 Healthy People 2020. Healthypeople 2020. 2016. [October 21, 2016]. https://www.healthypeople.gov.

State and Territorial Efforts to Reduce Health Disparities 1
About the Federal OMH and State and Territorial Minority Health Entities

The work of OMH, NIMHD, and HHS agency Offices 

of Minority Health is conducted in support of the 2018–

2022 HHS Strategic Plan and its five identified goals:

• Reforming, Strengthening, and Modernizing 

the Nation’s Healthcare System

• Protecting the Health of Americans Where They Live, 

Work, Learn, and Play

• Strengthening the Economic and Social Well-Being 

of Americans Across the Life-Span

• Fostering Sound, Sustained Advances in the 

Sciences

• Promoting Effective Management and Stewardship.

OMH’s Mission 

OMH’s mission is to improve the health of racial and 

ethnic minority populations through the development 

of health policies and programs that will help eliminate 

health disparities. Racial and ethnic minorities continue to lag behind other populations in many health 

outcome indices.4 Racial and ethnic minority populations are less likely to obtain preventive services, less 

likely to have access to quality health care, and more 

likely to suffer from serious illnesses than their nonminority.5 Health disparities among racial and ethnic 

minority populations may be found in geographical 

hotspots: areas with high disease prevalence or behaviors that put people at risk for acquiring a disease. 

Moreover, health disparities among racial and ethnic 

minority groups are often linked to social, economic, 

or environmental disadvantages,6,7 such as: 

• Poor access to health care service

• Concentrated poverty 

• Inadequate education and job opportunities

• Exposure to crime and violence

• Unsafe housing 

• Insufficient access to affordable healthy foods 

• Limited transportation options. 

These social, economic, and environmental conditions 

that impact the way people live and work are known 

as social determinants of health. OMH programs, 

policies, and practices address such factors, with the 

goal of affording everyone an opportunity to live a long, 

healthy, and productive life, and to improve the overall 

quality of life for the nation as a whole.

OMH’s Structure and Core Functions8

OMH is housed in the Office of the United States 

Secretary for Health and Human Services. The dually 

appointed Deputy Assistant Secretary for Minority 

Health and Director of the Office of Minority Health 

provides executive leadership for the OMH and is supported by an interdisciplinary team of policy, program, 

and administrative staff. 

The OMH’s core functions are to: 

• Promote the collection of health data by racial, 

ethnic, and primary language categories and 

strengthen infrastructures for data collection, 

reporting, and sharing

• Work to increase public awareness of the major 

health problems of racial and ethnic minorities and 

factors that influence health through collaborations 

and partnerships

• Establish and strengthen networks, coalitions, and 

partnerships to identify and solve health problems 

• Develop and promote policies, programs, and practices to eliminate health disparities and achieve 

health equity 

• Foster research, demonstrations, scientific investigations, and evaluations aimed at identifying and 

addressing health disparities 

• Fund demonstration programs that can inform 

health policy and the effectiveness of strategies 

for improving health disparities. 

4 Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report — United States, 2013. MMWR. 2013;62 

(Suppl 3):1-187. Available at: https://www.cdc.gov/mmwr/pdf/other/su6203.pdf. 

5 Artiga S, Foutz J, and Cornachione E, and Garfield R. (2016), Key Facts on Health and Health Care by Race and Ethnicity. Kaiser Family 

Foundation. Available at: https://www.kff.org/disparities-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity/.

6 Sealy-Jefferson S, Vickers J, Elam A, and Wilson, MR. Racial and Ethnic Health Disparities and the Affordable Care Act: A Status Update. 

Journal of Racial and Ethnic Health Disparities. 2015. 2(4):583-588.

7 Lancaster KJ and Bermudez OI, Beginning a discussion of nutrition and health disparities. The American Journal of Clinical Nutrition. 

2011;93(5):1161S-1162S. Available at: https://academic.oup.com/ajcn/article/93/5/1161S/4597882.

8 Office of Minority Health U.S. Department of Health and Human Services. 

Available at, https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=4.

State and Territorial Efforts to Reduce Health Disparities 2
About the Federal OMH and State and Territorial Minority Health Entities

OMH programs address disease prevention, health 

promotion, risk reduction, healthier lifestyle choices, 

use of health care services, and barriers to health 

care. OMH accomplishes its work through a multi-tiered 

approach to coordinate HHS health disparity programs 

and activities. 

These core functional areas involve assessing policy 

and programmatic activities for health disparity implications; building awareness of issues impacting the 

health of racial and ethnic minorities; developing 

guidance and policy documents; collaborating and 

partnering with agencies within HHS, across the federal 

government, and with other public and private entities; 

funding demonstration programs; and supporting projects of national significance. 

OMH established the National Partnership for Action 

(NPA)9 in 2007 to mobilize a nationwide, comprehensive, community-driven, and sustained effort focused 

upon combatting health disparities and achieving 

health equity. NPA’s mission is to increase the effectiveness of health disparity elimination efforts by 

coordinating efforts to address social determinants 

of health (SDoH) and facilitate a heightened awareness 

of the role of SDoH in health care disparities. NPA’s 

work is guided by five goals listed in Figure 1. 

Figure 1. The Five NPA Goals10

Goal 1: Awareness – Increase awareness of the significance 

of health disparities, their impact on the nation, and the 

actions necessary to improve health outcomes for racial 

and ethnic minorities and other underserved populations.

Goal 2: Leadership – Strengthen and broaden 

leadership for addressing health disparities at all levels. 

Goal 3: Health System and Life Experience – Improve 

health and healthcare outcomes for racial and ethnic minorities and other underserved populations.

Goal 4: Cultural and Linguistic Competency – Improve 

cultural and linguistic competency and the diversity of 

the health-related workforce.

Goal 5: Data, Research, and Evaluation – Improve data availability and coordination, utilization, and diffusion of research 

and evaluation outcomes.

 

The NPA expands OMH’s capacity and infrastructure 

for implementing the OMH programs and initiatives. As 

shown in Figure 2, the NPA engages multi-level partnerships to support its implementation structure. These 

strategic partnerships leverage individual and collective 

resources to increase their effectiveness and produce 

mutually beneficial outcomes across multiple levels 

and sectors. The NPA is implemented at the federal 

level through the Federal Interagency Health Equity 

Team (FIHET) and regionally through 10 Regional Health 

Equity Councils (RHECs). The FIHET is comprised of 

12 federal agencies, and the RHECs are non-federal 

coalitions including volunteer members from academia, 

government, and the private sector. National partners 

leverage resources and expand reach and network 

(National Indian Health Board, National Conference of 

State Legislatures, Association of State and Territorial 

Health Officials, and DentaQuest). State offices of 

minority health (SOMHs) work at the state level to align 

policies and programs with the NPA and with local and 

national partners to promote health equity in their communities. SOMHs serve as conduits between RHECs 

and state and local coalitions. They lead the effort to 

align state-level health equity plans with NPA goals.

9 National Partnership for Action to End Health Disparities. Office of Minority Health, U.S. Department of Health and Human Services. 

Available at: https://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=11.

10 For more information, please see the OMH National Partnership for Action to End Health Disparities website.

State and Territorial Efforts to Reduce Health Disparities 3
About the Federal OMH and State and Territorial Minority Health Entities

The Alignment of OMH’s Partnerships with State and 

Territorial Offices of Minority Health with the Health 

Disparities Survey and Report

The OMH’s history and organizational mechanisms 

provide a contextual framework for the data collection 

activity highlighted in this report. The OMH has maintained longstanding partnerships with state offices of 

minority health/health equity (or other state entity with 

similar function), other state agencies, tribes and tribal 

health agencies/organizations, and U.S. territories. 

These entities have been pivotal to the process of 

implementing the NPA. 

Each partnership is unique, adding diversity and 

considerable value to the collective efforts aimed at 

reducing health disparities and promoting health equity. 

Importantly, such partnerships have demonstrated 

states’ abilities to play a significant role in efficiently 

and effectively improving health outcomes in geographical hotspots (in communities) and addressing 

health disparities that affect minorities and disadvantaged populations. 

The diversity of priorities among the states and territories requires an individualized approach that allows 

each state to systematically identify and report its 

current status and efforts relative to: racial and ethnic 

health disparities; financial resources and revenue 

streams; organizational infrastructure; and technical 

assistance requirements. The challenge to improve 

minority health and eliminate health disparities relies 

on the commitment of state and territorial health 

departments to continuously improve health status and 

find innovative ways to monitor and tackle complicated 

problems with limited resources and staff. 

Figure 2. NPA Multi-Level Partnerships 

and Implementation Structure

 

Background on State and Territorial 

Minority Health Entities’ Relationship 

with the OMH

The need for reporting on state-level initiatives focused 

on health disparities, health equity, and minority health 

is based on the persistent prevalence of disparities 

and on the OMH’s priority for enhanced access to contextualized data and information on health disparities 

and health equity that are embedded in state initiatives. State data and information substantiate the existence of longstanding disparities in health and health 

care, which continue to pose significant public health 

risks. Such health disparities are evident throughout 

the nation and continue to disproportionately burden 

minority, vulnerable, and other at-risk subpopulation 

groups. As documented by the Institute of Medicine,11

poor health outcomes for African Americans, Hispanic 

Americans, American Indians and Alaska Natives, Asian 

Americans, Native Hawaiians, and Pacific Islanders 

are apparent when comparing their health indicators 

against those of the rest of the U.S. population. These 

populations experience higher rates of illness and 

death from many health conditions, such as heart 

disease, stroke, specific cancers, diabetes, HIV/AIDS, 

asthma, hepatitis B, and obesity. Such disparities 

in health outcomes merit systemic approaches that 

have the potential for achieving viable and substantive 

improvements. This Health Disparities Report is one of 

many OMH-initiated collaborations with state and territorial minority health entities promoting health equity, 

which play a pivotal role in promoting health equity 

and reducing the physical and financial costs of health 

disparities. Through this project, the OMH and these 

minority health entities collaborated to obtain data that 

ultimately will help inform the OMH policy and program 

investments. The diversity of state and territorial priorities and contexts are reflected in the profiles. From the 

onset, the OMH recognized the need to tailor its data 

collection approach to allow each state and territory to 

identify its unique challenges, specific racial and ethnic 

health disparities, financial resources, and organizational infrastructure. 

11 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health 

Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Communities in Action: Pathways to 

Health Equity. Weinsten JN, Geller A, Negussie Y, and Baciu A (editors). Washington (DC): National Academies Press (US); 2017.

State and Territorial Efforts to Reduce Health Disparities 4
Part I: Executive Summary 

The State and Territorial Efforts to Reduce Health 

Disparities Report (hereafter referred to as the Health 

Disparities Report) was developed in alignment with 

HHS priorities, the Office of Minority Health’s mission, 

and strategic priorities, including the NPA. This report 

provides a snapshot of each state and territory’s infrastructure around health equity, disparities elimination, 

and minority health. It explores, in detail, the specific 

activities and partnerships that establish the health 

equity landscape in each state and territory—including 

available resources, existing partnerships, activities, 

and funding dedicated to promoting health equity. This 

information is synthesized into a narrative description, 

based upon interviews with minority health entities in 

each state/territory. Each profile includes standardized 

quantitative data elements that assess demographics 

and condition prevalence within each state/territory, 

enabling common reference points across all states 

and territories that help with benchmarking efforts. 

Detailed descriptions of the implementation of statewide initiatives to reduce health disparities in the 50 

states, the District of Columbia, and four U.S. territories and/or commonwealths provide a foundation for 

the narrative. 

State approaches employed to address health disparities and promote health equity are grounded in 

scientific evidence that supports the utilization of a 

social determinants framework as a correlate factor in 

successful outcomes. Foundational research has also 

validated innovations considered best practices, which 

take into consideration the socio-environmental contexts in which people are born, live, work, learn, play, 

worship, and age. Through OMH’s partnerships with 

the states and territories and their contributions to this 

report, greater insight is provided regarding the types 

of innovations currently being implemented to promote 

health equity broadly across geopolitical regions. 

The need for identifying on state-level initiatives 

focused on health disparities, health equity, and 

minority health is based on the persistent prevalence 

of disparities, and on OMH’s priority for enhanced 

access to contextualized data and information on 

health disparities and health equity that are embedded 

in state initiatives. As previously stated, a report by 

the National Academies (Institute of Medicine) documents the many health disparities experienced by 

racial and ethnic minority populations. According to the 

2016 AHRQ Health Healthcare Quality and Disparities 

Report,12 while a small portion of measures for disparities may be decreasing for Blacks and Hispanics, most 

disparities have not changed significantly for any racial 

and ethnic group.

This State and Territorial Health Disparities Report 

is one of many OMH-initiated collaborations with state 

and territory minority health entities promoting health 

equity, which play a pivotal role in promoting health 

equity and reducing the physical and financial costs 

of health disparities. States and territories are well 

aware of the impact of disparities on individual and 

population health indices, as well as state and local 

budgetary resources. Indicators such as work and 

school absenteeism, service utilization, prevalence 

of chronic illnesses, preventable deaths, and accelerating health care expenditures are among the types 

of measures that illuminate how excess disease 

burdens affect the lives of people who are at greatest 

risk for poor health. These impacts have far-reaching 

implications for the health and well-being of all Americans. The intent of this effort is to obtain data that 

ultimately will help inform the OMH, and other federal 

state/territorial policy and program investments. The 

diversity of state and territorial priorities and contexts 

are represented by the profiles included in this report. 

The resulting profiles, therefore, reflect considerable 

variability in approaches to reduce health disparities. 

12 2016 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; July 2017. 

Agency of Healthcare Research and Quality (AHRQ) Pub. No. 17-0001.

State and Territorial Efforts to Reduce Health Disparities 5
Part I: Executive Summary

Initiatives identified in this report comprise a range 

of strategies, such as:

• Health In All Policies

• CLAS implementation

• Special population interventions (e.g., increasing 

physical activity, promoting oral health)

• Community engagement in research—-CommunityBased Participatory Research (CBPR)

• Integration of health equity strategies across sectors.

The persistent disparities juxtaposed against the rich 

diversity in state and territorial approaches to address 

them underscore OMH’s understanding of the perpetual 

challenges necessitating state and territorial health 

departmental commitments to continual improvement 

in health status. This population-centered mechanism 

helps to garner innovative ways to tackle complicated 

problems with limited resources and staff. Moreover, 

this invaluable report provides OMH with data and 

information to establish a baseline for the development and implementation of public policies as well as 

benchmarks that can be used to develop health equity 

tools such as a health equity scorecard, or report card, 

at the state level.

State and Territorial Efforts to Reduce Health Disparities 6
Part II. Acknowledgements

OMH launched the State and Territorial Efforts to 

Reduce Health Disparities Report production process 

with assistance from many individuals who graciously 

contributed their time and expertise to this effort. 

In particular, we are indebted to our Technical Expert 

Panel, which helped us and our contractor, Westat, 

to reach consensus on information to include within 

the data collection protocol. This participatory process 

helped to create a tailored instrument that would inform 

OMH’s understanding of the geopolitical contexts in 

which state and territorial health disparities reduction 

and health equity innovations were developed, funded, 

and deployed. 

We thank the State and Territorial Offices of Minority 

Health for their collaboration, contributions, and support for their commitment and generous dedication 

of their time for participating in the interview, providing 

written documentation to supplement information 

shared during the interview, and for reviewing and 

providing input on the final profile.

Similarly, we extend our gratitude to the following individuals for their consultation and input on federal data 

sources to capture relevant contextual information about 

each state and territory’s health equity infrastructure: 

Juanita Chinn (CDC/OPHSS/NCHS), Dianne Rucinski 

(OS/OASH), and Minh Wendt (OS/OASH).

Special thanks to the leadership of the Westat project 

team: Brenda Leath, Project Director; Jennifer Nooney, 

Project Manager; Sari Siegel, Report Task Lead; 

Stephanie Fry, Survey Task Lead; and Cal Pierce, Editor.

Finally, we want to recognize the individuals who 

directly contributed to the production of the Health 

Disparities Report: Carol Jimenez, JD, Deputy Director; 

Alexis D. Bakos, PhD, MPH, RN, Senior Advisor to the 

Deputy Assistant Secretary; Christine Montgomery, 

Senior Management and Program Analyst; and 

Stacey L. Williams, Regional Operations Officer, 

Division of Program Operations, Office of Minority 

Health (Contracting Officer’s Representative).

State and Territorial Efforts to Reduce Health Disparities 7
Part II. Acknowledgements

Technical Expert Panel Members

Dedra S. Buchwald, MD

University of Washington

Center for Native Population Health Disparities

325 9th Avenue #359780

Seattle, WA 98104 

Jeffrey Caballero

Executive Director

Association of Asian Pacific Community Health 

Organization

300 Frank H Ogawa Plaza

Oakland, CA 94612 

Dorothy Castille, PhD 

Health Scientist Administrator

National Institute on Minority Health & Disparities

6707 Democracy Boulevard, Suite 800

Bethesda, MD 20892 

Kimberly T. Fowler, PhD

Director of Technical Assistance and Research 

National Council of Urban Indian Health

924 Pennsylvania Avenue SE

Washington, DC 20003 

Karyne Jones

President & CEO

National Caucus and Center on Black Aging, Inc.

1220 L Street NW, Suite 800

Washington, DC 20005 

Craig A. Kennedy, MPH

Executive Director

Association of Clinicians for the Underserved

1420 Spring Hill Road, Suite 600

McLean, VA 22102 

Vivian Lasley-Bibbs, MPH

Region IV Board Member

National Association of State OMH - 

Office of Health Equity

Kentucky Department for Public Health 

275 E Main Street 

Frankfort, KY 40601

Monica Valdes Lupi, JD, MPH

CPO, Health Systems Transformation 

Association of State and Territorial Health Officials

2231 Crystal Drive, Suite 450

Arlington, VA 22202 

Alan Morgan

Chief Executive Officer

National Rural Health Association

1025 Vermont Avenue NW, Suite 1100

Washington, DC 20005 

Elena Rios, MD, MSPH

President & CEO

National Hispanic Medical Association

1920 L Street NW #725

Washington, DC 20036 

Lawrence Sanders

President

National Medical Association

8403 Colesville Road - Suite 820 

Silver Spring, MD 20910 

State and Territorial Efforts to Reduce Health Disparities 8
Part II. Acknowledgements

Participating States and Territories

1. Alabama 

2. Alaska 

3. American Samoa

4. Arizona 

5. Arkansas 

6. California 

7. Colorado 

8. Connecticut 

9. Delaware 

10. District of Columbia 

11. Florida 

12. Georgia 

13. Guam 

14. Hawaii 

15. Idaho 

16. Illinois 

17. Indiana 

18. Iowa

19. Kansas 

20. Kentucky 

21. Louisiana 

22. Maine 

23. Maryland 

24. Massachusetts 

25. Michigan 

26. Minnesota 

27. Mississippi 

28. Missouri 

29. Montana 

30. Nebraska 

31. Nevada 

32. New Hampshire 

33. New Jersey 

34. New Mexico 

35. New York 

36. North Carolina 

37. North Dakota 

38. Northern Mariana Islands

39. Ohio 

40. Oklahoma 

41. Oregon 

42. Pennsylvania 

43. Puerto Rico 

44. Rhode Island 

45. South Carolina 

46. South Dakota 

47. Tennessee 

48. Texas 

49. United States Virgin Islands 

50. Utah 

51. Vermont 

52. Virginia 

53. Washington 

54. West Virginia 

55. Wisconsin 

56. Wyoming 

Data Group Members

Alexis Bakos, PhD

Senior Advisor to the Director

Office of Minority Health

Juanita Chinn, PhD

Senior Service Fellow

National Center for Health Statistics

Centers for Disease Control and Prevention

Dianne Rucinski

Evaluation Officer

Division of Policy and Data

Office of Minority Health

Minh Wendt, PhD

Data Policy Lead

Division of Policy and Data

Office of Minority Health

State and Territorial Efforts to Reduce Health Disparities 9
Part III: Introduction & Background

The National Institutes of Health defines health 

disparities as “differences that exist among specific 

population groups in the United States in the attainment of full health potential that can be measured by 

differences in incidence, prevalence, mortality, burden 

of disease, and other adverse health conditions.”13

Disparities are often used within the context of two 

social constructs—race and ethnicity; however, they 

can also occur within the contexts of gender, sexual 

orientation, age, disability status, socioeconomic 

status, and geographic location.14 According to Healthy 

People 2020, all of these factors, in addition to race 

and ethnicity, shape an individual’s ability to achieve 

optimal health.15

The landmark 1985 report released by the United 

States Department of Health and Human Services 

(HHS), “The Secretary’s Task Force Report on Black 

and Minority Health” (Heckler Report), offered a stark 

and compelling account of the prevalence of health 

disparities among racial and ethnic minorities in the 

United States. This defining work led to the elevation 

of minority health to national priority status and the 

creation of the Office of Minority Health (OMH). 

Thirty-three years after the Heckler Report focused 

a national spotlight on the topic of disparities, health 

equity continues to be a pervasive national problem. 

Given the current population trends and trajectories, in 

which minority populations are an increasing proportion 

of the nation’s residents, the persistence of disparities 

has never had more serious implications. The growth 

of those populations experiencing poorer outcomes 

poses significant risks to the health of all Americans—

and the proportion of public dollars spent on improving 

health outcomes.

OMH seeks to improve the health of racial and ethnic 

minority populations through policy and program 

development that work to eliminate health disparities. 

Recognizing that categorical type and causation of disparities vary significantly across the country and that 

states have substantial responsibility for addressing 

population health, OMH has explicitly targeted states 

as an increasingly powerful vehicle in the journey 

to achieve health equity. OMH provided support for 

building capacity and infrastructure of state offices 

of minority health through planning contracts in the 

1990s. The State Partnership Grant Program and other 

demonstration grant programs have also served as 

mechanisms through which support has been provided. 

Some states continue to receive support from this 

program, and OMH works closely on an ongoing basis 

with all state and territorial offices of minority health 

to implement federal initiatives to improve minority 

health and eliminate health disparities.

The State and Territorial Efforts to Reduce Health 

Disparities Report (hereafter the Health Disparities 

Report) was developed in alignment with HHS 

priorities, the OMH mission, and strategic priorities. 

This was accomplished through detailed descriptions 

of the implementation of statewide initiatives and 

programs to reduce health disparities in the 50 states, 

the District of Columbia, and U.S. territories and/

or commonwealths. State solutions used to address 

health disparities and health equity are grounded in 

scientific evidence on the significance of using a social 

determinants framework. Foundational research has 

also validated innovations that are considered best 

practices, which take into consideration the contexts 

in which people are born, live, work, learn, play, worship, and age. Through the contributions to this report 

provided by representatives of the state and territorial 

minority health entities, we gain insights into the contexts and innovations that are being implemented to 

promote health equity broadly across regions. 

13 NIH, National Heart, Lung, and Blood Institute. Health disparities. http://www.nhlbi.nih.gov/health/educational/healthdisp. 

Reviewed April 2017.

14 National Academies of Sciences, Engineering, and Medicine; Ibid.

15 Healthy People 2020. Available at: https://www.healthypeople.gov. Accessed October 21, 2016.

State and Territorial Efforts to Reduce Health Disparities 10
Part III: Introduction & Background

The need for reporting on state level initiatives focused 

on health disparities, health equity, and minority health 

is based on the persistent prevalence of disparities 

that varies by region. Health care disparities continue 

to pose significant public health risks. As discussed 

in an Institute of Medicine report, differential health 

outcomes exist across and within all of the identified 

population subgroups.16 Further, scientific literature 

informs us of the etiology of health disparities, which 

can stem from health inequities—systematic differences in the health of groups and communities occupying unequal positions in society.17,18 Persistent health 

disparities across the nation continue to disproportionately burden minority, vulnerable, and other at-risk subpopulation groups. Poor health outcomes for African 

Americans, Hispanic Americans, American Indians and 

Alaska Natives, Asian Americans, Native Hawaiians, 

and Pacific Islanders are apparent when comparing 

their health indicators against those of the rest of the 

U.S. population. These populations experience higher 

rates of illness and death from health conditions such 

as heart disease, stroke, specific cancers, diabetes, 

HIV/AIDS, asthma, hepatitis B, and overweight and 

obesity. OMH’s primary responsibility is to improve 

health and health care outcomes for racial and ethnic 

minority communities by developing or advancing 

policies, programs, and practices that address health, 

social, economic, environmental and other factors that 

impact health.

Recognizing that state and territorial minority health 

entities play a pivotal role in promoting health equity 

and reducing the physical and financial costs of health 

disparities, OMH partnered with these entities to 

obtain local, contextualized data that ultimately will 

help inform OMH policy and program investments. 

The diversity of state and territorial priorities and contexts are represented by the profiles. From the onset, 

OMH recognized the need to tailor its data collection 

approach to allow each state to identify its unique 

challenges, specific racial and ethnic health disparities, 

financial resources, and organizational infrastructure. 

Reports from the states, not surprisingly, varied considerably in their approaches to reduce health disparities 

and promote health equity. 

Goals and Structure of the Health 

Disparities Report

The guiding framework for this report consists of three 

primary goals:

1) Present summary snapshots of infrastructure 

around health disparities reduction, health equity 

promotion, and minority health initiatives for each 

state and territory.

2) Incorporate quantitative data that assess demographics and prevalence for selected health conditions and mortality within each state and territory.

3) Describe available resources, existing partnerships,

activities, and funding dedicated to promoting 

health equity.

While policymakers have access to quantitative data 

sets that provide a configurative snapshot of an 

existing health and socio-demographic landscape, they 

often lack insight about critical situational factors that 

contextualize the data into a cogent and robust picture. 

OMH contracted with Westat to help bridge this contextual gap through the development of individual profiles 

on states and territories that synthesize existing data 

with the perspective of each minority health entity, 

thereby creating a more nuanced representation 

of the sub-federal health equity landscape.

This report is intended to provide a picture of each 

state and territory’s infrastructure around health equity, 

disparities elimination, and minority health. It explores, 

in detail, the specific activities and partnerships that 

establish the health equity landscape in each state 

and territory—including available resources, existing 

partnerships, activities, and funding dedicated to 

promoting health equity. This information is synthesized 

into a narrative description, based upon interviews with 

minority health entities in each state and territory. Each 

profile includes standardized quantitative data elements 

that assess demographics and disease/condition prevalence within each state and territory.

The first part of the State and Territorial Efforts to 

Reduce Health Disparities Report provides an overview 

of the report and its purpose. It also explores the role 

16 National Academies of Sciences, Engineering, and Medicine, Ibid.

17 Graham H. Social determinants and their unequal distribution: Clarifying policy understandings. Milbank Q. 2004;82(1):101-124.

18 Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National 

Academies Press. Available at: https://doi.org/10.17226/10260.

State and Territorial Efforts to Reduce Health Disparities 11
Part III: Introduction & Background

and significance of OMH’s partnership with states 

and territories, describes the role of key stakeholders 

in developing the data collection instrument and the 

methods used for data collection and reporting. 

The second section of the report presents profiles 

of each state and territory, which reflect a brief snapshot of findings for each state and territory. Each profile includes descriptions of the minority health entity 

(i.e., organizational structure and distribution of responsibility), program goals and activities (i.e., planning 

activities, documents, and health equity priorities and 

strategies), partnerships, staffing, and funding details. 

Each profile also includes standardized quantitative 

data to assess demographics and condition prevalence 

within each state and territory, enabling common reference points across all states and territories that help 

with benchmarking efforts. 

Methodology 

Recognizing that state and territorial minority health 

entities are critical partners to federal policymakers 

working towards a goal of zero health disparities, OMH 

and state/territorial minority health entities are dedicated to the use of partnerships to effectively and 

efficiently utilize limited resources and create systems 

change through the inclusion of all stakeholders to 

ultimately eliminate health disparities.

Earlier Association of State and Territorial Health 

Officials (ASTHO) surveys of state offices of minority 

health relied upon static instruments completed on 

paper or via the Internet. As the need for evolving 

landscape necessitated collection of more nuanced 

information grew, OMH transitioned to a more robust 

and “high-touch” data collection mechanism for this 

report and contracted with Westat and OMH to create 

a semi-structured telephone interview protocol that 

allowed researchers to delve into details and assess 

insights about the culture and infrastructure around 

health equity within each state or territory. 

OMH and Westat developed the interview protocol 

in close consultation with a technical advisory panel 

(TEP) established by OMH to provide input both into the 

report elements generally and on the survey collection 

protocol in particular. Comprised of key stakeholders, 

thought leaders, subject matter experts, and OMH partners (see Acknowledgments section for the full roster), 

the TEP met in December 2015, and its recommendations addressing appropriate categories, question 

sequencing, and specific language were incorporated 

into the final protocol. The major protocol sections 

include: organizational structure of each minority health 

entity, programmatic goals and activities, partnerships 

to advance health equity, existing human resources/

staffing within the minority health entity, and dedicated funding.

The protocol was then submitted to the U.S. Office of 

Management and Budget (OMB) and Westat’s Institutional Review Board (IRB). Upon obtaining both OMB19

and IRB20 approval to proceed, the team used the 

protocol to conduct seven pilot interviews with leaders 

within those state and territorial minority health 

entities. Westat synthesized the information gathered 

from each interview into a draft profile, submitted the 

seven pilot profile drafts for OMH’s review, and revised 

per OMH feedback. Using this information, Westat 

also finalized the profile structure and created a final 

profile template. 

During the pilot window, Westat also worked closely 

with OMH to identify and confirm the specific quantitative data points that appear within the profile’s data 

table. OMH confirmed both the variables and the specific data sources for each, and Westat amassed said 

data for each of the 56 profiles. Westat team members 

populated this information into a data table for each 

state and territory that would appear on the final page 

of the profile. Data sources for the tables include 

the following:

• American Community Survey Public Use Microdata, 

2016 (for total state population)

• Health Resources and Services Administration’s 

Designated Health Professional Shortage Area Statistics, 2018 (for primary care health professional 

shortage area population)

• Centers for Disease Control and Prevention’s (CDC) 

Wonder Online Database for vital statistics (infant 

mortality rate is the number of deaths per 1,000 

births in 2015; age-adjusted mortality rate is the 

number of deaths per 100,000 population in 2016)

19 OMB approval issued December 9, 2015 under OMB control number 0990-0441, expiration date: December 31, 2018.

20 Westat IRB approval issued April 21, 2017.

State and Territorial Efforts to Reduce Health Disparities 12
Part III: Introduction & Background

• CDC’s National Center for HIV/AIDS, Viral Hepatitis, 

STD, and TB Prevention (NCHHSTP) Atlas, 2015 

(for HIV prevalence rates)

• Behavioral Risk Factor Surveillance System, 2016 

(for prevalence of selected chronic diseases and 

preventive services). 

The Westat team then divided the 56 states and 

territories included in this report into sequential waves 

to ensure that the interviewers could focus upon one 

state or territory at a time, enabling them to compose 

language for the profile immediately upon completing 

each interview. This phased approach minimized the 

time between the initial interview and the final profile submission. The full team of Westat interviewers 

then began the data collection phase of the project by 

conducting semi-structured telephone interviews with 

contacts, provided by the Health Officials, at each state 

and territorial health entity. Interviewers drafted profile 

language and, as needed, coordinated subsequent contact with interviewees to obtain additional information 

clarifying questions raised during Westat’s internal fact 

checking and review process. Westat’s project leadership then revised the profiles and submitted them, in 

batches, to OMH. After Westat addressed any subsequent OMH questions or edits, the profile was shared 

with each state or territorial minority health entity for 

review. This final step provided an opportunity for each 

state or territory to clarify any inaccuracies or include 

pertinent updates to the narrative. OMH and Westat 

addressed any comments raised during the state/

territory review process, and Westat populated the final 

text into the template for each profile and produced the 

final report. It is important to note that each profile is 

intended to be a snapshot of the state/territory at the 

time of the interview with Westat team. Special notes 

are provided in the profiles of those jurisdictions that 

have undergone significant organizational changes 

since the survey interview was conducted.

Summary of Findings

In assessing the aggregated set of 56 state and territorial profiles, several themes emerge. This section 

provides a summary of findings from the aggregated 

set of profiles.

Minority health overview

An analysis of data included in the minority health overview sections indicate that, for example, 23 states and 

territories have in place a strategic plan specifically 

addressing minority health or health equity. Nearly all 

of these plans are publicly available. Among those that 

do not, 22 include health disparities or health equity 

goals within their state department of health strategic 

planning processes. Of the 45 states and territories 

with either a stand-alone or an integrated strategic plan 

addressing health equity issues, 12 updated the plan 

in or after 2016. 

Organizational structure and staffing

Minority health entities operate within the state or territorial departments of health. In most cases, an agency 

within the department is explicitly identified as the 

minority health entity, although some profiles indicate 

that the responsibilities of such an entity are spread 

across the entire department. 

Across all 56 states and territories, 216 full-time 

staff members work exclusively on health equity and 

minority health issues, with an average of 5 staff for 

each state or territory with any full-time staff (although 

10 states/territories reported having only 1 full-time 

staff member assigned to these issues). Another 11 

full-time individuals (from Texas and Louisiana) work 

at least 50 percent on health equity, disparities, or 

minority health topics. Six states and territories report 

that at least some of the department-level staff work 

on minority health and seven identified vacancies within 

its minority health entity at the time of the interview.

An official advisory body helps 33 states and territories 

set its priorities. In some cases, minority health-related 

priorities are also determined through other mechanisms, such as executive and legislative mandates 

(e.g., Florida).

State and Territorial Efforts to Reduce Health Disparities 13
Part III: Introduction & Background

Program goals and activities 

Among the most common program goals and activities 

are measure development and data collection/analysis 

(California). Common programs or activities are highlighted in Table 1, below. 

Table 1. Examples of State and Territorial Programs 

and Activities

Type of State Program or Activity

Number of States 

and/or Territories

“State Partnership Initiative to 

Address Health Disparities” 33

Cancer Screening 20

Mental Health and/or Substance 

Abuse 17

Health in All Policies 8

HIV Prevention or Treatment 

in Minority Communities 9

Oral Health Issues 5

Eliminating the Health Disparities 

Initiative 2

Suicide Prevention 2

Community-Based Participatory 

Research 2

Other activities include Medicaid expansion efforts, 

immunization programs, chronic disease management 

efforts targeting particular health issues (e.g., Florida’s 

diabetes self-management program for African and 

Hispanic communities). Some states and territories 

leverage multimedia educational efforts as well 

(e.g., Kansas’s video on social determinants of health).

Many states and territories address disparity reduction 

and equity among particular populations, such as children (18 states/territories). Of those efforts, common 

themes are prenatal and infant care (Alaska, Arkansas, 

Guam, Puerto Rico), dental screenings (Massachusetts 

and Missouri), and efforts targeting specific communities (e.g., Minnesota’s work on preventing violence 

against Asian children and women). Other populationbased initiatives address refugee health screening and 

services (13 states) or support the homeless (Maryland and Puerto Rico). Some states focus efforts on 

particularly vulnerable populations, like young children among the refugee community through “Friends 

of Refugees Mommy and Me” programming (Georgia) 

and efforts to reduce disparities among homeless 

youth (Maryland).

Partnerships

All 56 profiles reflect partnerships to improve minority 

health, health disparities, and health equity between 

public and nonpublic organizations (e.g., between the 

department of health and either universities, community-based organizations, or disease- or condition-specific nonprofit organizations) and/or collaborations 

between various public agencies (e.g., departments of 

health, education, justice, environment). Relative to the 

policy arena, several profiles highlight key partnerships 

involving state legislatures (8). States and territories 

partner frequently with universities (34), often to provide volunteer staffing for minority health entity offices 

or initiatives. In 11 states, minority health entities 

work together with faith-based organizations. In states 

or territories with a predominant minority population, 

partnerships often develop with agencies or organizations focused upon those specific groups. For example, 

given that 229 federally-recognized tribal entities call 

Alaska home, its health department meets biannually 

with the Alaska Native Health Board to discuss policy 

issues, set common priorities, and identify opportunities for collaboration. Nearly all states and territories 

(49) report having some contracts, memoranda of 

understanding, or similar formal structures (e.g., interagency agreements).

Funding 

Sources of funding for minority health entities vary. 

Most receive funds authorized by the legislature of the 

state or territory itself and some also receive federal 

dollars (e.g., from OMH, the Centers for Medicare and 

Medicaid Services, or CDC). Some also receive support from foundations (e.g., Kaiser Family Foundation, 

California Healthcare Foundation). For the 47 state and 

territorial profiles for which we have funding data, the 

federal government is the largest funding source for 

16 (34%), while the state/territory itself is the largest 

funding source for 31 (66%).

State and Territorial Efforts to Reduce Health Disparities 14
Part III: Introduction & Background

Conclusions

Despite having limited resources, this study found 

that states and territories are pursuing a wide array 

of activities to achieve health equity by tailoring efforts 

to their individual contexts (e.g., resource availability, 

demographics, and health disparity challenges). Overall, 

findings reflect rich programs and activities within most 

states and territories, examples of which include:

• The availability of strategic plans, some of which 

are in the public domain

• Established goals and objectives that address 

health disparities and/or health equity

• A separate minority health entity or minority 

health responsibilities are integrated within 

a state department

• An official advisory body

• Population-based disparity reduction 

and equity initiatives

• A vast array of diverse partnerships

• Funding authorized by state legislatures.

The breadth of initiatives speaks to the range 

of existing health disparities and the commitment 

of stakeholders to innovatively join efforts to improve 

minority health. As such, this research illustrates the 

profound effect that public-private partnerships can 

have on improving health and health care for all.

Legislative activity. An important partner for several 

states has been its own legislative body. In 2016, 

the National Conference of State Legislatures reports 

that 8 states enacted 11 measures addressing health 

disparities, equity, and minority health issues. For 

example, California and Hawaii adopted resolutions 

urging their state departments of health to endorse 

the “Screen at 23” campaign to screen all adult Asian 

Americans with a body mass index of 23 or more for 

type 2 diabetes as an effort to eliminate diabetes disparities. Minnesota, meanwhile, created a program that 

establishes a “good food access program” to increase 

the availability of and access to affordable, nutritious, 

and culturally appropriate food, including fresh fruits 

and vegetables, for underserved communities. Additionally, three measures remain pending in the New 

Jersey legislature, including one that establishes 

a commission on “Disparity in Treatment of Persons 

with Disabilities in Underrepresented Communities.”

Laying a future research agenda. This report lays 

critical groundwork to monitor progress by states 

and territories in their efforts to achieve health equity. 

These 56 profiles establish a benchmark against 

which we can assess future efforts, tracking progress 

as well as challenges and strategies to overcome 

them. Moving forward, biannual updates that include 

dashboards and additional indicators would provide an 

even more robust picture of each state’s and territory’s 

minority health landscape. 

Recommendations

Based on the state and territorial profiles, Westat has 

identified several key opportunities to expand upon the 

investment and foundation created by this contract. 

For example, one limitation of this work is that its 

focus is the individual state or territory without consideration of the broader regional efforts and implications 

of minority health initiatives. For this reason, expanded 

qualitative data collection efforts (i.e., augmenting the 

individual state/territorial surveys with regional focus 

groups of minority health entity staff) would provide 

a deeper vision of how the states and territories work 

together to address area-wide health equity issues. 

Other opportunities involve delving deeper into the data 

set developed for this report. Westat has developed 

a database of the 56 profiles, which can be leveraged 

to produce research briefs on such topics as statewide 

disparity-reducing policies, successful condition-specific 

efforts, replicable partnerships, and funding characteristics. Westat recommends, for example, that the 

OMH produce a series of dashboards and briefs on 

particular health conditions targeted by state/territoryidentified initiatives for which disparities are significant 

and/or growing. Examples might include state/territory 

efforts to reduce disparities in opioid use, infant mortality, diabetes, or HIV.

Researchers could also mine the database Westat 

amassed through this project to conduct a partnership analysis and inventory, documenting the types of 

organizations that states and territories have partnered 

with, how those partnerships have evolved over time 

to advance health equity goals, and what options other 

states or territories may have to create similar partnerships within their own borders. This analysis could 

highlight the complementary roles academic partners, 

state agencies outside of the minority health entity, 

and community-based organizations play in the health 

equity landscape—providing insights for states and territories interested in expanding existing partnerships.

State and Territorial Efforts to Reduce Health Disparities 15
Part III: Introduction & Background

Additionally, researchers could expand upon the data 

collected for this report to explore in more detail how 

states and territories operationalize and measure 

success of policy efforts (e.g., Medicaid expansions, 

Health in All Policies, or the “Eliminating Health Disparities Initiative”). Such an analysis could identify successful strategies states and territories could employ 

to further advance health equity. Other analyses could 

explore outcome variables such as high versus low 

funding streams, documenting activities of states and 

territories that have successfully secured foundation 

or federal dollars for disparity reduction that may 

be replicated.

State and Territorial Efforts to Reduce Health Disparities 16
Alabama

Introduction to Alabama’s Health Equity Activities

Alabama had an estimated 2016 population of 4,863,000. Blacks/African Americans are the largest racial-ethnic 

minority population (27 percent), followed by Hispanics/Latinos (4 percent) and Asian Americans and NHOPI 

(less than 1 percent). Persons self-identifying as multiracial or “other race” comprise 3 percent of the population.1 

Approximately 1,919,000 Alabama residents live within a primary care health professional shortage area.2

Minority health activities in the Alabama Department of Public Health (ADPH) are housed within the Nutrition and 

Physical Activity (NPA) Division of the Bureau of Health Promotion and Chronic Disease. Between 1991 and 2013, 

the ADPH included a standalone Office of Minority Health. That entity was discontinued in 2013; minority health 

activities resumed in 2015, when the ADPH received funding through a State Partnership Initiative to Address 

Health Disparities (SPI) grant from the U.S. Office of Minority Health. Minority health work under the 5-year grant 

functions as a program within the NPA Division. The goal of the SPI grant project is to “implement strategies that 

will aid in positive behavior change to address risk factors that can be controlled through behavior.” Grant activities 

focus on nutrition, physical activity, and access to health care services among minority populations in four 

geographic “hot spots” around the state.3

Alabama Minority Health Overview

Name of state/

territorial minority 

health entity

The former OMH was discontinued 

in 2013 and presently no 

standalone entity exists. The 

Nutrition and Physical Activity 

Division coordinates minority 

health activities.

Strategic plan in 

place to address 

minority health 

or health equity

No strategic plan has been 

developed since minority health 

activities resumed in 2015.

Date strategic plan 

was last updated N/A 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Not yet developed.

Key strategies 

used to achieve 

health equity

• Promoting physical activity

• Promoting healthy vending 

machines

• Improving access to health care 

services 

• Expanding Scale Back Alabama, 

a statewide weight loss program

Organizational Structure

Minority health activities stem from the SPI grant 

awarded in August 2015, which the NPA Division 

implements and coordinates. Additionally, the Governor’s Office of Minority Affairs was established in 

March 2016 by executive order. The former minority 

health program director participates in its work, 

advising the governor on minority health issues. 

That position was vacant at the time of the data 

collection for this report. 

The NPA Division has three staff members and one 

vacant program director position; none are dedicated 

full time to minority health and health equity initiatives. 

These include one program nutritionist (0.5 FTE), one 

wellness specialist and nutritionist (0.3 FTE), and the 

NPA Division Director (0.1 FTE). Community volunteers 

and University of Alabama interns help with some local 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 U.S. Department of Health and Human Services Office of Minority 

Health. Grant Program: State Partnership Initiative to Address 

Health Disparities

State and Territorial Efforts to Reduce Health Disparities 17
Alabama

programs. Additionally, each grant hot spot has a 

health coalition whose members help with recruitment 

and outreach. NPA’s program director position, which 

dedicates 50 percent time to minority health initiatives, 

is funded through the SPI grant. Other than filling the 

vacancy, no staffing changes are anticipated.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

Minority health 

activities are 

housed in the 

Nutrition and 

Physical Activity 

Division within 

the Alabama 

Department of 

Public Health, 

Bureau of Health 

Promotion and 

Chronic Disease

SMHE staffing (full-time equivalents) 4

Advisory committee or panel None

Program Goals and Activities

No strategic plan has been developed since minority 

health activities resumed with SPI grant funding in 

2015. Minority health work in the NPA Division 

focuses largely on the grant objectives. The ADPH 

also integrates minority health work into other funding 

sources and grant activity plans throughout the 

department. At the time of data collection, there were 

no plans to develop a strategic plan specific to minority 

health, health disparities, or health equity. However, the 

SPI grant project identifies several intermediate and 

long-term performance measures for monitoring 

progress during the grant period, all related to nutrition, 

obesity levels, lifestyle changes, and access to health 

care.3 Efforts to plan and conduct evaluations under 

the SPI grant have not been finalized.

ADPH minority health activities stem primarily from 

the SPI grant. The NPA Division coordinates and 

implements grant activities, and works with grant 

partners to set minority health priorities based on 

population need, focusing on areas with larger minority 

populations and higher obesity rates. Outside of the 

SPI grant, the NPA Division also participates in events 

with the University of Alabama and other entities to 

increase awareness of health disparities and health 

equity issues. 

Acronym List

Full Name of Agency Acronym Acronym

Alabama Department of Public Health ADPH

Nutrition and Physical Activity Division NPA Division

Alabama State Partnership Initiative 

to Assess Health Disparities grant SPI grant

The SPI grant designates four hot spots that have high 

obesity rates, low levels of physical activity, and limited 

access to health care. These areas have significant 

minority populations and include the cities of Demopolis, Greensboro, Livingston, and Marion. As part of 

SPI grant activities, the NPA Division strives to do the 

following in each of the hot spots (described in further 

detail below):

• Increase physical activity opportunities.

• Increase healthy nutrition options.

• Increase access to health care services.

• Expand the reach of the Scale Back Alabama weight 

loss program.

Seeking to increase the variety of physical activity 

opportunities available in the hot spot areas, the NPA 

Division determined that many community members 

were willing to start Zumba classes. As a result, the 

SPI grant is funding Zumba classes in the hot spots, 

as well as training opportunities to become Zumba 

instructors in those communities. 

The NPA Division also is working to get vending entities 

in the hot spots to offer healthier vending machine 

options in settings such as schools and hospitals. 

The NPA Division is especially seeking to increase 

access to healthy vending machine options in Tuscaloosa, which has a large Hispanic population.

The NPA Division also coordinates several SPI grant 

activities that aim to increase access to health care 

services within the hot spot areas. Each hot spot has 

a resource person who facilitates application for health 

insurance and promotes awareness of health facilities 

and services. A resource guide and mobile phone app 

were developed to assist in sharing such information. 

Seeking to expand the health care workforce, the NPA 

Division partners with the West Central Alabama Area 

State and Territorial Efforts to Reduce Health Disparities 18
Alabama

Health Education Center to encourage individuals 

to consider careers in health care within their 

local communities.

Finally, as part of the SPI grant, the statewide weight 

loss program, Scale Back Alabama, has created sites 

in each hot spot area where citizens can participate 

in the program, receive blood pressure monitoring and 

other health care services, and learn about healthier 

eating and exercise.

Partnerships

Primary 

collaborators

• West Central Alabama Area Health 

Education Center

• Alabama Cooperative Extension 

Services

• University of Alabama

• County health departments

• State Obesity Task Force

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda 

of understanding are implemented 

for some partnerships.

The NPA Division partners with governmental and 

nongovernmental organizations as part of the SPI 

grant to work toward eliminating health disparities and 

advancing health equity in Alabama. For example, the 

West Central Alabama Area Health Education Center 

serves several low-income counties with large minority 

populations and has a formal contract to assist with 

grant activities. The center focuses on increasing 

physical activity opportunities, promoting healthier food 

options, and increasing access to health care in the 

hot spots. 

The Alabama Cooperative Extension System assists 

with grant hot spot initiatives through an informal 

partnership. Through its strong connections within 

communities, the extension system works to 

implement Scale Back Alabama and promote healthier 

vending machine options.

The University of Alabama is located near one of the 

hot spots with a large Hispanic population. Through 

an informal partnership, the university allows the NPA 

Division to use campus facilities for meetings with 

health educators in the Hispanic community who assist 

with initiatives to increase physical activity, nutritious 

food choices, and access to health care. The NPA 

Division provides campus presentations to increase 

student awareness of health disparities and health 

equity issues.

The NPA Division partners with county health 

departments in the SPI grant hot spots to connect the 

program to community populations. The departments 

provide space for grant activities such as community 

forums and health meetings, and help disseminate 

information about Scale Back Alabama and physical 

activity opportunities. The formal contracts with county 

health departments are at the state level through 

the ADPH. 

Finally, the NPA Division partners with the State Obesity 

Task Force by sharing resources that are disseminated 

in the hot spots. Several NPA Division staff are 

members of the task force, and the NPA Division and 

the task force share information on a regular basis.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$200,000 (awarded 

annually beginning 

in August 2015)

Annual budget (FY 2015) of SMHE 

from state/territorial government $0

Largest funding source Federal government

Anticipated changes to budget None

The total FY 2015 funding for the minority health 

program was $200,000. The $200,000 is awarded 

annually as part of the 5-year U.S. Office of Minority 

Health State Partnership Initiative to Address Health 

Disparities (SPI) grant. The ADPH contracted with the 

West Central Alabama Area Health Education Center in 

2015, awarding the center a $30,000 subgrant to help 

carry out SPI grant strategies.

The minority health program did not anticipate any 

funding changes.

State and Territorial Efforts to Reduce Health Disparities 19
Alabama

Alabama State Data

Total Populationa: 

4,863,300

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 4.1 95.9 68.1 26.9 0.5 1.3 3.2 100.0 NA 

Percent of population 

medically uninsureda 27.2 9.0 8.2 12.2 17.3 11.9 18.9 9.7 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 8.6 5.7 14.3 SP SP NC 8.3 5.9

Age-adjusted 

mortality rateb 282.7 931 907.0 988.5 278.5 421.9 NC 920.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.4 15.0 14.4 16.7 19.3 10.3 14.1 15.0 13.6

Percent with 

diabetesc 7.5 14.9 13.9 17.1 17.4 2.9 11.6 14.6 10.8

Percent with 

heart diseasec 2.2 6.3 7.2 3.7 9.2 0.0 2.1 6.2 4.3

HIV rated 267.7 NC 123.1 747.4 21.3 58.9** 1317.5 302.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

56.2 73.9 71.5 79.8 69.1 59.3 61.3 73.2 72.2

Percent received 

oral health visit 

(past 12 months)c

63.7 62.6 64.2 58.1 60.6 72.9 60.0 62.6 66.5

Percent received 

flu vaccinec 31.6 36.9 39.4 31.7 30.0 32.1 24.1 36.9 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 58.9 per 100,000 population (32 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 270.1 per 

100,000 population (5 cases).

State and Territorial Efforts to Reduce Health Disparities 20
Alaska

Introduction to Alaska’s Health Equity Activities

Alaska had an estimated 2016 population of 742,000. American Indians/Alaska Natives (16 percent) are the 

largest racial-ethnic minority population, followed by Asian Americans and NHOPI (7 percent), Hispanics/Latinos 

(7 percent), and Blacks/African Americans (3 percent). Persons self-identifying as multiracial or “other race” 

comprise 9 percent of the population.1 Approximately 117,000 Alaska residents live within a primary care health 

professional shortage area.2

While minority health and health equity are not the exclusive focus of any one state entity, the Division of Public 

Health (DPH) within Alaska’s Department of Health and Social Services (DHSS) addresses health disparities and 

the health of minority populations. Indeed, among the DPH’s core values is health equity, which it defines as 

“ensuring all Alaskans have full and equal access to opportunities to lead healthy lives.” Disparity reduction also 

falls into the DPH’s broader mission, which is to “protect and promote the health of Alaskans.”3

Alaska Minority Health Overview

Name of state/

territorial minority 

health entity

N/A

Strategic plan in 

place to address 

minority health 

or health equity

Although there is no explicit 

strategic plan specifically 

addressing minority health or 

health equity, the Alaska Division 

of Public Health Strategic Plan, 

2016 – 2020 and the State 

Health Improvement Plan, Healthy 

Alaskans 2020, both address 

these issues.

Date strategic plan 

was last updated 2016

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The State Health Improvement 

Plan, Healthy Alaskans 2020, 

includes 25 leading health 

indicators for measuring progress 

toward health objectives.

Key strategies 

used to achieve 

health equity

• A key strategy from the Alaska 

Division of Public Health 

Strategic Plan 2016 – 2020 is 

to “collaborate to achieve health 

equity for Alaskans.”

• The Alaska Division of Public 

Health is working to reform 

and expand Medicaid.

Organizational Structure

The DPH operates within the DHSS, Alaska’s primary 

public health entity, and collaborates with partners 

throughout Alaska. Its director, who is also the DPH’s 

chief medical officer, has responsibility for addressing 

minority health, health disparities, and health equity as 

part of the DPH’s mission. Likewise, all DPH staff work 

to fulfill DPH’s goals, including ensuring health equity, 

and DPH activities reflect a commitment to issues 

affecting minority health, health disparities, and health 

equity. That said, no DPH staff work full time exclusively on minority health, health disparities, or health 

equity initiatives. 

No advisory committee or panel has responsibility for 

advising the DPH on minority health, health disparities, 

and health equity. However, various groups informally 

advise the DPH on activities, such as a tribal Medicaid 

advisory group and a resiliency working group. Multiple 

working groups contributed to developing the state 

health improvement plan, Healthy Alaskans 2020. Both 

the Alaska Division of Public Health Strategic Plan, 

2016-2020 and the State Health Improvement Plan, 

Healthy Alaskans 2020, were last updated in 2016.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Alaska Division of Public Health. Alaska Division of Public Health 

Strategic Plan 2016 – 2020. 

State and Territorial Efforts to Reduce Health Disparities 21
Alaska

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

There is no specific 

SMHE. The Alaska 

Division of Public 

Health within the 

Department of 

Social Services 

addresses minority 

health, health 

disparities, and 

health equity.

SMHE staffing (full-time equivalents) 0

Advisory committee or panel None

Program Goals and Activities

The DPH developed the Alaska Division of Public Health 

Strategic Plan 2016 – 2020 (“Strategic Plan”), a publicly 

available document that lists the DPH’s mission, vision, 

value, and goals. It articulates a list of strategies, 

beginning with a call for the DPH to: “[c]ollaborate 

to achieve health equity for Alaskans.” The DPH also 

worked with the DHSS and other partners to develop 

the state health improvement plan, Healthy Alaskans 

2020. In selecting objectives for Healthy Alaskans 

2020, one criterion was that “[o]bjectives should 

address [health] equity and differences in health status 

and services across different population sub-groups, 

including race, socioeconomic, age, gender, disability 

status, and geographic groups.”4 Other divisions within 

the DHSS also implement activities relevant to minority 

health, health disparities, and health equity. Other DPH 

initiatives that do not explicitly address health equity 

may have significant implications for minority health. 

For example, given that 35.4 percent of the state’s 

American Indian/Alaska Native population is 

uninsured,5 the recent Medicaid expansion—which 

expands eligibility and adds behavioral health to the 

list of covered services—helps to ameliorate an 

important disparity. Relatedly, the DHSS’s Tribal Health 

Program provides technical assistance to tribal health 

care providers during expansion and/or development 

of Medicaid programs.6

Acronym List

Full Name of Agency Acronym Acronym

Alaska Department of Health and Social 

Services DHSS

Division of Public Health DPH

Partnerships

Primary 

collaborators

• Alaska Native Tribal Health 

Consortium

• Alaska Native Health Board

• Anchorage Faith and Action 

Congregations Together

• Southcentral FoundationContracts 

or memoranda of understanding 

with any partners

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented for 

some partnerships (e.g., the Alaska 

Native Tribal Health Consortium).

The DPH and the DHSS collaborate with many partners 

as part of minority health, health disparities, and 

health equity activities. Because Alaska has 229 

federally recognized tribal entities,7 the DPH and the 

DHSS partner with several organizations addressing 

American Indian/Alaska Native health issues 

throughout the state. For example, the DPH meets 

biannually with the Alaska Native Health Board on 

broader policy decisions, policy implementation, priority 

setting, and to identify opportunities for collaboration. 

Through multiple memoranda of understanding, the 

DPH and the DHSS also work with the Alaska Native 

Tribal Health Consortium and regional tribal 

corporations. Specifically, the DPH and the Consortium 

collaborated on Healthy Alaskans 2020, while the 

Consortium and the DHSS jointly reviewed health 

improvement efforts from previous decades and 

identified an initial 71 possible health indicators that 

are useful today. Consultation with subject matter 

experts and public input from two online surveys led 

to the current list of 25 leading health indicators and 

associated targets.8

4 Alaska Department of Health and Social Services and Alaska Native Tribal Health Consortium. “Healthy Alaskans 2020 Health Assessment: 

Understanding the Health of Alaskans.”

5 American Community Survey Public Use Microdata, 2014.

6 Alaska Department of Health and Social Services, Office of the Commissioner. “Tribal Health Program: A Commitment to Improving the Health 

Status of Alaska Native People.” Last updated on the DHSS website in 2015. 

7 Bureau of Indian Affairs, Interior. Indian Entities Recognized and Eligible To Receive Services From the United States Bureau of Indian Affairs. 

(81 FR 2019). Publication Date: January 29, 2016.

8 Alaska Department of Health and Social Services and Alaska Native Tribal Health Consortium. HA 2020 Process.

State and Territorial Efforts to Reduce Health Disparities 22
Alaska

Divisions within the DPH also partner with various tribal 

groups to address minority health, eliminate health 

disparities, and achieve health equity. For example, the 

DPH Section of Emergency Programs contracts with 

tribal health organizations to distribute the Centers for 

Disease Control and Prevention’s strategic national 

stockpile, which is the nation’s largest pharmaceutical 

and medical supplies for use in severe public health 

emergencies when local supplies run out.9 A statewide 

immunization program, operated by the DPH Section of 

Epidemiology, also works closely with tribal health 

organizations. In 2014, their combined efforts resulted 

in childhood vaccination rates for 19–35 month-old 

children in Alaska Native populations (i.e., 76.2 

percent) that exceeded rates in non-native children in 

that same age cohort (i.e., 67.3 percent).10 Similarly, 

the DPH Section of Public Health Nursing staffs 22 

public health centers, many of which operate under 

tribal organizations. The DPH Section of Women’s, 

Children’s and Family Health, meanwhile, works with 

the Southcentral Foundation—an Alaska Native-owned, 

nonprofit, regional health care organization—to provide 

prenatal care support and prevent adverse childhood 

experiences. Additionally, a preliminary and informal 

partnership between the DPH and Anchorage Faith and 

Action Congregations Together—an organization of 

churches and faith communities with predominantly 

Hispanic populations—has emerged to improve access 

to drug rehabilitation facilities.

Funding 

Annualized budget (FY 2015) of 

state/territorial minority health 

entity (SMHE) across all income 

sources

Unavailable

Annual budget (FY 2015) of SMHE 

from state/territorial government Unavailable

Largest funding source Unavailable

Anticipated changes to budget Possible

The DPH and the DHSS funding come from multiple 

sources, with minority health, health disparities, and 

health equity activities integrated as part of larger 

initiatives to address the health of Alaskans. The DPH 

and the DHSS provide funding to many tribal health 

organizations through grants that are sometimes 

complex. For instance, one DPH grant had more than 

20 recipients. Following recent state budget decreases, 

funding is expected to decrease further.

9 Centers for Disease Control and Prevention. Office of Public Health Preparedness and Response. Strategic National Stockpile. Last updated 

on the CDC website on March 2, 2017.

10 Centers for Disease Control and Prevention. Office of Public Health Preparedness and Response. Strategic National Stockpile. Last updated 

on the CDC website on March 2, 2017.

State and Territorial Efforts to Reduce Health Disparities 23
Alaska

Alaska State Data

Total Populationa: 

4,863,300

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 6.9 93.1 64.8 3.0 15.9 7.2 9.2 100.0 NA 

Percent of population 

medically uninsureda 13.8 14.4 10.4 9.1 28.4 18.8 16.9 14.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 7.3 4.8 SP 14.5 SP NC 6.9 5.9

Age-adjusted 

mortality rateb 393.7 756.6 682.2 578.1 1226.6 525.7 NC 745.6 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 12.4 14.2 13.8 9.7 16.9 14.8 22.8 14.6 13.6

Percent with 

diabetesc 5.7 7.3 7.6 14.6 8.4 2.5 5.3 7.6 10.8

Percent with 

heart diseasec 2.5 2.8 3.7 0.0 1.8 0.3 0.4 2.8 4.3

HIV rated 167.7 NC 76.0 430.2 190.6 50.9** 115.9 109.3 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

46.0 60.8 61.0 85.3 54.7 56.4 45.6 60.2 72.2

Percent received 

oral health visit 

(past 12 months)c

69.3 65.5 66.2 76.1 58.8 70.7 63.4 65.8 66.5

Percent received 

flu vaccinec 11.5 35.5 34.0 57.9 36.0 38.1 18.6 34.9 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 50.9 per 100,000 population (19 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 44.7 per 

100,000 population (3 cases).

State and Territorial Efforts to Reduce Health Disparities 24
American Samoa

Introduction to American Samoa’s Health Equity Activities

American Samoa is an unincorporated U.S. territory, with an estimated 2010 population of 56,000. Pacific 

Islanders are the largest racial-ethnic population (93 percent), followed by Asians (4 percent). Persons selfidentifying as multiracial or “other race” comprise 4 percent of the population.1

Because most American Samoans belong to a racial minority group, the American Samoa Department of Health 

(ASDOH) embeds minority health and health equity activities throughout its work. As such, it does not have a 

separate office solely dedicated to minority health, health disparities, or health equity issues. The ASDOH’s primary 

responsibilities are to address the health needs of American Samoans and to lead advocacy efforts on their 

behalf. Initiatives and activities to address health disparities often involve both the ASDOH and the American 

Samoa Department of Human and Social Services (ASDHSS), requiring close collaboration to coordinate delivery 

of services. The ASDHSS is responsible for several programs that focus on improving the health and well-being 

of specific minority subpopulations in American Samoa.

American Samoa Minority Health Overview

Name of state/

territorial minority 

health entity

N/A; however, the American Samoa 

Department of Health (ASDOH) 

embeds minority health activities 

throughout its work and has 

several staff devoted to reducing 

health disparities.

Strategic plan in 

place to address 

minority health 

or health equity

No strategic plan with a specific 

focus on minority health or health 

equity is available. 

Date strategic plan 

was last updated N/A

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

No formal assessment plan 

is in place; however, a home 

visiting program helps the ASDOH 

measure and track health status in 

American Samoan villages.

Key strategies 

used to achieve 

health equity

• Implementing tuberculosis 

initiative 

• Improving access to quality 

health care

• Controlling communicable 

disease

Organizational Structure

The ASDOH is responsible for providing clinical health 

care services as well as public health services. The 

Department of Public Health within the ASDOH leads 

initiatives to improve the health of the American 

Samoa population. The ASDHSS, a lateral department 

to the ASDOH, includes the Special Supplemental 

Nutrition Program for Women, Infants, and Children 

(WIC), behavioral health services, and other social 

services programs. While the ASDOH works to advance 

the health of all American Samoans, the ASDHSS 

focuses on eliminating disparities on the islands 

and addressing the needs of non-Pacific Islander 

minority populations.

The ASDOH has approximately 280 staff members, 

and they spend at least some portion of their day 

working to achieve health equity. Three staff members, 

known as clinical care coordinators/health educators, 

work specifically to eliminate heath disparities. They 

focus primarily on the village health assessments 

and outreach, including providing health education 

and coordinating the care and services that each 

village needs.

1 U.S. Census Bureau. 2010 Census Island Areas: 2010 Census Detailed Crosstabulations.

State and Territorial Efforts to Reduce Health Disparities 25
American Samoa

Location of state/territorial 

minority health entity 

(SMHE) within state/

territorial government

The American Samoa 

Department of Health is 

one of several departments 

housed under the Office 

of the Governor, along 

with the American Samoa 

Department of Human and 

Social Services. 

SMHE staffing (full-time 

equivalents)

The American Samoa 

Department of Health 

has approximately 280 

employees, many of 

whom spend some time 

supporting health initiatives 

for the population.

Advisory committee or panel None

Program Goals and Activities

The ASDOH has an overarching strategic plan to 

assess and address the health concerns of each 

American Samoan village individually, taking into 

account the local culture and traditions of the 

community. A home visiting program and village-based 

surveys, along with territorial communicable and 

non-communicable disease surveillance, are used 

to evaluate the health concerns and needs of each 

village. The ASDOH and the ASDHSS use the results 

of these assessments to develop plans for delivering 

education and services to meet each village’s 

identified needs. 

Most ASDOH strategies are broad and affect the 

American Samoan majority population, but some 

target specific minority subpopulations experiencing 

disparities. For example, a tuberculosis initiative 

addresses the higher rates of tuberculosis among 

Filipino and other foreign-born populations in American 

Samoa. Strategies implemented in American Samoan 

community health centers also help to address the 

needs of non-Pacific Islander minority populations.

Acronym List

Full Name of Agency Acronym Acronym

American Samoa Department of Health ASDOH

American Samoa Department of Human 

and Social Services ASDHSS

A major focus of the ASDOH has been on improving 

access to care. Given that all American Samoans are 

eligible for Medicaid and/or Medicare, health care 

coverage is universal and standardized for the entire 

population. The ASDOH and the ASDHSS work 

collaboratively to expand the health care system’s reach 

by coordinating outreach to communities and ensuring 

that community health centers have the necessary 

staffing. Programming and initiatives implemented in the 

villages largely depend on local needs identified through 

community assessments and home visits. The goal is 

to identify people needing care and then link them to 

appropriate services, locally or beyond. As an example, 

the ASDOH and the ASDHSS are working to implement 

courier services for American Samoans in need of care 

who have transportation barriers. 

Communicable disease control is another major 

strategy to improve the health of all American 

Samoans. Led by the Office of the Governor, initiatives 

include partnering with mayors to clean up villages and 

providing information to villages on how to reduce the 

spread of communicable diseases. Prevention products 

(e.g., mosquito nets, repellent) and educational 

materials are provided free of charge to community 

members in areas where outbreaks are possible.

State and Territorial Efforts to Reduce Health Disparities 26
American Samoa

Partnerships

Primary 

collaborators

• American Samoa Department 

of Human and Social Services

• American Samoa Community 

College

• Lyndon B. Johnson Tropical 

Medical Center

Contracts or 

memoranda of 

understanding 

with any partners

Yes, memoranda of understanding 

are implemented for some 

partnerships (e.g., the ASDOH 

has a general memorandum of 

understanding with all American 

Samoan government entities, 

including the American Samoa 

Community College and Lyndon B. 

Johnson Tropical Medical Center).

The ASDOH partners with the ASDHSS in many of its 

efforts to eliminate health disparities and improve the 

health of all American Samoans by improving access 

to care, conducting village health assessments, and 

controlling communicable disease transmission. The 

ASDOH and ASDHSS collaborate with other government 

agencies, coalitions, and local community-based 

organizations to carry out the home visiting program 

in villages, and to support various other activities. 

The American Samoa Community College is another 

key partner for the ASDOH. An entomologist from 

the college provides consultative services on matters 

related to vector-borne diseases. The ASDOH also 

works with the American Samoa Community College 

to provide hands-on opportunities and mentorship for 

students. Students support ASDOH activities and 

initiatives as part of their course practicum, and those 

who participate in the mentorship program assist the 

ASDOH with program evaluations.

The ASDOH collaborates with the Lyndon B. Johnson 

(LBJ) Tropical Medical Center, the only hospital in 

American Samoa, to increase access to health care 

professionals and services for communities with 

limited access. Clinicians in American Samoa are 

concentrated in Pago Pago, the location of the medical 

center. When the ASDOH identifies a community that 

has a health care need that cannot be addressed 

locally, the ASDOH works with the LBJ Tropical Medical 

Center to find health care professionals who can travel 

to the area and provide services to the community. 

In some cases, the ASDOH will secure a local office 

or clinic space for visiting health care professionals, 

or coordinate transportation to shuttle community 

members to the LBJ Tropical Medical Center for 

needed care.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$12,000,000 for 

the American Samoa 

Department of 

Health (both clinical 

and public health)

Annual budget (FY 2015) of SMHE 

from state/territorial government

$1,400,000 

for the American 

Samoa Department 

of Health

Largest funding source Federal government

Anticipated changes to budget Likely

The total FY 2015 funding for the ASDOH to support 

both clinical and public health services for all American 

Samoans was $12,000,000. Of this annual budget, 

$1,400,000 was from local sources (e.g., the American Samoa government) and the remainder of the 

funding was from federal grants. These grants focused 

on a range of health priorities, including diabetes, 

tobacco cessation, communicable disease control, 

and breast and cervical cancer. The largest grant in 

FY 2015 was from the U.S. Department Health and 

Human Services, Health Resources and Services 

Administration for community health centers in American Samoa. The ASDOH expects to receive additional 

funding specifically to address and prevent the spread 

of Zika virus in the territory.

State and Territorial Efforts to Reduce Health Disparities 27
American Samoa

American Samoa Territory Data

Total Populationa: 

55,519 

Race Totals

Pacific Islander Asian 

(includes 

Filipino) Multiracial Other

Territory 

Total

National 

Samoan Tongan Other PI Total

Population 

Characteristics

Percent of state 

populationa 88.9 2.9 0.8 3.6 2.7 1.2 100.0 NA 

Percent of population 

medically uninsureda 58.0 80.1 68.9 62.1 56.5 39.0 59.2 16.3b

Health 

Disparities

Vital Statistics

Infant mortality rate 10.5c 5.9d

Age-adjusted 

mortality rated 1165.0 733.1

Prevalence of Selected Chronic Diseases

Asthmae NC 13.6

Diabetes 47.3f 10.8e

Heart Diseasee NC 4.3

HIVg 4.7 362.3

Preventive Services

Routine check-up 

(past 12 months)e NC 72.2

Oral health visit 

(past 12 months)e NC 66.5

Flu Vaccine Receivede NC 38.4

Note: This jurisdiction’s vital statistics, disease prevalence, and preventive services data are not available by race and ethnicity in the data 

sources compiled for this report. 

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: U.S. Census Bureau. 2010 Census Island Areas: 2010 Census Detailed Crosstabulations. 

b Source: U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2010.

c Source: U.S. Department of Interior Office of Insular Affairs. Health Data and Information System U.S. Territories and Freely Associated 

States: Final Report March 2009. 

d Source: CDC National Vital Statistics Reports, Deaths: Final Data for 2015.

e Source: Behavioral Risk Factor Surveillance System, 2016.

f Source: World Health Organization. American Samoa NCD Risk Factors Steps Report, 2004 data. 

g Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015.

State and Territorial Efforts to Reduce Health Disparities 28
Arizona

Introduction to Arizona’s Health Equity Activities

Arizona had an estimated 2016 population of 6,931,000. Hispanic/Latino residents are the largest racial-ethnic 

minority population (31 percent), followed by American Indian/Native Americans (4 percent), African Americans 

(4 percent), and Asian Americans and NHOPI (3 percent). Persons self-identifying as multiracial or “other race” 

comprise 12 percent of the population.1 Approximately 4,771,000 Arizona residents live within a primary care 

health professional shortage area.2

In 2004, the Arizona Department of Health Services’ (ADHS) Office of Health Systems Development (OHSD) 

established the Center for Minority Health (renamed the Arizona Health Disparities Center in September 2006) 

to address minority health and health equity in the state.

Arizona Minority Health Overview

Name of state/

territorial minority 

health entity

Arizona Health Disparities Center

Strategic plan in 

place to address 

minority health 

or health equity

Arizona Health Equity Stakeholder 

Strategies

Date strategic plan 

was last updated 2013

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Outcome and process measures 

are included in the strategic plan

Key strategies 

used to achieve 

health equity

• Implementing Culturally & 

Linguistically Appropriate 

Services (CLAS) Standards

• Developing health literacy 

materials for community partners 

and health systems

• Language Access

Organizational Structure

Within the ADHS, the Arizona Health Disparities Center 

(AHDC) is housed within the Health Systems Development Bureau of the Division of Public Health Services. 

The center serves in a department-wide capacity to 

address minority health issues. 

Acronym List

Full Name of Agency Acronym Acronym

Office of Health Systems Development OHSD

Health Disparities Center AHDC

Arizona Department of Health Services ADHS

The AHDC does not have an advisory committee 

specifically for minority health or health disparities. 

However, the center does have a Health Literacy 

Coalition funded by the U.S. Office of Minority Health. 

The coalition, which develops materials to address 

health literacy, includes partners that address health 

disparities in Arizona. The coalition’s members include 

federally qualified health centers, the Arizona Alliance 

for Community Health Members, the ADHS Refugee 

Health Program, Asian Pacific Community in Action, 

Native Health, and other community partners.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 29
Arizona

Across the ADHS, 10 staff members work full time 

on minority health, health disparities, and health equity. 

Four senior staff work full time on health disparities 

issues: the AHDC Office Chief, the Office of HIV Prevention Office Chief, the Native American Liaison, and the 

Border Health Liaison. There are also five mid-level, 

full-time staff, including a State Partnerships Initiative 

Program Manager, Health in Arizona Policy Initiative 

Manager, Native American Home Visiting Program 

Manager, LGBT Liaison–Tobacco Program, and Native 

American Liaison. As part of its junior staff, the center 

also employees a full-time epidemiologist and uses 

student interns from local universities when possible.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

Arizona Department 

of Health Services, 

Division of Public 

Health Services, 

Health Systems 

Development 

Bureau

SMHE staffing (full-time equivalents) 10

Advisory committee or panel No advisory 

committee for 

minority health or 

health disparities

Program Goals and Activities

In 2013, the AHDC published a state Strategic Plan, 

Arizona Health Equity Stakeholder Strategies,

3 to 

address minority health and health equity. The plan 

was developed with input from consumers and health 

and human services providers across the state. 

Arizona’s plan mirrors the format of National Stakeholder Strategy for Achieving Health Equity, a report 

published in 2011 by the U.S. Department of Health 

and Human Services’ Office of Minority Health. Through 

a strategic planning process, the AHDC will periodically 

reevaluate and update the Arizona Health Equity 

Stakeholder Strategies plan as needed to ensure that it 

aligns with the center’s overarching direction and goals.

The AHDC’s 2013 Strategic Plan lists diabetes, obesity, 

cancer, substance abuse, heart disease, and teen 

pregnancy as top health concerns for the state. 

The plan also outlines five goals for addressing health 

disparities: awareness; leadership; health system and 

life experience; cultural and linguistic competence; 

and data, research, and evaluation. For each goal, 

the plan identifies strategies, objectives, measures, 

and recommendations. 

With funding from the U.S. Office of Minority Health, 

the AHDC implements a host of strategies to eliminate 

health disparities. For example, the AHDC promotes 

adoption of the National Standards for Culturally and 

Linguistically Appropriate Services (National CLAS 

Standards) and launched a National CLAS Standards 

online training in 2014 in partnership with the Arizona 

Department of Health Services (ADHS), Bureau of Nutrition and Physical Activity. The purpose of the training is 

to bring awareness of the National CLAS Standards 

to people in health care settings. The AHDC has 

partnered with the Northern Area Health Education 

Center to provide continuing education credits for 

participants who complete the online training. The 

AHDC also created “Implementing CLAS Standards and 

Improving Cultural Competency and Language Access: 

A Practical Toolkit.”4 The practical guide provides 

resources for organizations seeking to implement 

the National CLAS Standards. Additionally, the AHDC 

established a Website to explain and disseminate the 

National CLAS Standards, as well as to promote their 

implementation; it also includes links to the federal 

Think Cultural Health Website.

Another important goal of the AHDC is to address the 

needs of people with limited English proficiency (LEP). 

HRC aims to improve access for people with LEP to 

interpretive services, resources, and information 

through research, strategic alliances, and resource 

development by providing health literacy materials 

at no cost to community partners, health systems, 

providers, and patients. Examples of available materials include:

• I Speak cards to assist people with limited English 

proficiency to communicate which language they 

speak when interacting with health care providers 

and others;

• Know Your Language Access Rights fact sheets that 

help people with limited English proficiency to understand their right to request a qualified medical inter3 The Arizona Health Equity Stakeholder Strategies: January 2013 report is available on the Arizona Department of Health website. Last 

accessed: 1/13/2018.

4 “Implementing CLAS Standards and Improving Cultural Competency and Language Access: A Practical Toolkit.” Published by the Arizona 

Health Disparities Center, produced by the Arizona Health Alliance for Language Access Rights, December 2014. Available on the Arizona 

Department of Health website. Last accessed: 1/13/2018.

State and Territorial Efforts to Reduce Health Disparities 30
Arizona

preter at no cost to them, and to provide information 

about available resources in the community; and 

• Laminated handouts with flags from countries/

regions that people with limited English proficiency 

can use to show their country of origin when interacting with health care providers and others.

In 2012, the AHDC formed the Arizona Health Alliance 

for Language Access Rights with the goal of “creating and sustaining a welcoming environment that 

embraces Language Access Services (LAS) in Arizona.” 

The alliance includes stakeholders from key government, community, and local organizations.

Partnerships

Primary 

collaborators

• Arizona county health departments

• Association of Community Health 

Centers

• Center for Rural Health at the 

University of Arizona

• Local universities

• Health in Arizona Policy Initiative

• Organizations that represent racial 

and ethnic groups

• Department of Health Services, 

Office of Border Health

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented for 

some partnerships (e.g., with county 

health departments).

At the state and local levels, the AHDC collaborates 

with governmental and nongovernmental agencies to 

advance its efforts to achieve health equity. It works 

closely with Arizona county health departments, which 

serve as “boots on the ground,” and are responsible 

for local implementation of the center’s programs. 

Intergovernmental agreements between the center and 

county departments specify deliverables to be provided 

and related funding. The center also partners with the 

Association of Community Health Centers, which has 

a network of 20 federally qualified health centers across 

Arizona that support more than 140 points of service. 

The AHDC also collaborates with local universities 

in Arizona to engage stakeholders and develop plans 

for addressing minority health disparities. These 

universities often provide technical assistance to 

the center, particularly on topics related to evaluation, 

methodologies, data metrics, and capacity building. 

In addition, the AHDC relies heavily on the Center for 

Rural Health at the University of Arizona for support 

addressing disparities in access to care among 

rural populations. 

Another partner of the AHDC is the Public Health 

Prevention Bureau, which sponsors the “Health 

in Arizona Policy Initiative,” of which the ADHC is a 

member. This effort focuses on statewide goals related 

to nutrition, physical activity, worksite wellness, school 

health, tobacco cessation, helping children with special 

needs, and addressing chronic disease.

Funding 

Annualized budget (FY 2014) of 

state/territorial minority health 

entity (SMHE) across all income 

sources

$8,708,232

Annual budget (FY 2014) of SMHE 

from state/territorial government $7,575,670

Largest funding source State tobacco tax

Anticipated changes to budget 

in FY 2015 None

The total FY 2014 funding for the AHDC was 

$8,708,232. The majority of funding was procured 

at the state level through tobacco taxes ($6,935,431), 

lottery income ($520,000), the center’s general fund 

($120,239), and the general fund from the Office of 

the Director (funding amount not specified). Each state 

funding stream is appropriated annually. Federal 

funding came from the U.S. Office of Minority Health, 

State Partnership Initiative to Address Health Disparities grant, and the U.S. Health Resources and Services 

Administration Title V Maternal and Child Health 

Services Block Grant Program. The U.S. Office 

of Minority Health awarded the center $200,000 

over 5 years beginning in August 2015.

State and Territorial Efforts to Reduce Health Disparities 31
Arizona

Arizona State Data

Total Populationa: 

6,931,071

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 31.0 69.0 75.8 4.4 4.4 3.4 12.1 100.0 NA 

Percent of population 

medically uninsureda 18.2 7.2 8.9 9.9 21.3 8.4 18.1 10.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.5 5.5 5.0 10.2 7.7 SP NC 5.5 5.9

Age-adjusted 

mortality rateb 595.9 686.5 667.4 799.8 872.9 403.8 NC 675.8 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.7 15.7 15.1 15.6 19.1 SP 11.4 14.7 13.6

Percent with 

diabetesc 11.5 10.5 10.3 13.5 17.5 SP 12.8 10.8 10.8

Percent with 

heart diseasec 3.3 4.7 4.8 2.8 1.9 SP 2.2 4.2 4.3

HIV rated 284.0 NC 228.6 825.3 267.3 99.7** 471.5 270.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

62.4 70.5 69.9 73.3 59.1 SP 58.2 68.3 72.2

Percent received 

oral health visit 

(past 12 months)c

51.7 66.5 65.5 58.2 50.5 SP 48.8 62.9 66.5

Percent received 

flu vaccinec 29.6 37.3 36.9 29.4 29.6 SP 26.4 35.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 99.7 per 100,000 population (178 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 205.6 per 

100,000 population (21 cases).

State and Territorial Efforts to Reduce Health Disparities 32
Arkansas

Introduction to Arkansas’ Health Equity Activities

Arkansas had an estimated 2016 population of 2,988,000. Blacks/African Americans are the largest racial-ethnic 

minority population (16 percent), followed by Hispanics/Latinos (7 percent), Asian Americans and NHOPI 

(2 percent), and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other 

race” comprise 5 percent of the population.1 Approximately 657,000 Arkansas residents live within a primary 

care health professional shortage area.2

In 1991, Arkansas established the Office of Minority Health and Health Disparities (OMHHD) to address concerns 

related to disparities in health status, especially among minority populations. The mission of the office is to 

provide leadership and promote heath equity for minority populations as defined by race/ethnicity, age, disability, 

education, gender, geographical location, income, and sexual orientation. In carrying out its mission, OMHHD is 

strategically placed under the Deputy Director for Public Health Programs to allow cross-cutting access to each 

ADH Center and collaborates with all programs to address the needs of minority populations.

Arkansas Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health and Health 

Disparities

Strategic plan in 

place to address 

minority health 

or health equity

The Arkansas Department of 

Health’s strategic plan includes 

a strategic plan regarding minority 

health.

Date strategic plan 

was last updated 2015 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Yes; the assessment plans are in 

the strategic plan and are specific 

to the goals of each center within 

the Department of Health.

Key strategies 

used to achieve 

health equity

• Hypertension and stroke 

awareness initiatives

• Healthy eating and exercise 

initiatives

• Infant mortality and expectant 

mother initiatives

• Teen pregnancy prevention

Organizational Structure

The ADH is a cabinet-level agency and reports directly 

to the Governor. The OMHHD has seven full-time staff, 

including the director, two health program specialists, 

a minority health manager, an epidemiologist, an 

administrative analyst and a nurse coordinator. Each 

staff member devotes 100 percent time to OMHHD 

activities. Staffing allocations are not expected to 

change during the next 2 years. In addition to these 

full-time positions, the Washington, DC-based Directors 

of Health Promotion and Education fellowship program 

and the University of Arkansas for Medical Sciences 

provide interns who work in the OMHHD. 

Acronym List

Full Name of Agency Acronym Acronym

Arkansas Department of Health ADH

Arkansas Minority Health Commission AMHC

Office of Minority Health and Health 

Disparities OMHHD

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 33
Arkansas

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OMHHD 

reports to the 

Deputy Director 

for Public Health 

Programs. The ADH 

is a cabinet-level 

agency and reports 

directly to the 

Governor

SMHE staffing (full-time equivalents) 7

Advisory committee or panel Yes, although the 

advisory committee 

has not convened 

in 3 years

Program Goals and Activities

A strategic plan regarding minority health, health 

disparities, and health equity is integrated into the 

ADH strategic plan and has been available since prior 

to 2010. This strategic plan was last updated in 2015 

(covering 2016–2019), and is updated every 4 years. 

Each ADH center (such as the Center for Health 

Protection and the Center for Health Advancement) 

has an assessment plan to measure goals related to 

health disparities; those plans are included in the ADH 

strategic plan. For example, the Family Health Branch’s 

assessment plan includes measurement of reduction 

of teen pregnancies among African American females. 

To set priorities and determine strategies, OMHHD staff 

and staff from ADH centers and branches come together 

to draft the ADH strategic plan. With input from ADH centers and branches, OMHHD staff examine disparity rates 

for the leading causes of death among different populations to identify and prioritize disparities. The OMHHD 

also has a legislative mandate to maintain and annually 

update a list of counties where life expectancies are 8 

to 10 years shorter than in other counties. The counties 

are commonly referred to as “red counties” and the 

Red County report is annually compiled by the OMHHD. 

AMHC staff then use the list to assemble a workgroup 

of agencies that will focus on a year-long health-related 

improvement project. 

The OMHHD promotes awareness of all at-risk populations, including those affected by racial, ethnic, disability, sexual orientation, and geographical location 

health disparities. Key strategies have included promoting healthy eating and exercise; it also has been 

working to reduce infant mortality and improve 

maternal health. To address hypertension and stroke 

disparities, the OMHHD developed the Arkansas 

Minority Barber and Beauty Shop Initiative, which aims 

to increase public awareness of disease prevention 

and management among African Americans and 

Latinos. The initiative, originally implemented in 

Pulaski County, has since been expanded to red 

counties through grant funding. 

To improve healthy eating and exercise, the Governor’s 

Office has endorsed a public-private partnership called 

Healthy Active Arkansas, which is a 10-year state plan 

to reduce obesity. Relatedly, the OMHHD started the 

Healthy Active Arkansas ambassador training program 

to disseminate obesity reduction information to 

minority communities. The program initially recruited 

training ambassadors from the pool of Miss Arkansas 

pageant contestants, as well as other beauty queen 

contestants from historically Black colleges and 

universities. The program now includes males, high 

school students, and college leaders on campus. 

Several initiatives have been developed in collaboration 

with the Family Health Branch aimed at improving the 

health of minority women and children. For example, 

the OMHHD partnered with African American sororities 

and fraternities to start Sisters United and Brothers 

United, which is a community-based initiative that 

focuses on folic acid intake, flu shots during pregnancy, 

breastfeeding, and safe sleep for infants. Families 

United, a version of the initiative tailored to the Latino 

population in Arkansas, also addresses higher rates 

of gestational diabetes among Latino women. The 

OMHHD also assists with other campaigns, such as 

Mocha Café, a breastfeeding support group for women 

of color. The “Say Yes to Best” initiative encourages 

women in counties with low breastfeeding rates and 

high rates of sudden infant death syndrome to breastfeed, speak to lactation consultants before they give 

birth, and use safe portable bassinets. The OMHHD 

also is assisting the Family Health Branch in its efforts 

to encourage the use of long acting reversible contraceptives (LARCs) by African Americans and Latinos. 

Another program, the Arkansas Minority Barber & 

Beauty Shop Health Initiative, was developed to 

increase public awareness about heart disease and 

stroke in a convenient location. Its primary objectives 

are to: screen for diabetes, high blood pressure, and 

cholesterol; educate communities about the importance of proper diet, physical exercise, and recognition 

of signs and symptoms of stroke and heart disease; 

and refer high-risk individuals identified through 

screening to local health units. Each year, with over 

200 community volunteers, the OMHHD screens over 

500 customers receiving services in local hair salons. 

State and Territorial Efforts to Reduce Health Disparities 34
Arkansas

Lastly, the OMHHD seeks to better serve the Marshallese American population. The Marshallese 

population is most concentrated in the northwest 

portion of the state and was affected by a major 

mumps outbreak in 2016. This outbreak reached 

almost 3,000 cases statewide, and more than half 

of these cases were in the Marshallese community. 

Arkansas is home to the largest concentration of 

Marshall Islanders within the contiguous United States.

Partnerships

Primary 

collaborators

• African American Fraternities 

and Sororities

• Arkansas Children’s Hospital

• Arkansas Minority Health 

Commission

• March of Dimes

• University of Arkansas 

for Medical Sciences

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented 

for some partnerships (i.e., grantfunded projects). For example, 

the OMHHD has a contract with 

Arkansas Children’s Hospital for 

Brother’s United.

Infant mortality reduction is a topic of several 

partnerships throughout the state. For example, the 

March of Dimes and the University of Arkansas for 

Medical Sciences have been key partners with the 

OMHHD in efforts to reduce infant mortality among 

minority populations. Together, they have hosted a 

forum called Let’s Talk About Breastfeeding. In another 

partnership with the March of Dimes to increase 

awareness about infant mortality in African American 

communities, a blog was developed to follow the 

pregnancy of a local celebrity. Arkansas Children’s 

Hospital holds monthly meetings, entitled Natural 

Wonders Meetings, as part of the Natural Wonders 

Partnership Council’s efforts to decrease infant 

mortality. As noted above, the OMHHD works closely 

with the AMHC to address minority health priorities 

in red counties.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$523,686

Annual budget (FY 2015) of SMHE 

from state/territorial government $338,686

Largest funding source Arkansas general 

revenue funds

Anticipated changes to budget None anticipated. 

The total FY 2015 funding for the OMHHD was 

approximately $523,686. In FY 2015, the largest 

single source of funding was from ongoing state 

general revenue ($338,686). The remainder was 

received during the second year of a 5-year U.S. 

Office of Minority Health grant ($185,000) that 

funds the Arkansas Minority Barber and Beauty Shop 

Initiative. The AMHC receives $1,604,983 in funding, 

most of which comes from the Arkansas Tobacco 

Settlement Commission ($1,604,714); the remainder 

is allocated from state general revenue funding. The 

AMHC distributes some of its funding as mini-grants 

to other organization, but the OMHHD does not fund 

other organizations.

State and Territorial Efforts to Reduce Health Disparities 35
Arkansas

Arkansas State Data

Total Populationa: 

2,988,248

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 7.2 92.8 76.6 15.7 0.7 1.6 5.3 100.0 NA 

Percent of population 

medically uninsureda 23.5 7.4 7.8 8.0 15.9 11.6 18.8 8.5 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 8.1 6.7 11.2 SP SP NC 7.5 5.9

Age-adjusted 

mortality rateb 319.1 905.6 883.8 1019.2 314.7 454.5 NC 893.2 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 10.9 14.7 14.3 13.7 30.2 0.2 11.6 14.4 13.6

Percent with 

diabetesc 5.7 14.0 13.1 16.2 22.5 18.2 6.7 13.6 10.8

Percent with 

heart diseasec 3.1 7.4 7.5 5.4 7.1 0.0 10.0 7.2 4.3

HIV rated 224.6 NC 127.3 631.3 27.3 44.0** 743.5 214.8 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

57.8 74.6 72.4 84.0 66.4 78.9 48.6 73.3 72.2

Percent received 

oral health visit 

(past 12 months)c

63.8 58.0 58.8 61.4 35.5 85.2 48.2 58.5 66.5

Percent received 

flu vaccinec 41.7 39.1 40.0 33.6 33.3 30.0 41.7 39.0 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 44.0 per 100,000 population (16 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 92.5 per 

100,000 population (5 cases).

State and Territorial Efforts to Reduce Health Disparities 36
California

Introduction to California’s Health Equity Activities

California had an estimated 2016 population of 39,250,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (39 percent), followed by Asian Americans and NHOPI (15 percent), Blacks/African Americans 

(6 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or 

“other race” comprise 19 percent of the population.1 Approximately 7,933,000 California residents live within a 

primary care health professional shortage area.2

In 2012, California statutorily mandated a restructuring of its public health program with the aim of achieving 

the highest level of health and mental health for all people—with a focus on socioeconomically disadvantaged 

populations—by addressing health disparities, and health equity priorities. Section 131019.5 of the California 

Health and Safety Code established the Office of Health Equity (OHE) within the California Department of Public 

Health (CDPH). Its purpose is to align state resources, decision-making, and programs to achieve optimal health 

for all people, including socioeconomically disadvantaged populations. Core activities of the OHE include 

conducting policy analysis, developing strategic policies and plans, and serving as a resource to other state 

agencies as they work to improve the social determinants of health, health care access and quality.

California Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity (OHE)

Strategic plan in 

place to address 

minority health 

or health equity

Portrait of Promise: The California 

Statewide Plan to Promote 

Health and Mental Health Equity

Date strategic plan 

was last updated 2015

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Performance measures included 

in the strategic plan

Key strategies 

used to achieve 

health equity

• California Reducing Disparities 

Project3

• Health in All Policies Task Force4

• Let’s Get Healthy California5

• Provide statewide leadership 

in policy, systems, and 

environmental change by 

improving health, equity, and 

environmental sustainability in 

California government decisionmaking, practices, and policies6

Organizational Structure

As the primary office responsible for addressing 

minority health, health disparities, and health equity in 

the state, OHE is housed within the California Department of Public Health and is composed of three units. 

First, the Community Development and Engagement 

Unit’s focus is to strengthen the CDPH’s ability to 

advise and assist other state agencies improve access 

to high quality of culturally and linguistically competent 

health care services. Additionally, the Health Equity 

Planning and Policy Unit brings a health equity focus to 

complex policy projects that require input and collaboration across multiple agencies and departments to 

achieve health, equity, and environmental sustainability. 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 California Department of Public Health’s “California Reducing 

Disparities Project.” Available on the CDPH website.

4 For more information, see the “Health in All Policies Resources” 

page at the California Department of Public Health Website.

5 Let’s Get Healthy California information is available on the 

“Letsgethealthy.ca.gov” website.

6 This is the mission of the Health Equity Policy and Planning Unit 

of the Office of Health Equity, which contains the Health in All 

Policies and Climate Change and Health Equity programs.

State and Territorial Efforts to Reduce Health Disparities 37
California

The Policy Unit contains the Health in All Policies Task 

Force and the Climate Change and Health Program. 

Finally, the OHE’s Health Research and Statistics Unit 

produces data for reports and provides information 

and technical assistance regarding health and mental 

health disparities to programs of the CDPH, state 

agencies, local health departments, and stakeholders. 

Acronym List

Full Name of Agency Acronym Acronym

California Department of Public Health CDPH

Office of Health Equity OHE

A group of experts, advocates, clinicians, and consumers who understand issues around disparities in 

health and mental health care, as well as health issues 

in underserved and underrepresented communities, 

serves as OHE’s Advisory Committee. It is composed 

of representatives from state agencies and departments, local health departments, community-based 

organizations, and service providers working to 

advance health and mental health equity for vulnerable 

communities. The Advisory Committee also consults 

regularly with the Office regarding policy recommendations, strategic plans, and cross-sectoral work. 

This body helps advance OHE’s goals and advises 

on the development and implementation of OHE’s 

Strategic Plan.

The OHE is staffed by individuals dedicated to minority 

health, health disparities, and health equity initiatives; 

it does not share staff with other CDPH offices. Its 

deputy director is appointed by the governor and 

confirmed by the state Senate. Other senior staff 

include health program managers, a senior communications consultant, and a research scientist supervisor. 

Mid-level staff include a communications consultant, 

health program specialists, and research scientists. 

The office also hosts paid and unpaid college interns.

Location of state/territorial 

minority health entity 

(SMHE) within state/

territorial government

The Office of Health Equity 

is an executive office within 

the California Department 

of Public Health

SMHE staffing (full-time 

equivalents) 20

Advisory committee or panel Yes

Program Goals and Activities

California’s OHE is legislatively mandated to establish 

a comprehensive, cross-sectoral strategic plan to 

eliminate health and mental health disparities and 

inequities. The strategic plan—Portrait of Promise: The 

California Statewide Plan to Promote Health and Mental 

Health Equity7— was first published in August 2015 

and will be updated biennially. This plan seeks to 

promote equitable social, economic, and environmental 

conditions to achieve optimal health, mental health, 

and well-being for all. It includes a demographic 

analysis of health and mental health equity in California, and a strategic plan to address inequalities. 

The strategic plan interventions are based on three 

main priorities: 

• Assessment—to yield knowledge of problems 

and possibilities 

• Communication—to foster shared understanding 

• Infrastructure development—to empower residents 

and institutions to act effectively within the health 

field, among potential health partners, and within 

local communities.

California is implementing many activities and initiatives to reduce health disparities and improve health 

equity. Launched in 2009, the California Reducing 

Disparities Project invests in community-defined, 

promising practices that address mental health disparities in five populations: African Americans, Asian/

Pacific Islanders, Latinos, LGBTQ individuals, and 

7 “Portrait of Promise: The California Statewide Plan to Promote Health and Mental Health Equity.” Report to the Legislature and the People 

of California by the Office of Health Equity, California Department of Public Health, August 2015. Available on the CDPH website.

State and Territorial Efforts to Reduce Health Disparities 38
California

Native Americans. Phase 1 of the project, completed 

in 2014, focused on developing strategies to transform 

the public mental health system and identifying 

community-based promising practices in each of the 

five targeted populations. Phase 2 is to fund selected 

approaches across the five targeted populations with 

strong evaluation, technical assistance, and capacity 

building components.

In 2010, the state created the Health in All Policies 

(HiAP) Task Force, which is staffed through a partnership between the State Health Department, the Public 

Health Institute, and a cabinet-level body called the 

Strategic Growth Council. HiAP is a collaborative 

approach to improving the health of all people by 

incorporating health, equity, and sustainability considerations into decision-making across sectors and policy 

areas. The Task Force has 22 member state agencies, 

such as Environmental Protection, Transportation, 

Education, Social Services, and Housing and Community Development. The Task Force works to promote 

a government culture that prioritizes the health and 

equity of all Californians across policy areas, incorporates health and equity into state agency practices, 

and provides a forum for agencies to identify shared 

goals and opportunities to enhance performance 

through collaboration.

California is a leader in addressing climate change, 

which has many health impacts that harm communities 

facing health inequities first and worst. The Climate 

Change and Health Equity Program (CCHEP) embeds 

health and equity in California climate change policy 

and planning, and embeds climate change and equity 

in public health policy and planning. CCHEP works 

with local, state, and national partners to assure that 

climate change mitigation and adaptation activities 

have beneficial effects on health, while not creating or 

deepening health inequities. The program implements 

California’s climate change laws and executive orders, 

contributing health equity considerations to grants, 

policies, and plans, and works to increase resilience 

to climate impacts by improving living conditions with 

and for people facing inequities. CCHEP provides 

health equity input into California’s plans for transportation, housing, land use planning, and other systems 

that affect health outcomes and vulnerability to climate 

change impacts, and supports systems that facilitate 

robust community engagement in decisions that affect 

daily life for residents. 

Another effort, Let’s Get Healthy California (LGHC), 

identifies and highlights creative and effective efforts 

from across the state that are working to improve 

health and advance health equity. LGHC is a 10-year 

plan aiming to improve the health of Californians 

through collective action across six goal areas. LGHC 

identifies a set of indicators in key dimensions that, 

taken together, convey the state of California’s health 

and well-being—at both the population and system 

level. Progress is evaluated by not only looking to 

improve statewide health outcomes but also to close 

the gaps across disparities.

Partnerships

Primary 

collaborators

• California Department of Health 

Care Services 

• California Department of 

Transportation

• California Department of 

Corrections and Rehabilitation

• Governor’s Office of Planning 

and Research

• Strategic Growth Council

• California Environmental Protection 

Agency

• Sierra Health Foundation

• The California Endowment

• California Healthcare Foundation

• Kaiser Family Foundation

• Local health departments

• Federal Reserve Bank of San 

Francisco

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships. Additionally, 

interagency agreements may also 

be used

The California OHE partners with governmental and 

nongovernmental agencies and organizations to 

eliminate health disparities and advance health equity. 

The office maintains an interagency agreement with 

the California Department of Health Care Services that 

outlines how they will work together to advance the 

Office’s mission. This includes collaborating with the 

Mental Health Services Division of the Department 

of Health Care Services to partner, inform, and offer 

cultural and linguistic sensitivity technical assistance; 

collecting and analyzing data; and serving on the 

office’s advisory committee. 

State and Territorial Efforts to Reduce Health Disparities 39
California

Through the Health in All Policies Task Force and 

Climate Change and Health Equity Program, the OHE 

has collaborated with other agencies within state 

government to promote health equity. For example, 

through the HiAP Task Force, staff work with the 

Department of Transportation to improve its grantmaking language to make it more accessible, 

equitable, and inclusive of public health issues such 

as active transportation, activities to make walking 

easier, and improving safe and accessible cycling 

opportunities. Other examples include a partnership 

with the Department of Corrections and Rehabilitation 

and the Department of General Services to improve 

access to healthier food options in correctional 

facilities. The OHE regularly provides technical 

assistance, and sometimes contracts, to local health 

departments across the state.

The OHE has also partnered with nongovernmental 

stakeholders to evaluate minority health, health 

disparities, and health equity best practices and to 

align these efforts. The Sierra Health Foundation, 

California Endowment, Kaiser Family Foundation, the 

California Healthcare Foundation, the Federal Reserve 

Bank of San Francisco, and other entities have helped 

the office foster a climate for educating Californians 

about health disparities and inequities.

Funding 

Annualized budget 

(FY 2017) of state/

territorial minority health 

entity (SMHE) across all 

income sources

$20,445,867 (includes $15 

million of the $60 million 

in one-time funding for pilot 

projects under the California 

Reducing Disparities Project 

related to behavioral health; 

funding awarded over 4 years)

Annual budget (FY 2017) 

of SMHE from state/

territorial government

Approximately 90% of the 

Office of Health Equity funding 

comes from state initiatives

Largest funding source State government

Anticipated changes 

to budget in FY 2018 No

The total FY 2017 funding for the OHE was 

$20,445,867. The office has several main funding 

sources. The Mental Health Services Act (MHSA) 

(Proposition 63) allocated $60 million over 4 years, 

beginning in fiscal year 2012 (without regard to fiscal 

years) for the California Reducing Disparities Project 

(CRDP). Additionally, the OHE, through the ongoing 

MHSA fund separate from the $60 million, received 

$2,230,000 (FY 2016) to support all personnel and 

administrative costs to oversee the CRDP. Another 

funding source is through the Air Pollution Control Fund 

of the California Global Warming Solutions Act of 2006 

(AB 32, Nunez, Chapter 488, Statutes of 2006), which 

helps fund the integration of health equity considerations into California’s climate change policies, grants, 

and plans. A small amount of funding is provided by 

the Centers for Disease Control and Prevention to help 

local health departments and the State prepare for and 

adapt to the health impacts of climate change. Approximately 90 percent of the office’s funding comes from 

state initiatives, but the office is positioning itself 

to take advantage of national/federal funding in 

the future.

State and Territorial Efforts to Reduce Health Disparities 40
California

California State Data

Total Populationa: 

39,250,017

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 38.9 61.1 59.6 5.8 0.7 14.7 19.2 100.0 NA 

Percent of population 

medically uninsureda 12.4 4.5 6.8 6.6 11.5 4.9 11.9 7.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.4 4.2 4.2 8.9 6.8 3.5 NC 4.4 5.9

Age-adjusted 

mortality rateb 516.5 642.6 650.6 812.3 382.2 394.2 NC 616.9 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 10.3 14.2 13.1 17.9 13.4 9.0 12.7 12.8 13.6

Percent with 

diabetesc 11.0 9.8 9.5 10.5 13.4 11.8 11.3 10.2 10.8

Percent with 

heart diseasec 2.3 3.8 3.8 2.5 2.9 2.4 2.3 3.4 4.3

HIV rated 374.8 NC 370.0 1106.7 235.1 100.1** 480.5 376.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

62.5 71.0 67.3 69.3 60.8 73.4 65.9 68.1 72.2

Percent received 

oral health visit 

(past 12 months)c

59.4 72.9 68.3 59.3 55.8 78.5 62.1 68.5 66.5

Percent received 

flu vaccinec 27.0 40.2 35.6 29.0 26.7 45.3 29.9 36.0 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 100.1 per 100,000 population (4,726 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 205.7 

per 100,000 population (245 cases).

State and Territorial Efforts to Reduce Health Disparities 41
Colorado

Introduction to Colorado’s Health Equity Activities

Colorado had an estimated 2016 population of 5,541,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (21 percent), followed by Blacks/African Americans (4 percent), Asian Americans and NHOPI (3 percent), 

and American Indians/Alaska Natives (1 percent). Multiracial and persons self-identifying as Other Race comprise 

7 percent of the population.1 Approximately 1,069,000 Colorado residents live within a primary care health 

professional shortage area.2

The Colorado Department of Public Health and Environment (CDPHE) is made up of 11 divisions. The Office 

of Health Equity (OHE) falls under the Division of Community Relations, which also involves communications, 

emergency preparedness, and the Office of Planning Partnerships and Improvement. The Office of Health 

Disparities and the Minority Health Advisory Commission were officially created through Senate Bill 242 in May 

2007. In 2013, House Bill 13-1088 changed the name of the office to the OHE and expanded it to serve lesbian, 

gay, bisexual, and transgender (LGBT), aging, disabled, low-socioeconomic, and geographic populations. The 

Minority Health Advisory Commission and the Interagency Health Disparities Leadership Council were consolidated 

into the Health Equity Commission, which advises OHE on minority health, health disparities, and health equity. 

The Commission is comprised of 13 community members and 2 state legislators (1 representative and 1 senator). 

Members are chosen based upon their geographic location, knowledge about health equity and environmental 

justice, and ability to effectively advise the CDPHE through the OHE.

Colorado Minority Health Overview

Name of state/territorial 

minority health entity Colorado Office of Health Equity

Strategic plan in place to 

address minority health 

or health equity

No strategic plan was in place to address minority health or health equity at the time of 

data collection. Plans regarding minority health, health disparities, and health equity are 

included in a 2013 minority health report. In collaboration with philanthropic partners, 

the Office of Health Equity intends to create a comprehensive planning document in 2017. 

Date strategic plan was last 

updated N/A

Assessment plan in place 

to measure progress toward 

reducing health disparities

N/A. An assessment plan will be included with the 2017 strategic plan. 

Key strategies used to 

achieve health equity

• Providing mandatory training to all staff on health equity and environmental justice

• Developing health equity policy encouraging all staff to think critically about serving 

minority populations

• Hiring new policy and community engagement staff in the Office of Health Equity

• Developing resources and tools to help staff think about how to incorporate health equity 

into their work

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 42
Colorado

Organizational Structure

The OHE has three full-time staff members who 

dedicate all of their time to minority health and health 

equity initiatives, but plans call for expansion to five 

full-time staff. Current full-time staff include the office’s 

director, a policy analyst, and a community engagement 

specialist. An ongoing Health Equity Commission 

advises on minority health and health equity issues. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OHE is housed 

within the Colorado 

Department of 

Public Health and 

Environment

SMHE staffing (full-time equivalents) 3

Advisory committee or panel The Health Equity 

Commission

Program Goals and Activities

In 2013 the OHE published a Health Disparities 

Report. The purpose of the report was to identify 

strengths and disparities for groups in the 10 areas 

CDPHE identified as winnable public health battles. 

While the report may be viewed as a call to action, it 

is not a comprehensive planning document that can 

be used as a strategic plan. The OHE, with the help 

of philanthropic partners, aims to produce a strategic 

plan and accompanying assessment plan in 2017. 

Without a strategic plan currently in place, the process 

by which minority health, health disparities, and health 

equity goals are set is still developing. A legislative 

mandate requires the OHE to exist and be funded by 

Colorado’s general revenue. The mandate also specifies the populations that the OHE must serve, which 

include minorities, the LGBT population, older adults, 

and those with mental health issues. Currently, many 

governmental and nongovernmental agencies are 

compiling data about minority health. These agencies 

are the CDPHE, the Colorado Department of Health 

Care Policy and Financing (responsible for administering the state Medicaid program), the Department of 

Human Services, the Colorado Health Foundation, the 

Colorado Health Institute, the Colorado Public Health 

Foundation, and others. The Colorado Health Foundation is the largest private funder of health initiatives 

in the state and recently increased its focus on health 

equity. The Colorado Health Institute and the Colorado 

Public Health Foundation have been instrumental in 

developing policy related to minority health in the state. 

By late 2017 or early 2018, the OHE will assemble the 

data collection efforts of these agencies into a report. 

The strategies OHE is currently leading to reduce 

health disparities and achieve health equity are part 

of the cultural change efforts within CDPHE to address 

health equity activities across the CDPHE. CDPHE 

initiated a policy, the Health Equity and Environmental 

Justice Principles, which encouraged, if not mandated, 

that all CDPHE staff seek opportunities to incorporate 

health equity and/or environmental justice into their 

work. To coincide with the implementation of this policy, 

the OHE developed a mandatory, online, 40-minute 

health equity and environmental justice training to 

assist in establishing a baseline across the CDPHE 

to inform all staff members about the CHPHE policy. 

To further support these efforts, the OHE is leading 

conversations with groups of 10–15 people in various 

divisions. The groups discuss specific examples of 

what it looks like to incorporate equity and justice into 

their work, how to be intentional in the use of data to 

drive decision-making, and how to avoid victim blaming 

when using data to tell the story of disparities. 

Acronym List

Full Name of Agency Acronym Acronym

Colorado Department of Public Health and 

Environment CDPHE

Office of Health Equity OHE

To support the focus on CDPHE’s new policy, the OHE 

started a major reorganization of its staff in December 

2015. New hires include a community engagement 

specialist and a policy analyst, and OHE plans to hire 

a health equity and environmental justice trainer. 

Finally, since the OHE itself is small, the OHE needed 

to develop the skills of CDPHE in order to better 

support health equity activities. Through the meetings 

and conversations that are part of the strategy to get 

all staff to think critically about serving minority populations, the OHE staff heard that there was a need for 

practical steps that staff could take to be more intentional about working for equity, so another strategy 

was to develop tools to assist staff. One tool describes 

what resources staff should have in place prior to 

initiating engagement activities. Another tool is the 

equity action plan, which addresses the equity-related 

questions that a staff member might want to consider 

before attempting to develop programs to serve 

State and Territorial Efforts to Reduce Health Disparities 43
Colorado

marginalized communities. These OHE tools and 

training resources do not specifically address particular 

minority populations or other populations. 

Partnerships

Primary 

collaborators

• Colorado local public health 

departments

• Colorado nonprofit community

• CDPHE leadership

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding.

In addition to the work described above, the OHE 

partners with governmental and nongovernmental 

organizations to work toward eliminating health 

disparities and advancing health equity in the state. 

For example, OHE’s equity and justice training is not 

just available to state-level, public health staff. Local 

public health departments also have access to this 

training, but they are not mandated to receive the 

training as state employees are. OHE works with local 

health departments and acts as a resource to maintain 

interest and engagement in health equity activities. 

There is no formal contract with local public health 

departments, but the OHE is working to establish 

a certain number of formal relationships with these 

agencies by the end of 2017. The OHE interacts with 

the nonprofit community in a similar way by sharing 

OHE resources and tools, since the nonprofit 

community is where much of the work around equity 

and minorities takes place. The OHE has shared 

resources with community partners, including the 

African American Health Alliance, the Latino Chamber 

of Commerce, and the Women’s Foundation of 

Colorado. The partnership with the CDPHE leadership 

focuses on promoting culture change within the 

1,400-person department and encouraging involvement 

by leadership of the department’s 11 divisions.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$575,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $425,000

Largest funding source State government

Anticipated changes to budget Possible (as reported 

at the time of data 

gathering)

The total FY 2015 funding for the OHE was $575,000. 

This funding is separate from other funding for CDPHE. 

In FY 2015, the office had three key funding sources: 

the state tobacco tax funding ($225,000); the State 

of Colorado general revenue funding ($200,000); and 

Federal Prevention Block Grant funding ($150,000). 

All these funding sources and amounts have been 

ongoing. The OHE did not provide any funding to 

partners or other entities in FY 2015, but it awards 

Health Disparities Grants totaling approximately 

$5,000,000 every 3 years to nonprofit organizations 

throughout the state to work on reducing health 

disparities among minority and marginalized populations. The grants were last made available in 2015. 

If changes occur in federal priorities, the level of 

funding for OHE might change.

State and Territorial Efforts to Reduce Health Disparities 44
Colorado

Colorado State Data

Total Populationa: 

5,540,545

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 21.3 78.7 84.2 4.2 0.9 3.3 7.4 100.0 NA 

Percent of population 

medically uninsureda 17.0 5.5 7.4 7.4 15.4 6.8 14.4 8.0 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.1 4.2 4.4 7.7 SP SP NC 4.7 5.9

Age-adjusted 

mortality rateb 666.3 668.2 676.1 725.0 496.5 412.7 NC 669.5 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 10.8 14.4 13.6 14.3 16.2 13.3 19.2 13.9 13.6

Percent with 

diabetesc 8.2 6.2 6.4 7.6 11.8 3.5 9.3 6.6 10.8

Percent with 

heart diseasec 2.5 3.2 3.1 2.0 4.7 0.6 2.7 3.0 4.3

HIV rated 282.9 NC 213.3 947.9 205.9 85.1** 289.1 253.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

56.6 64.7 63.3 69.1 61.5 64.8 60.0 63.4 72.2

Percent received 

oral health visit 

(past 12 months)c

57.1 70.0 68.8 54.9 62.3 69.5 62.7 67.8 66.5

Percent received 

flu vaccinec 39.9 43.6 43.1 39.4 48.6 46.3 38.3 43.0 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 85.1 per 100,000 population (118 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 220.8 per 

100,000 population (13 cases).

State and Territorial Efforts to Reduce Health Disparities 45
Connecticut

Introduction to Connecticut’s Health Equity Activities

Connecticut had an estimated 2016 population of 3,576,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (16 percent) followed by Blacks/African Americans (11 percent), Asian Americans and NHOPI 

(5 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 8 percent of the population.1 Approximately 459,000 Connecticut residents live within 

a primary care health professional shortage area.2

In 2014, Public Act 14-231 created the Connecticut Department of Public Health (CDPH)’s Office of Health Equity 

(OHE), replacing CDPH’s former Office of Multicultural Health. The OHE operationalizes the CDPH’s priority to 

“champion a culture of health equity.”3 Its specific mission is “to improve the health of all Connecticut residents 

by working to eliminate differences in disease, disability and death rates among ethnic, racial and other population 

groups that are known to have adverse health status or outcomes.”4 Housed within the CDPH’s Public Health 

Systems Improvement division, the OHE is tasked with ensuring that health equity is a crosscutting principle 

in all CDPH programs, data collection, and planning efforts.

Connecticut Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Health Equity released 

the Connecticut Department of Public 

Health Office of Health Equity Strategic 

Plan 2015-2018 in 2015, which 

it updates annually, as needed.5

Date strategic plan 

was last updated 2016

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Office of Health Equity monitors 

progress through the Healthy 

Connecticut 2020 Performance 

Dashboard. 

Key strategies 

used to achieve 

health equity

• Measuring the health equity impact 

of Connecticut Department of Public 

Health policies and programs

• Implementing a language access plan

• Identifying and monitoring indicators 

of health equity

• Developing Prevention Service 

Centers via State Innovation Model 

Test Grant

• Workforce development training in 

health equity 

Organizational Structure

The OHE is located within the Office of the Commissioner as part of Public Health Systems Improvement, an office focused on improving public health 

structures, systems, and outcomes. The OHE moved 

to Public Health Systems Improvement in December 

2010 to be in a better position to integrate health 

equity into the agency’s ongoing program and 

planning efforts.

The OHE has two full-time staff members who 

dedicate their time to health equity initiatives, 

including the program director and one epidemiologist. Another epidemiologist from the Community, 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 Designated HPSA Quarterly 

Summary.

3 Connecticut Department of Public Health Strategic Map 

Update 2015–2018: Addendum 1 to Agency Strategic Plan 

2013–2018. Available on the CDPH website. Last accessed 

7/14/2017. 

4 Connecticut Department of Public Health: Office of Health 

Equity website. Last accessed 7/14/2017.

5 Connecticut Department of Public Health Office of Health 

Equity Strategic Plan 2015–2018. Available on the CDPH 

website. Last accessed 7/14/2017.

State and Territorial Efforts to Reduce Health Disparities 46
Connecticut

Family, and Prevention section of the CDPH dedicates 

about 10 percent of time to health equity initiatives, 

focusing specifically on tracking and analyzing disparities found in chronic disease data. The OHE occasionally engages community health workers to support 

health equity activities. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Office of 

Health Equity is 

housed within 

the Connecticut 

Department of 

Public Health.

SMHE staffing (full-time equivalents) 2

Advisory committee or panel

Connecticut 

Multicultural 

Health Partnership, 

and Advisory 

Council of the 

Connecticut Health 

Improvement 

Coalition

Program Goals and Activities

Launched in 2015, the OHE’s strategic plan acts as 

a blueprint for integrating health equity principles into 

the CDPH’s programs, plans, and policies. The plan is 

publicly available on the OHE’s website and updated, as 

needed, on an annual basis. The OHE monitors progress 

of the strategic plan through the CDPH’s publicly available Healthy Connecticut 2020 Performance Dashboard, 

which tracks population indicators, performance measures, and health disparities for seven major focus 

areas, including health equity, cultural competency, and 

language services.

Assisted by organizations like the Connecticut Multicultural Health Partnership and guided by findings from the 

Healthy Connecticut 2020 State Health Assessment and 

the State Health Improvement Plan, the CDPH and the 

OHE identify health equity priorities as part of its 

strategic planning process. Additional priorities emerged 

when the CDPH received recognition from the Public 

Health Accreditation Board in March 2017, a distinction 

earned by 21 states that have met or exceeded national 

recognized public health standards around, among other 

topics, health equity.

OHE activities to reduce disparities include an effort to 

quantify the health equity impact of CDPH policies and 

programs. Led by the CDPH Government Relations 

Office, the OHE helped to institute agency-wide guidance 

documents to ensure that the CDPH is promoting health 

equity across all its efforts. Such documents help CDPH 

staff review the health equity impact of proposed 

legislation or policy changes. The OHE also helped 

create a checklist for grant proposals to document that 

applications address health equity concerns. Moving 

forward, the OHE will monitor the extent to which these 

documents are used throughout the CDPH. 

The OHE aims to build the knowledge and skills of CDPH 

staff through health equity training and education 

activities. For example, the OHE developed an online 

training focused on the National Standards for Culturally 

and Linguistically Appropriate Services in Health and 

Health Care (National CLAS Standards). The training is 

mandatory for all new CDPH employees and is available 

to local health departments and social service providers 

in Connecticut. The OHE also compiled the Health Equity 

Toolkit (i.e., a set of resources and tools designed to 

help CDPH staff, partners, and local health departments 

understand health equity) and is planning trainings for 

its use. Additionally, the OHE will continue to promote 

the National CLAS Standards in Connecticut through 

training, workshops, and online resources. 

Another strategy led by the OHE is the implementation 

of a language access plan. To support this strategy, the 

OHE collaborated with an internal CDPH workgroup to 

translate documents posted on the web, develop a 

language access chart, and improve signage in public 

health buildings. For example, the workgroup created 

language identification or “I speak” cards translated into 

the top 10 languages spoken in Connecticut. It also 

developed a process to support implementation and 

both monitor and evaluate use of this language 

access plan. 

Acronym List

Full Name of Agency Acronym Acronym

Connecticut Department of Public Health CDPH

Office of Health Equity OHE

In a collaborative effort with CDPH’s broader Public 

Health Systems Improvement division, the OHE works 

to identify and monitor indicators of health equity. The 

OHE also has been working with programs within the 

CDPH to develop and launch additional health equity 

dashboards to improve the CDPH’s ability to identify 

additional disparities and monitor the impact of CDPH 

efforts to eliminate them. 

State and Territorial Efforts to Reduce Health Disparities 47
Connecticut

The OHE also supports the development of Prevention 

Service Centers, funded through a State Innovation 

Model Test grant from the Centers for Medicare and 

Medicaid Innovation, to improve access to evidencebased community services and encourage investments 

in community health. Coordinated through the Office 

of the Lieutenant Governor and the Office of the 

Healthcare Advocate, these centers will be established 

in geographic areas experiencing significant disparities 

and will focus on three preventable and treatable 

conditions: diabetes, asthma, and hypertension.

Partnerships

Primary 

collaborators

• Connecticut Multicultural Health 

Partnership

• Connecticut Health Improvement 

Coalition

• Local health departments

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda 

of understanding.

Although it has no contracts or memoranda of 

understanding with any partners, the OHE engages 

governmental and nongovernmental organizations 

to collaboratively eliminate health disparities and 

advance health equity in Connecticut. A key partner 

is the Connecticut Multicultural Health Partnership, 

a statewide coalition of social service organizations, 

public health entities, advocacy groups, academic 

institutions, small businesses, and community 

members. The former CDPH Office of Multicultural 

Health established the Connecticut Multicultural Health 

Partnership in 2008. Since then, the partnership has 

played a lead role in implementing National CLAS 

Standards in Connecticut. The OHE and the 

Connecticut Multicultural Health Partnership have 

worked with local health departments on trainings 

and implementation of National CLAS Standards.

Another partner is the Connecticut Health Improvement 

Coalition, a consortium of community organizations and 

statewide agencies working together to implement 

Healthy Connecticut 2020, Connecticut’s State Health 

Improvement Plan. In 2016, the OHE worked closely 

with Public Health Systems Improvement to create a 

policy agenda for the coalition. They identified policies 

for the 2017 state legislative session that would 

improve health outcomes based on the objectives set 

in the State Health Improvement Plan. For example, 

the Maternal, Infant, and Child Health team focused 

on building support for paid family leave legislation. 

Another agenda item focused on reducing the 

prevalence of and disparities in childhood lead 

poisoning through the adoption of a property 

maintenance code. Also on the agenda was a proposal 

by the Commissioner of Public Health to integrate local 

health departments into districts. In 2016, Connecticut 

had 72 local health departments, and the services they 

provided varied by geographic location. The goal for 

integration was to improve service delivery and make 

it more equitable.

The OHE also collaborates with a variety of state 

agencies and departments, nonprofit organizations, 

and academic institutions on health equity activities.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$631,806

Annual budget (FY 2015) of SMHE 

from state/territorial government $487,008

Largest funding source State government

The total FY 2015 funding for the OHE was $631,806. 

In FY 2015, the office had two funding sources: The 

State of Connecticut ($487,008) and a 2-year State 

Partnership Initiative to Address Health Disparities 

grant from the U.S. Office of Minority Health 

($144,798). The last year of the State Partnership 

Grant was FY 2015. State funding is expected to 

remain relatively stable in future years. The OHE did 

not provide funding to other governmental or nongovernmental entities for health equity activities in 

FY 2015.

State and Territorial Efforts to Reduce Health Disparities 48
Connecticut

Connecticut State Data

Total Populationa: 

3,576,452

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 15.7 84.3 76.7 10.7 0.3 4.6 7.7 100.0 NA 

Percent of population 

medically uninsureda 12.1 3.5 4.0 5.7 14.4 6.0 10.9 4.8 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 7.7 4.9 4.5 12.8 SP SP NC 5.7 5.9

Age-adjusted 

mortality rateb 504.8 662.0 658.0 707.5 111.6 329.8 NC 654.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 19.5 15.0 15.0 17.6 12.6 12.6 21.2 15.5 13.6

Percent with 

diabetesc 10.8 9.7 9.4 14.9 9.6 6.0 10.9 9.9 10.8

Percent with 

heart diseasec 1.9 3.9 4.1 2.0 4.8 1.0 2.1 3.6 4.3

HIV rated 829.9 NC 145.4 1140.8 179.8 69.1** 536.6 338.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

72.0 76.8 76.0 82.7 58.9 71.5 71.5 76.1 72.2

Percent received 

oral health visit 

(past 12 months)c

69.6 79.8 80.1 74.7 54.9 76.0 68.5 78.4 66.5

Percent received 

flu vaccinec 35.3 44.1 44.7 37.1 28.5 43.0 35.7 43.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 69.1 per 100,000 population (92 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 377.0 per 

100,000 population (4 cases).

State and Territorial Efforts to Reduce Health Disparities 49
Delaware

Introduction to Delaware’s Health Equity Activities

Delaware had an estimated 2016 population of 952,000. Blacks/African Americans are the largest racial-ethnic 

minority population (22 percent), followed by Hispanics/Latinos (9 percent), Asian Americans and NHOPI 

(4 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 5 percent of the population.1 Approximately 233,000 Delaware residents live within 

a primary care health professional shortage area.2

Within the Delaware Department of Health and Social Services, the Division of Public Health (DPH) Bureau of 

Health Equity (BHE) is dedicated to addressing issues affecting the health of minority populations. The mission of 

the BHE is “to promote and advocate for policy, programs, services, and initiatives which will eliminate the impact 

of the social determinants of health to ensure all Delawareans can achieve their optimal health with a special 

focus on the underserved populations of Delaware.”3 The BHE seeks to reduce health disparities of minority 

populations including racial-ethnic minorities, people with disabilities, women, and individuals identified as lesbian, 

gay, bisexual, transsexual, and questioning (LGBTQ). The DPH uses a health equity lens when providing services 

and carrying out activities.

Delaware Minority Health Overview

Name of state/

territorial minority 

health entity

Division of Public Health, Bureau of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

The Division of Public Health’s Health Equity Strategy Map outlines strategies for achieving health equity.

The Delaware Division of Public Health 2014 – 2017 Strategic Plan is an integrated plan with health 

equity as a strategic priority.

Date strategic 

plan was last 

updated

The Division of Public Health’s Health Equity Strategy Map is updated annually, as necessary.

The Delaware Division of Public Health 2014 – 2017 Strategic Plan was last updated August 2014.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Components of the Division of Public Health’s Health Equity Strategy Map include data-driven objectives.

The Delaware Division of Public Health 2014 – 2017 Strategic Plan includes assessment components 

to measure progress toward outcomes, objectives, and strategic priorities.

Key strategies 

used to achieve 

health equity

• Increasing knowledge and awareness of health equity and social determinants of health

• Implementing a health in all policies approach

• Increasing cultural competency

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Bureau of Health Equity. Health Equity homepage. Last accessed July 22, 2017. 

State and Territorial Efforts to Reduce Health Disparities 50
Delaware

Organizational Structure

The DPH leadership team serves as an informal 

advisory committee to the BHE. The DPH leadership 

team meets monthly to review the DPH Health Equity 

Strategy Map and update progress toward meeting 

objectives. The BHE is housed within the DPH. The 

Office of Minority Health and the Office of Women’s 

Health are both within the BHE. The BHE addresses 

minority health through these offices.

The BHE has two full-time staff members and one 

part-time staff member who work on health equity. 

However, all DPH staff work to achieve health equity. 

Full-time staff include the BHE chief and the director 

of the Office of Women’s Health; the latter position is 

vacant. The one part-time (80 percent full-time) administrative specialist works on initiatives and activities at 

the BHE exclusively. One public health associate, 

funded through the U.S. Centers for Disease Control 

and Prevention (CDC), worked on initiatives and 

activities at the BHE. Certain staff from the DPH 

volunteer some of their time to BHE initiatives 

and activities.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Bureau of 

Health Equity is 

housed within 

the Division of 

Public Health 

of the Delaware 

Department of 

Health and Social 

Services

SMHE staffing (full-time equivalents) 2

Advisory committee or panel Unavailable

Program Goals and Activities

The DPH has developed a structured approach for 

achieving health equity, which it calls the Health Equity 

Strategy Map. Created in 2012, the map illustrates 

the role of assessment components in reducing health 

disparities and guides the BHE in setting priorities.4

The DPH leadership team meets monthly both to review 

the Health Equity Strategy Map objectives and to monitor 

progress in achieving them; it plans to update the 

document in 2017. In addition, the DPH created the 

Delaware Division of Public Health 2014 – 2017 Strategic Plan between September 2013 and August 2014. 

This plan identifies four strategic priorities: “Promote 

Healthy Lifestyles, Improve Access to High Quality and 

Safe Healthcare, Achieve Health Equity, and Improve 

Performance.”5 By September 2017, the DPH leadership team intends to form a Strategic Plan Action 

Committee to develop and plan a new DPH strategic 

plan for 2018 through 2022.6

Acronym List

Full Name of Agency Acronym Acronym

Bureau of Health Equity BHE

Division of Public Health DPH

To help set priorities, the BHE brings together health 

care stakeholders from public, nonprofit, and private 

agencies and organizations for an annual health equity 

summit. Through the summit the BHE offers a vehicle 

to provide input on issues not currently addressed, 

seek feedback from attendees, and conduct county-level 

workshops. During these workshops, community 

members, nonprofit organizations, and private entities 

offer their insights about a range of health issues. The 

feedback then informs the BHE’s priorities and goalsetting activities for the upcoming year. 

The BHE seeks to address health disparities through 

several strategies, including increasing knowledge and 

awareness of health equity and social determinants of 

health, addressing health equity through a Health in all 

Policies approach, and increasing cultural competency. 

It operationalizes these strategies by collaborating with 

the DPH to identify high-priority areas (“hot-spots”), 

with local health and other agencies to address equity 

issues in the hot spots, and with the nongovernmental 

organizations that host activities celebrating minority 

health month.

Using a Health in all Policies approach and a systems 

perspective, the BHE aims to bring together health and 

non-health sectors to enhance agency and organization 

capacity for meeting the needs of underserved individuals. The BHE has formed a Health in all Policies 

4 Division of Public Health. Health Equity Strategic Map. Available on the Delaware Division of Public Health website. Last accessed July 22, 

2017.

5 Delaware Health and Social Services, Division of Public Health. Delaware Division of Public Health 2014-2017 Strategic Plan. Available on 

the Delaware Division of Public Health website. Last accessed July 22, 2017.

6 Ibid.

State and Territorial Efforts to Reduce Health Disparities 51
Delaware

Collaborative that includes individuals both from 

governmental agencies and the private sector to 

determine whether proposed policies pose a positive 

or neutral impact on health. As part of this effort, the 

BHE trains individuals participating in the collaborative 

who, in turn, will train others in their respective organizations and agencies.

Twice a year, the BHE provides cultural competency 

training that is mandatory to all public health staff. 

It also offers the training to health care providers, 

such as staff at federally qualified health centers and 

clinicians outside of public health. The BHE also works 

with outside organizations to assess cultural 

competency levels of DPH staff and DPH services 

and to create an implementation plan for the National 

Standards for Culturally and Linguistically Appropriate 

Services in Health and Health Care (National 

CLAS Standards). 

Partnerships

Primary collaborators • AIDS Delaware

• Autism Delaware

• Beautiful Gate Outreach Center

• Breastfeeding Coalition of Delaware

• Cancer Support Community

• Cape Pharmacy

• Children & Families First

• Christiana Care Health Services

• Cross Cultural Health Care Program

• Delaware Department of Education

• Delaware Coalition Against Domestic 

Violence

• Delaware Department of Health and Social 

Services, Division for the Visually Impaired

• Delaware Department of Health and Social 

Services, Division of Public Health

• Delaware Department of Health and Social 

Services, Division of Services for Aging and 

Adults with Physical Disabilities

• Delaware Department of Justice

• Delaware Healthcare Association

• Delaware Hospice

• Doctors Pathology Services

• Each One Teach One

• Goeins-Williams Associates

• La Red Health Center

• Latin American Community Center

• Metropolitan Wilmington Urban League

• Planned Parenthood of Delaware

• Quality Insights

• Social Solutions

• Susan G. Komen

Contracts or memoranda 

of understanding with any 

partners

Yes, contracts or memoranda of 

understanding are implemented for some 

partnerships.

To reduce health disparities, the BHE works with a 

broad range of governmental, nongovernmental, and 

private partners. For example, the BHE collaborates 

with the DPH to identify areas with high levels of 

disease burden and poverty. The DPH, in turn, sends 

health educators to such hot-spots, where they engage 

and educate individuals, community-based health 

agencies and organizations, and those serving priority 

populations about social determinants of health and 

health equity issues. These health educators also work 

with non-health agencies, such as the state’s 

Department of Justice and Department of Education, 

to address a range of priority issues in hot-spot areas. 

The BHE partners with state-level departments in other 

capacities, as well. At its 2016 Health Equity Summit, 

for example, the Department of Education presented 

on its own health equity initiatives and activities, 

including collaborations it has developed with private 

agencies that fund nurse-provided health care 

services in schools.

In an effort to provide HIV-related services to at-risk 

populations, such as screening and treatment, the DPH 

formally partners with Christiana Care Health Systems 

(a statewide healthcare provider), the Latin American 

Community Center (which provides health and social 

services particularly to African American and Hispanic/

Latino Delaware residents, including pediatric lead 

abatement treatments), and the Beautiful Gate 

Outreach Center. The BHE provides these partners 

with funding to commemorate important equity-related 

events, such as minority health month.

The BHE previously partnered with Georgetown 

University to survey public health staff regarding 

the National CLAS Standards. More recently, it has 

contracted with Goeins-Williams Associates to evaluate 

application of the National CLAS Standards by 

conducting focus groups with DPH service recipients. 

The BHE also collaborates with another organization to 

review findings from both the public health staff survey 

State and Territorial Efforts to Reduce Health Disparities 52
Delaware

and the focus group assessment, and then develop 

a National CLAS Standards implementation plan.

Additionally, the BHE and DPH collaborate with 

divisions within the Delaware Department of Health 

and Social Services, including the Division of Services 

for Aging and Adults with Physical Disabilities and the 

Division for the Visually Impaired. Nongovernmental 

organizations with whom the BHE and DPH partner 

include: AIDS Delaware, Autism Delaware, the 

Breastfeeding Coalition of Delaware, the Cancer 

Support Community, Cape Pharmacy, Children & 

Families First, Cross Cultural Health Care Program, 

Delaware Coalition Against Domestic Violence, 

Delaware Healthcare Association, Delaware Hospice, 

Doctors Pathology Services, Each One Teach One, 

La Red Health Center, Metropolitan Wilmington Urban 

League, Planned Parenthood of Delaware, Quality 

Insights, Social Solutions, and the Susan G. 

Komen Foundation.

Funding 

Annual budget (FY 2017) of state/

territorial minority health entity 

(SMHE) across all income sources

Unavailable

Annual budget (FY 2017) of SMHE 

from state/territorial government $319,300

Largest funding source Delaware government

Anticipated changes to budget None

The total FY 2015 funding for the BHE was $363,000 

(or $557,300 or $607,300). The BHE receives 

$319,300 from the Delaware government for health 

equity initiatives and activities. For FY 2015, the BHE 

received $50,000 in federal grants. From 2015 to 

2019, the BHE also received a federal grant for 

violence prevention from the CDC, through the Office 

of Women’s Health, for $238,000 a year. The BHE 

funds several nongovernmental organizations, including 

the Latin American Community Center ($5,104), 

Beautiful Gate Outreach Center ($2,500), and 

Goeins-Williams Associates ($31,480). The BHE does 

not anticipate funding changes in the next 2 years.

State and Territorial Efforts to Reduce Health Disparities 53
Delaware

Delaware State Data

Total Populationa: 

952,065

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 9.1 90.9 69.2 21.7 0.4 4.1 4.6 100.0 NA 

Percent of population 

medically uninsureda 15.9 5.3 5.6 7.5 6.4 4.7 11.4 6.2 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 9.5 7.9 13.4 SP SP NC 9.1 5.9

Age-adjusted 

mortality rateb 502.7 755.0 749.3 803.1 340.2 277.8 NC 746.2 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 10.9 12.8 11.5 16.6 20.0 12.9 15.6 12.9 13.6

Percent with 

diabetesc 7.5 10.9 10.3 12.9 5.2 7.2 11.0 10.8 10.8

Percent with 

heart diseasec 1.0 4.2 5.0 1.6 0.6 1.2 3.3 4.0 4.3

HIV rated 446.3 NC 181.8 1133.4 116.4 23.0** 910.6 404.9 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

72.2 79.2 77.2 86.3 90.6 65.6 82.6 79.2 72.2

Percent received 

oral health visit 

(past 12 months)c

54.3 68.4 70.8 61.7 43.2 68.7 57.1 67.9 66.5

Percent received 

flu vaccinec 38.1 41.8 45.3 29.6 23.4 51.6 41.1 41.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 23.0 per 100,000 population (7 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 362.3 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 54
District of Columbia 

Introduction to District of Columbia’s Health Equity Activities

The District of Columbia had an estimated 2016 population of 681,000. Blacks/African Americans are the largest 

racial-ethnic minority population (47 percent), followed by Hispanics/Latinos (11 percent), Asian Americans and 

NHOPI (4 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as 

multiracial or “other race” comprise 8 percent of the population.1 Approximately 249,000 District of Columbia 

residents live within a primary care health professional shortage area.2

In 2015, the District of Columbia Department of Health (DOH) created the Office of Health Equity (OHE) by 

administrative order. Its mission is to address the root causes of health disparities—beyond health care and 

health behaviors—by supporting multi-sectorial efforts to enable all DC residents to reach their optimal health.3

The OHE’s overarching goal is to improve the context for equitable opportunities for health in the District of 

Columbia. Based on the recently released DC Health Systems Plan,4 barriers to health care access are less tied 

to quantity and relate more to complementary issues, such as transportation, cost, cultural competency, and hours 

of operation. Over the last decade, the District of Columbia’s focus, supported by major investments in primary 

care facilities across the city, means that DC now has a network of well-distributed Federally Qualified Health 

District of Columbia Minority Health Overview

Name of state/territorial minority 

health entity District of Columbia Department of Health, Office of Health Equity

Strategic plan in place to 

address minority health or health 

equity

Yes. The District of Columbia Department of Health’s DC Healthy People 2020 strategies 

directly reference promoting health equity and addressing health disparities and 

disparate populations.

Date strategic plan was last 

updated 2016

Assessment plan in place 

to measure progress toward 

reducing health disparities

The District of Columbia Department of Health’s DC Healthy People 2020 (shared 

community agenda) includes over 160 objectives, many of which measure and track 

disparate outcomes by race, ethnicity, gender, age, and/or geography. 

Key strategies used to achieve 

health equity

Promoting a multi-sectorial health policies approach across public, private, and nonprofit 

sectors. This is operationalized by applying a 3-pronged strategy, including the following:

• Building multi-sector collaborations

• Leveraging community-based participatory research

• Demonstrating health equity practice change. 

Note: OHE will release the inaugural “Health Equity Report” for the District of Columbia 

in winter 2017 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Government of the District of Columbia Department of Health. Office of Health Equity website. Last accessed 1/24/2018.

4 Government of the District of Columbia Department of Health (May 2017). Draft District of Columbia Health Systems Plan. Available at the 

DOH website. Last accessed: 1/24/2018

State and Territorial Efforts to Reduce Health Disparities 55
District of Columbia 

Centers (FQHCs) and hospital-based private and specialized practices. As a consequence, although isolated gaps 

may exist, capacity is not the leading issue. A recent assessment shows that residents frequently opt to travel 

significant distances to access primary care services. This is despite the fact that there are access points in 

their communities. Overall, while some gaps and barriers exist—especially related to specialty care services—

the District’s greatest challenges relate to the social determinants of health—income, race, education, and 

transportation—which represent the critical barriers to care.

Organizational Structure

In 2015, a DC Department of Health (DOH) administrative order established the OHE within DOH to 

address the root causes of health disparities. The DC 

Commission on Health Equity—developed under DC 

Act 21-44 “Commission on Health Equity Amendment 

Act of 2016” (August 18, 2016), was launched June 

2017. It will consist of nine voting and eight non-voting 

members; the former must have expertise in particular 

topics, including health disparities, social and human 

services, early learning and education, minority communities, economic development, and ecology and 

the environment.5,6 The Commission will serve in an 

advisory capacity to the OHE, DOH, the mayor, and the 

DC Council. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

OHE is a division 

of the District 

of Columbia 

Department of 

Health—it is 

one of 6 DOH 

Administrations 

SMHE staffing (full-time equivalents) 5

Advisory committee or panel Commission on 

Health Equity—

launched June 

2017

The OHE has five full-time staff members dedicated 

to addressing the root causes of health disparities and 

health inequities, increasing opportunities for health, 

and promoting health equity. Full-time OHE staff include 

the director, two public health analysts, a public health 

advisor, and a community engagement coordinator. In 

FY16, the OHE also had two student interns (in public 

health and urban planning) from George Washington 

University. The new Commission on Health Equity will 

have a total of 17 (unpaid) advisory commissioners, 

appointed by the mayor and DC Council. 

Program Goals and Activities

The DOH has an integrated strategic approach to 

addressing health disparities and health inequities and 

promoting health equity. Addressing the social determinants of health is one of DOH’s five Strategic Priorities. 

All six DOH Administrations—including the OHE—are 

charged to integrate addressing health disparities and 

inequities and promoting health equity as a priority in 

all their work. 

The District of Columbia Department of Health’s 

DC Healthy People 2020 was published in April 2016. 

Also of note, DOH recently released the DC Health 

Systems Plan (2017), which focuses more specifically 

on the Health Care Delivery System. It includes 

specific goals under Community Health Improvement, 

to promote health equity, improve health outcomes, 

and reduce disparities. 

DC Healthy People 2020, a shared community agenda 

focusing on population health improvement, was developed as a multi-sectorial collaboration using a health 

equity lens. It recommends over 80 strategies that focus 

on social and structural determinants of health and 

changing the context through policy, aiming to address 

health disparities and disparate populations.7 DC 

Healthy People 2020 includes assessment components, 

via over 160 objectives that are tracked over time. At the 

time of data collection, the DOH Office of Policy Planning 

and Evaluation (CPPE) was developing the DC Health 

Systems Plan, focused on the health care delivery 

system. Simultaneously, the OHE was developing a 

Health Equity Report, as well as the launch the Commission on Health Equity, both expected to be completed 

prior to publication of this report.

The OHE mission charges this administration to focus 

on the root causes of health disparities, “beyond 

health care and health behaviors.” The OHE therefore 

emphasizes the need to act on the social determinants 

of health, outside of the traditional health care and 

5 Council of the District of Columbia (2014). D.C. Act 20-484. 

6 Council of the District of Columbia. Law 2-192, Commission on Health Disparities Establishment Act of 2014.

7 Government of the District of Columbia Department of Health (April 2016). DC Healthy People 2020 Framework. 

State and Territorial Efforts to Reduce Health Disparities 56
District of Columbia 

health delivery systems. The OHE provides leadership 

within DOH and across the District of Columbia in the 

practical application of health in all polices, programs, 

and practices. The data and evidence confirm that place 

and race matter for health in the District. Upon release 

of the Health Equity Report 2017, the OHE in collaboration with the Commission on Health Equity (CHE) will 

hold community conversations across the District, to 

inform priority setting focused on improving opportunities for health. 

Acronym List

Full Name of Agency Acronym Acronym

District of Columbia Department of Health DOH

District of Columbia Office of Health Equity OHE

The OHE also promotes a shared community agenda 

to achieve health equity, and uses several major 

strategies to reduce health inequities. To promote and 

achieve health equity, the OHE recognizes that public 

health activities alone cannot control most social 

determinants of health, and that clinical medicine 

alone cannot prevent or correct all adverse outcomes. 

For these reasons, the OHE seeks to develop datadriven, evidence-based, and evidence-informed strategies that leverage multi-sector collaborative partnerships. The OHE uses a “health in all policies” approach 

to improving community health and equity; it serves as 

a liaison and technical adviser to its five sister DOH 

Administrations, District Government agencies, private 

and nonprofit partners, health care partners, and 

community groups and residents. For instance, in 

2016, the OHE worked with the District of Columbia 

Department of Transportation and other partners 

to implement “Vision Zero,” an initiative to eliminate 

traffic fatalities and advance pedestrian and 

bicycle safety. 

Another major OHE strategy leverages communitybased participatory research. The OHE defines 

“community” to include nonprofit organizations, 

hospital practitioners, agencies, and others. The 

OHE seeks to apply data-driven and evidence-based 

research methods, tools, and practices—such as 

geographic information systems (GIS) analysis—and 

to publish reports with community partners to build 

an evidence base to inform policymaking. It also seeks 

to measure social determinants and health outcomes, 

enabling it to identify opportunities for eliminating 

health inequities across socioeconomic and demographic subpopulations. The OHE plans to use communitybased participatory research to inform and support the 

design, development, implementation, and evaluation 

of health equity programs. Mechanisms for doing so 

have evolved. Historically, DC has collected and 

analyzed data primarily across the District of Columbia’s 

eight wards. However, recognizing that the ward-based 

analysis misses more granular disparities, the OHE has 

started evaluating data by statistical neighborhoods 

based on census tracts. This analysis will provide the 

baseline for a planned inaugural health equity report. 

Another major OHE strategy is demonstrating health 

equity practice change. As such, it is developing and 

implementing initiatives that have the potential to 

improve population health generally and promote 

health-enhancing opportunities, especially among 

vulnerable populations. For instance, the OHE worked 

with other District agencies and community partners 

on a Safer Stronger Advisory Committee to prevent 

violence using a public health approach.8 The OHE 

also worked with other District agencies, community 

residents and developers on the Buzzard Point 

Community Health and Safety Study,9 an assessment 

of potential health and safety issues facing Buzzard 

Point, a residential community within the city’s 

southwestern quadrant. 

8 Government of the District of Columbia (August 2015). Safer Stronger DC. Available at the “Executive Office of the Mayor” website. 

Last accessed: 1/24/18

9 District of Columbia Department of Health, Office of Health Equity (August 2016). Buzzard Point Community Health and Safety Study 

(CHASS). Available on the DOH website. Last Accessed: 3/27/2017.

State and Territorial Efforts to Reduce Health Disparities 57
District of Columbia 

Partnerships

Primary 

collaborators

• All five DOH Administrations—CPPE; 

CHA; HAHSTA; HEPRA; HRLA

• District of Columbia Department of 

Energy and Environment

• District of Columbia Department 

of Transportation

• District of Columbia Office 

of Planning

• Office of Deputy Mayor for Planning 

and Economic Development

• Office of the City Administrator

• Office of the Chief Medical Examiner

• District of Columbia Housing 

Authority

• DC Healthy Communities 

Collaborative 

• Kaiser Permanente

• Advisory Neighborhood Commission 

6D

• Empower DC

• Breathe DC

• District of Columbia Chamber 

of Commerce

• George Washington University

• Georgetown University

• Howard University

• Office of the State Superintendent 

for Education (OSSE)

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda 

of understanding are implemented 

for some partnerships.

The OHE works with many private, governmental, 

and nongovernmental organizations to achieve its 

overarching goal. For example, it informally partnered 

with the following District of Columbia agencies 

to address the brownfield site (i.e., a potentially 

contaminated property) that was ultimately redeveloped 

to house the new DC United Soccer Stadium: the 

Department of Energy and Environment, the Office of 

Deputy Mayor for Planning and Economic Development, 

the Office of Planning, the Department of 

Transportation, the Office of the City Administrator, 

and the District of Columbia Housing Authority. After 

analyzing health outcome data by census tract in the 

nearby residential neighborhoods, the OHE found 

increased rates for some diseases, together with 

significant socioeconomic disparities in risk and 

protective factors. It published these findings in a 

report, accompanied by recommendations, to protect 

community residents from adverse health effects, such 

as from dust and neighborhood quality of life impacts 

during construction.10

In another partnership example, the Rockefeller 

Foundation recently inducted the District of Columbia 

into a global network of “100 Resilient Cities.”11

The OHE has collaborated with the Office of the 

City Administrator to incorporate health and equity 

considerations in the overarching strategy, and with 

the DC Office of Planning to add a “resilience element” 

promoting health and equity considerations within 

the District of Columbia’s Comprehensive Plan update, 

which will guide future development in the city.12

The OHE also works in partnership with the District of 

Columbia Department of Transportation, together with 

DOH Administrations, Center for Policy Planning and 

Evaluation (CPPE), and the Health Emergency 

Preparedness and Response Administration (HEPRA), 

on the “Vision Zero” Initiative. This effort seeks to 

attain zero fatalities and serious injuries to residents 

and visitors on DC streets. The CPPE’s data analysis 

found that the city’s serious or fatal injuries 

predominately involved racial or ethnic minorities, 

particularly African Americans, and in many cases 

involved children or older adults.13

In addition, the OHE works with DOH’s Health 

Emergency Preparedness and Response Administration 

(HEPRA) to develop a trauma registry that engages 

local hospitals and trauma centers as partners. This 

registry tracks all trauma patients entering emergency 

rooms from trauma centers. Its initial goal was to track 

related serious injuries and fatalities, but the 

collaboration has enabled enhanced communication 

between the DOH, trauma centers, and other agencies 

that will enable a more robust registry that tracks 

additional detail (e.g., cause of injury and 

ambulatory transports).

10 Ibid.

11 The Rockefeller Foundation. 100 Resilient Cities. Website last accessed: 3/27/2017.

12 District of Columbia Office of Planning. Resilience. Available at the Office of Planning’s website. Last accessed: 3/27/2017.

13 Government of the District of Columbia (December 2015). A Plan of Action, Vision Zero, Safe Streets for Washington, D.C. Available at the 

“DC Vision Zero” website. Last accessed: 3/27/2017.

State and Territorial Efforts to Reduce Health Disparities 58
District of Columbia 

The OHE also collaborated with the Office of the Chief 

Medical Examiner (OCME) on the Safer Stronger 

Advisory Committee, co-chaired by DOH and OCME 

directors. Following a spike in violence in the summer 

of 2015, the DOH took the lead in engaging the city 

in discussion of a public health approach to violence 

by gathering a 31-member public-private committee 

with representatives from social services, economic 

development, community organizations and courts. 

The committee made 55 multi-sectorial 

recommendations to prevent violence in a published 

report that was distributed to all deputy mayors.14

Another OHE collaboration is with the DC Healthy 

Communities Collaborative, which includes four 

hospitals (Providence Health System, Howard University 

Hospital, Children’s National Health System, and Sibley 

Memorial Hospital), four community health centers 

(Community of Hope, Bread for the City, Mary’s Center, 

and Unity Health Care), and two associations (DC 

Primary Care Association and DC Hospital Association). 

Under the Affordable Care Act, nonprofit health 

systems submit Community Benefit Plans every 3 

years to maintain their IRS nonprofit status. Part of 

these requirements includes completing a community 

health needs assessment (CHNA) and improvement 

plan (CHIP). Through collaboration, the OHE promotes 

the alignment of the DC Healthy Communities 

Collaborative CHNA and CHIP with the strategic goals 

and priorities of DC Healthy People 2020 (DOH’s shared 

community agenda). Working towards a more formal 

partnership is envisioned in the medium term, which 

would leverage DOH local data in the Collaboration’s 

CHNA process.15

Academic partnerships are another important DOH 

and OHE strategy. The OHE informally collaborates and 

consults with local universities, including Georgetown 

University, George Washington University, and Howard 

University. Indeed, OHE staff have given lectures and 

taught classes in these institutions, and academic 

staff from these schools participate in DOH and 

OHE activities. 

Community-wide strategic engagement and information 

sharing are another part of the OHE’s strategies for 

achieving health equity. For example, it has attended 

and presented to the DC Chamber of Commerce to 

inform Chamber committees and members about their 

role within a multi-sector “health in all policies” 

framework for improving community health and 

promoting health equity. This approach was presented 

by the DOH director to the DC Chamber of Commerce’s 

committee on health.

Funding 

Annual budget (FY 2017) of state/

territorial minority health entity 

(SMHE) across all income sources

$1,100,000

Annual budget (FY 2017) of SMHE 

from state/territorial government $1,100,000

Largest funding source District of Columbia 

government

Anticipated changes to budget None

The total FY 2015 funding for the OHE was zero 

dollars, because it had not been formally launched. 

In FY 2016, the OHE’s budget was $600,000. In FY 

2017, the OHE’s budget was $1,100,000. The District 

of Columbia fully funds the OHE. The OHE does not 

fund nongovernment organizations. The OHE does 

not anticipate funding changes in the next few years.

14 Government of the District of Columbia Department of Health (June 2016). Safer, Stronger DC Advisory Committee Final Report. Available 

at the DOH website. Last accessed: 3/28/2017. 

15 District of Columbia Healthy Communities Collaborative (June 2016). District of Columbia Community Health Needs Assessment. Available 

at the “DC Health Matters” website. Last accessed: 3/28/2017.

State and Territorial Efforts to Reduce Health Disparities 59
District of Columbia 

District of Columbia Data

Total Populationa: 

681,170

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 10.9 89.1 40.9 47.2 0.1 3.9 7.9 100.0 NA 

Percent of population 

medically uninsureda 11.3 3.2 2.1 4.7 0.0 2.0 11.6 4.1 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 14.0 SP 13.6 SP SP NC 8.8 5.9

Age-adjusted 

mortality rateb 412.6 779.7 422.3 1040.1 SP 356.5 NC 766.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 21.4 14.5 11.4 17.2 SP 19.8 20.7 15.1 13.6

Percent with 

diabetesc 3.0 8.2 2.5 14.1 SP 2.0 3.9 7.7 10.8

Percent with 

heart diseasec 0.3 2.6 1.6 3.7 SP 0.0 1.0 2.4 4.3

HIV rated 1954.1 NC 1098.5 4113.7 1018.8 306.7** 4411.4 2590.2 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

71.4 80.0 69.2 89.5 SP 74.2 75.0 78.9 72.2

Percent received 

oral health visit 

(past 12 months)c

74.2 76.7 80.5 73.0 SP 74.4 74.9 76.6 66.5

Percent received 

flu vaccinec 32.6 37.7 47.0 28.8 SP 37.5 29.2 37.0 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 306.7 per 100,000 population (73 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 2730.4 per 

100,000 population (8 cases).

State and Territorial Efforts to Reduce Health Disparities 60
Florida

Introduction to Florida’s Health Equity Activities

Per Florida’s Community Health Assessment Resource Tool Set, Florida had an estimated 2016 population of 

20,231,092. Hispanics/Latinos are the largest racial-ethnic minority population (25 percent), followed by Blacks/

African Americans (16 percent), Asian Americans and NHOPI (3 percent), and American Indians/Alaska Natives 

(less than 1 percent). Persons self-identifying as multiracial or “other race” comprise 5 percent of the population.1

Approximately 5,991,000 Florida residents live within a primary care health professional shortage area.2

In 2004, the Florida State Legislature established the Office of Minority Health within the Florida Department of 

Health (DOH). The name was changed to the Office of Minority Health and Health Equity (OMHHE) on July 1, 2016.3

Florida Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health and Health 

Equity

Strategic plan in 

place to address 

minority health 

or health equity

Yes, health equity is integrated into 

all strategic plans of the Florida 

Department of Health. 

Date strategic plan 

was last updated

Strategic plans are updated 

quarterly and annually.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Within each strategic plan, 

objectives are specified. 

Key strategies 

used to achieve 

health equity

• Diabetes self-management 

programming for African American 

and Hispanic communities

• HIV prevention and intervention 

in minority communities

• Health in All Policies initiative

• Healthiest Weight Initiative

• Chronic Disease Management

Florida statute mandates 10 

priority areas that are addressed 

by the OMHHE. These priority 

areas include: Cancer, Diabetes, 

Cardiovascular Disease, Sickle 

Cell Disease, Infant and Maternal 

Mortality, Dental Health, Lupus, 

Adult and Child Immunizations, 

Social Determinants of Health, 

HIV/AIDS

Organizational Structure

The Florida legislators created the Senior Health Equity 

Officer position, which reports to the deputy secretary 

for health, who reports to the state surgeon general. 

A group of program staff and local health department 

directors comprise the Health Equity Program Council, 

which serves in an advisory role to the OMHHE. 

Members of the Health Equity Program Council champion health equity and implement activities within their 

respective communities.

The OMHHE has six full-time staff who are dedicated 

to minority health and health equity activities. Staff 

include the Senior Health Equity Officer, The Closing 

the Gap Grant Administrator, two mid-level staff who 

are responsible for contract management and event 

coordination, and two administrative support staff. 

The OMHHE anticipates that additional staff will join 

the office, but details are unknown at this time. 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Florida DOH, Minority Health and Health Equity website. Last 

accessed 7/20/17

State and Territorial Efforts to Reduce Health Disparities 61
Florida

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Office of 

Minority Health 

and Health Equity 

is within the Office 

of the Deputy 

Secretary for 

Health.

SMHE staffing (full-time equivalents) 6

Advisory committee or panel Health Equity 

Program Council

Program Goals and Activities

Although the OMHHE does not have a strategic plan 

focusing specifically on minority health or health 

disparity elimination, all DOH strategic plans promote 

health equity and health equity processes are 

embedded in the plans and strategies of all bureaus 

and divisions at the Florida Department of Health. 

Promoting health equity in all public health activities 

was a guiding principle for the DOH while developing 

its latest strategic plan. That document, the Agency 

Strategic Plan 2016–2018, includes strategies and 

objectives to address five strategic priorities and reach 

identified goals, including the strategy to “eliminate 

racial disparity in infant mortality.”4 In addition, the DOH 

is working on an update of the Florida State Health 

Improvement Plan to cover the period of 2017–2021.5

In Florida, minority health and health equity priorities 

are set through executive and legislative mandate. 

Available data and state health assessments aid the 

DOH in decision-making about priorities. Nongovernmental stakeholders are also involved in the prioritysetting process. A State Health Improvement Plan 

Steering Committee is responsible for identifying 

priorities as part of the process for updating the plan.6

Acronym List

Full Name of Agency Acronym Acronym

Florida Department of Health DOH

Office of Minority Health and Health Equity OMHHE

To improve minority health and reduce disparities, the 

OMHHE partners with local health organizations to 

provide diabetes self-management classes for African 

American and Hispanic communities. The DOH Division 

of Disease Control and Health Protection supports 

minority health by providing HIV prevention and intervention services in minority communities. Additionally, 

the HIV Prevention Program promotes HIV prevention 

among minority communities through a statewide 

media campaign that includes advertising, social 

media, and outreach events.7 Statewide initiatives, 

such as Healthiest Weight Florida, promote health 

among all Floridians, including racial and ethnic 

minority populations. 

In Hillsborough and Pinellas Counties, the DOH 

is working on a Health in all Policies strategy to 

encourage consideration of health in policies across 

different sectors in the county.8 To advance Health 

in All Policies, local health department staff create 

recommendations and share with stakeholder and 

policymakers and advocate for inclusion of health 

in the policymaking process. 

Partnerships

Primary 

collaborators

• Franklin County Public Health

• Gulf County Health Department

• Hebni Nutrition Consultants

• Metropolitan Charities

• Mother Care Network

• Sickle Cell Foundation

• Latino Salud

• Caridad

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The OMHHE partners with a range of organizations 

to advance minority health and health equity in Florida. 

The OMHHE collaborates with Metropolitan Charities 

on HIV prevention activities, including interventions, 

testing, and outreach to African American/Black and 

Hispanic youth ages 13–19. Hebni Nutrition 

Consultants, a community-based, nonprofit organization 

partners with the OMHHE to promote heathy eating 

4 Florida Department of Health: Agency Strategic Plan 2016-2018. Available on the Florida DOH website. Last accessed 7/20/17.

5 Florida Department of Health: State Health Improvement Plan (SHIP). Available on the Florida DOH website. Last accessed 7/20/17.

6 Ibid.

7 Florida DOH, HIV/AIDS Section website. Last accessed 7/20/17.

8 Florida DOH in Hillsborough County Health in All Policies. Available on the Florida DOH website. Last accessed 7/20/17.

State and Territorial Efforts to Reduce Health Disparities 62
Florida

among diverse populations. Through this partnership, 

Hebni Nutrition Consultants launched Fresh Stop, 

a mobile farmers market to improve access to fresh 

fruits and vegetables for vulnerable populations in 

Central Florida.9 Additionally, the OMHHE and Hebni 

Nutrition Consultants have worked on expanding 

Project Oasis, a program aimed at reducing the risk 

of diabetes by promoting consumption of fruits 

and vegetables.

Other significant nongovernmental partner 

organizations include the Sickle Cell Foundation 

and the Mother Care Network. The OMHHE contracts 

with the Sickle Cell Foundation to provide education, 

screening, case management, and support services 

for individuals with sickle cell disease or sickle cell trait 

and affected families in Orange, Seminole, and Osceola 

Counties (i.e., the Tri County area). Mother Care 

Network and the OMHHE work together on a 

community-based program aimed at improving health 

outcomes for individuals with type 2 diabetes and 

cardiovascular disease in Gadsden County.

In addition, through the Closing the Gap grant the 

OMHHE partners with the University of Florida College of 

Medicine’s Mobile Outreach Clinic, which both facilitates 

training and provide services to include low-income and 

underserved communities in and around Alachua 

County.10 Also supported by the OMHHE’s Reducing 

Racial and Ethnic Health Disparities “Closing the Gap” 

grant, Gulf and Franklin County Health Departments 

deliver healthy cooking demonstrations in grocery stores 

and facilitate healthy eating curriculum in faith-based 

organizations. This work aligns with other initiatives, 

including Healthiest Weight Florida and Community 

Health Improvement Plans.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$2,800,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $2,800,000

Largest funding source State

Anticipated changes to budget No

The FY 2015 budget for the OMHHE was $2,800,000, 

which includes state general revenue and has been 

stable at this level for 3 years. There were no additional sources of funding for the OMHHE in FY 2015. 

The OMHHE does not anticipate changes in the levels 

and sources of funding.

9 Information is available on the Fresh Stop website. Last accessed 7/20/17.

10 Information is available on the University of Florida, College of Medicine’s Mobile Outreach Clinic website. Last accessed 7/20/17.

State and Territorial Efforts to Reduce Health Disparities 63
Florida

Florida State Data

Total Populationa: 

20,612,439

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 24.9 75.1 75.5 16.1 0.3 2.8 5.4 100.0 NA 

Percent of population 

medically uninsureda 19.7 10.8 12.0 15.8 24.7 11.4 19.0 13.0 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.4 6.9 4.7 10.8 SP 6.2 NC 6.2 5.9

Age-adjusted 

mortality rateb 517.0 705.8 663.1 742.3 318.1 331.5 NC 666.6 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.9 10.8 10.9 11.7 14.3 9.0 10.6 11.0 13.6

Percent with 

diabetesc 11.0 12.1 11.4 14.8 9.1 10.9 10.6 11.8 10.8

Percent with 

heart diseasec 2.9 5.2 5.3 3.0 4.8 4.0 3.5 4.7 4.3

HIV rated 595.2 NC 302.4 1929.8 126.7 102.4** 1112.7 615.2 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

74.1 78.6 77.9 80.7 64.7 76.6 71.9 77.8 72.2

Percent received 

oral health visit 

(past 12 months)c

61.0 65.1 66.1 58.9 65.2 70.5 56.1 64.4 66.5

Percent received 

flu vaccinec 27.5 37.3 37.5 27.1 21.8 35.8 28.7 35.1 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 102.4 per 100,000 population (480 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 375.6 per 

100,000 population (40 cases).

State and Territorial Efforts to Reduce Health Disparities 64
Georgia

Introduction to Georgia’s Health Equity Activities

Georgia had an estimated 2016 population of 10,310,000. Blacks/African Americans are the largest racialethnic minority population (32 percent), followed by Hispanics/Latinos (9 percent), Asian Americans and NHOPI 

(4 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 5 percent of the population.1 Approximately 3,239,000 Georgia residents live within 

a primary care health professional shortage area.2

The state is often thought of as consisting of “two Georgias”: the sparsely-populated areas—where health care 

inaccessibility is a significant issue, and the greater Atlanta metropolitan area. Given the range of needs facing 

both rural and urban Georgians, the Georgia Department of Public Health conducted focus groups and listening 

sessions throughout the state to help inform its efforts to set strategic priorities. The information and feedback 

was used to develop the State Health Assessment (SHA). The input gathered in the SHA identified maternal and 

child health, chronic disease, and access to care as key areas of concern. 

According to the Georgia SHA, various populations face significant health disparities across different health 

outcome areas. For example, African American women are more likely than White women to be diagnosed with 

breast cancer at later stages, regardless of insurance status, and more likely to die of breast cancer in Georgia. 

Low income children are more likely to be overweight or obese. White males in rural communities are more likely 

to use tobacco products than other population groups in Georgia. Partners, stakeholders, and community members 

from throughout the state that participated in the SHA community forums felt that health equity was an important 

consideration in the SHA priority areas selected as well as an important framework for action on many of the 

priority areas.

The Georgia Department of Public Health (GDPH) seeks to improve the health of all Georgians by integrating 

the promotion of health equity into all statewide public health programs and services and into the organizational 

culture of the department. As such, the GDPH continues to enhance and grow its cross-sectional health equity 

and minority health focus throughout the organization. Because minority health and health equity activities 

are integrated into all departmental programs, the Office of the Chief of Staff manages oversight of health 

equity initiatives.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 65
Georgia

Georgia Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health

Strategic plan in 

place to address 

minority health 

or health equity

No minority health strategic 

plan has been developed since 

2014. The 2016–2021 Georgia 

State Health Improvement Plan 

(SHIP) incorporates themes of 

health disparities and health 

equity through the identification 

of social determinants of health 

relevant to specific strategies and 

activities. Health equity will also be 

included within the department’s 

strategic plan. 

Date strategic plan 

was last updated N/A

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

SHIP performance measures 

related to health disparities are 

monitored and tracked on a regular 

basis. Programs also monitor 

progress in association with routine 

grantee reporting to funders. For 

ongoing assessment, future plans 

include tracking and monitoring 

progress of health equity measures 

within the agency-wide performance 

management system. 

Key strategies 

used to achieve 

health equity

• Ensure departmental divisions, 

sections, and programs 

use a comprehensive set of 

strategies including community 

engagement, data collection and 

analysis, evaluation, and policy 

development to advance health 

equity, reduce health disparities, 

and improve minority health.

• Assist staff in gaining a 

comprehensive understanding 

of identifying and addressing 

health equity issues by ensuring 

the appropriate and relevant 

workforce development and 

trainings are provided.

• Establish and enhance 

multi-sector state and local 

partnerships to address health 

inequities

Organizational Structure

Some GDPH programs have staff with dedicated time 

towards health equity and minority health tasks and 

responsibilities. This includes the GDPH director of 

the Chronic Disease Prevention Section, who dedicates 

5 percent time to minority health and health equity 

initiatives; a Food and Language Nutrition Program 

manager serving 100 percent time on minority health 

and health equity initiatives; and a food and language 

nutrition evaluator, who dedicates 25 percent time 

to minority health and health equity initiatives. 

Location of 

state/territorial 

minority health 

entity (SMHE) 

within state/

territorial 

government

Health equity and minority health 

activities and strategies are embedded 

within programs throughout the 

department and are coordinated 

collectively through the Office of the 

Chief of Staff. 

SMHE staffing 

(full-time 

equivalents)

1.5

Advisory 

committee 

or panel

Currently, the GDPH is in the process 

of developing an internal health equity 

committee of representatives from 

the agency’s internal programs. The 

GDPH also has future plans to convene 

a workgroup of internal and external 

partners focused on health equity that 

will meet at least twice per year and will 

advise the GDPH on matters related to 

minority health, health disparities and 

opportunities to promote health equity. 

Program Goals and Activities

The GDPH is in the process of developing a health 

equity action plan to capture and track the various 

health equity activities throughout the programs. 

Additionally, the GDPH is developing a departmental 

health indicators list to assist in developing programspecific health equity measures and support programs’ 

efforts to assess health disparities and minority 

health. Below are some of the departmental health 

equity and minority health-related goals and activities. 

In seeking National Public Health Accreditation, the 

GDPH engaged in quality improvement efforts that 

clarified the department’s plans for ensuring health 

equity, reducing health disparities, and meeting other 

objectives including those outlined in the SHIP. The 

SHIP, which is publicly available on the GDPH website, 

addresses health equity and health disparities issues, 

particularly around maternal and child health, chronic 

State and Territorial Efforts to Reduce Health Disparities 66
Georgia

disease, and access to care. GDPH programs collaborate with partners throughout the state to achieve the 

SHIP goals and objectives. One of the health equity 

activities noted in the SHIP is to provide transportation 

vouchers for children and youth with special health 

care needs (CYSHCN) to access needed services as 

well as cover liability insurance for church vans to 

provide transportation to services for CYSHCN. Another 

health equity-related SHIP strategy is to reduce disparities in cancer morbidity and mortality. 

The GDPH divisions, sections, and programs are 

required to collaborate with the Division of Workforce 

Management to ensure workforce development and 

training around the definitions of health equity and 

health disparities, and strategies to promote health 

equity, improve minority health, and reduce health 

disparities in Georgia. Trainings include an annual 

Cultural Competency training and Health Equity trainings offered internally and by external partners. The 

GDPH has worked with Region IV Public Health Training 

Center to offer health equity and cultural competency 

trainings to departmental staff. The GDPH is also in 

the process of developing a health equity training 

specific to the department and the unique health 

disparity priorities in Georgia. 

The GDPH telehealth program seeks to achieve the 

Healthy People 2020 goal concerning the use of health 

communication strategies and health information 

technology to improve population health outcomes, 

improve health care quality, and achieve health equity. 

Additionally, the GDPH connects heavily to the 

other several related objectives that support shared 

decision-making between patients and providers. 

The telehealth movement helps this shared decisionmaking and fundamentally changes the relationship 

between patients and providers to an interaction that 

supports an informed, bilateral conversation to improve 

health. Other health equity-related Healthy People 

2020 objectives that are utilized within the GDPH 

telehealth program include goals to deliver reliable and 

actionable health information, to connect with culturally 

diverse and hard-to-reach populations, and provide 

sound principles in the design of programs and interventions that result in healthier behaviors.

The GDPH’s Office of Emergency Preparedness and 

Office of State Refugee Health recognized cultural 

and language barriers as factors contributing to health 

inequity among the refugee population, specifically, as 

it relates to refugees’ knowledge and needs regarding 

public health emergency preparedness. To address this 

issue, the state office partnered with DeKalb County 

Health Department and the Georgia Coalition of 

Refugee stakeholders to initiate a pilot program 

to build resilience among the refugee community 

in DeKalb County, Georgia. As a result of the success 

of the pilot, the group decided to continue program 

community preparedness/education, program public 

information/communication, and expansion of the 

program for the refugee population. 

Georgia reports disparities in oral health similar to 

the national findings. In Georgia the highest percentage 

of tooth decay is reported among non-Hispanic Black 

children (24.7 percent) while the lowest was reported 

among non-Hispanic White children (13.2 percent). 

The percentage among Hispanic children (23.7 percent) was very similar to non-Hispanic Blacks. There 

were disparities by race/ethnicity. Parents of Hispanic 

children in Georgia reported the lowest percentage 

of preventive dental visits (69.6 percent) compared 

to both the national estimate for Hispanic children 

(73.9 percent) and peers of other races in Georgia. 

Within Georgia, the most sizable ethnic disparity for 

childhood dental visits was in Hispanic children ages 

1 to 17 years old in 2011/2012. Only 69.6 percent of 

Hispanic children had one or more preventive dental 

care visits (check-ups and cleanings) compared to 

73.9 percent of Hispanic children nationally and 77.5 

percent of non-Hispanic White children in Georgia.

To address these health disparities, one of the program’s strategies is to promote oral health among 

low-income Hispanic mothers and children in Georgia. 

To implement this strategy, the Oral Health Education 

Initiative for low-income Hispanic children and adolescents will revise its education to reduce barriers in 

language and cultural differences among Hispanic 

populations. The program partners with the Georgia 

Department of Education and the GDPH local public 

health districts to complete the necessary activities. 

Acronym List

Full Name of Agency Acronym Acronym

Georgia Department of Public Health GDPH

State Health Assessment SHA 

State Health Improvement Plan SHIP 

Children and youth with special health care 

needs CYSHCN

State and Territorial Efforts to Reduce Health Disparities 67
Georgia

Another GDPH Oral Health program strategy is 

to develop one oral health resource database for 

CYSHCN. This is accomplished by identifying data 

sources and collecting data to develop a special 

needs dental access database with location of practices serving special needs children and adults/ 

special services offered, such as general anesthesia, 

orthodontics, insurance accepted, and other specialties. The Oral Health program partners with the following entities to achieve this goal: Georgia Dental 

Association, Georgia Association for Primary Care, 

and Federally Qualified Community Health Centers. 

The GDPH’s HIV Program seeks to increase the provision of integrated services to reduce social determinants of health and reduce HIV-related health disparities. In doing so, the program utilizes the U.S. 

Department of Health and Human Services, Office 

of Minority Health’s National Standards for Culturally 

and Linguistically Appropriate Services (CLAS) in Health 

and Health Care to ensure that efforts to address HIV 

prevention, care, and treatment service goals are 

infused with cultural competency and cultural sensitivity. 

Additionally, one of the strategies in the Georgia 

Integrated HIV Prevention and Care Plan is to provide 

HIV resources in communities/ZIP codes with the 

highest concentration of health disparities. Related 

activites include: 

• Identifying communities/ZIP codes with highest 

concentration of health disparities 

• Assessing disparities in communities/ZIP codes 

where HIV is most heavily concentrated to identify 

existing HIV services well an HIV resource gaps and 

barriers 

• Based on assessment, establishing the health 

resources to be provided through mobile clinic 

system

• Developing partnerships with existing HIV service 

providers in targeted areas

• Developing and implementing communications plan 

to educate community and existing providers about 

the availability of mobile clinic HIV services and how 

to access these services

• Implementing system of at least two mobile clinics to 

serve identified ZIP codes with highest concentrations 

of health disparities and improve access to care

• Integrating HIV services in existing clinical practices.

The Georgia Tobacco Use Prevention Program leads the 

GDPH’s efforts to implement the Georgia SHIP strategy 

to identify and eliminate tobacco-related disparities 

among population groups. To do this, the program and 

its partners identify and direct interventions toward 

populations disproportionately impacted by tobacco 

use. Currently, the following population groups experience the highest burden of tobacco use in Georgia: 

• Adult males (22 percent)

• Adults with an estimated income below federal 

poverty level (31.7 percent)

• Adults with less than a high school diploma 

(29 percent)

• Adults who are Medicaid recipients (26 percent). 

Another activity from this strategy is to expand the 

number of partners from all sectors and racial and 

ethnic groups, as well as age groups, engaged in 

tobacco control initiatives. Current partners include: 

Local Public Health Departments, Georgia Department 

of Education, Parent Teacher Association, Georgia 

Parks and Recreation Association, University System 

of Georgia and the Technical College System of 

Georgia, Historically Black Colleges and Universities, 

Association of City and County Governments, American 

Cancer Society, American Lung Association, American 

Heart Association, Georgia Public Health Association, 

and the Georgia Tobacco Statewide Coalition.

Staff within the GDPH’s Division of Health Protection, 

Chronic Disease Prevention Section work on several 

health equity initiatives. For example, one project 

seeks to improve outcomes through an integrated food 

and language nutrition program targeting early childcare educators and families of dual-language learners 

in three small, at-risk cities (Dalton, Valdosta, and 

Clarkston). The project includes trainings with early 

childhood education professionals on strategies to 

educate and partner with families around increasing 

healthy eating, improving physical activity, and supporting language acquisition. Through this project, 

section staff are developing profiles for the three 

communities that assess key outcomes (i.e., nutrition 

adequacy, physical activity, school readiness, and 

academic performance), and documenting observed 

racial and ethnic disparities. 

Through the Office of Minority Health’s State Partnership Initiative grant, the GDPH partners with state and 

local partners to collaborate on efforts to improve 

State and Territorial Efforts to Reduce Health Disparities 68
Georgia

outcomes and eliminate identified disparities. Georgia 

Early Education Alliance for Ready Students conducted 

community listening sessions in the three target 

communities to learn more about current strategies 

and barriers early childhood educators and families 

have to providing a nutrition- and language-rich environment for children under 5. Emory University’s Nell 

Hodgson Woodruff School of Nursing, the Atlanta 

Speech School, and HealthMPowers developed the 

training and toolkit for early childhood educators based 

on their expertise and community listening sessions 

findings. The Friends of Refugees Mommy & Me Family 

Literacy Program provided expertise in developing the 

training materials and a pilot peer-to-peer home visiting 

component for young children living in refugee families. 

The GDPH also partnered closely with Georgia Department of Early Care and Learning to assure fidelity of 

the intervention to early care quality-rated standards 

and to assist in connecting with local early care 

communities in the three target cities.

Partnerships

Primary collaborators • Atlanta Speech School

• Emory University, including the School 

of Nursing

• Friends of Refugees – Mommy & Me Family 

Literacy Program

• Georgia Department of Early Care and 

Learning

• Georgia Early Education Alliance for Ready 

Students 

• HealthMPowers

• DeKalb County Board of Health 

• GDPH Emergency Preparedness 

• Region IV Public Health Training Center 

• Georgia Coalition of Refugee

• MARTA; Metropolitan Atlanta Rapid Transit 

Authority

• Local Faith-based organizations

• Emergency Medical Services

• Local Public Health Departments

• Georgia Department of Education

• Parent Teacher Association

• Georgia Parks and Recreation Association

• University System of Georgia and the 

Technical College System of Georgia

• Historically Black Colleges and Universities

• Association of City and County Governments

• American Cancer Society

• American Lung Association

• American Heart Association

• Georgia Public Health Association

• Georgia Tobacco Statewide Coalition

• Georgia Dental Association

• Georgia Association for Primary Care

• Federally Qualified Community Health 

Centers

Contracts or memoranda 

of understanding with any 

partners

Yes, contracts or memoranda of 

understanding are implemented for some 

partnerships.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$2,800,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $2,800,000

Largest funding source State

Anticipated changes to budget No

The total FY 2015 budget focused solely on health 

equity and minority health was $200,000, funded 

exclusively by the SPI grant. This amount reflects the 

only grant solely designated for health equity and 

minority health efforts. The GDPH has a total of 52 

grants which have a health equity and/or minority 

health component. FY 2015–2016 was the first year 

of the 5-year SPI grant. The GDPH provided funding 

to several other governmental or nongovernmental 

entities for health disparities or health equity activities 

in FY 2015 as part of the SPI grant, including the 

Atlanta Speech School, the Emory University School 

of Nursing, Friends of Refugees Mommy & Me Family 

Literacy Program, the Georgia Early Education Alliance 

for Ready Students, and HealthMPowers. 

It is hoped that funding sources will increase as 

organization’s health equity efforts continue to grow.

State and Territorial Efforts to Reduce Health Disparities 69
Georgia

Georgia State Data

Total Populationa: 

10,310,371

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 9.3 90.7 58.8 31.6 0.4 3.9 5.3 100.0 NA 

Percent of population 

medically uninsureda 32.7 11.5 12.2 14.0 31.3 11.7 23.8 13.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.8 8.1 5.3 12.4 SP 3.1 NC 7.8 5.9

Age-adjusted 

mortality rateb 342.5 819.9 792.4 859.3 158.4 393.6 NC 800.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.1 13.8 13.5 14.6 19.9 4.7 11.1 13.5 13.6

Percent with 

diabetesc 9.1 12.4 12.5 13.0 11.8 4.2 11.3 12.3 10.8

Percent with 

heart diseasec 2.2 4.8 5.5 4.0 2.0 0.0 3.2 4.7 4.3

HIV rated 488.8 NC 203.0 1323.5 100.9 64.0** 2219.3 588.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

62.8 75.6 73.2 80.7 53.6 71.6 62.8 74.8 72.2

Percent received 

oral health visit 

(past 12 months)c

61.2 64.1 66.2 59.6 46.4 69.0 59.1 63.8 66.5

Percent received 

flu vaccinec 28.9 35.7 41.0 27.6 40.2 25.5 25.1 35.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 64.0 per 100,000 population (210 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 282.6 per 

100,000 population (14 cases).

State and Territorial Efforts to Reduce Health Disparities 70
Guam

Introduction to Guam’s Health Equity Activities

Guam, the largest island in the Mariana Islands, located in the western North Pacific Ocean, is an unincorporated 

U.S. Territory with a land area of 210 square miles. It had an estimated 2010 population of 159,000. Native 

Hawaiians and Other Pacific Islanders (NHOPI) are the largest minority population (49 percent), followed by Asians 

(34 percent). Persons self-identifying as multiracial comprise 9 percent of the population.1

A gubernatorial executive order created the Guam Office of Minority Health (OMH) in 2010. Originally named the 

State Office of Minority Health, the Guam OMH strives “to promote the elimination of health disparities in minority 

communities specifically to reduce health disparities in cancer, obesity and overweight.”2

Guam Minority Health Overview

Name of state/

territorial minority 

health entity

Guam Office of Minority Health

Strategic plan in 

place to address 

minority health 

or health equity

The Guam Office of Minority Health 

was involved in the planning 

for Guam’s Non-Communicable 

Disease Strategic Plan (2014–

2018). 

A comprehensive strategic plan for 

the Department of Public Health 

and Social Services is being 

developed

Date strategic plan 

was last updated 2013

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

• Evaluation plan included in the 

Non-Communicable Disease 

Strategic Plan (2014-2018).

• The Guam Office of Minority 

Health partners with the 

U.S. Office of Minority Health 

Resource Center and local 

consultants who assist with 

measurement

Key strategies 

used to achieve 

health equity

• Community Garden Project

• Salt Reduction Initiative

• Breastfeeding Promotion

• Worksite Wellness Program

• Culturally and Linguistically 

Appropriate Services in Health 

and Health Care (CLAS) trainings

• Guam Language Access Plan

Organizational Structure

Located within the Division of Public Health and 

Social Services’ Bureau of Community Health Services, 

the Guam OMH is responsible for administering noncommunicable disease control and health promotion 

programs, as well as the federal Centers for Disease 

Control and Prevention’s Behavioral Risk Factor 

Surveillance System.3 Other Department of Public 

Health and Social Services divisions include the 

Bureau of Communicable Disease Control, the Bureau 

of Family Health and Nursing Services, the Bureau 

of Nutrition Services, and the Bureau of Primary 

Care Services. 

At this time, the Guam OMH has one full-time, mid-level 

staff member who is fully dedicated to working on 

minority health, health disparity, and health equity 

initiatives. The Health Services Administrator’s primary 

department is the Department of Public Health and 

Social Services, but is responsible for BCHS operations and staff. This senior-level staff member, who 

is involved in all BCHS programs, can dedicate only 

approximately 10 percent time to working specifically 

on minority health initiatives. Volunteers, including 

unpaid interns from the University of Guam, help to 

support Guam OMH activities.

1 U.S. Census Bureau. 2010 Census Island Areas: 2010 Census 

Detailed Crosstabulations

2 Available on the Guam Office of Minority Health website. Last 

accessed 6/16/2016.

3 See Guam’s DPHSS’s Bureau of Community Health Services 

Webpage. Last accessed 1/13/2018.

State and Territorial Efforts to Reduce Health Disparities 71
Guam

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Guam Office 

of Minority Health 

is located within 

the Bureau of 

Community Health 

Services, which 

is within the 

Department of 

Public Health and 

Social Services.

SMHE staffing (full-time equivalents) 1

Advisory committee or panel None

Program Goals and Activities

The Guam OMH participated in planning efforts that 

led to the development of the Guam Non-Communicable 

Disease Strategic Plan: 2014-2018 (“Strategic 

Plan”),4 which aims to reduce the prevalence of noncommunicable diseases on the Island. It focuses both 

on improving health outcomes broadly and on using 

culturally relevant strategies to promote healthy 

behaviors (e.g., the Live HEALTHY Guam! media campaign). The Strategic Plan includes a comprehensive 

evaluation and assessment structure, complete with 

specific metrics to quantify all modifiable risk factors 

identified by the Plan’s prevention strategies and 

objectives. Assistance with measurement issues 

related to minority health, health disparities, and health 

equity comes from the U.S. Office of Minority Health 

Resource Center. Local consultants also provide 

evaluation services for the Guam Department of Public 

Health and Social Services (DPHSS) and are active 

participants in developing and conducting evaluations 

in alignment with the Strategic Plan. 

In 2017, the Guam DPHSS began developing a comprehensive division-wide Strategic Plan that will include 

strategies for addressing minority health and health 

equity. Within the division-wide Strategic Plan, the 

Guam OMH plans to announce a new name for the 

office—the Guam Office of Minority Health and Health 

Equity—to encompass its focus on reducing health 

disparities and achieving health equity. 

The Guam OMH relies on several data sources to 

help inform priorities related to minority health, health 

disparities, and health equity. Two primary data sources 

are DPHSS client surveys and feedback from service 

providers. Client surveys, including those conducted 

at community outreach events, help the DPHSS identify 

community needs. The Guam OMH also reviews data 

from DPHSS client intake forms to inform its priorities. 

Service providers also offer feedback to improve 

access and care delivery, sharing success stories 

about caring for multicultural and multiethnic populations, providing feedback on barriers and challenges, 

and informing the Guam OMH when materials in 

particular service locations need to be translated into 

additional languages. Other Guam OMH partners 

include higher education institutions, the Guam Legislature, the U.S. Department of Veterans Affairs, local 

U.S. military facilities, the Archdiocese of Hagatna, 

Catholic Social Services, and other organizations to 

set priorities.

Language access remains a major priority of the Guam 

OMH. Other efforts to achieve health equity within the 

Island focus on prevention and chronic disease reduction, including efforts to improve healthy behaviors 

around weight management and tobacco use. Initiatives led by the Bureau of Community Health Services 

(BCHS) or the Guam DPHSS that address ethnic 

disparities in chronic disease treatment and prevention 

include a Community Garden Project, a Salt Reduction 

Initiative, Breastfeeding Promotion, a Worksite Wellness Program, and tobacco cessation services. 

Because of the high prevalence across the Island, 

these initiatives have been implemented throughout 

Guam. While the BCHS or the DPHSS lead these 

initiatives, the Guam OMH plays a key role in planning 

and implementation activities.

Community Garden Project. Primarily targeting singlefamily households, the Guam DPHSS, in partnership 

with the University of Guam, leads the Community 

Garden Project. Through this program, families receive 

gift cards to buy items and supplies for gardening and 

learn about growing fruits and vegetables at home. 

The Guam DPHSS is looking to expand this successful 

effort to nonprofit organizations and schools. 

4 “Live Healthy Guam: Guam Non-Communicable Disease Strategic Plan 2014-2018.” A collaborative effort by the Department of Public 

Health and Social Services and the Non-Communicable Disease Consortium. December 2013. Available on the Guam DPHSS website. Last 

accessed 1/13/2018.

State and Territorial Efforts to Reduce Health Disparities 72
Guam

Acronym List

Full Name of Agency Acronym Acronym

Guam Department of Public Health and 

Social Services DPHSS

Guam Office of Minority Health Guam OMH

DPHSS’s Bureau of Community Health 

Services BCHS

Salt Reduction Initiative. In partnership with the 

University of Hawaii, BCHS also established the Salt 

Reduction Initiative, which has enlisted 50 restaurants 

to voluntarily remove salt dispensers from tables and 

offer brochures highlighting the dangers of excessive 

salt consumption. The initiative, which has signed on 

an additional 25 restaurants to remove salt dispensers 

in 2017, also urges restaurant chefs to reduce salt 

content in prepared meals and to develop additional 

resources for the public. 

Breastfeeding Promotion. A major milestone of the 

BCHS’ breast feeding promotion efforts included the 

enactment of a law supporting women’s right to 

breastfeed anywhere on the Island. Other efforts have 

sought to identify dedicated breastfeeding rooms in 

all government offices and have introduced a breastfeeding training certification program to ensure there 

are certified lactation specialists on Guam. The 

breastfeeding promotion activities seek to educate 

women about the health benefits of breastfeeding, 

eradicate inaccurate beliefs about the practice and, 

ultimately, to make breastfeeding a cultural norm. 

The BCHS partners with the Federal Special Supplemental Nutrition Program for Women, Infants, and 

Children (WIC) to promote breastfeeding and disseminate information to women of childbearing age.

Worksite Wellness. In response to a gubernatorial 

executive order, the BCHS implemented the Worksite 

Wellness Program5 to reduce the incidence of cancer, 

obesity, and cardiovascular disease on the Island. 

Government of Guam employees can use 3 hours 

per work week to engage in a wide array of physical 

activities at their government workplace or at a 

wellness facility (e.g., aerobic dancing, swimming, 

dancing, weight training, martial arts, and yoga), 

as well as meditation and healthy cooking classes. 

The program also offers additional educational and 

wellness activities.

Language Services. The Guam OMH spearheads a 

range of language access services across the Island. 

For example, the DPHSS mandated that any Guam 

government employee in direct contact with a consumer 

or client take an 8-hour Culturally and Linguistically 

Appropriate Services in Health and Health Care (CLAS) 

training course. The Guam OMH provides, on average, 

one training per month for approximately 100 people. 

Although the trainings are mandated only for Guam 

government employees, there has been interest in 

expanding the trainings to hospital personnel and other 

social service providers. In addition, the Guam OMH 

provides CLAS trainings for all Guam judiciary staff. The 

Guam Language Access Plan, also under the purview of 

the Guam OMH, operates in conjunction with “Culture 

and Language Access Service Partners,” a coalition that 

aims to diminish language and culture barriers on 

Guam.6 Culture and Language Access Service Partners 

includes representatives from the Guam judiciary, law 

enforcement, educators, the Guam DPHSS, nonprofit 

organizations, and other stakeholder groups.

Partnerships

Primary 

collaborators

• University of Guam

• Guam Legislature

• Guam judiciary

• Archdiocese of Hagatna

• Guam’s Alternative Lifestyle 

Association

• Health Services of the Pacific

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented for 

some partnerships (e.g., Guam’s 

Alternative Lifestyle Association).

Several organizations work closely with the Guam 

OMH to address health disparities. For example, the 

University of Guam partners with the Guam OMH on 

the Guam Cancer Registry, the Community Garden 

Project, tobacco cessation services, sexual health, and 

violence prevention. Governmental agencies also play 

a role. The Guam Legislature also provides support 

in advancing DPHSS initiatives, enacting policies 

and laws to promote healthier living. The Guam OMH 

5 Government of Guam Worksite Wellness Steering Committee. “Government of Guam Worksite Wellness Program.” Revised July 2012. 

Available on the Guam DPHSS website. Last accessed 1/13/2018.

6 Bernadine Racoma. “Coalition in Guam Wants to Break Language and Cultural Barriers through Translation.” January 31, 2014. Day 

Translations. Available at the Day Translations website. Last accessed: 1/13/2018

State and Territorial Efforts to Reduce Health Disparities 73
Guam

works closely with the Island’s judiciary to certify 

interpreters for court and health care settings, train 

interpreters, and provide compensation for certified 

translation services.

Two nonprofit organizations, the Archdiocese of 

Hagatna and Guam’s Alternative Lifestyle Association, 

have become key partners with the Guam OMH. 

The Archdiocese publishes a weekly newspaper that 

regularly includes a column written by the Guam 

DPHSS focusing on diseases and prevention. Guam’s 

Alternative Lifestyle Association, a community-based 

organization that exists to strengthen the quality of life 

for gay, lesbian, bisexual, and transgendered persons, 

worked in collaboration with Guam OMH in the development of the Non-Communicable Disease Strategic Plan. 

Guam OMH also partners with “Health Services of the 

Pacific,” a private home health agency providing care 

to clients suffering from chronic and other conditions. 

Several Health Services of the Pacific employees are 

dually employed by the DPHSS and provide health 

education and chronic disease management support 

to bedbound clients.

Funding 

Annualized budget (FY 2014) of 

state/territorial minority health 

entity (SMHE) across all income 

sources

$100,000

Annual budget (FY 2014) of SMHE 

from state/territorial government $100,000

Largest funding source Territorial government

Anticipated changes to budget in 

FY 2016 No

The total FY 2014 funding for the Guam OMH was 

$100,000. This funding level has been consistent 

for the past 3 years. Prior to receiving funding from 

the Territory of Guam, the Guam OMH received funding 

directly from the U.S. Office of Minority Health.

State and Territorial Efforts to Reduce Health Disparities 74
Guam

Guam Territory Data

Total Populationa: 

159,358

Race Totals

Pacific Islander Asian

White

Multiracial OtherTerritory 

Total

National 

Chamorro Chuukese Total

Other 

PI Filipino Korean

Other 

Asian

Population 

Characteristics

Percent of state 

populationa 37.3 7.0 5.0 26.3 2.2 5.1 7.1 9.4 2.0 100.0 NA 

Percent of population 

medically uninsureda 13.3 32.9 31.4 27.8 57.4 31.3 9.5 14.9 11.4 21.1 16.3b

Population 

Characteristics

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black or 

African 

American

Asian 

American 

and 

NHOPI*

Multi-racial 

or Other

National 

Total

Other 

Asian

Health 

Disparities

Vital Statistics

Infant mortality ratec NC NC NC NC NC NC 5.9 6.6

Age-adjusted 

mortality ratec NC NC NC NC NC NC 728.8 717.6

Prevalence of Selected Chronic Diseases

Asthmad 15.6 9.6 4.5 SP 10.1 11.1 13.6 14.1

Diabetesd 12.8 9.6 4.8 SP 11.1 8.1 10.8 10.8

Heart diseased 8.2 3.7 4.8 SP 3.5 5.3 4.3 3.8

HIVe SP NC SP SP SP SP 362.3 657.8

Preventive Services

Routine check-up 

(past 12 months)d 70.8 67.1 76.1 SP 66.8 64.1 67.1 72.2

Oral health visit 

(past 12 months)d 63.8 58.5 77.6 SP 58.7 49.9 58.6 66.5

Flu vaccined 33.6 29.7 55.2 SP 28.1 23.6 29.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: U.S. Census Bureau. 2010 Census Island Areas: 2010 Census Detailed Crosstabulations.

b Source: U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2010.

c Source: CDC National Vital Statistics Reports, Deaths: Final Data for 2015.

d Source: Behavioral Risk Factor Surveillance System, 2016.

e Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015.

*Native Hawaiian and Other Pacific Islander

State and Territorial Efforts to Reduce Health Disparities 75
Hawaii 

Introduction to Hawaii’s Health Equity Activities

Hawaii had an estimated 2016 population of 1,429,000. Asian Americans and NHOPI are the largest racial-ethnic 

minority population (48 percent), followed by Hispanics or Latinos (10 percent), Blacks or African Americans 

(2 percent), and American Indians/Alaska Natives (less than 1 percent). Multiracial or other minority racial groups 

comprise 25 percent of the population.1 Approximately 184,000 Hawaii residents live within a primary care health 

professional shortage area.2

In the late 1980s, the Office of Hawaiian Health evolved to focus more broadly on health equity issues, and 

changed its name to the Office of Health Equity (OHE), with a specific focus on addressing health disparities across 

Hawaii. The OHE was unstaffed at the time of data collection, and the future direction of the OHE and 

responsibilities of OHE staff were under Hawaii Department of Health (HDH) review to ensure they are aligned 

with the mission of the OHE and the goals of the HDH. Despite the halt in OHE activity during this transition, 

the Chronic Disease Prevention and Health Promotion Division (CDPHPD) of the HDH is leading many initiatives 

to eliminate health disparities and achieve health equity.

Hawaii Minority Health Overview

Name of state/

territorial minority 

health entity

The Office of Health Equity was established to 

address health disparities in Hawaii, but it is 

currently unstaffed and its future direction is 

under review by the state.

Strategic plan in 

place to address 

minority health 

or health equity

A strategic plan specifically to address minority 

health or health equity is not available. However, 

comprehensive plans that take into account 

social determinants of health are included in the 

Hawaii Department of Health Strategic Plan

Date strategic plan 

was last updated 2016

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

A formal plan to measure progress toward 

reducing health disparities is not available. 

However, a dashboard to track progress toward 

reaching the goals in the Hawaii Department of 

Health Strategic Plan is publicly available.

Key strategies 

used to achieve 

health equity

• Working with federally qualified health centers 

to improve care delivery

• Improving access to primary care and cancer 

screening

• Improving language access services 

• Promoting physical activity

• Promoting Supplemental Nutrition Assistance 

Program education (SNAP-Ed)

• Promoting tobacco prevention and education 

program

Organizational Structure

The CDPHPD is housed within the Health 

Resources Administration of the HDH. 

While there is no advisory committee or 

panel present to advise the CDPHPD on 

minority health and health disparity issues, 

the Office of Affirmative Action serves as a 

resource while the Office of Health Equity 

remains unstaffed. In addition, the Language Access Advisory Council aids the 

Office of Language Access by providing 

guidance on language access laws, 

policies, and services.3

A number of staff from the CDPHPD spend 

at least some portion of their work day on 

1 American Community Survey Public Use Microdata, 

2016.

2 Health Resources and Services Administration. 

2018. Designated Health Professional Shortage 

Areas Statistics: First Quarter of Fiscal Year 2018 

Designated HPSA Quarterly Summary.

3 State of Hawaii, Office of Language Access. Meet 

the Council. Available at the Hawaii Department of 

Health website. Last accessed 01/30/2017. 

State and Territorial Efforts to Reduce Health Disparities 76
Hawaii

minority health, health disparity, or health equity 

initiatives. Full-time staff include the Bilingual Health 

Education Aide program manager, an environmental 

change specialist, the SNAP-Ed coordinator, a school 

health coordinator, bilingual health aides, and Easy 

Access Project staff. At least 11 individuals spend time 

working on minority health, health disparity, and health 

equity activities. However, these activities are 

embedded in daily work activities for most staff in the 

HDH. No timeline had been established at the time of 

data collection for hiring dedicated OHE personnel. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Chronic 

Disease 

Prevention and 

Health Promotion 

Division is housed 

within the Hawaii 

Department of 

Health, Health 

Resources 

Administration.

SMHE staffing (full-time equivalents) 11

Advisory committee or panel None

Program Goals and Activities

No separate strategic plan focuses solely on minority 

health, health disparities, or health equity. However, the 

HDH has an overarching strategic plan—last updated in 

August 2016—that describes Hawaii’s strategic health 

priorities. Achieving health equity is a goal of the HDH, 

and as such, is integrated throughout much of the plan. 

The HDH updates the plan as new issues or objectives 

arise. To track and monitor Hawaii’s progress toward the 

goals set forth in the strategic plan, HDH staff and 

others can access a dashboard reporting tool on the 

HDH website. The tool includes 21 metrics for monitoring the state’s progress toward reaching the goals. 

Acronym List

Full Name of Agency Acronym Acronym

Hawaii Department of Health HDH

Chronic Disease Prevention & Health 

Promotion Division CDPHPD

Office of Health Equity OHE

Collection of statewide health-related surveillance and 

disparity data, in addition to monitoring of vital records, 

helps inform priority setting in Hawaii. Federal guidance 

and funding opportunities also aid the HDH in identifying 

priorities. Several other entities assist the HDH in some 

respect with setting goals, including the Native Hawaiian 

health community, the University of Hawaii, federally 

qualified health centers (FQHCs), the Hawaii Primary 

Care Association, and the Hawaii Public Health Institute. 

The CDPHPD is working on many strategies to achieve 

health equity and eliminate health disparities. One focus 

of the CDPHPD is to improve quality of care and access 

to care by working with FQHCs and other partners. 

For example, staff are working to improve the diagnosis 

and management of asthma and diabetes, and to 

implement quality improvement processes at FQHCs 

for these two conditions. The CDPHPD is also working 

to implement self-management education and prevention programming at FQHCs. In addition, the CDPHPD 

is leading efforts to improve primary care access for 

patients with diabetes, hypertension, and/or asthma. 

Preventive strategies include increasing cancer 

screening rates by improving access to breast, cervical, 

and colorectal cancer screening throughout the state. 

Language access services and cultural competency 

trainings are key strategies led by the CDPHPD with 

support from the Office of Language Access and the 

Bilingual Health Services unit. The CDPHPD is working 

to increase access to medical translation services 

for Micronesians and other limited and non-Englishproficient cancer patients. The Bilingual Health 

Education Aide program provides interpretation and 

culturally sensitive health care access support and 

services for minority populations, including immigrants, 

migrants, Native Hawaiians, and people with limited or 

no English proficiency. The federally funded Easy 

Access Project provides an opportunity for newly 

arrived immigrants and migrants to receive a needs 

assessment and connect with a Bilingual Health 

Education Aide for support in navigating the health 

care system and obtaining health-related services.4

Several CDPHPD activities are underway to promote 

physical activity and healthy lifestyles. The CDPHPD is 

working with communities to promote physical activity 

through signage, worksite policies, social support, and 

joint use agreements. The CDPHPD is also involved in 

developing and implementing transportation and 

4 State of Hawaii, Department of Health, Bilingual Health Services – Chronic Disease Prevention & Health Promotion. Available at the Hawaii 

Department of Health website. Last accessed 02/01/2017. 

State and Territorial Efforts to Reduce Health Disparities 77
Hawaii

community plans that promote walking. The CDPHPD’s 

Supplemental Nutrition Assistance Program Education 

(SNAP-Ed) promotes healthy eating among low-income 

populations through activities such as nutrition education, community gardens, and mobile produce markets. 

Staff are also working to increase access to healthy 

foods among SNAP participants by working with farmers 

markets to accept SNAP benefits through the electronic 

benefit transfer (EBT) system. 

The CDPHPD’s Tobacco Prevention and Education 

Program aims to promote tobacco cessation, prevent 

tobacco use among vulnerable and disparate populations, and protect non-smokers from tobacco smoke 

exposure.5 Staff are conducting outreach to dentists, 

obstetricians and gynecologists, and Medicaid-accepting 

health care providers to promote Hawaii’s Tobacco 

Quitline. The CDPHPD also leads efforts to train staff 

who work at organizations serving mostly at-risk, minority 

populations on conducting brief tobacco cessation 

interventions. Implementing smoke-free policies in 

public housing and improving access to cessation 

services are also key activities. 

Partnerships

Primary 

collaborators

• University of Hawaii School 

of Medicine

• Hawaii Primary Care Association

• Federally qualified health centers

• Hawaii Public Health Institute

• Hawaii Department of Human 

Services

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

In addition to the work described above, the CDPHPD 

partners with many organizations to work toward 

achieving health equity in Hawaii. The University of 

Hawaii School of Medicine’s Department of Native 

Hawaiian Health is a key partner on advocacy and 

policy initiatives pertaining to Native Hawaiians. The 

CDPHPD collaborates as a joint sponsor with the 

University of Hawaii School of Medicine on the state’s 

combined medical-public health journal, Hawai’i Journal 

of Medicine & Public Health.

The HDH Mental Health Division contracts with an 

FQHC in Hawaii to provide mental health services to 

minority populations, and supports chronic disease 

prevention activities through this partnership. The 

CDPHPD also contracts with the Hawaii Public Health 

Institute, also known as the Coalition for a TobaccoFree Hawaii. The Hawaii Public Health Institute 

collaborates with CDPHPD to implement strategies and 

programs to eliminate health disparities and improve 

the health of the state’s population. Recent efforts 

through this partnership include the implementation 

of a bicycle sharing program in Honolulu and various 

tobacco cessation activities.

The CDPHPD also works closely with the Hawaii 

Department of Human Services, Hawaii State Medicaid 

agency on maternal and child health initiatives. Hawaii 

has adopted the “two-generation approach” that was 

developed by the Ascend Group at the Aspen Institute.6

The CDPHPD collaboration with the Medicaid agency 

aims to carry out the two-generation approach by 

simultaneously delivering public health and social 

services to the parent in need and his or her children.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$12,944,000 (for the 

Hawaii Department 

of Health)

Annual budget (FY 2015) of SMHE 

from state/territorial government

$7,357,000 (for the 

Hawaii Department 

of Health)

Largest funding source State of Hawaii

Anticipated changes to budget No information 

obtained

In FY 2015, the HDH had an annual budget of 

$12,944,000 for population health management 

activities. This includes six federal grants from the 

Centers for Disease Control and Prevention (CDC) to 

address a range of chronic diseases. CDC’s Preventive 

Health and Health Services Block Grant helps support 

Hawaii’s Easy Access Project that provides healthrelated services and support for immigrants and 

migrants.7 The largest source of funding was from 

5 State of Hawaii, Department of Health, Tobacco Control – Chronic Disease prevention & Health Promotion Division. Tobacco Prevention 

& Education Program. Available at the Hawaii Department of Health website. Last accessed 01/20/2017.

6 The Aspen Institute, Ascend. The Two-Generation Approach. Available at the Aspen Institute website. Last accessed 01/31/2017.

7 Centers for Disease Control and Prevention, Preventive Health and Health Services Block Grant. Hawaii. Available at the CDC website. 

Last accessed 02/01/2017.

State and Territorial Efforts to Reduce Health Disparities 78
Hawaii

the State of Hawaii, which includes funding for HDH 

staff salaries and the Bilingual Health Services unit. 

This state funding was supported by the Tobacco 

Settlement Special Fund allotment to the HDH.

The CDPHPD provides funding to several governmental 

and nongovernmental organizations for health promotion activities that aim to achieve health equity. In 

FY 2015, The Kohala Center, the YMCA, and Kokua 

Kalihi Valley received funding to provide nutrition 

education services for SNAP-eligible Hawaiians. Money 

is also allocated to FQHCs to address health disparities. In addition, the CDPHPD provides funding to the 

Hawaii Primary Care Association, the Hawaii Public 

Health Institute, the Hawaii Department of Education, 

the University of Hawaii Conference and Events Services, and the Honolulu Theatre for Youth to improve 

the health of Hawaiians.

State and Territorial Efforts to Reduce Health Disparities 79
Hawaii

Hawaii State Data

Total Populationa: 

1,428,557

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 10.4 89.6 25.1 1.7 0.2 47.9 25.1 100.0 NA 

Percent of population 

medically uninsureda 5.1 3.4 3.8 7.6 0.0 3.4 3.4 3.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 5.6 3.3 SP SP 6.5 NC 5.7 5.9

Age-adjusted 

mortality rateb 897.4 554.5 634.2 487.1 SP 553.3 NC 572.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 25.8 16.4 13.3 17.3 SP 14.3 26.3 17.2 13.6

Percent with 

diabetesc 7.6 10.6 6.0 11.5 SP 13.3 11.0 10.5 10.8

Percent with 

heart diseasec 1.8 3.7 4.1 6.6 SP 3.7 2.8 3.6 4.3

HIV rated 315.4 NC 480.3 719.4 330.0 87.9** 128.6 233.1 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

66.5 73.4 70.2 88.6 SP 77.2 67.2 72.8 72.2

Percent received 

oral health visit 

(past 12 months)c

67.7 73.7 74.4 86.7 SP 75.5 66.1 73.0 66.5

Percent received 

flu vaccinec 32.9 40.1 37.0 50.1 SP 43.6 34.6 39.4 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 87.9 per 100,000 population (413 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 228.6 per 

100,000 population (250 cases).

State and Territorial Efforts to Reduce Health Disparities 80
Idaho 

Introduction to Idaho’s Health Equity Activities

Idaho had an estimated 2016 population of 1,683,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (12 percent), followed by Asian Americans and NHOPI (2 percent), American Indians/Alaska Natives (2 

percent), and Blacks/African Americans (1 percent). Persons self-identifying as multiracial or “other race” comprise 

7 percent of the population.1 Approximately 532,000 Idaho residents live within a primary care health professional 

shortage area.2

Health equity activities are addressed by the Division of Public Health (DPH) of the Idaho Department of Health and 

Welfare (DHW). However, certain content areas within the DPH (e.g., tobacco prevention programs) have an explicit 

health equity component staffed by the DPH. Because many of the tobacco prevention activities are coordinated 

with the American Indian tribes, the DPH team has significant tribal experience and works closely with the DHW’s 

tribal liaison. The DPH is moving the tobacco prevention specialist’s organizational oversight to the DPH Deputy 

Director level or the DHW level, rather than serving through a specific grant. There is no standing committee or 

panel that advises the DPH on issues directly addressing minority health, health disparities, and health equity, but 

a representative group within the DPH reviews a health equity plan, which is one of the key initiatives of the Bureau 

of Community and Environmental Health.

Idaho Minority Health Overview

Name of state/

territorial minority 

health entity

N/A

Strategic plan in 

place to address 

minority health 

or health equity

None

Date strategic plan 

was last updated N/A

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

No

Key strategies 

used to achieve 

health equity

• Family planning program

• Pregnancy prevention programs

• Home visiting program

• HIV, STD, and hepatitis programs

• Project Filter

• Refugee health screenings

Organizational Structure

Idaho does not have a specific office dedicated to 

minority health, health disparities, and health equity, 

but these roles fall under the jurisdiction of the DPH. 

The DPH is part of the DHW, which reports directly to 

the governor. One DPH staff position is dedicated to 

health disparities activities; this health program 

specialist is funded by the Project Filter grant, but 

works with efforts across the DPH. For some DPH 

projects, volunteers are involved in health equity 

activities, but no regular volunteers or interns are 

primarily involved in these activities. Staffing allocations for health equity activities are not expected 

change. 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 81
Idaho

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

Minority health 

is addressed by 

the DPH, which is 

located with the 

DHW. 

SMHE staffing (full-time equivalents) 1

Advisory committee or panel None

Program Goals and Activities

The State Health Improvement Plan uses data from the 

Behavioral Risk Factor Surveillance System, the U.S. 

Census, and other sources to identify populations facing 

health disparities. At-risk groups include rural and 

frontier area residents, low socioeconomic areas, 

Hispanic/Latino communities, and other minority 

populations. Several DPH programs seek to improve 

minority health, promote health equity, and reduce 

health disparities by targeting populations at highest 

risk for health disparities. 

Acronym List

Full Name of Agency Acronym Acronym

Division of Public Health DPH

Department of Health and Welfare DHW

Health equity priorities within the DPH are often defined 

by requirements of the grants that fund its specific 

projects. For example, the DPH operates three programs 

funded by separate grants that all address family 

planning and maternal health. One, a family planning 

program aimed at adults at or below 150 percent of the 

federal poverty level, provides family planning services 

in all 44 Idaho counties and primarily serves rural and 

Hispanic residents. A pregnancy prevention program 

provides culturally specific programming and specifically 

targets Hispanic teens. Finally, a home visiting program 

partners with Idaho’s seven local health districts to work 

with predominantly Hispanic pregnant women and new 

parents, most of whom are in rural and/or low socioeconomic areas. 

Other programs that serve minority populations address 

STD prevention, smoking cessation, and health screenings for refugees. The DPH bureaus work together on an 

HIV, STD, and hepatitis program that has grant-specific 

requirements to address disparities in developing 

education, testing, and outreach strategies. In addition, 

the DPH collaborates with the Hispanic Cultural Center 

to provide HIV, STD, and hepatitis outreach to Hispanic 

communities. The Project Filter smoking cessation 

program, which seeks to decrease the population of 

smokers by three percent, targets American Indians 

and Alaska Natives and engages stakeholders from 

these communities. A refugee health program works 

exclusively with minority populations and provides 

physical and mental health screening services. 

Partnerships

Primary 

collaborators

• Local health districts

• Tribes and the Northwest Portland 

Area Indian Health Board

• Hispanic Cultural Center

• Allies Linked for the Prevention 

of HIV and AIDS (“a.l.p.h.a.”)

• Idaho Primary Care Association

• State Department of Education

• Refugee resettlement agencies

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented for 

some partnerships (e.g., those with 

local health districts, a.l.p.h.a., the 

Hispanic Cultural Center, and others).

To address minority health, health equity, and health 

disparities, the DPH collaborates with a range of 

organizations. It holds many contracts with local health 

districts that primarily serve American Indians, 

Hispanics/Latinos, and seasonal workers. The DPH 

also partners directly with American Indian tribes to 

address tobacco prevention objectives. It also 

collaborates with the Northwest Portland Area Indian 

Health Board, located in Portland, Oregon, which 

manages Idaho’s tribal health data. Additionally, the 

DPH has contracts in place with the Hispanic Cultural 

Center and Allies Linked for the Prevention of HIV and 

AIDS (“a.l.p.h.a.”). The DPH helps a.l.p.h.a. obtain HIV 

oral swab tests for use in alternative or non-medical 

settings. Other DPH partners include Idaho’s Primary 

Care Association (which is comprised of community 

health centers and federally qualified health centers), 

the Idaho State Department of Education, and refugee 

resettlement agencies.

State and Territorial Efforts to Reduce Health Disparities 82
Idaho

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

There is no funding 

specifically for 

minority health entity.

Annual budget (FY 2015) of SMHE 

from state/territorial government None

Largest funding source N/A

Anticipated changes to budget None

No part of the DPH budget specifically funds activities 

related to minority health, health equity, or health 

disparities. However, the grant that funds Project 

Filter’s anti-tobacco activities funds the health program 

specialist responsible for ensuring health equity for the 

grant. The DPH does not expect any changes to 

sources of funding or allocations over the next 2 years.

State and Territorial Efforts to Reduce Health Disparities 83
Idaho

Idaho State Data

Total Populationa: 

1,683,140

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 12.3 87.7 89.5 0.6 1.5 1.7 6.6 100.0 NA 

Percent of population 

medically uninsureda 24.2 8.8 9.9 10.0 22.2 11.9 18.1 10.7 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 5.0 4.9 SP SP SP NC 4.7 5.9

Age-adjusted 

mortality rateb 498.3 736.9 730.9 421.1 589.3 425.9 NC 725.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 10.6 12.9 12.7 SP 17.6 0.2 10.6 12.7 13.6

Percent with 

diabetesc 9.0 9.0 8.6 SP 13.8 5.3 17.2 8.8 10.8

Percent with 

heart diseasec 1.5 4.0 3.9 SP 5.5 0.0 0.9 3.9 4.3

HIV rated 113.4 NC 67.7 1036.6 73.5 37.9** 126.9 79.2 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

49.5 60.5 60.2 SP 54.8 60.9 57.0 59.9 72.2

Percent received 

oral health visit 

(past 12 months)c

54.4 64.7 64.0 SP 57.3 80.5 57.4 64.0 66.5

Percent received 

flu vaccinec 23.5 35.2 34.6 SP 30.4 37.1 20.0 34.3 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 37.9 per 100,000 population (7 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 84
Illinois 

Introduction to Illinois’ Health Equity Activities

Illinois had an estimated 2016 population of 12,802,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (17 percent), followed by Blacks/African Americans (14 percent), Asian Americans and NHOP 

(5 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 9 percent of the population.1 Approximately 3,847,000 Illinois residents live within 

a primary care health professional shortage area.2

In 1991, the Illinois General Assembly passed legislation creating the Center for Minority Health Services (CMHS). 

Its mission is to “improve the health and [well-being] of Illinois’ racial and ethnic minority populations through 

the development of health policies and culturally linguistically appropriate programs that will eliminate 

health disparities.”

Illinois Minority Health Overview

Name of state/

territorial minority 

health entity

Illinois Department of Public Health, Center 

for Minority Health Services

Strategic plan in 

place to address 

minority health 

or health equity

The Center for Minority Health Services has a 

standalone strategic plan that is not publicly 

available. It aligns with the Illinois Department 

of Public Health Five Year Strategy 2014 

– 2018, which identifies reducing health 

disparities as an overarching priority.

Date strategic plan 

was last updated 2014

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Center for Minority Health Services 

has a plan in place for measuring progress 

towards health disparity reduction, as does 

the Illinois Department of Public Health.

Key strategies 

used to achieve 

health equity

• Increasing access to health care 

for underserved and underinsured 

communities through Wellness on Wheels 

mobile units

• Conducting flu shot clinics for uninsured 

and underinsured individuals

• Offering hepatitis B outreach and education 

to individuals of Asian and African descent

• Providing minorities with outreach and 

online eligibility assessment for enrollment 

into the AIDS Drug Assistance Program

• Conducting health screenings, outreach, 

health promotion, and services for newly 

arriving refugees

Organizational Structure

The CMHS addresses health disparities and 

minority health issues in Illinois. Located 

within the IDPH, it falls under the Office of the 

Director and is comprised of five full-time staff 

members (i.e., the CMHS chief, three program 

administrators, and an administrative assistant) who dedicate 100 percent of their time 

to minority health initiatives. Three additional 

IDPH program administrators work closely 

with the CMHS on minority health activities. 

In addition, the CMHS has one contractual 

epidemiologist for the Refugee Health Program 

and engages both paid and unpaid interns. 

Location of state/territorial 

minority health entity 

(SMHE) within state/

territorial government

The Center for 

Minority Health 

Services is housed 

within the Illinois 

Department of 

Public Health

SMHE staffing (full-time 

equivalents) 5

Advisory committee or panel None

1 American Community Survey Public Use Microdata, 

2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas 

Statistics: First Quarter of Fiscal Year 2018 Designated 

HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 85
Illinois 

Program Goals and Activities

Acronym List

Full Name of Agency Acronym Acronym

Illinois Department of Public Health IDPH

Center for Minority Health Services CMHS

The Illinois Department of Public Health Five Year 

Strategy 2014-2018, last updated in 2014, identifies 

health disparity reduction as a key priority area. 

The CMHS also has its own strategic plan, which aligns 

with the goals and objectives of the IDPH. Both the 

CMHS and the IDPH have assessment plans in place 

to measure progress on their efforts. 

Priorities for minority health, health disparities, and 

health equity in Illinois are set in a variety of ways. 

State legislative initiatives determine state-level 

funding for health equity activities. Within the IDPH, 

the CMHS is largely responsible for setting its own 

priorities, although grant awards and nongovernmental 

stakeholders can also influence its agenda.

A major focus of the CMHS is increasing access 

to preventive health care in medically underserved 

minority communities. The CMHS leads the Wellness 

on Wheels pwrogram, which offers free preventive 

health screenings and referrals through mobile units 

based in designated regions across the state. Each 

unit travels to various events and locations, thereby 

serving a range of populations across each region. 

Four of the five units were purchased by the CMHS 

with a grant from the U.S. Office of Minority Health. 

In addition to maintaining all five mobile units, the 

CMHS provides grant funding to the organizations that 

use these units to deliver preventive health services. 

In addition, the CMHS coordinates mobile unit scheduling when communities request a mobile unit for 

an event.

The CMHS also focuses on outreach and education 

efforts to address health disparities in Illinois. One 

initiative, funded through a CMHS grant program, 

provides Hepatitis B outreach, awareness, and education to foreign-born Asian and African immigrant and 

refugee communities. The program’s goals include 

increasing screenings and vaccination rates, 

decreasing transmission rates, and reducing risky 

behaviors. Five grantees receive funding to produce 

culturally and linguistically competent educational 

materials that address cultural and societal issues 

that may result in screening/vaccination rate disparities. These grantees also provide referrals and connect 

individuals to screening and vaccination services. 

In another outreach effort, the CDPH manages a grant 

program that provides outreach and education services 

designed to increase minority participation in the AIDS 

Drug Assistance Program. This program, funded 

through Part B of the Ryan White HIV/AIDS Treatment 

Extension Act of 2009 (Public Law 111-87), specifically 

targets minority populations and uninsured/underinsured individuals who may not be aware that they are 

eligible for free AIDS prescription drugs and other 

services through the AIDS Drug Assistance Program.

Many of the CMHS’s activities support the Refugee 

Health Program, which is located within the CMHS 

and promotes the health of newly arriving refugees. 

The CMHS issues grant awards for the provision of 

health screenings to refugees arriving in Illinois. 

Screenings must be completed within 90 days of arrival 

in a culturally competent and linguistically appropriate 

setting. The CMHS issues additional grants to refugeeserving organizations to provide outreach, health 

promotion, interpretation, medical case management, 

nutrition, and mental wellness services. Grantees work 

with the CMHS to ensure that refugees receive health 

screenings and other necessary resources or services. 

The U.S. Department of Health and Human Services 

Office of Refugee Resettlement and the Illinois Department of Human Services provide funding for this 

grant program. 

State and Territorial Efforts to Reduce Health Disparities 86
Illinois 

Partnerships

Primary 

collaborators

• Asian Health Coalition

• Asian Human Services

• Aunt Martha’s Aurora Community Health Center

• Brothers Health Collective

• Champaign Urbana Public Health District

• Community Health and Emergency Services

• DuPage County Health Department

• East Side Health District

• Fifth Street Renaissance

• Greater All Nations Tabernacle Church of God 

in Christ

• Heartland Health Outreach

• Illinois Department of Human Services

• Illinois Migrant Council

• Illinois Public Health Association

• Mexican Consulate in Chicago 

• Midwest Asian Health Association

• Sinai Medical Group Touhy

• Pan-African Association

• Puerto Rican Cultural Center 

• Regional CARE Association

• Rock Island County Health Department

• Springfield Urban League

• Walgreens

• Winnebago County Health Department

• World Relief DuPage/Aurora

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of understanding are implemented for some partnerships 

(e.g., all CMHS grantees).

A strategic priority of the IDPH is to develop and 

expand partnerships to help improve the health of 

the people of Illinois. As such, working collaboratively 

with grantees to address minority health and health 

disparities is an overarching strategy used by the 

CMHS. By working with grantees, the CMHS leverages 

the unique expertise that local and regional 

organizations offer. For example, the Wellness 

on Wheels program discussed above relies on five 

organizations to operate the mobile units and provide 

preventive health screenings: Regional CARE 

Association, Champaign Urbana Public Health District, 

Community Health and Emergency Services, Springfield 

Urban League, and Fifth Street Renaissance. These 

organizations are geographically dispersed throughout 

Illinois, which allows the Wellness on Wheels program 

to provide free health services to medically 

underserved minority communities throughout 

the state.

As another example, the Refugee Health Program 

collaborates with a variety of organizations to provide 

health services to newly arriving refugees. For the 

provision of health screenings, the CMHS issues grant 

awards to five health care providers: Aunt Martha’s 

Aurora Community Health Center, DuPage County 

Health Department, Rock Island County Health 

Department, Sinai Medical Group Touhy, and 

Winnebago County Health Department. The CMHS has 

formal relationships with other refugee-serving 

organizations through a grant program intended to 

complement the health screening program. Heartland 

Health Outreach, Pan-African Association, and World 

Relief DuPage/Aurora provide health outreach, health 

promotion, interpretation services, medical case 

management, nutrition services, and mental wellness 

services to refugee populations in Illinois. In addition, 

the CMHS collaborates with staff from the Illinois 

Department of Human Services to support the Refugee 

Health Program. 

In another effort aimed at increasing access to 

preventive health care services, the CMHS helps 

organize flu shot clinics throughout the state. The 

CMHS links minority and underserved communities 

to a flu shot voucher program funded by Walgreens 

and the U.S. Department of Health and Human 

Services. Walgreens distributes vouchers through 

outreach efforts and at community events and, for 

those without health insurance, Walgreens provided 

a free flu shot through the voucher process. To further 

improve immunization rates in underserved 

communities, Walgreens provided screenings and 

vaccinations to individuals with insurance and helped 

them process claims.

State and Territorial Efforts to Reduce Health Disparities 87
Illinois 

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$4,299,545

Annual budget (FY 2015) of SMHE 

from state/territorial government $1,877,560

Largest funding source Federal government

In FY 2015, the total funding for minority health 

activities in Illinois was $4,299,545. The CMHS 

received $1,877,560 from the State of Illinois and 

$2,421,985 in federal grant funding to support the 

strategies described in this summary. A significant 

portion of CMHS funding is allocated for grant awards; 

it typically issues 40 to 50 grant awards each year. 

While federal funding has been fairly consistent, state 

funding has decreased in recent years.

State and Territorial Efforts to Reduce Health Disparities 88
Illinois 

Illinois State Data

Total Populationa: 

12,801,539

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 17.0 83.0 71.2 14.2 0.2 5.4 9.0 100.0 NA 

Percent of population 

medically uninsureda 15.7 4.8 5.3 7.4 14.0 6.6 15.8 6.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.3 6.2 4.7 12.4 SP 3.9 NC 6.0 5.9

Age-adjusted 

mortality rateb 450.7 746.1 707.0 948.5 141.7 363.7 NC 724.3 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.1 14.7 13.6 17.5 16.5 8.8 23.7 14.3 13.6

Percent with 

diabetesc 11.3 10.2 9.7 15.7 5.0 7.7 8.5 10.3 10.8

Percent with 

heart diseasec 2.3 4.1 4.3 3.1 4.4 1.6 1.6 3.9 4.3

HIV rated 405.7 NC 144.6 1101.9 199.8 76.1** 1527.8 330.1 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

64.6 71.5 69.1 81.0 54.0 67.2 74.2 70.7 72.2

Percent received 

oral health visit 

(past 12 months)c

58.3 67.2 69.0 56.9 47.0 62.3 55.3 66.1 66.5

Percent received 

flu vaccinec 35.0 36.8 37.9 30.0 22.8 40.6 26.9 36.3 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 76.1 per 100,000 population (436 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 727.7 per 

100,000 population (21 cases).

State and Territorial Efforts to Reduce Health Disparities 89
Indiana 

Introduction to Indiana’s Health Equity Activities

Indiana had an estimated 2016 population of 6,663,000. Blacks/African Americans are the largest racial-ethnic 

minority population (9 percent), followed by Hispanics/Latinos (7 percent), Asian Americans and NHOPI (2 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 5 percent of the population.1 Approximately 3,260,000 Indiana residents live within a primary care health 

professional shortage area.2

The Indiana State Department of Health (ISDH) Office of Minority Health (OMH) was created in 1991. Its mission 

is “to improve the health of all racial and ethnic populations in Indiana through increased awareness, partnerships, 

and the development and promotion of effective health policies and programs that help to reduce minority health 

disparities.”3 The OMH is responsible for advancing the legislatively-mandated Minority Health Initiatives (Indiana 

Code 16-46-11).

Indiana Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Minority Health is 

updating an existing strategic plan.

Date strategic plan 

was last updated

The Office of Minority Health last 

updated the strategic plan in 2010. 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Office of Minority Health 

intends to include a plan for 

monitoring progress in the updated 

strategic plan.

Key strategies 

used to achieve 

health equity

• Advocating for the elimination of 

health disparities and increasing 

health equity

• Promoting culturally competent 

and linguistically appropriate 

services and health care delivery

• Promoting and supporting 

minority health efforts by 

obtaining funding for specific 

programs and initiatives

• Improving data collection, 

analysis, and dissemination 

of information

Organizational Structure

Housed within the ISDH, the OMH employs four fulltime staff members—including the director, a health 

disparities epidemiologist, an office manager, and a 

project coordinator. The project coordinator is a grantfunded contracted position. In addition, the OMH 

engages unpaid interns throughout the year and, with 

funding from the Indiana Minority Health Coalition, paid 

interns in the summer. The OMH does not currently 

have a committee or panel that advises on minority 

health or health equity. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Office of 

Minority Health 

is housed within 

the Indiana State 

Department of 

Health.

SMHE staffing (full-time equivalents) 4

Advisory committee or panel None

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 See the Indiana State Department of Health’s webpage. Last 

accessed: October 2, 2017

State and Territorial Efforts to Reduce Health Disparities 90
Indiana

Program Goals and Activities

The OMH is revising an existing strategic plan, which 

was first launched in 2003 and updated most recently 

in 2010. In the upcoming version, which will be publicly 

available on its website, the OMH intends to include a 

plan for monitoring progress. A core function of the OMH 

is serving as a member of the Interagency State Council 

on Black and Minority Health, an organization that plays 

a key role in determining health equity priorities in 

Indiana. The OMH also relies on its partner organizations to help identify priorities. 

Acronym List

Full Name of Agency Acronym Acronym

Indiana State Department of Health ISDH

Office of Minority Health OMH

An overarching focus of the OMH is to advocate for 

strategies that eliminate health disparities and increase 

health equity in Indiana. Raising awareness of health 

equity issues and creating linkages between partner 

organizations and state agencies is a related and key 

part of its scope, as is improving access to health care 

and health outcomes. In support of these goals, the 

OMH participates in a wide range of activities. For 

example, it sponsors the INShape Indiana Black and 

Minority Health Fair, which provides free health screenings at the annual Indiana Black Expo Summer Celebration. The OMH also works to incorporate health equity 

into ISDH policies (e.g., supporting efforts to increase 

workforce diversity, cultivate community-driven partnerships, and ensure outreach to key minority health 

stakeholders for their input into the ISDH’s strategic 

planning process). 

Another OMH objective is to promote culturally competent and linguistically appropriate services. To this end, 

the OMH trains staff from the ISDH and other state 

agencies about the National Standards for Culturally and 

Linguistically Appropriate Services in Health and Health 

Care (National CLAS Standards). Such educational 

activities promotes proficiency with the National CLAS 

Standards, which helps ensure that state services and 

resources are culturally appropriate. Additionally, the 

OMH seeks to promote cultural competency among 

partner organizations by, for example, helping to publicize the National CLAS Standards at an annual minority 

health conference and supporting cultural competency 

training for data collectors. 

The OMH also helps to secure resources for specific 

programs and initiatives. For example, the OMH received 

funding from the U.S. Office of Minority Health State 

Partnership Grant Program, which supports the EMPOWERED (“Enhancing Minority Partnership Opportunities; 

Working to Eliminate Disparities”) program. Through the 

EMPOWERED effort, the OMH collaborates with a range 

of statewide partners on health education initiatives on 

obesity, infant mortality, breastfeeding in minority populations, and smoking cessation. The OMH also collaborates with many partners to procure additional funding 

for health equity activities.

Improving the collection, analysis, and dissemination 

of racial and ethnic minority population data is another 

OMH priority. Together, the OMH and the ISDH Data 

Analysis Team have been advocating to increase the 

sample size of racial and ethnic minorities within 

Behavioral Risk Factor Surveillance System (BRFSS) 

surveys. Such oversampling would improve the reliability 

of sub-population estimates and aid efforts to identify 

and monitor disparities. The OMH also works with the 

Indiana Minority Health Coalition’s Racial and Ethnic 

Minority Epidemiology Center to advance the State 

Master Research Plan, an effort to develop research 

strategies that reduce health disparities among racial 

and ethnic minorities. To support data analyses and 

dissemination, the OMH provides epidemiological 

support to internal and external partners. The OMH also 

works with the Interagency State Council on Black and 

Minority Health to release annual reports on the status 

of minority health in Indiana. 

Partnerships

Primary 

collaborators

• Indiana Black Expo

• Indiana Latina Expo

• Indiana Minority Health Coalition

• Interagency State Council on Black 

and Minority Health

• Local community advocacy groups

Contracts or 

memoranda of 

understanding 

with any partners

Formal contracts or memoranda 

of understanding are implemented 

for some partnerships.

Many of the minority health efforts undertaken by the 

OMH rely heavily on external help. The OMH, therefore, 

partners with many governmental and nongovernmental 

organizations. For example, to convene the INShape 

Indiana Black and Minority Health Fair, the OMH 

established a formal contract with Indiana Black Expo, 

a nonprofit community service organization.

State and Territorial Efforts to Reduce Health Disparities 91
Indiana

Another key OMH partner is the Indiana Minority Health 

Coalition, a statewide nonprofit agency with whom the 

OMH formally contracts to support implementing 

legislatively mandated Minority Health Initiatives. The 

Indiana Minority Health Coalition receives state funding 

through these initiatives, which it then distributes to 

local minority health coalition affiliates and communitybased organizations.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$460,867

Annual budget (FY 2015) of SMHE 

from state/territorial government $261,000

Largest funding source State government

The total FY 2015 funding for the OMH was $460,867. 

In FY 2015, the office had two primary funding sources: 

the State of Indiana ($261,000) and a 5-year State 

Partnership Initiative to Address Health Disparities 

grant from the U.S. Office of Minority Health 

($199,867). The OMH provides about $45,000 of its 

budget to support the annual INShape Indiana Black 

and Minority Health Fair.

The State of Indiana appropriates additional funding for 

the Minority Health Initiatives. In FY 2016, the Indiana 

General Assembly appropriated more than $2 million 

to the legislatively mandated Minority Health Initiatives. 

The OMH is responsible for directing the Minority 

Health Initiatives and dispersing those funds to partner 

organizations.

State and Territorial Efforts to Reduce Health Disparities 92
Indiana

Indiana State Data

Total Populationa: 

6,633,053

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 6.8 93.2 83.5 9.3 0.3 2.2 4.7 100.0 NA 

Percent of population 

medically uninsureda 20.1 7.5 7.8 9.7 13.4 6.7 14.5 8.3 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 8.1 7.3 6.7 11.9 SP SP NC 7.3 5.9

Age-adjusted 

mortality rateb 441.6 846.5 828.4 980.2 203.4 414.7 NC 835.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.1 14.6 13.7 20.6 31.4 8.9 27.3 14.5 13.6

Percent with 

diabetesc 8.8 11.7 11.2 15.9 16.1 6.4 13.7 11.6 10.8

Percent with 

heart diseasec 2.2 4.9 5.0 4.4 7.8 0.2 4.3 4.9 4.3

HIV rated 306.6 NC 120.5 780.6 38.5 148.0** 564.2 195.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

54.3 68.4 68.0 71.6 52.3 58.7 64.5 68.0 72.2

Percent received 

oral health visit 

(past 12 months)c

53.9 63.0 63.9 50.3 44.9 63.8 60.9 62.5 66.5

Percent received 

flu vaccinec 28.5 38.3 38.6 30.8 22.0 34.1 46.7 37.9 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 148.0 per 100,000 population (169 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 93
Iowa 

Special Note: The Office of Minority and Multicultural Health (OMMH) was not reauthorized by the Iowa state 

legislature effective July 1, 2017. The mission and functions of the OMMH are being integrated throughout the 

Iowa Department of Public Health. 

Introduction to Iowa’s Health Equity Activities

Iowa had an estimated 2016 population of 3,135,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (6 percent), followed by Blacks/African Americans (4 percent), Asian Americans and NHOPI (3 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 3 percent of the population.1 Approximately 727,000 Iowa residents live within a primary care health 

professional shortage area.2

The Iowa Department of Public Health (IDPH) formed an Office of Minority Health in 2005; state law mandated its 

establishment in 2006.3 In 2010, its name changed to the Office of Minority and Multicultural Health. The OMMH 

is housed in the Bureau of Oral Health and Delivery Systems within the IDPH Division of Health Promotion and 

Chronic Disease Prevention. The OMMH’s mission is to “promote and facilitate health equity” with the vision of 

“100 percent health care access and zero percent health disparity for Iowa’s minority and multicultural 

communities.”4 A key emphasis of the OMMH is promoting cultural competency within the health care community. 

The 15-member OMMH Advisory Council is appointed by the health department director to inform and support 

OMMH activities to achieve health equity in Iowa.

Iowa Minority Health Overview

Name of state/territorial minority 

health entity Office of Minority and Multicultural Health

Strategic plan in place to address 

minority health or health equity

The Iowa Department of Public Health Office of Minority and Multicultural Health’s 

Strategic Plan.

Date strategic plan was last 

updated 2015

Assessment plan in place 

to measure progress toward 

reducing health disparities

The assessment plan is a part of the larger Healthy Iowans strategic plan that evolved 

from a statewide needs assessment. Healthy Iowans: Iowa’s Health Improvement Plan

focuses on measurable goals and tracks progress on statewide health issues.5

Key strategies used to achieve 

health equity

• Trainings for all new department staff about social determinants of health

• Department-wide training on the National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care

• Breast and cervical cancer screening outreach to Latino women 

• Quarterly Advisory Council meetings 

• Coordination with “Des Moines Age-Friendly City Initiative”

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Iowa Department of Public Health. Minority and Multicultural Health: What We Do Profile. 

4 Iowa Department of Public Health. Office of Minority and Multicultural Health Strategic Plan, 2012 to 2017. 

5 Iowa Department of Public Health. “Iowa’s Health Improvement Plan 2012-2016: 2015 Revisions.” Website of the IDPH. Last accessed 

December 1, 2017

State and Territorial Efforts to Reduce Health Disparities 94
Iowa

Organizational Structure

State legislators created the OMMH in 2006 to 

address health disparities and minority health issues 

in Iowa. Administrative rules were promulgated in 2011 

to establish the OMMH Advisory Council, which consists of 15 voting members from designated regions 

and public- and private-sector organizations. 

The OMMH has one full-time staff member, the executive officer, who dedicates half of her time to minority 

health and health equity initiatives. Beyond this 

executive officer position, the OMMH regularly engages 

unpaid interns (and, when grant funding is available, 

paid interns) to help with its activities. No upcoming 

staffing changes were anticipated at the time of 

data collection. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OMMH is 

housed in the 

Bureau of Oral 

Health and Delivery 

Systems within the 

Iowa Department 

of Public Health, 

Division of Health 

Promotion and 

Chronic Disease 

Prevention. 

SMHE staffing (full-time equivalents) 0.5

Advisory committee or panel OMMH Advisory 

Council

Program Goals and Activities

OMMH 2012 Strategic Plan, Healthy Iowans: Iowa’s 

Health Improvement Plan 2012-2016, is publicly available on the OMMH’s website. It implements methods 

to increase health care access and reduce disparities 

in health outcomes among racial and ethnic minorities, 

immigrants, and refugee populations in Iowa. Developed 

with input from the OMMH Advisory Council and other 

stakeholder organization leaders, the strategic plan 

outlines the core functions and strategic initiatives 

of the OMMH. The plan spans FY 2012 to 2017, 

and the previous one covered FY 2007 to 2011.

The OMMH sets priorities both through the strategic 

plan and the OMMH Advisory Council. State 

policymakers, along with public and private sector 

partners and stakeholders, help identify areas of focus. 

Additionally, recent grant funding opportunities are 

including more language specifically addressing health 

equity and disparities, which is also driving minority 

health priorities throughout the state. 

Iowa tracks health indicators both to identify trends and 

establish benchmarks, allowing for comparisons to other 

states. Specifically, Healthy Iowans is a publicly available 

statewide population health plan that measures progress toward reducing health disparities and achieving 

health equity in Iowa. Its development involved stakeholder organizations and individuals across the state.6

A major focus of the OMMH is increasing cultural 

competency in health care. The OMMH trains all new 

IDPH employees about social determinants of health 

using the interactive Life Course Game. Game participants take on a role with specific social and biological 

risk and protective factors that lead to varied health 

outcomes. The training concludes with a discussion 

on the social determinants of health in the populations 

served by the IDPH. In addition, the OMMH offers 

a department in-service training on the National 

Standards for Culturally and Linguistically Appropriate 

Services in Health and Health Care (National CLAS 

Standards) as part of its effort to increase communication across all department employees. The National 

CLAS Standards training is available on request by 

bureaus and programs associated with the IDPH. 

Another OMMH activity to promote health equity 

involves targeted outreach to vulnerable populations. 

For example, the OMMH works with the IDPH Bureau of 

Chronic Disease Prevention and Management (BCDPM) 

to develop specific strategies that encourage breast 

and cervical cancer screenings among Latino women. 

The joint OMMH/BCDPM team has identified communities with large numbers of underserved Latino women, 

and discussions with community members have helped 

guide outreach. 

Acronym List

Full Name of Agency Acronym Acronym

Iowa Department of Public Health IDPH

Office of Minority and Multicultural Health OMMH

IDPH Bureau of Chronic Disease 

Prevention and Management BCDPM

6 Ibid.

State and Territorial Efforts to Reduce Health Disparities 95
Iowa

The OMMH also promotes networking across programs 

and initiatives related to health equity. Through quarterly 

OMMH Advisory Council meetings, the OMMH gains 

input about IDPH initiatives. For example, the Advisory 

Council has provided input on the state’s tobacco 

cessation programing efforts to reach under-reached 

or vulnerable populations. Additionally, the OMMH’s 

executive director has attended several meetings on 

the Des Moines “Age-Friendly City Initiative” to better 

understand and represent the needs of minority 

and multicultural populations. 

Partnerships

Primary 

collaborators

Selected list includes:

• Iowa Comprehensive Cancer 

Consortium

• Polk County Health Department

• Region VII Health Equity Heartland 

Advisory Council

• Title V Maternal and Child Health 

Services Block Grant Program

• Several Iowa academic institutions

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding.

Governmental and nongovernmental organizations 

partner with the OMMH to work toward eliminating 

health disparities and advancing statewide health 

equity. For example, the OMMH coordinates with the 

Polk County Health Department on the Des Moines 

Age-Friendly City Initiative. Additionally, the OMMH 

partners with the federal Title V Maternal and Child 

Health Services Block Grant Program in the Bureau 

of Family Health by providing trainings on request and 

at semiannual meetings with contractors. No formal 

contract exists between the OMMH and the Title V 

Program, but the OMMH executive officer’s position 

description includes language calling for coordination 

with the Program. Together, the OMMH and Title V 

Program work toward reaching national goals and 

objectives related to minority and multicultural health 

and health disparities. 

Although there is no formal contract between them, 

the OMMH executive officer regularly participates 

in meetings of the IDPH-funded Iowa Comprehensive 

Cancer Consortium to share data and represent 

the issues and needs of underserved populations. 

The OMMH executive officer also is a member of the 

Region VII Heartland Regional Health Equity Council 

and works with the Council to enhance data collection 

and reporting efforts across rural states. 

Finally, the OMMH partners with several public 

and private academic institutions to improve health 

equity in Iowa, presenting on specific minority and 

multicultural health topics upon request. It also 

regularly coordinates with Des Moines University 

and other schools to recruit for preceptorships 

and internships. The OMMH has established formal 

agreements for student experiences as required 

by IDPH and each institution.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$120,315

Annual budget (FY 2015) of SMHE 

from state/territorial government $37,768

Largest funding source Federal Title V Block 

Grant

Anticipated changes to budget

Possible changes 

to flexibility in use 

of funds

The total FY 2015 funding for the OMMH was 

$120,315. In FY 2015, the office had two key funding 

sources: the federal Title V Block Grant ($82,547) 

and the state cervical cancer screening appropriation 

($37,768). The Title V Block Grant for child health care 

was consistent at that level from FY 2013 to FY 2015, 

while the state cervical cancer screening funding was 

a one-time appropriation. The OMMH did not provide 

any funding to other governmental or nongovernmental 

entities for health disparities or health equity activities 

in FY 2015.

Funding for the OMMH became a separate line item 

in the IDPH budget in FY 2016 due to an IDPH reallocation request approved by the governor’s office. This 

reallocated state funding is set aside specifically for 

the OMMH to support the office’s 0.5 full-time equivalent position that was previously funded through shared 

support across IDPH programs. No upcoming funding 

changes for the OMMH were anticipated at the time 

of data collection, but IDPH has been involved in conversations with legislators with the goal of increasing 

the flexibility of funds appropriated to the IDPH.

State and Territorial Efforts to Reduce Health Disparities 96
Iowa

Iowa State Data

Total Populationa: 

3,134,693

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 5.7 94.3 90.3 3.5 0.4 2.6 3.3 100.0 NA 

Percent of population 

medically uninsureda 14.4 3.5 3.8 6.3 9.5 3.7 12.2 4.2 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 4.4 4.0 8.1 SP SP NC 4.2 5.9

Age-adjusted 

mortality rateb 400.6 726.9 718.3 962.6 569.8 403.1 NC 721.1 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.4 12.1 12.0 10.3 SP 6.9 16.6 12.2 13.6

Percent with 

diabetesc 9.2 9.4 9.4 6.6 SP 4.7 10.8 9.3 10.8

Percent with 

heart diseasec 1.0 4.1 4.1 0.0 SP 0.0 2.2 3.9 4.3

HIV rated 180.6 NC 68.2 574.0 54.9 96.0** 423.9 93.5 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

67.2 72.5 72.7 76.5 SP 56.7 69.7 72.4 72.2

Percent received 

oral health visit 

(past 12 months)c

73.8 71.6 72.7 65.7 SP 61.4 60.4 71.8 66.5

Percent received 

flu vaccinec 37.0 47.1 47.8 33.3 SP 41.2 38.0 46.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 96.0 per 100,000 population (58 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 97
Kansas 

Introduction to Kansas’ Health Equity Activities

Kansas had an estimated 2016 population of 2,907,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (12 percent), followed by Blacks/African Americans (6 percent), Asian Americans and NHOPI (3 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 6 

percent of the population.1 Approximately 802,000 Kansas residents live within a primary care health professional 

shortage area.2

Minority health and health equity activities in Kansas are coordinated through the Special Population Health (SPH) 

section of the Kansas Department of Health and Environment’s (KDHE) Bureau of Community Health Systems 

(BCHS). Its predecessor, the Center for Health Equity, lost funding in 2012. Since then, issues addressing health 

disparities and minority health have been under the Bureau’s SPH purview, although other Bureau initiatives have 

also addressed health equity issues. There is no advisory committee or panel for minority health, health 

disparities, or health equity issues in the KDHE.

Kansas Minority Health Overview

Name of state/

territorial minority 

health entity

No standalone entity. The Bureau’s 

SPH coordinates minority health 

activities.

Strategic plan in 

place to address 

minority health 

or health equity

No strategic plan specific to 

minority health or health equity is 

available. 

Date strategic plan 

was last updated N/A

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

None

Key strategies 

used to achieve 

health equity

• Increasing farmworker access to 

health care through the Kansas 

Statewide Farmworker Health 

Program

• Enhancing emergency 

preparedness in Native American 

tribes

• Development and distribution 

of a video, Health in 3D: 

Diversity, Disparities, and Social 

Determinants

• Development of a website to 

promote cultural competency in 

nursing care

Organizational Structure

Minority health and health equity activities are 

managed through the Kansas Department of Health 

and Environment’s Bureau of Community Health 

Systems, Special Population Health section. Promoting 

minority health and health equity is a new role for the 

Bureau’s SPH, which has one full-time staff member. 

This position dedicates the majority of time to the 

Kansas Statewide Farmworker Health Program and 

approximately 5 percent of time to health equity 

and minority health efforts. No staffing changes 

are anticipated. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

Minority health 

activities are 

coordinated 

through the 

KDHE Bureau of 

Community Health 

Systems’ SPH. 

SMHE staffing (full-time equivalents) 0.05

Advisory committee or panel None

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 98
Kansas

Program Goals and Activities

No strategic plan specific to minority health and health 

equity is available. To develop its health equity-related 

priorities, the Bureau’s SPH director is gathering information on programs within the KDHE to catalogue existing 

health equity efforts and identify gaps. In addition, the 

KDHE’s department-wide strategic plan emphasizes 

consideration of health equity across programs and 

initiatives. The BCHS’s SPH section promotes farmworker access to health care, emergency preparedness 

in Native American tribes, and development of educational resources on cultural competency in health 

care delivery. 

Acronym List

Full Name of Agency Acronym Acronym

Bureau of Community Health Systems BCHS

Kansas Department of Health and 

Environment KDHE

Special Population Health SPH

The Kansas Statewide Farmworker Health Program 

(KSFHP), established in 1994 and managed by the 

Bureau’s SPH section, helps low-income migrant and 

seasonal farmworkers and their families access health 

care services. A grant from the U.S. Health Services 

and Resources Administration supports services that 

families receive as part of this program. The Bureau’s 

SPH section also provides education to farmworkers 

on such health issues as tobacco use, diabetes, and 

hypertension. Outreach emphasizes the importance of 

exercise, annual physical exams, vaccinations, colorectal 

cancer screenings, and prenatal care. Because 75 

percent of KSFHP clients are Latino and 24 percent are 

Low-German Mennonites, the SPH section distributes 

educational materials in English, Spanish, and German. 

Bilingual staff are available to communicate information 

directly with each of these populations. 

Public health preparedness is a priority of the BCHS. 

Kansas’ four federally recognized Native American tribes 

receive federal grant dollars through the Bureau’s Public 

Health Emergency Preparedness Cooperative Agreement. These funds support the SPH section’s efforts 

to ensure that the tribes have adequate resources, 

including physician coverage, should emergencies occur. 

In addition to these activities, the BCHS—supported by 

staff from the SPH section and in partnership with the 

REACH Healthcare Foundation—developed a 25-minute 

self-study web-based training module and accompanying 

video to explain how diversity, disparities, and social 

determinants (the “three Ds”) play a role in Kansas’ 

public health. Entitled “Health in 3D: Diversity, Disparities, and Social Determinants,” the video is being widely 

distributed to local health departments, federallyqualified community health centers, and other partners, 

who are all encouraged to share the DVDs broadly. The 

module and video is also available as a publicly accessible course on “Kansas TRAIN,” an online educational 

resource. To emphasize the range of demographics 

present throughout the state, the video includes interviews of Kansans representing several groups, including 

rural residents; Spanish-speaking populations; and 

lesbian, gay, bisexual, and transgender communities. 

Bureau staff are also involved in developing the Kansas 

Action Coalition’s website, Kansas Center for Cultural 

Competency Advancement, which will provide information to nurses on implementing culturally congruent 

nursing care. 

Partnerships

Primary 

collaborators

• REACH Healthcare Foundation

• Kansas Action Coalition

• Health clinics, local health 

departments, and federally-qualified 

community health centers across 

Kansas

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

Several organizations partner with the Bureau’s SPH 

section to eliminate health disparities and advance 

statewide health equity. For example, the REACH 

Healthcare Foundation provided funding for the 

educational video, Health in 3D: Diversity, Disparities, 

and Social Determinants. Multiple members of the 

BCHS’s Local Public Health Program staff serve on the 

Kansas Action Coalition, a body focused on supporting 

Kansan nurses by implementing the Institute of 

Medicine’s 2010 report, entitled Future of Nursing: 

Leading Change, Advancing Health. With BCHS support, 

the Coalition is developing a website for the Kansas 

Center for Cultural Competency Advancement—an 

organization dedicated to promoting a culturally 

competent statewide nursing workforce. 

State and Territorial Efforts to Reduce Health Disparities 99
Kansas

Through the Kansas Statewide Farmworker Health 

Program, the Bureau’s SPH section has contracts with 

about 700 clinics throughout Kansas, including local 

health departments, federally-qualified community 

health centers, hospitals, private providers, dentists, 

and pharmacies. Each partner has a signed provider 

agreement formalizing the partnership. Staff with the 

Bureau’s SPH section supports several clinics serving 

large communities of farmworkers to help make 

appointments, follow up on bills, and schedule 

meetings. Bureau staff may only coordinate with 

other clinics when particular farmworker families 

need services.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

N/A

Annual budget (FY 2015) of SMHE 

from state/territorial government N/A 

Largest funding source N/A 

Anticipated changes to budget None

There was no dedicated funding for minority health and 

health equity activities in the Bureau’s SPH section; no 

funding changes are anticipated.

State and Territorial Efforts to Reduce Health Disparities 100
Kansas

Kansas State Data

Total Populationa: 

2,907,289

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 11.6 88.4 84.6 6.0 0.7 2.8 5.9 100.0 NA 

Percent of population 

medically uninsureda 20.0 7.1 7.4 16.8 11.0 8.4 17.6 8.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.9 5.9 5.6 9.4 SP SP NC 6.0 5.9

Age-adjusted 

mortality rateb 507.7 765.6 750.4 935.1 984.7 422.1 NC 756.8 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 9.8 13.4 12.9 17.7 23.4 2.4 18.6 13.3 13.6

Percent with 

diabetesc 6.3 9.7 9.1 14.6 10.2 5.1 9.9 9.4 10.8

Percent with 

heart diseasec 0.9 4.2 4.0 3.0 5.0 0.6 4.4 3.9 4.3

HIV rated 205.8 NC 76.6 519.5 40.9 50.2** 346.3 118.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

55.8 69.9 69.0 71.5 70.3 67.4 56.0 68.9 72.2

Percent received 

oral health visit 

(past 12 months)c

58.3 68.1 68.9 59.1 49.1 71.0 53.7 67.6 66.5

Percent received 

flu vaccinec 29.6 38.6 39.2 29.4 24.5 31.9 31.1 38.0 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 50.2 per 100,000 population (34 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 55.3 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 101
Kentucky 

Introduction to Kentucky’s Health Equity Activities

Kentucky had an estimated 2016 population of 4,437,000. Blacks/African Americans are the largest racial-ethnic 

minority population (8 percent), followed by Hispanics/Latinos (3 percent), Asian Americans and NHOPI (2 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 3 percent of the population.1 Approximately 1,117,000 Kentucky residents live within a primary care 

health professional shortage area.2

Kentucky’s Office of Health Equity (OHE), established in 2008, is housed in the Commissioner’s Office of the 

Kentucky Department of Public Health (KDPH). The KDPH is part of Kentucky’s Cabinet for Health and Family 

Services, whose secretary reports directly to the governor. As part of the KDPH’s executive leadership, the OHE 

is able to respond promptly to ideas, planning, and implementation of health equity initiatives. The OHE strives 

to “address health disparities among racial and ethnic minorities, and rural Appalachian populations.”3 An internal 

OHE advisory committee comprised of division directors and assistant directors provides strategic guidance.

Kentucky Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

No strategic plan. The OHE uses a 

yearly work plan of activities based 

on state needs. 

Date strategic plan 

was last updated N/A

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The OHE uses 5- and 10-year 

health status and health outcomes 

trend data to measure progress. 

Key strategies 

used to achieve 

health equity

• Promoting community-based 

participatory research

• Disseminating data on health 

disparities

• Promoting use of evidencebased strategies related to 

chronic disease prevention and 

management

• Educating on social determinants 

of health and their impact on 

health outcomes

• Using a health equity framework 

to address health disparities

Organizational Structure

Located within the KDPH Commissioner’s Office, the 

OHE “provides input using a health equity lens for 

numerous initiatives and committees” at the local, 

state, and national level.4 Its internal Health Equity 

Advisory Committee strives to provide insight and 

guidance on OHE areas of focus. 

The OHE has one full-time managing epidemiologist 

and one half-time program assistant who devotes 

60 percent time to minority health and health equity 

initiatives. The epidemiologist provides oversight 

and guidance on health equity initiatives, funding 

opportunities, collaborations and partnerships, 

curriculum development and training, interpretation 

of data, and other duties. The program assistant 

oversees administrative activities and supports KDPH 

staff in cultural competency, cultural sensitivity, and 

health literacy. Beyond these two positions, staff 

across the KDPH work to support the OHE’s health 

equity mission. 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Available on the Kentucky Cabinet for Health and Family Services, 

Office of Health Equity website. Last accessed July 10, 2017.

4 Ibid.

State and Territorial Efforts to Reduce Health Disparities 102
Kentucky

Other staffing support comes from community 

volunteers, who participate on several initiatives. 

The OHE serves as a University of Louisville School 

of Public Health and University of Kentucky School of 

Public Health practicum placement site where students 

can gain experience in health disparities and health 

equity work. No upcoming staffing changes are 

anticipated at this time. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OHE is housed 

within the Kentucky 

Department of 

Public Health’s 

Commissioner’s 

Office

SMHE staffing (full-time equivalents) 1.5

Advisory committee or panel Health Equity 

Advisory Committee

Program Goals and Activities

Based on the State Health Assessment and State 

Health Improvement Plan, the OHE develops and 

follows a work plan that includes specific initiatives. 

Internal discussions are underway for more formal 

strategic planning. 

The OHE promotes the use of a health equity framework 

across all OHE and KDPH activities, with attention to 

root causes that impact population health. OHE priorities are data-driven and based on geographic and 

population-specific needs. The OHE uses Behavioral 

Risk Factor Surveillance System (BRFSS) data, the Office 

of Health Policy’s hospitalization and emergency department data, and the OHE’s own Kentucky Minority Health 

Status Report to identify issues that need to be 

addressed. Kentucky law requires the OHE to produce 

a Minority Health Status Report every 2 years that 

includes data stratified by race and ethnicity. The OHE 

also uses information from community-based organizations and coalitions to shape its work plan to address 

community needs. 

To assess progress toward reducing health disparities, 

the OHE looks at trends in health status and health 

outcomes over 5- and 10-year periods. It is currently 

developing a rubric for measuring health equity. OHE 

areas of focus also align with federal priorities from the 

National Partnership for Action and state priorities from 

the state health assessment, the State Health Improvement Plan, Healthy People 2020, and the governor’s 

Kentucky Health Now Plan. 

In support of the National Partnership for Action focus 

areas, the OHE promotes community-based participatory 

research through several activities. For example, the 

OHE participated in Bless Your Heart, a Million Hearts 

initiative of the American Heart Association that used 

a faith-based model to encourage African American 

congregants with hypertension to reduce blood pressure. Similar faith-based models are also used in 

Eastern Kentucky for cancer prevention and HIV and 

human papillomavirus prevention. Through community 

health action teams funded by the Centers for Disease 

Control and Prevention, the OHE supports communitybased participatory research through neighborhood 

associations. The OHE also works closely with the 

University of Louisville and the University of Kentucky to 

promote community-based participatory research and is 

planning to administer small community-based participatory research grants to local health departments on 

community safety, health, and wellness. 

Acronym List

Full Name of Agency Acronym Acronym

Kentucky Department for Public Health KDPH

Kentucky Office of Health Equity OHE

The OHE works with divisions across the KDPH on 

translation and dissemination of state and local data on 

health disparities. By disseminating data in lay language, the OHE helps communicate to a broad audience 

what the numbers mean and how they impact populations, communities, and individual health. Using data 

from the aforementioned sources, coupled with the HIV/

AIDS Surveillance Report and county health rankings, 

the OHE develops infographics that identify disparities 

and inequities for specific populations. It then disseminates these infographics to KDPH workgroups, coalitions, community-based partners, and to the public via 

the KDPH website. The OHE is developing infographics 

on chronic disease impact that convey morbidity and 

mortality in communities and populations across 

the state. 

Chronic disease prevention is a priority area for the OHE. 

It provides technical assistance on the health equity 

components of such work across the department. 

The OHE also supports the Health Access Nurturing 

Development Services program for expectant parents 

and Kentucky’s Women’s Cancer Screening Program—

which uses community health workers to reach women. 

Other programs supported by OHE include Health 

State and Territorial Efforts to Reduce Health Disparities 103
Kentucky

Homes and Kentucky’s CARE Collaborative for heart 

disease and stroke prevention. It uses geographic, 

demographic, and poverty-level data to target populations for evidence-based interventions to ensure access 

to quality health care and services.

Education is a key strategy employed by the OHE, which 

conducts trainings for KDPH employees, communitybased partner organizations, and the general public. 

The OHE emphasizes awareness and education around 

social determinants and provides standardized definitions of health disparities, health equity, and social 

justice. It continually educates its internal and external 

partners on what those terms mean, how they impact 

health, and how they apply to their programs. For 

example, the OHE conducts in-person trainings, workshops, and small group seminars to educate the public 

health workforce to better address population health. 

Online trainings are also available as web-based courses 

on Kentucky’s Training Finder Real-time Affiliate Integrated Network (TRAIN), an online learning resource of 

the Public Health Foundation. The OHE conducts a 

Bridges Out of Poverty training that emphasizes that 

poverty can be situational, generational, and a strong 

driver of stakeholder decisions. The Bridges Out of 

Poverty training includes a follow-up component called 

Bridges Into Health that focuses on health care and 

health services. 

Partnerships

Primary 

collaborators

• City of Louisville’s Center for Health 

Equity

• Health Equity Network

• KDPH Chronic Disease Prevention 

Branch

• Kentucky Cancer Consortium

• University of Louisville School 

of Public Health and Information 

Sciences

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships

The OHE partners with state and local health departments, community and faith-based organizations, 

neighborhood associations, coalitions, academic 

institutions, internal KDPH programs, and other state 

and local government agencies. 

The OHE has worked with the City of Louisville’s 

Center for Health Equity since 2008. Like the OHE, 

the Center for Health Equity aims to expand the 

definition of health equity and health inequities and 

focuses on how policy and systems changes can 

promote health equity in specific populations. The OHE 

communicates regularly with the center in an effort 

to expand initiatives beyond Louisville and Jefferson 

County, where the center is well established. Together, 

the OHE and Center for Health Equity are working on 

general health equity policies, and seeking to help 

communities understand regulations and have a voice 

for health equity. 

The Kentucky Cancer Consortium consists of about 

60 profit and nonprofit organizations that meet 

quarterly to discuss five focus areas of cancer: cancer 

prevention, screening, quality of life, survivorship, and 

treatment. The consortium forms workgroups to 

address each area and determine needs for specific 

populations based on race/ethnicity, age, geography, 

and gender. The OHE and the consortium are working 

on health literacy and survivorship issues, with an 

emphasis on lung cancer screening and policy, since 

lung cancer is the leading cause of cancer morbidity 

and mortality in the state. The OHE has a 

memorandum of understanding regarding its 

partnership with the Consortium. 

The OHE works with the KDPH Chronic Disease 

Prevention Branch on health disparities initiatives 

related to colorectal cancer, heart disease, stroke, 

asthma, and diabetes. For example, the OHE is working 

with the Chronic Disease Prevention Branch to increase 

colorectal cancer screening for African American men 

in urban areas. 

Another partner is the Health Equity Network, originally 

created through an OHE grant, which continues its 

health equity work in Lexington County. The OHE 

provides technical assistance and guidance to the 

network on health disparities, social determinants 

of health, and health equity issues. It also helps the 

network find ways to leverage data to address critical 

access issues and areas of need within certain 

communities. The Health Equity Network is 

collaborating with medical associations to decrease 

community violence and bullying among children and 

is seeking ways to involve law enforcement, schools, 

and the wider community.

State and Territorial Efforts to Reduce Health Disparities 104
Kentucky

Finally, the University of Louisville School of Public 

Health and Information Sciences coordinates with the 

OHE to educate students, faculty, and staff on cultural 

competency and health literacy. Together, the OHE and 

the University are developing initiatives to support 

undergraduate students and prepare them for graduate 

studies or professional careers based on an 

understanding of the social determinants of health. 

The OHE has conducted lectures at the university, 

and has provided workshops and training materials.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$150,000

Annual budget (FY 2015) of SMHE 

from state/territorial government None

Largest funding source 

State Partnership 

Initiative to Address 

Health Disparities 

grant from the U.S. 

Office of Minority 

Health

Anticipated changes to budget

Possible changes 

to flexibility in use 

of funds

The total FY 2015 funding for the OHE was $150,000, 

all from the State Partnership Initiative to Address 

Health Disparities grant from the U.S. Office of Minority 

Health. Subsequently, OHE funding has remained 

consistent at approximately $150,000 since 2016, 

funded by the federal Preventive Health and Health 

Services Block Grant and state resources. The OHE 

provides limited funding to county and local health 

departments to address health disparities.

No funding changes for the OHE are anticipated.

State and Territorial Efforts to Reduce Health Disparities 105
Kentucky

Kentucky State Data

Total Populationa: 

4,436,974

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 3.4 96.6 87.1 8.4 0.2 1.5 2.8 100.0 NA 

Percent of population 

medically uninsureda 21.3 5.0 5.2 7.0 3.9 7.4 11.6 5.5 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 6.8 6.6 8.9 SP SP NC 6.7 5.9

Age-adjusted 

mortality rateb 349.8 946.6 941.8 967.9 215.9 406.1 NC 938.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 14.7 15.3 15.0 16.6 24.3 9.1 20.0 15.2 13.6

Percent with 

diabetesc 5.3 13.3 13.2 13.9 15.8 10.2 11.8 13.2 10.8

Percent with 

heart diseasec 6.0 6.8 7.0 3.8 7.1 0.0 15.4 6.8 4.3

HIV rated 399.9 NC 117.0 753.0 74.6 81.7** 586.4 179.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

83.8 76.8 77.1 78.7 74.0 70.8 74.6 77.1 72.2

Percent received 

oral health visit 

(past 12 months)c

68.4 62.3 62.9 61.0 47.5 67.9 54.7 62.5 66.5

Percent received 

flu vaccinec 26.1 38.8 39.0 37.2 24.0 51.5 24.5 38.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 81.7 per 100,000 population (41 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 50.3 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 106
Louisiana 

Introduction to Louisiana’s Health Equity Activities

Louisiana had an estimated 2016 population of 4,682,000. Blacks/African Americans are the largest racialethnic minority population (33 percent), followed by Hispanics/Latinos (5 percent), Asian Americans and NHOPI 

(2 percent), and American Indians/Alaska Natives (less than 1 percent). Multiracial and persons self-identifying 

as “other race” comprise 3 percent of the population.1 Approximately 2,720,000 Louisiana residents live within 

a primary care health professional shortage area.2

The Louisiana Department of Health (LDH) and the Minority Health Affairs Commission established the Louisiana 

Bureau of Minority Health Access and Promotions (BMHAP) in the late 1990s. The BMHAP addresses public health 

issues related to minorities and mainly serves five populations: African Americans, Hispanics and Latinos, American 

Indians, Asians and Pacific Islanders, and economically disadvantaged Whites. Separate from the BMHAP, the Office 

of Public Health (OPH) lists reducing health disparities among its priorities. The BMHAP has partnered with the 

OPH to address health concerns such as diabetes and infant mortality and, since 2016, has been a close partner 

in addressing priorities. A 32-member Minority Health Coalition (MHC)—comprising individuals from federally 

qualified health centers, health advocates, city council members, and individuals from churches and other 

community organizations—advises the BMHAP on minority health, health disparities, and health equity.

Louisiana Minority Health Overview

Name of state/

territorial minority 

health entity

Bureau of Minority Health Access 

and Promotions

Strategic plan in 

place to address 

minority health 

or health equity

Yes

Date strategic plan 

was last updated 2007

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

No

Key strategies 

used to achieve 

health equity

• Minority Health Month campaign 

(April)

• Online statewide physical activity 

and nutrition challenges

• Emergency preparedness 

planning for racial/ethnic 

communities

• Regional infant mortality program

Organizational Structure

The BMHAP has an executive director, an outreach 

coordinator, and a secretary whose primary department 

is not the BMHAP but who spends 50 percent time on 

BMHAP initiatives. Beyond these positions, the BMHAP 

engages a network of volunteers and unpaid interns to 

help with minority health activities. These volunteers and 

other collaborations are key to achieving the goals of the 

BMHAP and the OPH. While no plans exist to increase 

the number of staff working on minority health and health 

equity initiatives, three staff members contribute at least 

half of their time to minority health activities. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The BMHAP is 

under the Office 

of the Secretary 

SMHE staffing (full-time equivalents) 3 

Advisory committee or panel Minority Health 

Coalition

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 107
Louisiana

Program Goals and Activities

After Hurricane Katrina in 2005, the BMHAP worked with 

the Choctaw Tribe (representing some of the residents 

of affected neighborhoods) to develop the Community 

Preparedness Response Network, a program for surveying neighborhoods. Door-to-door survey teams 

noticed that, while minorities might be disproportionately 

concentrated in neighborhoods with lower socioeconomic status, many economically disadvantaged Whites 

lived in the same neighborhoods. The BMHAP therefore 

adjusted its campaigns to serve economically disadvantaged Whites as well as minority populations. As one of 

the BMHAP’s strategies for achieving health equity, the 

Community Preparedness Response Network aims to 

help economically disenfranchised and minority populations throughout the state quickly respond and evacuate 

in the event of future emergencies. 

Acronym List

Full Name of Agency Acronym Acronym

Bureau of Minority Health Access 

and Promotions BMHAP

Louisiana Department of Health LDH

Office of Public Health OPH

Minority Health Coalition MHC

The BMHAP has a standalone strategic plan for 

minority health, health disparities, and health equity 

that has been in place since creation of the BMHAP. 

Prior to Hurricane Katrina, the strategic plan was 

updated every 5 years. The plan was last updated in 

2007, after Hurricane Katrina. At that time, the Community Preparedness Response Network emergency 

preparedness annual training was integrated into the 

strategic plan. Although there are evaluations of 

individual programs, there is no overall assessment 

plan to measure progress toward reducing health 

disparities. The OPH also has a 5-year strategic plan 

that includes reducing health disparities as one of its 

top five priorities.

The BMHAP primarily sets minority health, health 

disparities, and health equity priorities in Louisiana 

with guidance from the MHC and from community 

leaders and organizations. The MHC is integral to 

priority setting since its members interact with the 

communities that the BMHAP serves. The BMHAP 

has made obesity reduction a priority. Infant mortality 

reduction is another priority, but it plans to let the OPH 

lead that effort as part of its plan to reduce disparities. 

The OPH sets its own minority health, health disparities, and health equity priorities with input from a 

health summit organized by a partner nonprofit organization, the Louisiana Center for Health Equity. 

Several strategies are underway to reduce health 

disparities, improve minority health, and achieve health 

equity. One strategy is the Minority Health Month 

campaign, led by the BMHAP and the MHC since 2016. 

The BMHAP gives funds to the MHC to distribute to 

community partners that hold minority health activities 

such as screenings, workshops, physical activity 

classes, and health fairs throughout the month of April. 

Another BMHAP strategy, the Own Your Own Health 

campaign, is an online physical activity and nutrition 

tracking system designed for teams of two or more 

people to see who can accumulate the most miles and 

lose the most weight. In 2016, 12,000 people signed 

up to participate. In 2017, the online system allowed 

for public and private challenges, and the BMHAP 

included city versus city challenges to see which cities 

could accumulate the most miles. These challenges 

focused on 16 cities and 32 schools in minority 

neighborhoods. The Miss Louisiana Organization 

partners with the BMHAP to address obesity reduction; 

each pageant competitor adopts one of the schools 

and serves as captain for the challenge competition. 

A final strategy to improve health equity aims to reduce 

infant mortality. The BMHAP and the OPH are leading 

efforts to reduce the number of infant deaths and the 

number of low birth weight babies. Applying a strategy 

developed in Arkansas and Oklahoma, the BMHAP 

leads a community baby shower toolkit effort with 

help from the OPH and other partners. The toolkit 

helps communities organize community baby showers, 

targeting expectant and new mothers in three areas 

with the highest rates of infant mortality (public health 

regions 1, 8, and 9). The BMHAP also funds mini-grants 

to support infant mortality programs in other localities. 

These efforts primarily serve African American women 

where infant mortality rates are highest, but also serve 

Hispanic women. As part of its infant mortality reduction efforts, the OPH leads the Nurse-Family Partnership program that serves all parishes in the state; 

the program is open to all mothers who qualify but 

primarily serves African American mothers. The OPH 

also supports the Parents as Teachers home visiting 

program in northern Louisiana and oversees the 

Louisiana Fetal and Infant Mortality Review Network. 

State and Territorial Efforts to Reduce Health Disparities 108
Louisiana

Partnerships

Primary 

collaborators

• Office of Public Health

• Amerigroup

• Louisiana Primary Care Association

• Governor’s Council on Physical 

Fitness and Sports

• Southeast Louisiana Area Health 

Education Center

• Pennington Biomedical Research 

Center

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

With its connections among minority populations, 

the BMHAP serves as a partner to the OPH in its role 

of leading efforts to address public health concerns 

such as diabetes and tobacco control. Working 

together, the agencies are better able to improve the 

health of minority communities. The BMHAP has formal 

contracts with Amerigroup, the Louisiana Primary Care 

Association, the Governor’s Council on Physical Fitness 

and Sports, the Southeast Louisiana Area Health 

Education Center, and Pennington Biomedical Research 

Center. Amerigroup, a managed care organization, 

sponsors the Own Your Own Health program and the 

Minority Health Month campaign. This sponsorship 

allows the BMHAP to provide mini-grants to partners 

throughout the state. Amerigroup’s communications 

division works closely with the BMHAP to help with 

outreach. The Louisiana Primary Care Association, 

which represents all federally qualified health centers 

in Louisiana, distributes funding for the Minority Health 

Month campaign and is involved in nearly all BMHAP 

programs. The Governor’s Council on Physical Fitness 

and Sports is a key partner for addressing obesity, 

especially among youth and children. The council 

oversees physical fitness testing, games, and 

competitions in schools and trains physical education 

teachers in disadvantaged schools. The Southeast 

Louisiana Area Health Education Center helps provide 

training and provides an outreach coordinator for the 

BMHAP. The outreach coordinator helps with 

implementation of safeTALK, a program that teaches 

community members to identify and reduce suicide 

risk. The Pennington Biomedical Research Center helps 

measure the outcomes of the Own Your Own Health 

program, safeTALK, and several physical fitness 

programs. The BMHAP also partners with individuals 

in communities; sororities; the Special Supplemental 

Nutrition Program for Women, Infants, and Children; 

and the March of Dimes to achieve program goals.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

Approximately 

$360,000

Annual budget (FY 2015) of SMHE 

from state/territorial government None

Largest funding source U.S. Office of 

Minority Health grant

Anticipated changes to budget None

The total FY 2015 funding for the BMHAP was approximately $360,000. In FY 2015, the largest single 

source of funding was a U.S. Office of Minority Health 

grant ($200,000). The other sources of funding were 

an ongoing Medicaid outreach grant that has been 

consistent since 2003 ($100,000); an ongoing Centers for Disease Control and Prevention grant that has 

been consistent since 2004 ($30,000); Amerigroup 

sponsorship for the Own Your Own Health program 

($20,000); and ongoing U.S. Office of Minority Health 

Region VI funding that has been consistent since 2004 

(approximately $10,000). The BMHAP funded approximately $137,000 worth of community grants in FY 

2015. Funding from the BMHAP went to support five 

minority-serving agencies and programs. The largest 

amount went to the 32-member MHC partners in 

underserved areas to carry out Minority Health Month 

activities ($80,000). Funding also went to four Native 

American tribes in support of the Community Preparedness Response Network strategic goal for emergency 

preparedness training in the event of infectious disease outbreaks ($30,000); the Growing Up Fit Early 

Years obesity prevention program at Head Start centers 

($15,000); an Asian/Pacific Islander community for 

a program that assesses mental health as it relates 

to diabetes ($10,000); and rural parish sheriff departments to obtain the Are You OK? telephone reassurance program for elderly persons, homebound individuals, and latch-key children ($2,000).

State and Territorial Efforts to Reduce Health Disparities 109
Louisiana

Louisiana State Data

Total Populationa: 

4,681,666

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 4.9 95.1 61.9 32.5 0.6 1.7 3.3 100.0 NA 

Percent of population 

medically uninsureda 31.0 10.0 9.1 13.0 18.5 11.3 25.2 11.0 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 7.7 5.4 11.0 SP SP NC 7.6 5.9

Age-adjusted 

mortality rateb 394.0 885.3 828.5 996.4 348.9 361.8 NC 870.5 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.8 14.4 12.4 18.5 17.2 5.8 14.4 14.4 13.6

Percent with 

diabetesc 8.5 12.4 11.2 14.0 25.8 9.0 6.5 12.2 10.8

Percent with 

heart diseasec 1.6 6.0 6.5 4.8 5.0 3.0 5.4 5.9 4.3

HIV rated 500.0 NC 207.3 1107.4 126.2 98.4** 845.3 504.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

59.0 73.5 71.3 78.2 62.5 46.3 48.8 72.5 72.2

Percent received 

oral health visit 

(past 12 months)c

60.5 57.0 61.9 48.3 45.5 58.8 40.2 56.8 66.5

Percent received 

flu vaccinec 14.2 34.1 34.6 30.4 37.9 35.6 26.8 33.1 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 98.4 per 100,000 population (67 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 367.9 per 

100,000 population (6 cases).

State and Territorial Efforts to Reduce Health Disparities 110
Maine 

Introduction to Maine’s Health Equity Activities

Maine had an estimated 2016 population of 1,331,000 and its racial-ethnic minority populations include: Blacks/

African Americans (2 percent), Hispanics/Latinos (2 percent), American Indians/Alaska Natives (1 percent), and 

Asian Americans and NHOPI (1 percent). Persons self-identifying as multiracial or “other race” comprise 2 

percent of the population.1 Approximately 85,000 Maine residents live within a primary care health professional 

shortage area.2

Housed within the Maine Department of Health and Human Services, the Maine Center for Disease Control 

and Prevention (MCDC) is comprised of five divisions, each of which addresses health equity. The MCDC’s mission 

is “to provide the leadership, expertise, information and tools to assure conditions in which all Maine people can 

be healthy.”3

Maine Minority Health Overview

Name of state/

territorial minority 

health entity

Maine’s Office of Health Equity 

closed in early 2016 and 

responsibilities transferred to the 

MCDC.

Strategic plan in 

place to address 

minority health 

or health equity

Information on the Maine 

Center for Disease Control and 

Prevention’s strategic plan for 

minority health and health equity 

is documented in Healthy Maine 

2020.

Date strategic plan 

was last updated 2015

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Shared Community Health 

Needs Assessment includes data 

evaluations that will guide future 

actions.

Key strategies 

used to achieve 

health equity

• Improving health disparity data

• Refining Behavioral Risk Factor 

Surveillance Survey questions, 

and increasing sample size

• Coordinating with partners 

to improve population-specific 

needs assessments

• Improving access to sexual 

assault support for lesbian, 

gay, bisexual, and transgender 

individuals

• Developing geographically 

specific priorities and strategies 

Organizational Structure

The MCDC, housed within the Maine Department 

of Health and Human Services, does not have a 

committee or panel that advises on minority health 

or health equity. One MCDC staff member, an 

accreditation and performance improvement manager, 

devotes approximately 30 percent time to health 

disparities and health equity. The MCDC does not have 

volunteers or interns, and does not anticipate changes 

in staff allocations. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

N/A

SMHE staffing (full-time equivalents) N/A

Advisory committee or panel None

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Maine Center for Disease Control & Prevention. About 

Us. Available at the Maine MCDC website. Last accessed 

8/21/2017.

State and Territorial Efforts to Reduce Health Disparities 111
Maine

Program Goals and Activities

Acronym List

Full Name of Agency Acronym Acronym

Maine Center for Disease Control and 

Prevention MCDC

Healthy Maine 2020 is a publicly available MCDC 

publication intended to help with planning, reporting, 

and responding to Maine’s public health issues. As 

one of its goals, Healthy Maine 2020 aims to “achieve 

health equity, eliminate disparities, and improve the 

health of all groups.”4 Additionally, Maine’s Shared 

Community Health Needs Assessment was updated 

November 18, 2015, replacing the 2012 State 

Health Assessment.

Much of the MCDC’s efforts toward reducing disparities 

and achieving health equity involve partnerships and 

collaborations with various organizations. For example, 

the MCDC worked with two firms (Market Decisions 

Research and Hart Consulting) to develop the 2015 

Shared Community Health Needs Assessment, which 

was developed through the Maine Shared Health 

Needs Assessment and Planning Process. That process, which represents a collaboration between the 

MCDC, Central Maine Healthcare, Eastern Maine 

Healthcare Systems, Maine General Health, and 

MaineHealth, seeks to “turn data into action” and 

implement comprehensive health improvement strategies.5 The 2016 Needs Assessment informs priority 

setting by setting health disparities reduction goals 

for each MCDC division. 

Strategies implemented across the MCDC to improve 

minority health include improving health disparity data 

collection and analysis. For example, the MCDC is 

working with the University of Southern Maine to conduct an assessment of all relevant and available data 

sources. It is also coordinating with partners to improve 

population-specific needs assessments, such as 

enhancing access to sexual assault support for lesbian, 

gay, bisexual, and transgender (LGBT) individuals. 

The MCDC also participates in the BRFSS, a telephone 

survey that tracks risk behaviors and health conditions 

throughout the United States, and has added two 

questions about gender identity to the BRFSS that 

will enhance knowledge of the state’s LGBT population. 

Additionally, the MCDC is providing resources for a larger 

sample size per county to improve the reliability of 

BRFSS subpopulation analyses.

While not guided by legislative mandates to set priorities for health equity, the MCDC Division of Public 

Health Systems works with nine legislatively mandated 

public health districts (eight geographic districts 

and one tribal district) to reduce health disparities.6

Geographically-specific priorities and strategies, 

therefore, have been another focus of MCDC’s health 

equity activities. Specifically, District Public Health 

Improvement Plans, a product of a MCDC collaboration 

with public health districts, provide geographicallytailored plans to meet needs of the state’s minorities, 

many of whom are clustered in particular regions of the 

state. Such plans also help target disparities reduction 

efforts with Maine’s federally recognized tribal entities. 

Partnerships

Primary 

collaborators

• Catholic Charities 

• City of Portland 

• Maine Access Foundation 

• Maine Coalition Against Sexual 

Assault 

• Tribal Health District 

• University of Southern Maine

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The MCDC had formally contracted with the University 

of Southern Maine to assess available public health 

data sets—such as vital statistics, hospital discharge 

data, and census data—to determine their reliability, 

limitations, and potential as new data sources for 

particular populations. The assessment examined data 

by race, ethnicity, sexual orientation, gender identity, 

income, age, and gender and has produced 

recommendations to improve health disparity data. 

Implementation of those recommendations has been 

a focus of MCDC efforts (see Program Goals and 

Activities section, above).

4 Healthy Maine 2020. Available at the Maine Center for Disease Control and Prevention website. Last accessed 8/21/2017.

5 Maine Shared Health Needs Assessment & Planning Process. 2015 Shared Community Health Needs Assessment. Available on the public 

health data page within MCDC’s website. Last accessed 8/21/2017. 

6 Bureau of Indian Affairs. Tribal Leaders Directory. Available through the U.S. Department of the Interior’s Bureau of Indian Affairs’ website. 

Last accessed 8/21/2017.

State and Territorial Efforts to Reduce Health Disparities 112
Maine

Additionally, the MCDC has coordinated with a range 

of partners to improve population-specific needs 

assessments. One community partner, for example, 

conducted a survey focused on immigrants in Lewiston 

and Auburn. MCDC collaborators in the needs 

assessments effort include the City of Portland, 

federally recognized tribal entities, Catholic Charities, 

and the Maine Access Foundation.

The MCDC formally contracts with the Maine 

Coalition Against Sexual Assault to increase cultural 

competency of sexual assault agencies regarding 

LGBT communities. To support this work, the MCDC 

is developing partnerships with LGBT advocacy 

organizations and sexual assault agencies. 

Finally, the MCDC formally contracts with several 

nongovernmental organizations to reduce health 

disparities. One such formal collaboration is with 

the Tribal Health District, which is governed by the 

four Maine tribes (the Penobscot, Passamaquoddy, 

Micmac, and Maliseet, collectively known as 

Wabanaki). Together, the MCDC and the Tribal 

Health District set priorities and seek to improve 

public health by implementing District Public Health 

Improvement Plans.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$1,330,928

Annual budget (FY 2015) of SMHE 

from state/territorial government Zero

Largest funding source Federal

Anticipated changes to budget None

The FY 2015 funding for MCDC minority health activities was $1,330,928. The MCDC receives funding for 

minority health activities from a Preventive Health and 

Health Services Block Grant from the U.S. Centers for 

Disease Control and Prevention.7 The MCDC funds 

nongovernment organizations, including the University 

of Southern Maine ($99,822) and the Maine Coalition 

Against Sexual Assault ($110,605). The MCDC does 

not anticipate funding changes in the next 2 years.

7 U.S. Centers for Disease Control and Prevention Services. PHHS Block Grant Contacts Available on the PHHS webpage within the federal 

MCDC’s website. Last accessed 8/21/2017.

State and Territorial Efforts to Reduce Health Disparities 113
Maine

Maine State Data

Total Populationa: 

1,331,479

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 1.5 98.5 94.5 1.7 0.6 1.3 2.1 100.0 NA 

Percent of population 

medically uninsureda 14.9 7.8 7.8 14.6 14.1 3.1 10.0 7.9 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 6.3 6.4 SP SP SP NC 6.6 5.9

Age-adjusted 

mortality rateb 272.1 760.9 762.8 496.2 819.7 257.6 NC 759.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.1 16.7 16.4 8.7 23.1 21.2 31.3 16.7 13.6

Percent with 

diabetesc 6.4 10.6 10.5 3.6 14.5 0.8 16.5 10.5 10.8

Percent with 

heart diseasec 5.0 5.2 5.2 0.7 10.3 0.8 5.8 5.2 4.3

HIV rated 625.4 NC 103.9 1458.4 84.9 44.9** 316.9 128.5 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

73.5 73.2 73.4 68.4 61.9 62.6 71.0 73.1 72.2

Percent received 

oral health visit 

(past 12 months)c

71.1 63.6 64.1 51.9 42.8 65.7 53.0 63.6 66.5

Percent received 

flu vaccinec 35.7 41.7 41.8 54.0 29.5 54.4 27.2 41.5 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 44.9 per 100,000 population (6 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 314.5 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 114
Maryland

Introduction to Maryland’s Health Equity Activities

Maryland had a 2016 population of 6,016,000. Blacks/African Americans (30 percent) are the largest racial-ethnic 

minority population, followed by Hispanics/Latinos (10 percent), Asian Americans and NHOPI (6 percent), and 

American Indians/Alaska Natives (0.2 percent). Persons self-identifying as multiracial or “other race” comprise 

7 percent of the population.1 Approximately 1,178,000 Maryland residents live within a primary care health 

professional shortage area.2

In 2004, state legislation created the Office of Minority Health and Health Disparities (MHHD) within the Maryland 

Department of Health and Mental Hygiene (DHMH).3 The MHHD focuses on vulnerable populations and populations 

that experience health disparities.

Maryland Minority Health Overview

Name of state/

territorial minority 

health entity

Department of Health and Mental 

Hygiene, Office of Minority Health 

and Health Disparities

Strategic plan in 

place to address 

minority health 

or health equity

Yes. The Office of Minority Health 

and Health Disparities annually 

updates its strategic plan, aligning 

it with the annually-updated 

Department of Health and Mental 

Hygiene’s strategic plan.

Date strategic plan 

was last updated

The Office of Minority Health and 

Health Disparities strategic plan is 

currently being updated; it was last 

updated in 2016. 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Office of Minority Health and 

Health Disparities strategic plan 

will include an assessment plan 

with specific objectives and goals.

Key strategies 

used to achieve 

health equity

• Build community capacity

• Address health in all policies

• Increase understanding of what 

creates health

Organizational Structure

The director of the MHHD reports to the Maryland 

Secretary of Health and Mental Hygiene and has 

relationships across all departments within the DHMH. 

The Minority Outreach and Technical Assistance 

grantees serve as advisors to the MHHD.

In total, the MHHD has nine full-time staff that devote 

100 percent time to MHHD activities and one staff 

member who devotes 75 percent time to MHHD 

activities. Full-time staff include a program director, 

a deputy director, a senior program manager, two 

program administrators, a program specialist (contractual), a data analyst (contractual), an executive assistant, 

and a secretary. A health equity manager position is 

vacant. The MHHD also has a structured unpaid 

internship program that is competitive nationwide.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Maryland General Assembly (2004). HB 86/SB 177. 

State and Territorial Efforts to Reduce Health Disparities 115
Maryland

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The MHHD is 

housed within 

the Maryland 

Department 

of Health and 

Mental Hygiene

SMHE staffing (full-time equivalents) 9

Advisory committee or panel Minority Outreach 

and Technical 

Assistance 

grantees serve as 

advisors to the 

MHHD

Program Goals and Activities

In January 2017, under a new Maryland Secretary of 

Health and Mental Hygiene, the DHMH was developing 

an updated strategic plan to align with new and/or 

evolving priorities. At that time, the MHHD also was 

conducting its annual strategic plan update to ensure 

continued alignment with the Department’s plan; the 

MHHD plan was expected to be completed in the spring 

of 2017. Most recently updated in 2016, the MHHD 

plan includes an assessment strategy with performance 

metrics and specific objectives. The MHHD sets priorities through a data-driven process that includes feedback from localities, as well as priorities established by 

state legislation (e.g., requirements to focus on specific 

health disparities).

Acronym List

Full Name of Agency Acronym Acronym

Maryland State Department of Health 

and Mental Hygiene DHMH

Office of Minority Health and Health 

Disparities MHHD

One MHHD disparities reduction strategy is to strengthen 

community capacity by funding 16 Minority Outreach and 

Technical Assistance grantees to develop and implement 

community-based health equity programs. Grantee 

organizations receive technical assistance and training 

from MHHD to sustain funding and programs in local 

communities. Technical assistance includes webinars on 

such topics as data collection and reporting, evaluation, 

and grant writing. Minority Outreach and Technical 

Assistance grantees use community-based engagement 

and implement evidence-based interventions based on 

needs assessments. They also work with partners to 

build organizational capacity and provide feedback from 

Maryland’s localities to help set MHHD priorities. The 

MHHD provides connections to DHMH public health 

programs, such as the Environmental Health Bureau 

and the Center for HIV Prevention and Health Services, 

to provide support and access to additional resources 

to strength grantee capacity and foster collaboration.

The MHHD also builds multisector collaborations 

through partnerships with both state agencies and 

nongovernmental entities to reduce health disparities. 

For instance, it leads a Health and Homelessness 

Workgroup and participates in the Maryland Interagency Council on Homelessness. Together with other 

agencies, the MHHD is also applying for a grant from 

the Centers for Medicare and Medicaid Services 

to address specific health disparities.

In addition, the MHHD seeks to increase understanding 

of the factors that drive health disparities and, likewise, 

build awareness of what creates health. It does so by 

conducting education programs on health equity, social 

determinants of health, and cultural and linguistic 

competence. Minority Outreach and Technical Assistance grantees participate by conducting health fairs, 

seminars, and other informative programs. Other 

educational efforts planned by the MHHD include 

educating staff within the state’s federally qualified 

health centers and members of various state boards 

and commissions. The MHHD is also partnering with 

academic institutions to deploy educational programming around “what creates health in the community.” 

Finally, the MHHD also works with in-state universities 

to recruit for its internship program.

Partnerships

Primary 

collaborators

• Center for HIV Prevention and 

Health Services

• Environmental Health Bureau

• Morgan State University

• Mary’s Center (federally qualified 

health center)

• Associated Black Charities

• Asian American Center of Frederick

• Maryland Department of Human 

Resources

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda 

of understanding are implemented for 

some partnerships.

State and Territorial Efforts to Reduce Health Disparities 116
Maryland

The MHHD works with agencies and nongovernmental 

partners, particularly workgroups and advisory groups, 

to address health disparities. Such partners include: 

the Maryland Interagency Council on Homelessness, 

the Health and Homelessness workgroup, a Governor’s 

Office for Children’s workgroup on youth and homelessness, an advisory group for a grant regarding disabilities that the DHMH Center for Chronic Disease Prevention and Control received from the U.S. Centers for 

Disease Control and Prevention, and a rural health 

workgroup on workforce development and vulnerable 

populations. The MHHD also leads an advisory group 

to engage stakeholders to develop strategies for 

developing Maryland’s community health workforce. 

Such activities are informal and do not involve memoranda of understanding.

Building capacity is another focus of the MHHD. It does 

so through collaborations with such agencies as the 

Environmental Health Bureau, which provides funding 

to the Minority Outreach and Technical Assistance 

grantees to address the effects of climate change. 

The MHHD also partners with the Center for HIV 

Prevention and Health Services to provide additional 

funding for the Minority Outreach and Technical Assistance grantees to enhance their capacity to provide 

HIV-related outreach and education. Maryland Medicaid, 

the Maryland Department of the Environment, and the 

Maryland Department of Housing and Community 

Development are among other state governmental 

organizations with which the MHDH partners to support 

priority issues at the community level.

Morgan State University and Mary’s Center, a federally 

qualified health center, also collaborate with the MHHD 

through a State Partnership Grant from the U.S. Office 

of Minority Health. In ZIP codes with high uninsured and 

minority populations, the MHHD has a formal contract 

with Mary’s Center to increase access to primary care 

services and reduce both emergency department visits 

and hospital readmissions by leveraging community 

health workers. Through a memorandum of understanding (MOU), the MHHD also works with one of the 

Minority Outreach and Technical Assistance grantees, 

Associated Black Charities, which has been implementing a community health worker intervention in 

Dorchester County. The Asian American Center of 

Frederick, one of the Minority Outreach and Technical 

Assistance grantees, partners with the MHHD via an 

MOU as well.

The MHHD works with other offices and agencies, such 

as local health departments, academic institutions, 

and the Maryland Department of Human Resources 

to prioritize heath disparities efforts. For example, in 

an effort to address the needs of the state’s homeless 

population, the MHHD and several other agencies 

(including the state Departments of Human Resources, 

Transportation, Housing and Community Development, 

Public Safety and Correctional Services, and the larger 

DHMH) collaborate through the Maryland Interagency 

Council on Homelessness to develop a statewide plan. 

At this time, the MHHD leads the Council’s Health and 

Homelessness Workgroup, which is conducting 

assessments and developing strategies to address 

health needs of the homeless population.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$2,222,455

Annual budget (FY 2015) of SMHE 

from state/territorial government $2,092,455

Largest funding source State government

Anticipated changes to budget Possible

Total FY 2015 funding for the MHHD was $2,222,455, 

comprising allocations from two sources: the State of 

Maryland ($2,092,455) and the U.S. Office of Minority 

Health ($130,000). State funding may be adjusted 

on an annual basis. Funding from the U.S. Office of 

Minority Health includes a State Partnership Grant that 

supports the MHHD collaborations with Mary’s Center 

and Morgan State University.

The MHHD received three cycles of funding from the 

U.S. Office of Minority Health from 2005 to 2015, 

totaling more than $1.5 million. In addition, in 2015, 

the MHHD provided state general funding to nongovernmental community-based organizations in 12 jurisdictions that have the highest proportion of minorities. 

That funding was earmarked for implementing health 

disparities programs to improve birth outcomes, reduce 

cardiovascular disease morality, improve flu vaccination 

rates, increase health awareness, and provide education and outreach within minority populations. In FY 

2015, the MHHD provided a total of $550,000 to nongovernmental entities. As noted earlier, the MHHD 

funds 16 Minority Outreach and Technical Assistance 

grantees to address local health disparities.

State and Territorial Efforts to Reduce Health Disparities 117
Maryland

Maryland State Data

Total Populationa: 

6,016,447

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 9.8 90.3 56.4 29.9 0.2 6.3 7.2 100.0 NA 

Percent of population 

medically uninsureda 21.3 4.7 4.9 6.4 11.0 5.3 17.7 6.3 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.4 6.7 4.3 10.8 SP 5.3 NC 6.6 5.9

Age-adjusted 

mortality rateb 339.9 734.9 706.4 814.7 235.3 337.3 NC 717.6 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.1 14.6 13.5 16.8 20.9 7.8 13.5 14.1 13.6

Percent with 

diabetesc 8.1 11.0 9.8 13.9 9.7 6.3 9.0 10.8 10.8

Percent with 

heart diseasec 2.5 3.9 4.6 2.9 3.5 1.1 4.3 3.8 4.3

HIV rated 511.7 NC 163.1 163.1 144.8 64.3** 2340.3 657.8 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

69.5 76.7 74.5 82.4 77.1 68.9 69.0 76.3 72.2

Percent received 

oral health visit 

(past 12 months)c

58.5 70.5 73.7 64.3 60.2 69.5 59.1 69.9 66.5

Percent received 

flu vaccinec 30.3 44.4 48.6 35.4 34.6 44.3 30.5 43.5 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 64.3 per 100,000 population (205 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 161.0 per 

100,000 population (4 cases).

State and Territorial Efforts to Reduce Health Disparities 118
Massachusetts

Introduction to Massachusetts’ Health Equity Activities

Massachusetts had an estimated 2016 population of 6,812,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (12 percent), followed by Blacks/African Americans (8 percent), Asian Americans and NHOPI 

(7 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 7 percent of the population.1 Approximately 539,000 Massachusetts residents live within 

a primary care health professional shortage area.2

The Massachusetts Department of Public Health (MDPH) promotes the health and well-being of all residents by 

ensuring access to high-quality public health and health care services, and by focusing on prevention, wellness 

and health equity. MDPH’s Office of Health Equity (OHE) serves as an agency-wide resource, providing technical 

assistance to MDPH programs, and promoting principles and policies to inform the way health services are 

designed and delivered, in order to address health inequities.

Massachusetts Minority Health Overview

Name of state/

territorial minority 

health entity

Massachusetts Department of Public Health, Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

A strategic plan with a specific focus on minority health or health equity is not available. 

The Massachusetts Department of Public Health Strategic Plan 2014-20163 includes strategies for 

addressing health disparities in minority populations as part of the larger goal of improving health for 

all. In the fall of 2017, the Office of Health Equity was incorporated into a broader Office of Population 

Health and MDPH will be developing a new plan to address health equity.

Date strategic plan 

was last updated 2014 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Massachusetts Department of Public Health (MDPH) Strategic Plan 2014-2016 includes 

measurable objectives for each standard outlined in the plan. The MDPH recently established 

a quality improvement office responsible for monitoring progress based on the plan. MDPH’s 

mission statement specifically states “promoting health equity” by addressing data, disparities, 

and determinants.

Key strategies 

used to achieve 

health equity

• Agency-wide data collection standards

• Contractual requirements for health providers to meet Culturally and Linguistically Appropriate 

Services (CLAS) National Standards

• Health care interpreter services to monitor and support language access planning and practice

• Oral Health Equity Project to increase the number of children age 0–14 who see the dentist every year

• Health and Disabilities Program for public health policy/systems change to improve the health 

of people with disabilities

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Massachusetts Department of Public Health Strategic Plan 2014-2016.

State and Territorial Efforts to Reduce Health Disparities 119
Massachusetts

Organizational Structure

The OHE was established to address health disparities 

and minority health issues in Massachusetts and 

provides support to MDPH bureaus and programs. 

It also convenes internal advisory workgroups for 

specific initiatives. 

The OHE has seven staff members in total. Five of its 

staff members dedicate 100 percent of their time to 

health equity initiatives, including the office’s director, 

the deputy director, three program coordinators, and 

one support specialist. Two staff members split time 

between OHE and other MDPH units: the coordinator 

for the Oral Health Project and an epidemiologist 

dedicate, respectively, 50 percent and 35 percent time 

exclusively on minority health initiatives through the 

OHE. In addition, the OHE also hires a dental consultant and occasionally engages interns hired though the 

Massachusetts Commission for the Blind as well as 

graduate students through various schools of public 

health to help with its activities.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Office of 

Health Equity is 

housed within the 

Massachusetts 

Department of 

Public Health.

SMHE staffing (full-time equivalents) 7

Advisory committee or panel Yes

Program Goals and Activities

The MDPH, as part of its 2014–2016 strategic plan, 

has adopted a crosscutting approach to promoting 

health equity and reducing disparities in which each 

MDPH bureau and program shares responsibility for 

these goals. The MDPH has created a Racial Equity 

Leadership Team (RELT) to lead this work across the 

agency, with the goal of embedding health equity into 

all areas and levels of the organization rather than 

relegated to a siloed office. In addition, to oversee 

both the data and health equity teams a new Assistant 

Commissioner for Population Health position was 

created. This will facilitate collaboration and leverage 

both teams in support of key priorities. In recent years, 

the MDPH has made substantial progress in identifying 

priority areas related to health equity, and the office is 

still the lead in these specific areas. For example, the 

OHE has procured federal grants to fund such activities 

as priority setting and establishing community advisory 

boards to provide OHE with input on a range of specific 

topics. In turn, the OHE advises MDPH’s bureaus on 

how to use data to guide decisions, prioritize efforts 

and, more generally, operationalize promoting health 

equity in the context of ongoing activities. 

Acronym List

Full Name of Agency Acronym Acronym

Massachusetts Department of Public 

Health MDPH

Office of Health Equity OHE

The OHE is also leading the Health and Disabilities 

Program, another strategy that promotes public health 

policy and systems change to improve the health of 

people with disabilities. Funded through a U.S. Centers 

for Disease Control and Prevention grant, this effort 

prioritizes health issues such as physical activity, 

targeting people with mobility limitations or intellectual 

disabilities. One activity, an 8-week diabetes health 

management program, is a collaborative effort between 

the OHE and the Massachusetts Department of 

Veterans’ Services. The OHE is collaborating with 

“Mass in Motion,” a MDPH program that promotes 

healthy eating and physical activity. The OHE also 

supports the Health and Disability Partnership, a 

coalition of disability advocacy organizations, state 

agencies, and other stakeholders working to improve 

the health of people with disabilities in Massachusetts.

Among the many related endeavors sponsored by the 

OHE is an initiative to establish agency-wide standards 

for data collection. Race, Ethnicity and Language 

(REaL) data collection standards were produced in 

2015 in collaboration with the former Bureau of Health 

Information, now the Office of Data Management, and 

are posted online. Such standardization aims to 

improve the quality of data used to identify disparities 

and, as a result, better inform equity-related policy and 

program development. All MDPH bureaus collect these 

data for their programs and services, which contribute 

to approximately 300 separate datasets. Training on 

the REaL data collection standards was developed and 

delivered to staff responsible for data collection by the 

Bureau of Health information in 2014. In 2016, the 

OHE led MDPH’s efforts to develop sexual orientation 

and gender identity data collection standards, which 

are posted online. It conducted this work in collaboration with the Office of Data Management and staff from 

across MDPH bureaus, including the Office of HIV/

AIDS, which provided funding for a consultant to draft 

State and Territorial Efforts to Reduce Health Disparities 120
Massachusetts

the standards. Current efforts include standardizing 

data collection on housing stability and homelessness 

across MDPH programs and future efforts include 

standardizing data collection on disability status.

Another strategy to achieve health equity is the OHE’s 

decade-long leadership in the MDPH Culturally and 

Linguistically Appropriate Services (CLAS) Initiative. 

Specifically, the OHE has been working to implement 

the National CLAS Standards within MDPH programs 

and among vendors who receive direct service grants 

from the MDPH. The OHE provides ongoing training to 

educate MDPH staff on the National CLAS Standards 

and ensure that they are built into all MDPH bureaus’ 

procurement policies, vendor service delivery, and 

methods by which contract managers evaluate and 

monitor the work of vendors. In addition, the OHE 

conducts trainings for MDPH contract managers and 

vendors on materials it has developed, including a 

National CLAS Standards manual and self-assessment 

tool for vendors, as well as an annual internal assessment to monitor the MDPH’s progress in meeting the 

standards. The OHE developed CLAS-related materials 

to aid in the implementation and ongoing assessment 

of implementation efforts, including the Making CLAS 

Happen Manual, the CLAS Self-Assessment Tool for 

Providers, and the CLAS Internal Assessment for Public 

Health Agencies, all of which have been shared widely 

with other state offices of minority health.

Improving patient-provider communication is another 

core equity strategy for the OHE. To ensure access 

to medical interpretation and health communication, 

health care facilities across the state are implementing 

national and statewide requirements to deliver 

interpreter services to individuals with limited English 

proficiency. The OHE collaborates with the MDPH 

Bureau of Health Care Safety and Quality, as well 

as health care facilities, to monitor language access 

service access. It also reviews and advises on 

regulations—for example, the OHE recently sought 

to expand statewide interpretation services to include 

sign language.

Partnerships

Primary 

collaborators

• Massachusetts Department of 

Public Health: Office of Oral Health; 

Office of Local and Regional Health; 

Early Intervention Program; Women, 

Infants and Children (WIC) Nutrition 

Program

• Massachusetts Department of 

Veterans’ Services

• Health and Disability Partnership

• Brandeis University

• Worcester Public Schools

• Holyoke Public Schools

• Family Health Center of Worcester

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

Many of the programs and projects undertaken by 

the OHE depend in large part on external help. To that 

end, the OHE partners with many governmental and 

nongovernmental organizations in its effort to eliminate 

health disparities and advance health equity in 

Massachusetts. For example, to implement the 

Oral Health Equity Project described above, the OHE 

established formal contracts with local government 

and community organizations—including Worcester 

Public Schools, Holyoke Public Schools, the Family 

Health Center of Worcester, and Holyoke Health Center. 

The OHE also has a formal contract with Brandeis 

University, which provides evaluation consulting for 

its Health and Disability Program. 

The OHE also collaborates with a variety of MDPH 

offices and programs, including the Office of Oral 

Health, the Office of Local and Regional Health, the 

Early Intervention Program, and the Women, Infants 

and Children (WIC) Nutrition Program. It also partners 

with the Massachusetts Department of Veterans’ 

Services on health equity initiatives for the Health 

and Disability Program.

State and Territorial Efforts to Reduce Health Disparities 121
Massachusetts

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$690,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $130,000

Largest funding source Federal government

The total FY 2015 funding for the OHE was $690,000. 

In FY 2015, the office had four funding sources: the 

Commonwealth of Massachusetts ($130,000) and 

three federal grants. Specifically, the OHE received a 

grant of $300,000 from the U.S. Centers for Disease 

Control and Prevention to support its Health and 

Disability Program. It also received a State Partnership 

Grant Program for the CLAS initiative from the U.S. 

Office of Minority Health ($150,000) and a Maternal 

and Child Health Services Block Grant to support such 

activities as the health care interpreter services 

($110,000). Funding is expected to remain relatively 

stable in future years.

The OHE has provided funding to local governmental 

organizations in Massachusetts. For example, in 2015, 

10 local boards of health in Massachusetts received 

funding from the OHE to participate in the Immunization Equity Initiative, an effort aimed at reducing 

disparities in immunization rates among racial, ethnic, 

and linguistic populations in Massachusetts. In 

FY 2016 and FY 2017, the OHE provided funding to 

community partners in Worcester and Holyoke as part 

of its Oral Health Equity Project. This will continue in 

FY 2018 and FY 2019. In FY 2018, the OHE will also 

provide funding to three Mass in Motion communities 

to enhance/adapt for people with disabilities the work 

they do to promote opportunities for healthy eating and 

active living in the places people live.

State and Territorial Efforts to Reduce Health Disparities 122
Massachusetts

Massachusetts State Data

Total Populationa: 

6,811,885

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 11.5 88.5 78.7 7.5 0.2 6.5 7.2 100.0 NA 

Percent of population 

medically uninsureda 4.9 2.2 2.1 4.1 9.9 3.2 4.8 2.5 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 6.4 3.8 3.8 8.6 SP SP NC 4.3 5.9

Age-adjusted 

mortality rateb 466.0 662.3 690.7 604.8 330.5 317.3 NC 669.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 16.4 15.1 15.0 19.4 23.1 13.0 16.9 15.3 13.6

Percent with 

diabetesc 9.8 9.2 8.9 13.7 21.6 5.5 9.6 9.1 10.8

Percent with 

heart diseasec 2.5 4.2 4.5 2.4 4.5 0.6 3.8 4.0 4.3

HIV rated 899.8 NC 181.8 1474.1 233.3 103.4** 480.8 338.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

78.2 79.2 79.7 82.9 75.2 73.7 74.2 79.3 72.2

Percent received 

oral health visit 

(past 12 months)c

69.7 75.0 76.3 66.1 49.4 71.3 67.6 74.7 66.5

Percent received 

flu vaccinec 36.5 42.6 43.5 37.5 29.9 34.6 3.1 42.1 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 103.4 per 100,000 population (379 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 175.7 per 

100,000 population (4 cases).

State and Territorial Efforts to Reduce Health Disparities 123
Michigan 

Introduction to Michigan’s Health Equity Activities

Michigan had an estimated 2016 population of 9,928,000. Blacks/African Americans are the largest racial-ethnic 

minority population (14 percent), followed by Hispanics/Latinos (5 percent), Asian Americans and NHOPI 

(3 percent), and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other 

race” comprise 4 percent of the population.1 Approximately 2,194,000 Michigan residents live within a primary 

care health professional shortage area.2

In 2004, the Health Disparities Reduction and Minority Health Section (HDRMHS) replaced the Michigan 

Department of Health and Human Services (MDHHS) Office of Minority Health. In 2007, Public Act 653 required 

the MDHHS to establish strategic plans, policies, and structures to address health disparities. The HDRMHS 

serves as the coordinating body within the MDHHS to address health disparities. Its mission is to “provide a 

persistent and continuing focus on assuring health equity and eliminating health disparities among Michigan’s 

populations of color.”3

Michigan Minority Health Overview

Name of state/

territorial minority 

health entity

Michigan Department of Health and 

Human Services, Health Disparities 

Reduction and Minority Health Section

Strategic plan in 

place to address 

minority health 

or health equity

Michigan Health Equity Roadmap4

Date strategic plan 

was last updated 2010

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Health Disparities Reduction 

and Minority Health Section provides 

an annual report to the Michigan 

legislature on the status of minority 

health in Michigan.

Key strategies 

used to achieve 

health equity

• Improving race/ethnicity data 

collection, data systems, and data 

accessibility

• Promoting and sustaining effective 

partnerships and programs

• Promoting public education and 

awareness related to social justice 

and the social determinants of health

• Ensuring equitable access to quality 

health care

• Strengthening community engagement, 

capacity, and empowerment

Organizational Structure

The Michigan Department of Health and Human 

Services’ Health Disparities Reduction and Minority 

Health Section has been coordinating departmental 

health equity activities since its establishment in 

2004. It was moved in 2013 and is now housed 

within the MDHHS Policy, Planning, and Legislative 

Services Administration to reflect the Department’s 

recognition of health equity as a crosscutting issue. 

Although the HDRMHS itself does not have a formal 

advisory body, the MDHHS’s internal Health Equity 

Steering Committee is a staff resource on equity1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 Designated HPSA Quarterly 

Summary.

3 Michigan Department of Health and Human Services. Health 

Disparities Reduction and Minority Health Section (HDRMHS) 

website. Last accessed 8/2/2017.

4 Michigan Health Equity Roadmap: A vision and framework 

for improving the social and health status of racial and 

ethnic populations in Michigan. Published in February 2010 

by the Michigan Department of Community Health, Division 

of Health, Wellness and Disease Control, Health Disparities 

Reduction and Minority Health Section (HDRMHS). Available 

on the HDRMHS website. Last accessed 8/2/2017.

State and Territorial Efforts to Reduce Health Disparities 124
Michigan

related issues and, occasionally, serves in an advisory 

capacity for the HDRMHS.

The HDRMHS has four full-time staff members who 

devote 100 percent of their time to minority health 

initiatives: a section manager, a program specialist, 

a program coordinator, and a training coordinator. 

Many other MDHHS staff, including an equity coordinator 

and an epidemiologist from the MDHHS Maternal Child 

Health Epidemiology Section, also dedicate time 

to health equity activities. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Health 

Disparities 

Reduction and 

Minority Health 

Section is housed 

within the Michigan 

Department of 

Health and Human 

Services.

SMHE staffing (full-time equivalents) 4

Advisory committee or panel

The MDHHS 

Health Equity 

Steering Committee 

occasionally works 

in an advisory 

capacity for the 

HDRMHS.

Program Goals and Activities

In 2010, the HDRMHS released the Michigan Health 

Equity Roadmap (“Roadmap”), which outlines a vision 

and recommended strategies for reducing health 

disparities in Michigan. The Roadmap identifies five 

overarching priority areas: 

1. Race/ethnicity data

2. Government and community capacity

3. Social determinants of health

4. Access to quality health care

5. Community engagement and empowerment

The HDRMHS aligns minority health priorities with the 

priority areas identified in the Roadmap. It also relies 

on input from community groups, data, and research 

to guide decision-making. To track progress toward 

reducing health disparities, the HDRMHS delivers an 

annual health equity report to the Michigan legislature 

documenting MDHHS efforts to advance health equity. 

The HDRMHS also releases data reports to monitor 

progress toward improving minority health and reducing 

health disparities. The Roadmap, health equity reports, 

and data reports are publicly available online.5

HDRMHS strategies to reduce health disparities and 

improve minority health align with the five priority areas 

identified in the Roadmap. One of those strategies is to 

improve race and ethnicity data collection, data systems, 

and data accessibility. To support that strategy, the 

HDRMHS helps fund standalone behavioral risk factor 

surveys on specific racial/ethnic populations in Michigan. These surveys capture data on racial and ethnic 

populations that are too small to be accurately represented by statewide Behavioral Risk Factor Surveillance 

System (BRFSS) surveys. The HDRMHS also leads the 

Michigan Health Equity Data Project, which monitors 

health equity by gathering data for five of Michigan’s 

racial and ethnic minority populations and combining 

it into a single data set. Every 2 years, the HDRMHS 

updates the data set and releases data briefs as part 

of its annual report to the legislature. 

Another strategy of the HDRMHS is to promote and 

sustain effective partnerships and programs by 

strengthening the capacity of local communities to 

address health disparities. This aligns with the second 

priority area identified in the Roadmap: developing 

government and community capacity. Specifically, the 

HDRMHS established a program to assist local organizations in assessing community needs and designing 

appropriate interventions. Community groups can apply 

to the HDRMHS for small grants to support these 

activities and may participate in HDRMHS-led trainings 

to secure future funding.

Acronym List

Full Name of Agency Acronym Acronym

Health Disparities Reduction and Minority 

Health Section HDRMHS

Michigan Department of Health and 

Human Services MDHHS

In a third strategy, the HDRMHS promotes public 

education and awareness related to social justice 

and the social determinants of health. The HDRMHS 

facilitates workshops for MDHHS staff and partners 

on the National Standards for Culturally and Linguisti5 All of these reports are available on the Health Disparities Reduction and Minority Health Section (HDRMHS) website. Last accessed 

8/2/2017.

State and Territorial Efforts to Reduce Health Disparities 125
Michigan

cally Appropriate Services in Health and Health Care 

(National CLAS Standards). It also developed and 

launched an online health equity training module 

in 2017. Open to MDHHS staff, contractors, and the 

public, this module provides an overview of the issues 

and describes how to view public health activities 

through a health equity lens. The HDRMHS also 

developed a health equity toolkit, publicly available 

on the HDRMHS’s website, designed for external 

organizations to promote awareness about the social, 

economic, and environmental factors that contribute 

to health. 

The HDRMHS’s fourth strategy is to lead and participate in activities to ensure equitable access to quality 

health care. Some of the activities are funded through 

Michigan’s State Innovation Model Test grant from the 

Center for Medicare & Medicaid Innovation, as well as 

other grants that support community health innovation. 

For example, the HDRMHS has worked with minority 

communities, including tribal populations, to raise 

awareness of Michigan’s Medicaid expansion and 

encourage the use of preventive health services. 

It has also partnered with community health centers 

on literacy programs that focus on health and 

health insurance.

Strengthening community engagement, capacity, and 

empowerment is the HDRMHS’s fifth strategy. It builds 

partnerships by creating linkages between governmental and nongovernmental organizations with 

shared goals. 

Partnerships

Primary 

collaborators

• MDHHS Bureau of Epidemiology 

and Population Health

• Mercy Health (part of Trinity Health)

• Michigan Department of Civil Rights

• Michigan Public Health Institute

• Practices to Reduce Infant Mortality 

through Equity Initiative

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The HDRMHS collaborates with a wide range of 

organizations to reduce health disparities and improve 

minority health. For example, for the Practices 

to Reduce Infant Mortality through Equity (PRIME) 

Initiative, it partners with several organizations 

(i.e., the MDHHS, the Michigan Public Health Institute, 

the W.K. Kellogg Foundation, academic institutions, 

public health entities, and advocacy groups) on many 

activities, including cultural competency and health 

equity trainings. The Michigan Public Health Institute 

also works closely with the HDRMHS on other 

activities—such as social justice trainings and a 

collective impact assessment of MDHHS activities—

and has a contract with the MDHHS formalizing the 

partnership. The institute also contracts with the 

HDRMHS on independent health equity efforts. 

Additional HDRMHS partners on health equity activities 

include other state agencies and MDHHS bureaus, 

as well as community health centers.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$884,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $484,000

Largest funding source State government

Anticipated changes to budget None reported

The total FY 2015 funding for the HDRMHS was 

$884,000. The HDRMHS received $484,000 in state 

funding, including $283,000 from State General Funds 

and $201,000 from the Healthy Michigan Fund. It also 

received a $400,000 Federal Preventive Health and 

Health Services Block Grant in FY 2015.

The HDRMHS issued National Minority Health Month 

mini-grants to community-based organizations, faithbased organizations, community health centers, 

educational institutions, youth-serving agencies, and 

local health departments. It also provided funding for 

cultural competency trainings, implementation of the 

National CLAS Standards among partner organizations, 

and health literacy programs aimed at increasing the 

use of preventive health services. The HDRMHS also 

assists in funding the MDHHS’s standalone Minority 

Health BRFSS surveys.

State and Territorial Efforts to Reduce Health Disparities 126
Michigan

Michigan State Data

Total Populationa: 

9,928,300

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 5.0 95.1 78.5 13.8 0.5 3.0 4.3 100.0 NA 

Percent of population 

medically uninsureda 12.5 5.2 5.0 7.5 10.5 7.1 8.0 5.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 9.0 6.4 5.1 12.4 SP SP NC 6.5 5.9

Age-adjusted 

mortality rateb 634.2 786.1 765.9 971.2 825.9 327.7 NC 785.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 12.2 16.5 15.7 20.8 20.1 6.8 19.7 16.3 13.6

Percent with 

diabetesc 9.7 11.3 10.9 12.6 12.4 9.2 13.9 11.2 10.8

Percent with 

heart diseasec 2.5 5.3 5.5 3.9 9.7 0.8 5.0 5.1 4.3

HIV rated 230.6 NC 75.3 736.4 55.3 45.0** 378.2 174.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

63.6 74.3 73.1 80.5 69.2 69.8 67.6 73.9 72.2

Percent received 

oral health visit 

(past 12 months)c

67.6 70.7 72.0 63.9 61.5 71.8 57.4 70.5 66.5

Percent received 

flu vaccinec 33.6 36.6 38.4 27.0 30.9 32.5 31.0 36.5 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 45.0 per 100,000 population (109 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 94.1 per 

100,000 population (2 cases).

State and Territorial Efforts to Reduce Health Disparities 127
Minnesota 

Introduction to Minnesota’s Health Equity Activities

Minnesota had an estimated 2016 population of 5,520,000. Blacks/African Americans are the largest racial-ethnic 

minority population (6 percent), followed by Hispanics/Latinos (5 percent), Asian Americans and NHOPI (5 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 5 

percent of the population.1 Approximately 464,000 Minnesota residents live within a primary care health professional 

shortage area.2

In 1993, the state established an Office of Minority Health, which was renamed the Office of Minority and 

Multicultural Health (OMMH) in 2001. The office’s first strategic plan, which sought to increase awareness of racial and 

ethnic disparities, was published in 1995. Its 

1997 “Populations of Color in Minnesota – 

A Health Status Report” helped lay the foundation 

for its 1998 legislative report calling for the 

collection of standardized racial and ethnic health 

data. Today, the Executive Office of the Minnesota 

Department of Health includes the Centers 

for Health Equity and Community Health (CHECH), 

which is comprised of four centers: the Center for 

Health Equity (CHE), the Center for Health Data, 

the Center for Emergency Preparedness and 

Response, and the Center for Public Health 

Practice. The OMMH is housed within the CHE. 

Established in 2013 after a statewide 

assessment documented a range of health 

inequities, the CHE was developed to advance 

health equity by engaging communities and 

incorporating advancement of health equity in 

all of the MDH’s activities.3 The CHE regularly 

interacts with the Center for Health Data and 

its Center for Health Statistics on health equity 

projects involving disparities research. 

Until 2016, the OMMH included an advisory 

committee. In early 2017, the MDH created 

an agency-wide Health Equity Advisory and 

Leadership (HEAL) Council. The new external 

group represents communities most impacted 

by health inequities and meets regularly to advise 

the MDH on a range of health equity issues.

Minnesota Minority Health Overview

Name of state/

territorial minority 

health entity

Center for Health Equity (which includes 

the Office of Minority and Multicultural 

Health)

Strategic plan in 

place to address 

minority health 

or health equity

Minnesota Department of Health Strategic 

Plan

Date strategic plan 

was last updated 2017

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Yearly work plans assess progress toward 

goals of the strategic plan. An employee 

survey includes items on health equity 

activities.

Key strategies 

used to achieve 

health equity

• Build a shared understanding and 

internal capacity for advancing health 

equity.

• Identify and creatively address barriers 

to working differently.

• Change systems, structures, and 

policies that perpetuate inequities and 

structural racism.

• Listen authentically to and partner with 

communities.

• Improve the collection, analysis, and 

use of data for advancing health equity.

• Communicate our commitment to 

advancing health equity

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Minnesota Department of Health. About the Center for Health Equity. Available on the Center for Health Equity website. Last accessed 7/17/17.

State and Territorial Efforts to Reduce Health Disparities 128
Minnesota

Organizational Structure

The CHE was established in 2013 in tandem with 

a health equity report that revealed significant health 

disparities in Minnesota. The CHE has nine full-time 

staff members. Staff include a director, assistant 

director, a community engagement planner, a health 

equity planner/coach, two grant managers, one research 

scientist, one management analyst, and one 

administrative assistant. Additional staff across the 

MDH also spend time on health equity issues. The CHE 

works closely with the director of its parent division, the 

CHECH, as well as its assistant director and staff in the 

Center for Public Health Practice and the Center for 

Health Statistics. An MDH tribal director leads efforts 

on health equity in American Indian populations 

in Minnesota. 

The CHE regularly hosts summer interns for either 

academic credit or salary. Community partners 

frequently volunteer to help at CHE community events 

or through advisory committees. No upcoming staffing 

changes are anticipated. 

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Center for 

Health Equity 

is one of four 

centers within 

the Centers for 

Health Equity and 

Community Health 

in the Minnesota 

Department of 

Health. 

SMHE staffing (full-time equivalents) 9

Advisory committee or panel

MDH external 

health equity 

(HEAL) council

MDH I-HEALTH 

(internal health 

equity) council 

Program Goals and Activities

The MDH’s agency-wide strategic plan for 2015–2019 

asserted that “to achieve a state where everyone in 

Minnesota has the opportunity to be healthy, regardless of race, ethnicity, gender, social class, or geography, MDH must become better equipped to advance 

health equity.”4 The plan focuses on health equity 

across six identified strategic areas: building internal 

capacity and a shared understanding of what creates 

health, community engagement, data collection and 

analysis, policy systems and structures, identifying 

barriers, and communicating the MDH’s commitment 

to advancing health equity. 

The agency-wide strategic plan, publically available on 

the MDH website, was created with input from the CHE 

with the intent to influence work across the MDH in 

order to close the gaps in health disparities. The most 

recent MDH strategic plan applies to FY 2015–2019. 

The OMMH created previous health equity-related plans. 

The MDH strategic plan serves as a roadmap for developing specific work plans across the agency. The CHE 

and the Center for Public Health Practice are working 

together to develop a work plan that assesses progress toward the goals laid out in the agency’s strategic 

plan. The work plan focuses on how the agency is 

doing work differently to better address health disparities. The MDH also administers an employee survey 

every 2 years to assess progress across the department. The survey addresses comfort level in talking 

about race and feeling equipped to conduct work to 

advance health equity.

Minority health, health disparities, and health equity 

priorities in Minnesota are set largely from the multiyear recommendations from the legislatively mandated 

2014 Advancing Health Equity in Minnesota report that 

provides an overview of health disparities in Minnesota. The report emphasized the social determinants 

of health, stressed a health in all policies approach, 

and made seven recommendations:

1. Advance health equity through a health in all 

policies approach.

2. Continue investments in efforts that are currently 

working to advance health equity.

3. Provide statewide leadership for advancing health 

equity.

4. Strengthen community relationships and partnerships to address health equity.

5. Redesign MDH grant making to advance health 

equity.

6. Make health equity an emphasis throughout 

the agency.

7. Strengthen the collection and analysis of data 

to advance health equity.

4 Minnesota Department of Health. MDH Strategic Plan Annual Report (2016) and Work Plan (2017). Available on the MDH website. 

Last accessed 7/17/17.

State and Territorial Efforts to Reduce Health Disparities 129
Minnesota

Acronym List

Full Name of Agency Acronym Acronym

Center for Health Equity CHE

Center for Health Equity and Community 

Health CHECH

Minnesota Department of Health MDH

Office of Minority and Multicultural Health OMMH

The CHE has ongoing conversations to engage with the 

ethnic, community-based, and faith-based organizations 

and other partners that contributed to the report. It 

prioritizes building trust and maintaining transparency 

throughout processes to advance health equity. 

The Centers for Health Equity and Community Health 

division collaborates to develop and promote trainings 

on health equity for staff and executive leadership 

across the MDH. In December 2016, the centers 

began offering 4-hour training sessions on racial equity 

to MDH staff, and continue to provide educational 

programming on an ongoing basis for staff across the 

department. To date, one-third of the 1,500 MDH staff 

have been trained. Many MDH staff also have attended 

the governmental Minnesota Tribal and State Relations Training. Finally, the MDH initiative, “Changing 

the Narrative About What Creates Health—Essential 

Steps in Improving Population Health in Minnesota,” 

further builds staff capacity to advance health equity. 

These trainings all focus on reframing the dominant 

narrative that health is simply about health care or an 

individual’s behaviors. Currently, the CHECH also offers 

additional trainings, such as a community engagement 

training and and narrative training, to promote a deeper 

understanding of health equity issues and how to 

change the narrative around what creates health. 

In addition to building organizational capacity to 

advance health equity within the MDH, the CHE and the 

Center for Public Health Practice (PHP) work together 

to build community capacity to advance health equity. 

For example, the CHE grant managers provide training, 

technical assistance, and consultation to over 30 Eliminating Health Disparities Initiative grantees. Others 

within CHECH provide training and technical assistance 

to local public health partners collecting and analyzing 

health equity data; staff within the PHP and the Center 

for Health Statistics worked closely with public health 

departments to implement a health equity data guide. 

The CHECH recently piloted a new health equity data 

assessment with 10 local community health boards 

and plans to support the additional remaining 31 community health boards in local public health to conduct 

data assessment.

The CHECH also works with local public health (LPH) 

departments and community-based organizations to 

enhance community engagement through conversations on advancing health equity. Staff regularly conduct presentations with LPH community leadership 

teams and others to share insights about disparityreduction strategies and learn about local activities. 

Since November 2016, the CHE has hosted three community conversations averaging ~150–300 attendees 

per event from community-based, social services, and 

local public health organizations. The community conversations focused on challenges and lessons learned 

from previous health equity efforts. More information 

about these events is available on the CHE website. 

As part of its strategy to advance health equity, the 

CHE oversees several grants, many of which are legislatively mandated through the Eliminating Health Disparities Initiative grant program. Established in 2001, this 

program was designed to help reduce health status 

gaps among populations of color, including American 

Indians. Grantees include 32 community-based organizations, clinics, and tribes and focus on priority health 

areas, including breast and cervical cancer screening, 

diabetes, cardiovascular disease, diabetes, HIV/AIDS 

and STIs, immunizations, infant mortality, teen pregnancy, and violence and unintentional injury.5

The CHE also administers advancing health equity grant 

programs to organizations addressing health disparities 

through policy and systems change. The CHE administers a grant to Voices for Racial Justice, a project 

focusing on incarceration among populations of color 

and its impact on the health of those incarcerated, their 

families, and their communities. The CHE also oversees 

a grant to Neighborhood Hub, which focuses on social 

determinants of health and how housing impacts health 

in the North Minneapolis community. 

In addition, as a part of the MDH’s effort to view 

health through a “health equity lens” in all MDH grant 

programs, the CHE is working to ensure that health 

equity is a criterion for state-funded project awards. 

For example, the Statewide Health Improvement Part5 Minnesota Department of Health. Priority Health Areas of the Eliminating Health Disparities Initiative. Available on the MDH website. Last 

accessed 7/17/17.

State and Territorial Efforts to Reduce Health Disparities 130
Minnesota

nership, which funds local public health partners and 

community organizations throughout the state, includes 

a significant health equity component. That program 

focuses on reducing obesity, promoting healthy physical activity and eating, and reducing tobacco use, and 

requires each grantee to have a community leadership 

team that provides data on health equity. 

Finally, throughout its activities, the MDH advocates a 

“Health-in-all-Policies” philosophy. As former president 

of the Association of State and Territorial Health Officials, former MDH Commissioner Ehlinger made nearly 

100 health equity-related presentations in 2016 and 

challenged other state health commissioners across 

the country to adapt a health equity plan as part of 

their work. The MDH Commissioner regularly meets 

with the Minnesota governor’s cabinet and engages in 

conversations across many agencies and sectors, such 

as transportation and housing.

Partnerships

Primary 

collaborators

• Local city and county public health 

departments

• 32 Eliminating Health Disparities 

Initiative Grantees (communitybased organizations, clinics, 

and tribes) 

• 2 advancing health equity grantees: 

Voices for Racial Justice and 

Neighborhood Hub (ended in 2017)

• Statewide Health Improvement 

Partnership grantees

• Other community-based 

organizations

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

Several organizations collaborate with the CHE to work 

toward eliminating health disparities and advancing 

statewide health equity. For example, as noted above, 

many local health departments have formal 

partnerships with the CHECH through the Statewide 

Health Improvement Partnership grant program to 

reduce obesity and tobacco use. The CHECH also 

partners with local public health departments on 

strategies to collect and use health equity data. 

Through a 5-year State Partnership Initiative to Address 

Health Disparities (SPI) grant from the U.S. Office of 

Minority Health, the CHE works with local health 

professionals and community leaders in Hennepin 

County on reducing infant mortality in the African 

American population. The CHE also formally partners 

with its 32 Eliminating Health Disparities Initiative 

grantees (i.e., community-based organizations, clinics, 

and tribes) and 2 advancing health equity grantees 

(Voices for Racial Justice and Neighborhood Hub) on 

trainings, technical assistance, and consultation on 

health equity activities. In addition, the CHE regularly 

works with a variety of community partners informally. 

The MDH and the CHE coordinate on health equity 

initiatives with other state government agencies 

including the Department of Transportation, the 

Department of Housing and Urban Development, 

and the Department of Human Services. In 2016, 

the CHE was legislatively mandated to collaborate 

with the Department of Human Services, the 

Department of Public Safety, and the Council on Asian 

Pacific Minnesotans to conduct a working group report 

on violence against Asian women and children. 

The report is available on the CHE website.

Funding 

Annual budget (FY 2016) of state/

territorial minority health entity 

(SMHE) across all income sources

Over $6 million

Annual budget (FY 2016) of SMHE 

from state/territorial government Over $6 million

Largest funding source 

State funding for the 

Eliminating Health 

Disparities Initiative 

Anticipated changes to budget Possible budget 

reductions

The total FY 2016 funding for the CHE was more than 

$6 million. Significant state funding sources for health 

equity activities include funding for the Eliminating 

Health Disparities Initiative (over $5 million), funding 

for the Advancing Health Equity Grants ($500,000), 

and funding for the Working Group on Violence 

Against Asian Women and Children ($200,000). 

Federal sources for health equity include an annual 

U.S. Office of Minority Health grant ($195,000/year) 

and portions of Minnesota’s Preventive Health and 

Health Services Block Grant from the Centers for 

Disease Control and Prevention. 

The CHECH has provided funding to local public 

health departments, clinics, and other communitybased organizations through its several grantee 

programs. Possible reductions in funding for the 

CHE are anticipated.

State and Territorial Efforts to Reduce Health Disparities 131
Minnesota

Minnesota State Data

Total Populationa: 

9,928,300

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 5.1 94.9 83.2 5.9 1.1 4.9 4.9 100.0 NA 

Percent of population 

medically uninsureda 18.5 3.6 3.4 7.5 19.2 3.7 14.6 4.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 5.2 4.2 10.4 SP 6.0 NC 5.2 5.9

Age-adjusted 

mortality rateb 387.8 650.6 641.4 713.0 1073.2 446.4 NC 648.1 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.0 11.3 11.0 15.1 22.6 7.7 11.8 11.2 13.6

Percent with 

diabetesc 8.1 8.4 8.4 9.1 17.9 5.7 10.9 8.5 10.8

Percent with 

heart diseasec 1.5 3.6 3.9 1.6 2.7 1.3 2.5 3.6 4.3

HIV rated 392.4 NC 100.3 736.4 232.0 69.1** 362.3 171.3 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

67.2 71.4 71.5 76.3 68.9 62.7 69.1 71.3 72.2

Percent received 

oral health visit 

(past 12 months)c

59.9 75.2 76.1 62.2 62.1 73.8 60.4 74.7 66.5

Percent received 

flu vaccinec 37.6 44.4 44.9 39.3 40.1 41.7 35.8 44.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 69.1 per 100,000 population (141 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 255.2 per 

100,000 population (5 cases).

State and Territorial Efforts to Reduce Health Disparities 132
Mississippi 

Special Note: The information in this profile is from FY 2015 and does not reflect the Mississippi State Department 

of Health’s (MSDH) current organizational structure or health equity strategies. Like many states, the MSDH has 

faced challenging budget cuts in the last few years. During FY 2016, the MSDH received a 30 percent budget cut 

in state general funds, thereby forcing an organizational restructure for the MSDH, particularly in programs heavily 

funded with state dollars. As a result, the Office of Health Disparity Elimination was merged with the Office of Policy 

Evaluation and Government Relations. On a positive note, this transition encouraged the focus of health equity as 

a cross cutting strategic priority to be engrained in all of the organization’s policies, processes, and procedures. 

It fosters strategies to assure health equity in all of the programs and to promote Health in all Policies throughout 

the agency and with its partners and collaborators. The MSDH kept the positions of the Health Equity Director, 

Operations Management Analyst, and a part-time bilingual coordinator.

Introduction to Mississippi’s Health Equity Activities

Mississippi had an estimated 2016 population of 2,989,000. Blacks/African Americans are the largest minority 

population (38 percent), followed by Hispanics/Latinos (3 percent), Asian Americans and NHOPI (1 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 2 percent of the population.1 Approximately 1,748,000 Mississippi residents live within a primary care 

health professional shortage area.2

In 2003, the MSDH’s Office of Health Promotion and Health Equity (OHPHE) created the Office of Health Disparity 

Elimination (OHDE) specifically to address health disparities. Its mission is “to identify health inequities and their 

root causes and to promote evidence-based solutions to create a more equitable system” (MSDH/OHDE, 2015). 

A 2015 report prepared by the MSDH/OHDE and Office of Health Data and Research, State of the State: Annual 

Mississippi Health Disparities and Inequalities Report,

3 examines health disparities throughout Mississippi. The first 

report of its kind, it highlights inequalities in health among Mississippi’s racial and ethnic minority populations.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 State of the State: Annual Mississippi Health Disparities and Inequalities Report. Available on the MSDH website.

State and Territorial Efforts to Reduce Health Disparities 133
Mississippi

Mississippi Minority Health Overview

Name of state/

territorial minority 

health entity

Mississippi State Department of 

Health, Office of Health Disparity 

Elimination

Strategic plan in 

place to address 

minority health 

or health equity

A strategic plan with a specific 

focus on minority health or 

health equity is not available. 

The comprehensive Mississippi 

State Department of Health 

Strategic Plan4 includes strategies 

for addressing health disparities 

in minority populations as part 

of its larger goals of improving 

health for all Mississippians. 

A State Health Improvement Plan 

is being developed and will include 

approaches for reducing health 

disparities.

Date strategic plan 

was last updated

The Mississippi State Department 

of Health Strategic Plan was last 

updated in November 2014.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Mississippi State Department 

of Health Strategic Plan includes 

measureable objectives for each 

fiscal year. In conjunction with 

the forthcoming State Health 

Improvement Plan, the MSDH plans 

to develop processes for evaluating 

outcomes and measuring progress 

toward Statewide health goals.

Key strategies 

used to achieve 

health equity

• Bridging the Gap: Medical 

interpreter trainings

• Assessment of National 

Standards for Culturally and 

Linguistically Appropriate 

Services (National CLAS 

Standards)

• Community Research Fellows 

Training

• Tobacco cessation efforts 

in vulnerable populations

• Hypertension education 

in barbershops

• Sisters United infant mortality 

reduction project

Organizational Structure

The MSDH/OHDE was established in 2003 to address 

health disparities and minority health issues in the 

State. Advisory committees are sometimes formed 

for specific activities or initiatives that the office leads; 

however, there is no ongoing presence of a committee 

or panel that advises on minority health or health 

disparity issues. Located within the MSDH’s Office 

of Health Promotion and Health Equity (OHPHE), the 

OHDE works collaboratively with the Office of Tobacco 

Control and the Office of Preventive Health to promote 

health and health equity for all Mississippi residents. 

The MSDH/OHDE has eight full-time staff members 

who dedicate their time to minority health and health 

disparity initiatives. Full-time staff include the office’s 

director, the director of its Cultural and Linguistic 

Services Division, the director of Data and Targeted 

Programs, two health program specialists, the director 

of Health Promotion and Education, a special project 

officer, an administrative staff member, an operations 

manager analyst, and an operation manager. The 

OHPHE Director dedicates time equally between the 

Office of Tobacco Control, the OHDE, and the Office 

of Preventive Health—and therefore spends one third 

time working exclusively on minority health initiatives. 

MSDH/OHDE occasionally engage unpaid interns to 

help with its activities.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OHDE is 

housed within the 

Mississippi State 

Department of 

Health, Office of 

Health Promotion 

and Health Equity.

SMHE staffing (full-time equivalents) 8

Advisory committee or panel None

4 Mississippi State Department of Health Fiscal Years 2016-2020: Strategic Plan. Prepared in Accordance with the Building a Better 

Mississippi Instructions, November 2014. Available on the MSDH website.

State and Territorial Efforts to Reduce Health Disparities 134
Mississippi

Program Goals and Activities

The MSDH has an overarching Health Strategic Plan—

last updated in November 2014—that addresses 

minority health and health disparities as part of its larger 

goal to improve the health of all Mississippians. However, 

neither the MSDH nor its subdivisions have developed 

a strategic plan focusing specifically on minority health 

and healthy equity. The Office of Preventive Health and 

the Office of Tobacco Control has developed projectspecific strategic plans to address priority health concerns in the State, such as tobacco control and stroke 

prevention—and these plans address health equity as 

part of their overall objectives. These individual plans, 

developed for a 5-year time span, are publicly available.

Acronym List

Full Name of Agency Acronym Acronym

Mississippi State Department of Health MSDH

Office of Health Disparity Elimination OHDE

Office of Health Promotion and Health 

Equity OHPHE

To provide a broader, up-to-date vision, the MSDH is 

developing a State Health Improvement Plan, with input 

from many nongovernmental stakeholders, which will 

focus on reducing health disparities. In conjunction with 

the State Health Improvement Plan development, the 

MSDH plans to implement a system to evaluate outcomes and measure progress toward the plan’s goals 

and objectives. Future updates to the MSDH Strategic 

Plan will address specific Plan-identified health priorities. 

The MSDH/OHDE is working on many strategies to 

achieve health equity and eliminate disparities among 

Mississippi’s racial and ethnic minority populations. In 

recent years, the office has made substantial progress 

in identifying priority areas related to health equity, aided 

by the NIH Health Disparities Strategic Plan and Budget, 5

the National Prevention Strategy,6 and the Health and 

Human Services Action Plan to Reduce Racial and 

Ethnic Health Disparities.7 The MSDH/OHDE has 

procured grants that help with priority setting. Community advisory boards at times offer advice on priorities 

and activities within specific communities. In addition, 

the MSDH/OHDE has been working with the U.S. Office 

of Minority Health to learn about national priorities 

related to health disparities and identify what the office 

can address at the State level.

One major MSDH/OHDE strategy is to offer medical 

interpreter trainings to staff at health departments, 

federally qualified health centers, community health 

centers, and hospitals. The MSDH/OHDE became 

licensed in medical interpretation through the “Bridging 

the Gap Cross Cultural Health Care Program,” enabling 

it to provide 40-hour trainings. Previously, no trainings 

were available for medical interpreters in the state. 

In addition, the MSDH/OHDE offers workshops for health 

care providers on how to work effectively with interpreters.

In 2014, the MSDH/OHDE initiated an effort to educate 

all MSDH employees and staff at Mississippi’s nine 

public health districts on the National Standards for 

Culturally and Linguistically Appropriate Services 

(National CLAS Standards), as well as on other aspects 

of cultural and linguistic competence. The MSDH 

partnered with Georgetown University to develop these 

trainings. Subsequently, the MSDH/OHDE worked with 

Georgetown University to survey MSDH staff, interview 

key informants, and conduct patient focus groups to 

assess the use of the National CLAS Standards within 

the MSDH. This assessment also included a policy 

scan of MSDH manuals to identify reference to and 

use of CLAS Standards. Its results, which the MSDH/

OHDE presented to department leadership, identified 

short-term actions, including providing more National 

CLAS Standards trainings for department employees 

and implementing more signage about language 

services offered in MSDH settings. The MSDH/OHDE 

also plans to share the assessment results with the 

public health districts and will continue reviewing 

departmental policy language to assess the need for 

any new policies regarding the National CLAS Standards.

The MSDH/OHDE also leads Mississippi’s Sisters 

United—an infant mortality education program funded 

through a grant from the March of Dimes—in collaboration with the Maternal and Child Health division of the 

Office of Health Services. Under a memorandum of 

understanding with graduate sorority chapters in the 

State, Sisters United partners with African American 

sorority chapters and engages graduate members 

5 U.S. Department of Health and Human Services, NIH Health Disparities Strategic Plan and Budget: Fiscal Years 2009-2013. Available on the 

NIMHD NIH website.

6 U.S. Department of Health and Human Services National Prevention Strategy. Available on the Surgeon General’s website.

7 U.S. Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities. Available on the U.S. Office of Minority Health’s 

website.

State and Territorial Efforts to Reduce Health Disparities 135
Mississippi

in train-the-trainer sessions. A training video aimed 

at sorority chapters, developed by the MSDH/OHDE, 

features four evidence-based strategies to prevent 

infant mortality: folic acid intake, breastfeeding, safe 

sleep practices, and healthy weight management. After 

the training, the sororities take the information back to 

their communities and conduct infant mortality prevention education events. Sisters United was initiated in 

three public health districts in Mississippi with high 

infant mortality rates, and then has been expanded 

to other districts. 

Another MSDH/OHDE effort aimed at reducing health 

disparities is the Community Research Fellows Training. 

This 16-week research training program seeks to 

empower minority and other underserved populations 

and improve community knowledge and capacity to participate in research. The training covers many aspects 

of research, including quantitative data collection, 

qualitative data collection, and clinical trials. Program 

participants learn how to be better consumers of 

research and encouraged to use this knowledge 

to identify and address issues in their community. 

Tobacco cessation is a specific topic around which 

Mississippi seeks to reduce health disparities. 

The Office of Tobacco Control leads these efforts, as 

outlined in its strategic plan. Relatedly, the MSDH/

OHDE partners with the Institute for Disability Study 

on activities related to tobacco cessation in vulnerable 

populations, including the Leadership Academy, a 

statewide initiative to reduce tobacco usage. Many 

stakeholders, including state agencies, health plans, 

and substance abuse/mental health organizations 

participate in the Leadership Academy. The Office of 

Tobacco Control has worked with the U.S. Substance 

Abuse and Mental Health Services Administration 

(a partner in the Leadership Academy) to develop and 

implement tobacco cessation strategies. A website 

that is being developed for health care providers 

and community members will provide resources 

for tobacco cessation.

The Mississippi Office of Preventive Health has a 

collaborative agreement with the U.S. Centers for 

Disease Control and Prevention to address cardiovascular disease in the Mississippi Delta, a region with a 

high proportion of African Americans and people of low 

socioeconomic status. One part of the agreement aims 

to educate African American men about cardiovascular 

disease. Ongoing activities include screenings in 

barbershops, referrals to services, and education 

about hypertension. The Office of Preventive Health 

has developed toolkits to expand the program beyond 

the Delta area. 

Partnerships

Primary 

collaborators

• My Brother’s Keeper

• Boat People SOS

• Mercy Housing and Human 

Development

• Gulf States Health Policy Center

• Public and private educational 

institutions

• Local health departments

• Mississippi State Department of 

Health: Office of Tobacco Control, 

Office of Preventive Health, and 

Office of Adolescent Health

• i-Think Group

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships

In addition to the work described above, the MSDH/

OHDE partners with many governmental and 

nongovernmental organizations to work towards 

eliminating health disparities and advancing health 

equity in the state. For example, the MSDH/OHDE 

collaborates with community-based organizations to 

provide education on the Affordable Care Act and 

disseminate information in particular minority 

communities. One such organization, My Brother’s 

Keeper, seeks to reduce health disparities by improving 

the health and well-being of minority populations. The 

MSDH/OHDE works with My Brother’s Keeper on 

several contracts, including the Community Research 

Fellows Training program and efforts to educate 

Mississippi’s minority communities about the 

Affordable Care Act.

Another major partner, Boat People SOS, connects the 

MSDH/OHDE with the Vietnamese community. Boat 

People SOS is a community-based organization that 

focuses on empowering and improving the health of 

Vietnamese populations. MSDH/OHDE has formal 

contracts with Boat People SOS to provide Vietnamese 

translation services and to conduct collaborative work 

around, for example, hepatitis B, as well as general 

Affordable Care Act education efforts within 

Vietnamese communities. The MSDH/OHDE also 

has a formal contract with Mercy Housing and Human 

Development for hepatitis B activities in Vietnamese 

communities and other vulnerable populations.

The MSDH/OHDE has a partnership with Gulf States 

Health Policy Center to offer the Community Research 

Fellows Training Program in 2016. 

State and Territorial Efforts to Reduce Health Disparities 136
Mississippi

Additionally, the MDHE/OHDE partners with several 

academic institutions to improve health equity in the 

state. The Healthy Linkages Initiative—a collaboration 

between the MHDE/OHDE, the University of Mississippi 

Medical Center, and federally qualified health centers— 

was established after Hurricane Katrina to improve 

communication between the partnering organizations 

and improve access to health care for minority and 

vulnerable populations. Tougaloo College, a historically 

black college located in Tougaloo, is another major 

partner that works with the office to provide Affordable 

Care Act education. MHDE/OHDE also partners 

with the University of Southern Mississippi and the 

University of Mississippi Center for Population Study. 

A professor at the University of Southern Mississippi 

supports research and analysis on minority health 

issues for the office, and the University of Mississippi 

Center for Population Study assists with qualitative 

research initiatives and has provided support for the 

Community Research Fellows Training program.

In addition to the nongovernmental and academic 

collaborators, MSDH/OHDE partners with local health 

departments, the nine public health districts, and other 

MSDH agencies. For example, the MSDH/OHDE works 

closely with local health departments to disseminate 

information and carry out activities within local 

communities. It also partners with other MSDH 

programs—including the Office of Tobacco Control, 

Office of Preventive Health, and Office of Adolescent 

Health—on activities to eliminate health disparities 

and advance health equity for minority and other 

vulnerable populations.

To conduct community education about the Affordable 

Care Act, the MSDH/OHDE has hired the i-Think Group, 

a policy-oriented consultant organization. The i-Think 

Group also participated in a partnership with the office, 

the University of Mississippi Medical Center, and 

federally qualified health centers to conduct Affordable 

Care Act education throughout the state.

Funding 

Annualized budget (FY 2015) of 

State/territorial minority health 

entity (SMHE) across all income 

sources

$750,000–798,000

Annual budget (FY 2015) of SMHE 

from State/territorial government $500,000

Largest funding source State government

Anticipated changes to budget in 

FY 2016 Possible

The total FY 2015 funding for the MSDH/OHDE was 

$750,000–798,000. In FY 2015, the office had four 

key funding sources: One was the State of Mississippi 

($500,000), an amount that has been consistent over 

the past 3 years. The MSDH/OHDE received a grant of 

$150,000–$198,000 from the U.S. Office of Minority 

Health to prevent hepatitis B in Vietnamese communities. It also received a $25,000 grant from the March 

of Dimes Foundation and a $75,000 grant from the 

State Infant Mortality Program to address the state’s 

high infant mortality by funding the Mississippi Sisters 

United project. The office may not receive the same 

level of funding for infant mortality reduction in 

FY 2016, but no significant changes in funding levels 

from the State of Mississippi or the U.S. Office of 

Minority Health are anticipated.

The MSDH/OHDE provides funding to some nongovernmental community organizations to advance health 

equity. For example and as noted above, African 

American sorority chapters at universities in the state 

that are involved in Mississippi Sisters United receive 

small grants to address infant mortality in minority 

communities. The MSDH/OHDE also provides funding 

to Boat People SOS and Mercy Housing and Human 

Development to carry out hepatitis B prevention 

activities in Vietnamese communities (the funding was 

awarded by the U.S. Office of Minority Health). Finally, 

Tougaloo College also receives MSDH/OHDE funding 

through a subgrant provided by the University Of 

Mississippi Medical Center to educate and link the 

public to Affordable Care Act resources.

State and Territorial Efforts to Reduce Health Disparities 137
Mississippi

Mississippi State Data

Total Populationa: 

2,988,726

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 2.9 97.1 58.5 38.0 0.4 0.9 2.2 100.0 NA 

Percent of population 

medically uninsureda 30.5 12.0 10.6 14.8 24.6 10.6 25.3 12.6 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 9.7 7.0 12.5 SP SP NC 9.5 5.9

Age-adjusted 

mortality rateb 215.7 959.1 918.3 1012.0 706.5 469.0 NC 948.9 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.7 12.8 12.3 13.2 13.8 SP 18.0 12.7 13.6

Percent with 

diabetesc 7.2 13.7 12.1 16.9 8.8 SP 9.7 13.7 10.8

Percent with 

heart diseasec 0.0 6.0 7.0 4.2 5.1 SP 5.3 5.9 4.3

HIV rated 451.7 NC 122.5 750.8 96.3 66.3** 1985.8 374.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

55.1 75.9 72.5 81.4 82.3 SP 56.6 75.3 72.2

Percent received 

oral health visit 

(past 12 months)c

62.8 57.3 59.5 53.2 57.9 SP 60.7 57.4 66.5

Percent received 

flu vaccinec 42.0 37.0 41.5 30.2 26.5 SP 25.6 37.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 66.3 per 100,000 population (17 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 114.9 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 138
Missouri 

Introduction to Missouri’s Health Equity Activities

Missouri had an estimated 2016 population of 6,093,000. Blacks/African Americans are the largest racial-ethnic 

minority population (12 percent), followed by Hispanics/Latinos (4 percent), Asian Americans and NHOPI 

(2 percent), and American Indians/Alaska Natives (less than 1 percent). Multiracial and persons self-identifying 

as “other race” comprise 4 percent of the population.1 Approximately 2,314,000 Missouri residents live within 

a primary care health professional shortage area.2

Housed within the Missouri Department of Health and Senior Services (DHSS), the Missouri Office of Minority 

Health (MOMH) was established solely to address minority health, health disparities, and health equity. It was 

formed largely as a result of efforts by the Missouri Legislative Black Caucus (LBC). In partnership with the MOMH, 

a volunteer regional health alliance with representatives from each of the state’s six MOMH districts (Eastern, 

Northwestern, Northwestern, Central, Southeastern, and Southwestern) provides insight on health equity issues in 

Missouri. It holds regular calls to discuss current health equity issues and to hear from other organizations with 

which the MOMH seeks to build regional collaborations. This alliance is separate from the Regional Health Equity 

Council, which covers the four states in the U.S. Department of Health and Human Services’ Region VII (Iowa, 

Kansas, Missouri, and Nebraska). The Regional Health Equity Council (RHEC) is comprised of directors of minority 

health and their designees in each of these four states. Various committees within the RHEC sponsor monthly 

conference calls to discuss pertinent issues affecting Region VII. With assistance from epidemiologists 

representing each state, the health equity council drafted a Health Equity Blueprint for Region VII.

Missouri Minority Health Overview

Name of state/territorial 

minority health entity Missouri Office of Minority Health 

Strategic plan in place to 

address minority health 

or health equity

A strategic plan is available 

at the department level. 

Date strategic plan was 

last updated 2016

Assessment plan in place 

to measure progress 

toward reducing health 

disparities

No formal assessment plan 

is in place. 

Key strategies used to 

achieve health equity

• Promotion of preventive 

screenings

• Promotion of exercise

• Promotion of heathy eating

• Promotion of regular visits 

to primary care physicians

• Promotion of heathy lifestyles

Organizational Structure

The MOMH is located within the DHSS Office of the 

Director and has a legislative mandate to advise 

the Director of DHSS on departmental, local, 

statewide, or federal policies and procedures that 

may adversely affect the health of minorities. Its 

four-person staff, including the MOMH chief, two 

health program representatives, and an administrative assistant, contribute all of their time to MOMH 

and DHSS activities. Interns and volunteers may 

also assist MOMH staff. There are no concrete 

plans to expand the number of employed staff.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 Designated HPSA Quarterly 

Summary.

State and Territorial Efforts to Reduce Health Disparities 139
Missouri

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The MOMH is under 

the DHSS Office of 

the Director 

SMHE staffing (full-time equivalents) 4

Advisory committee or panel The regional health 

alliance

Program Goals and Activities

To address issues that may adversely impact minority 

health and to set priorities for its activities, the MOMH 

works closely with directors of other DHSS divisions 

(e.g., the Division of Senior and Disability Services, the 

Division of Regulation and Licensure, and the Division 

of Community and Public Health). The goals and 

activities of the MOMH strategic plan are integrated 

into the larger DHSS strategic plan. The DHSS strategic 

plan was a part of the 2016 Public Health Accreditation 

Board accreditation process, which eventually led to 

accreditation for the DHSS. 

In addition to the DHSS strategic plan, the MOMH 

releases reports on a range of health equity issues 

(e.g., dental health disparities). These reports address 

topics of concern to racial and ethnic minorities; the 

lesbian, gay, bisexual, and transgender community; and 

rural health populations. Generated every 4 years by 

the MOMH—in partnership with the Office on Women’s 

Health and the Office of Primary Care and Rural 

Health—the most recent set of reports were published 

in 2013–2014 and include strategies to improve health 

outcomes. The MOMH and DHSS measure progress 

toward reducing health disparities primarily by working 

with epidemiologists to review data and trends across 

known health disparity issues. 

Most of the strategies underway to address minority 

health, health disparities, and health equity are related 

to health promotion and are led by the MOMH in 

conjunction with the Division of Community and Public 

Health. The MOMH uses tailored health messaging to 

engage individuals in minority communities and 

encourage them to participate. The initiatives supporting the preventive screenings strategies include 

Show Me Healthy Women, Sista Strut, and WISEWOMAN—which offers screenings for breast cancer, 

cervical cancer, heart disease, and stroke prevention. 

These initiatives accomplish goals similar to breast 

cancer walks, but with a significant focus on culturally 

competent marketing and outreach. Other related 

health promotion efforts include a prostate cancer 

walk, colorectal screenings, and dental screenings for 

children. These screening efforts mostly target African 

Americans and other minorities. 

Acronym List

Full Name of Agency Acronym Acronym

Missouri Office of Minority Health MOMH

Missouri Department of Health and Senior 

Services DHSS

Missouri Legislative Black Caucus LBC

The MOMH leads efforts to promote exercise and 

reduce obesity in an area of Kansas City with poor 

health outcomes. Efforts to promote healthy eating 

strategies include partnering with the American Heart 

Association to distribute healthy cookbooks and 

partnering with Hispanic and Asian leaders to address 

health food choices in grocery stores that serve 

specific racial and ethnic populations. The MOMH 

and the Division of Community and Public Health lead 

another related initiative, with assistance from the 

Office of Primary Care and Rural Health and the U.S. 

Department of Agriculture, which funds food trucks 

and/or community gardens that promote healthy 

eating. The MOMH has reviewed proposals to assess 

which might have the biggest impact on healthy eating 

in minority communities.

The MOMH and the Office of Primary Care and Rural 

Health lead the strategy to promote regular visits to 

primary care physicians. This involves working with 

federally qualified health centers to encourage community residents to get regular care and preventive 

screenings. Another strategy to promote healthy 

lifestyles includes faith-based initiatives and a smoking 

cessation quit line. In concert with one faith-based 

initiative, Fourth Sunday, the MOMH has partnered 

with pastors to encourage them to speak about health; 

in one case, a church was encouraged to operate 

a gymnasium. 

State and Territorial Efforts to Reduce Health Disparities 140
Missouri

Partnerships

Primary 

collaborators

• Missouri Legislative Black Caucus

• Black Health Care Coalition

• Lincoln University

• People’s Health Centers

• I-Heart Radio

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented for 

all partnerships except those with 

the Missouri Legislative Black Caucus 

and the Black Health Care Coalition.

Most of the minority health strategies underway in 

Missouri involve partnerships with other organizations. 

The Missouri LBC is one of the most important MOMH 

partners, but no formal contract exists between the 

organizations. The MOMH informs the LBC about 

health outcomes of concern to African American 

communities, invites LBC members to attend forums 

held in their areas, and conducts educational sessions 

with LBC members. LBC members reach out to the 

MOMH to assist with health fairs (e.g., offering health 

screenings by a federally qualified health center at 

a community-wide event or initiating a campaign to 

distribute toothbrushes in rural areas). The MOMH also 

works with state legislators from underserved districts 

to address disparities due to socioeconomic status. 

The MOMH formally contracts with the Black Health 

Care Coalition in Kansas City for obesity prevention 

through the Fit Families initiative. 

The MOMH also maintains a memorandum of 

understanding and a contract with Lincoln University, 

a historically black college/university (HBCU) that 

purchased technology enabling the MOMH to broadcast 

monthly educational webinars to senior citizens at all 

extension campuses. These webinars address topics 

such as heart health, Alzheimer’s disease, and 

dementia. Lincoln University also hosts the Missouri 

Institute on Minority Aging forum, which presents 

current information affecting senior citizens. Initially, 

the forum solely served African American seniors, 

but it now serves a mix of African American and 

Hispanic seniors. 

The MOMH supports the Betty Jean Kerr People’s 

Health Centers, a federally qualified health center, 

and participates in a back-to-school festival where the 

MOMH facilitates the performance of health screenings 

to a very large minority population. The MOMH provided 

technical assistance to the Betty Jean Kerr People’s 

Health Centers to build an adolescent mental health 

facility for children. In addition, the MOMH has an 

agreement with I-Heart Radio to support Sista Strut, 

a 5k walk to increase breast cancer awareness within 

the African American community.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$800,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $800,000

Largest funding source State of Missouri

Anticipated changes to budget None

The total FY 2015 funding for the MOMH was approximately $800,000. In FY 2015, the only source of 

funding was from the State of Missouri general revenue. Although the MOMH was involved in many of 

DHSS activities, the $800,000 was solely used to fund 

MOMH’s activities and salaries. The MOMH activity 

budget supported Lincoln University and various other 

partnership programs. The amount of funding designated for the MOMH has decreased in past years.

State and Territorial Efforts to Reduce Health Disparities 141
Missouri

Missouri State Data

Total Populationa: 

6,093,000

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 4.0 96.0 82.2 11.5 0.5 2.1 3.7 100.0 NA 

Percent of population 

medically uninsureda 22.1 8.7 8.6 12.3 16.8 10.2 13.8 9.3 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 6.5 5.4 11.9 SP SP NC 6.5 5.9

Age-adjusted 

mortality rateb 384.0 815.6 794.5 975.8 297.0 400.1 NC 808.2 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 13.2 14.5 14.1 16.8 19.5 12.8 17.0 14.5 13.6

Percent with 

diabetesc 11.8 11.5 11.3 13.7 9.3 6.1 11.5 11.5 10.8

Percent with 

heart diseasec 6.4 4.7 4.7 4.2 7.5 2.5 2.8 4.6 4.3

HIV rated 361.9 NC 135.7 913.8 63.8 74.0** 456.6 234.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

70.3 71.8 71.3 75.7 64.3 75.4 67.5 71.7 72.2

Percent received 

oral health visit 

(past 12 months)c

50.9 61.8 62.3 58.6 36.4 70.8 56.6 61.5 66.5

Percent received 

flu vaccinec 27.0 43.1 43.4 41.0 23.9 39.5 29.2 42.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 74.0 per 100,000 population (72 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 91.1 per 

100,000 population (5 cases).

State and Territorial Efforts to Reduce Health Disparities 142
Montana 

Introduction to Montana’s Health Equity Activities

Montana had an estimated 2016 population of 1,043,000. American Indians/Alaska Natives are the largest 

racial-ethnic minority population (7 percent), followed by Hispanics/Latinos (4 percent), Asian Americans and 

NHOPI (1 percent), and Blacks/African Americans (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 3 percent of the population.1 Approximately 330,000 Montana residents live within 

a primary care health professional shortage area.2

As one of only a few states in which American Indians/Alaska Natives comprise the largest racial-ethnic minority 

group, Montana established the Office of American Indian Health (OAIH) within the Department of Public Health 

and Human Services (DPHHS) per a 2015 governor-issued Executive Order. Its mission is to reduce disparities 

and improve a range of health outcomes (e.g., cardiovascular disease, cancer, and lifespan) for American Indians. 

Located within the department’s Director’s Office, the American Indian Health Director guides the department’s 

effort to address minority health, health disparities, and health equity in Montana. Since 2013, a DPHHS tribal 

relations manager has been dedicated to improve the department’s relationship with Montana’s tribes, urban 

Indian programs, and Indian Health Service.

Montana Minority Health Overview

Name of state/

territorial minority 

health entity

Montana/Office of American Indian Health

Strategic plan in 

place to address 

minority health 

or health equity

Not as of yet, but will be created once the American Indian Health Director position is filled 

in summer 2018.

Date strategic plan 

was last updated N/A

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

• The DPHHS’s State of the State’s Health: A State Health Assessment Report on the Health 

of Montanans (2013) identifies health disparity priorities. 

• The DPHHS’s State Health Improvement Plan (2012–2017) is a 5-year plan with annual updates 

addressing, among other topics, health disparities. 

• Proposed priority areas for the DPHHS’s 2018–2022 State Health Improvement Plan include 

disparities in chronic disease, maternal and child health, behavioral health, unintentional injury, 

and adverse childhood experiences. 

Key strategies 

used to achieve 

health equity

• Conducting tobacco use reduction activities

• Conducting home visits with low-income pregnant women and new mothers

• Increasing access to the Women, Infants, and Children Program 

• Increasing awareness about heart disease and stroke

• Ensuring availability of emergency preparedness plans

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 143
Montana

Organizational Structure

The American Indian Health Director (AIHD) is a staff 

position reporting directly to the DPHHS director who, 

in turn, reports to the governor. A tribal relations 

manager also works under the director, but is independent of the AIHD. The DPHHS consults with the AIHD 

and the tribal relations manager when working with 

tribes or seeking technical assistance. The AIHD 

position that vacated in early 2017. In addition, a 

mid-level tobacco prevention specialist in the Public 

Health and Safety Division works full-time with the 

tribes. Several mid-level staff in the Public Health and 

Safety Division also contribute to health disparity 

activities. Through the AmeriCorps VISTA program, 

others have worked on health disparity issues in the 

tobacco program. It is anticipated that staffing allocations may evolve over the next 2 years.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of American Indian 

Health operates directly under 

the director of the Department 

of Public Health and Human 

Services. 

Advisory committee 

or panel

Chaired by the department 

director, the Internal Indian Health 

Collaborative was established 

in DPHHS in spring 2017 to 

focus on health disparities and 

developing strategies to address 

them in concert with the work of 

the AIHD.

Program Goals and Activities

The DPHHS Public Health and Safety Division, which 

oversees all public health programs, is guided by a 

5-year strategic health plan. A public health assessment 

conducted every 5 years informs the strategic plan and 

helps to identifies priority public health issues. 

While the strategic health plan addresses equity issues, 

its primary focus is to reduce disparities between rural 

and urban populations. The public health assessment, 

however, considers public health priorities of racial and 

ethnic minorities and specifically offers detailed information on racial-ethnic disparities affecting American 

Indians. A Public Health System Improvement Taskforce, 

which includes leaders of tribal and local health departments, develops the assessment, reviews its results, 

and subsequently suggests several key public health 

priorities. Additionally, the U.S. Indian Health Service 

funds the Rocky Mountain Tribal Epidemiology Center, 

which supports tribal public health workgroups and 

advisory coalitions that provide the OAIH feedback 

that it uses when establishing its priorities.

As part of state legislation regarding the use of state 

tobacco master settlement funds, the DPPHS must 

provide tobacco prevention services for Montana’s 

recognized American Indian tribes of which there are 

eight, each with their own tribal governing body. Such 

services, which are coordinated through the DPHHS 

Public Health and Safety Division, include efforts to: 

reduce exposure to secondhand smoke, discourage 

smoking/electronic nicotine product use initiation 

among youth, implement smoke-free policies on school 

campuses and in low-income housing, and assist in 

tobacco cessation efforts. The DPHHS also offers tribes 

financial support to fund full-time tobacco use prevention staff. The Montana Tobacco Quit Line, operated 

through National Jewish Health in Denver, provides free 

or low-cost cessation materials to all Montanans. Most 

recently, DPHHS created the American Indian Commercial Tobacco Quit Line which seeks to make available 

American Indian counselors who can provide tailored 

services to tribal communities. To increase awareness 

of these services among Indian communities, the Public 

Health and Safety Division works with a media contractor to develop tribal-specific materials. 

Through the Family and Community Health Bureau, the 

DPHHS supports evidence-based models for home visits 

with low-income pregnant women and new mothers—

which are disproportionately Indian. The DPHHS works 

directly with participating tribes to help support lowincome families with children under age 5, including 

home visits using the “Parents as Teachers” tribal-specific and culturally appropriate home visit model. Another 

Bureau program focuses on healthy nutrition by providing 

tribes with funding to implement the Women, Infants, 

and Children Program and supporting breastfeeding 

efforts. In a separate program, the DPHHS Nutrition and 

Physical Activity Program works with labor and delivery 

hospitals across Montana to support the Baby-Friendly 

Hospital Initiative, which certified a participating hospital 

on the Blackfeet Reservation. 

Acronym List

Full Name of Agency Acronym Acronym

Department of Public Health and Human 

Services DPHHS

Office of American Indian Health OAIH

State and Territorial Efforts to Reduce Health Disparities 144
Montana

In addition, the Public Health and Safety Division has 

implemented a cardiovascular health awareness program to address heart disease morbidity and mortality 

disparities among American Indian communities, many 

of which are in remote locations with limited access to 

cardiology services. The program features tribal-specific 

campaigns about the warning signs and symptoms of 

heart attack and stroke. Plans are underway to expand 

telehealth capacity in small critical access hospitals, 

providing rapid access to neurologists. Another Public 

Health and Safety Division initiative, funded by the U.S. 

Centers for Disease Control and Prevention (CDC), 

seeks to ensure that each American Indian community 

has in place a DPHHS-reviewed emergency preparedness plan in the event of a flood, disease outbreak, 

or other natural disaster. 

Partnerships

Primary 

collaborators

• Tribal health department leaders

• Urban Indian Health Center leaders

• Billings Area Indian Health Service

• Montana Healthcare Foundation

• Rocky Mountain Tribal Epidemiology 

Center 

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented for 

some partnerships. For example: 

• Multiple contracts are in place with 

tribal health leaders for various 

activities.

• DPHHS maintains a memorandum 

of understanding with the Rocky 

Mountain Tribal Epidemiology 

Center. 

• DPHHS contracts with the Montana 

Healthcare Foundation in support of 

the projects it funds.

Leaders from the health departments of Montana’s 

federally recognized tribes are key DPHHS collaborators 

on efforts to improve American Indian health. The DPHHS 

maintains contracts with tribal health departments to 

support efforts around tobacco use prevention, healthy 

nutrition, and emergency preparedness; it also partners 

with other agencies to secure funding supporting 

additional American Indian health activities. 

To help tribes conduct local community health 

assessments, the DPHHS maintains a memorandum 

of understanding to support data sharing with the 

Rocky Mountain Tribal Epidemiology Center, a 

nongovernmental agency funded by the U.S. Indian 

Health Service. The center has applied for additional 

funding on behalf of tribes for tribal specific projects 

(e.g., it sought an award from the CDC to implement 

several chronic disease programs). Another DPHHS 

partner is the Montana Healthcare Foundation, a 

nonprofit organization established in 2013. In addition 

to funding tribal-specific initiatives and convening 

American Indian health leaders throughout the year, the 

foundation regularly issues requests for proposals and 

has expanded support for mental health access and 

substance use treatment in Montana. All foundationfunded projects involve contracts with the DPHHS. 

Another frequent DPHHS partner is the Billings Area 

Indian Health Service, a U.S. Indian Health Servicefunded agency addressing health care needs of tribal 

communities throughout Montana and Wyoming.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

Approximately $4.1 

million for American 

Indian health 

activities across the 

three largest sources

Annual budget (FY 2015) of SMHE 

from state/territorial government

Approximately 

$175,000 

Largest funding source USDA for WIC 

program for food

Anticipated changes to budget None

The DPHHS budget does not include a line item for the 

OAIH as it is included as part of the Director’s Office 

budget. The OAIH’s three largest funding sources 

include the U.S. Department of Agriculture, the tobacco 

master settlement agreement, and the CDC. 

Specifically, FY 2015 awards included $2,300,000 for 

efforts supporting healthy foods and $750,000 for the 

Special Supplemental Nutrition Program for Women, 

Infants, and Children (U.S. Department of Agriculture); 

$775,000 for tobacco cessation efforts—of which 

$75,000 explicitly supports the Quit Line (tobacco 

master settlement agreement); and $250,000 for 

emergency preparedness support (CDC). 

Other sources of funding are difficult to enumerate 

because the DPHHS budget does not separately identify 

funding for minority health activities. For example, as part 

of a global contract with the Montana Healthcare Foundation, the DPHHS provides approximately $50,000 to the 

Rocky Mountain Tribal Epidemiology Center for community health assessments. Montana’s budget for minority 

health activities may change during the next 2 years if 

there are changes in federal funding.

State and Territorial Efforts to Reduce Health Disparities 145
Montana

Montana State Data

Total Populationa: 

1,042,520

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 3.5 96.5 88.9 0.3 6.6 0.9 3.3 100.0 NA 

Percent of population 

medically uninsureda 15.2 8.1 7.1 2.3 24.3 14.6 10.1 8.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 5.6 4.9 SP SP SP NC 5.8 5.9

Age-adjusted 

mortality rateb 566.7 743.6 719.1 880.2 1176.8 398.8 NC 743.2 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.2 13.1 12.4 SP 21.0 SP 17.3 13.0 13.6

Percent with 

diabetesc 4.7 8.3 7.7 SP 15.9 SP 8.2 8.1 10.8

Percent with 

heart diseasec 0.9 3.8 3.6 SP 3.64 SP 4.5 3.7 4.3

HIV rated 132.4 NC 60.3 431.1 55.5 14.9** 180.2 66.1 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

70.7 66.9 67.2 SP 66.3 SP 64.4 67.0 72.2

Percent received 

oral health visit 

(past 12 months)c

61.4 66.1 66.4 SP 64.0 SP 51.2 65.8 66.5

Percent received 

flu vaccinec 30.9 39.8 39.4 SP 40.8 SP 35.6 39.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 14.9 per 100,000 population (1 case); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 322.6 per 

100,000 population (2 cases).

State and Territorial Efforts to Reduce Health Disparities 146
Nebraska 

Introduction to Nebraska’s Health Equity Activities

Nebraska had an estimated 2016 population of 1,907,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (11 percent), followed by Blacks/African Americans (5 percent), Asian Americans and NHOPI 

(2 percent), and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other 

race” comprise 4 percent of the population.1 Approximately 28,000 Nebraska residents live within a primary care 

health professional shortage area.2

The Nebraska Department of Health and Human Services (Nebraska DHHS) identifies its Office of Health 

Disparities and Health Equity (OHDHE) as its minority health entity. Envisioning “Nebraska’s culturally diverse 

populations are as healthy as possible,” the OHDHE’s mission is to “promote and support the advancement of 

health equity in Nebraska using data, partnerships, funding, and training and technical assistance.”3 To this end, 

its efforts primarily focus on racial-ethnic minorities, American Indians, refugees, and immigrants.4

Nebraska Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Disparities 

and Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

The Nebraska Department of 

Health and Human Services 

Division of Public Health Office 

of Health Disparities and Health 

Equity Strategic Plan is updated 

periodically.

Date strategic plan 

was last updated 2018 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The strategic plan is updated 

annually to mark progress on 

objectives. Assessment plans are 

also part of the broader Nebraska 

Public Health Improvement Plan. 

Key strategies 

used to achieve 

health equity

• Build capacity of organizations 

to develop best practices to 

advance health equity through 

training and technical assistance. 

• Utilize data collection and 

analysis to inform stakeholders 

and advance health equity.

• Encourage and support 

partnerships to affect policies, 

systems, and programs that 

contribute to the promotion 

of health equity.

Organizational Structure

The Office of Health Disparities and Health Equity 

is housed within the Nebraska Department of Health 

and Human Services, Division of Public Health (DPH), 

Community and Rural Health Planning Unit. It has a 

central office in Lincoln and four satellite offices in 

Omaha, York, and Kearney. The OHDHE’s advisory 

Minority Health Council meets at least quarterly and 

consists of up to 25 members appointed by the 

director of the Nebraska DHHS. These individuals 

range from consumers to providers and represent 

Nebraska’s racial-ethnic minorities across the state’s 

geographic regions.5

The OHDHE has 13 staff members, all of whom work 

full time on minority health and health equity initiatives. 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Nebraska Department of Health and Human Services Division of 

Public Health Office of Health Disparities and Health Equity. 2018-

2021 Strategic Plan. Available on the Nebraska HHS website. 

Last accessed 8/27/2017.

4 Nebraska Department of Health and Human Services. Office of 

Health Disparities and Health Equity. Available on the Nebraska 

HHS website. Last accessed 6/19/2018.

5 Nebraska Department of Health and Human Services. Office 

of Health Disparities and Health Equity.

State and Territorial Efforts to Reduce Health Disparities 147
Nebraska

Staff members include an administrator, four health 

program managers, an epidemiologist, 2 community 

health educators, a data analyst, a program analyst, 

and a staff assistant. OHDHE team members often 

provide technical assistance to other divisions of the 

Nebraska DHHS. The OHDHE collaborates with the 

Centers for Disease Control and Prevention’s public 

health associate program; three associates have 

assisted with minority health projects and initiatives. 

Given anticipated funding constraints, the OHDHE 

expects limited hiring over the next 2 years.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OHDHE is 

housed within 

the Nebraska 

Department of 

Health and Human 

Services, Division 

of Public Health, 

Community and 

Rural Health 

Planning Unit. 

SMHE staffing (full-time equivalents) 11

Advisory committee or panel Minority Health 

Council

Program Goals and Activities

Available on its website, the OHDHE’s current strategic 

plan (covering FY 2018–2021) lists the goals, focus 

areas, and outcomes the office is working towards. The 

OHDHE updates its strategic plan to indicate objectives 

accomplished each year. It also uses a dashboard to 

track and monitor the leading causes of mortality for 

each minority population at the state and local health 

department level. 

The OHDHE’s priorities are largely data driven and are 

developed with input from the Minority Health Council, 

community-based organizations, and other partners. 

Efforts to reduce health disparities, however, are not 

limited to the OHDHE—they are integrated into activities 

of offices and programs throughout the DPH. Examples 

include the DPH’s plans addressing cancer, chronic 

disease, and maternal and child health identify disparities and strategies to reach minority and non-English 

speaking populations. Both the DPH’s strategic plan 

and the Nebraska DHHS Nebraska Public Health 

Improvement Plan include health equity priorities 

with input from the OHDHE and its partners. 

Acronym List

Full Name of Agency Acronym Acronym

Division of Public Health DPH

Office of Health Disparities and Health 

Equity OHDHE

Nebraska Department of Health and 

Human Services

Nebraska 

DHHS

Increasing cultural competency in health care has 

been a major focus of activity. The OHDHE provides 

in-person training and technical assistance on cultural 

intelligence, social determinants of health, and the 

National CLAS Standards to community organizations 

and staff throughout the Nebraska DHHS. It also 

collaborates with the DPH’s Maternal Child Adolescent 

Health Program to expand education on the National 

CLAS Standards. Trainings can be requested via the 

OHDHE website, which also includes an educational 

video and links to additional resources. Additionally, 

the OHDHE sponsors a Minority Health Conference, 

where it also disseminates information on all its 

training opportunities. 

Another OHDHE strategy for achieving health equity 

is to analyze quantitative data and prepare reports on 

the health and socioeconomic status of racial-ethnic 

minorities for use by other DPH divisions, local health 

departments, quality improvement organizations, 

federally qualified health centers (FQHCs), tribes, 

community-based organizations, and the public. It works 

closely with the state’s four federally-recognized Native 

American tribes to improve the collection of tribe-specific 

data. For example, work is beginning on collaborative 

efforts with the tribes to publish health status report 

for each of the four tribes. The OHDHE also recently 

expanded data collection on the state’s expanding 

refugee population and plans to publish a report on 

health status identified through a Behavior Risk Factor 

Surveillance Survey. Through a legislative mandate, the 

OHDHE also provides funding to address health disparities in minority populations in counties with minority 

populations of 5 percent or greater. 

It also published in 2015 a Health Disparities Report 

documenting health status data of racial and ethnic 

minorities throughout the state.6 Focusing on two 5-year 

time periods (2001–2005 and 2006–2010), the docu6 Nebraska Department of Health and Human Services. Nebraska Health Disparities: Executive Summary. September 2015. Available on the 

Nebraska HHS website. Last accessed 8/27/2017.

State and Territorial Efforts to Reduce Health Disparities 148
Nebraska

ment included a report card summarizing each racial 

and ethnic minority group’s health and socioeconomic 

status, as well as charts illustrating Nebraska’s progress 

on Healthy People 2010 objectives. The OHDHE plans to 

update the Health Disparities Report with a third 5-year 

timeframe to show trends and progress toward the 

Healthy People 2020 objectives. 

Partnerships

Primary 

collaborators

• Local public health departments

• Federally qualified health centers

• Community Cultural centers

• Federally recognized tribes

• Region VII Health Equity Council

• University of Nebraska Medical 

Center, University of Nebraska 

Minority Health Disparities Initiative, 

research initiatives, and councils

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The OHDHE partners with local public health 

departments, FQHCs, and cultural centers through 

minority health initiative sub-awards and other grants. 

Nebraska’s local public health departments function as 

independent entities and, through funding sub-awards, 

they collaborate with the ODHDE to improve the health 

of minorities in Nebraska through various evidencebased initiatives. 

With funding through Nebraska’s Native American 

Public Health Act and the Preventative Health and 

Health Services Block Grant funding, the OHDHE 

contracts with the state’s four federally recognized 

tribes to assess needs and address both chronic 

disease and behavioral health issues. For example, the 

OHDHE is working with two tribes to address diabetes 

in American Indians in one Nebraska County. Without 

a formal contract, the OHDHE also works with the 

Great Plains Tribal Chairmen’s Health Board to discuss 

and assess needs.

The OHDHE director and several members of the 

OHDHE Minority Health Council serve on the Region 

VII Health Equity Council, which has worked with the 

OHDHE to publish a heart disease disparities report 

for Region VII. This report highlights how African 

Americans and Native Americans are disproportionally 

affected by heart disease in Iowa, Kansas, Missouri, 

and Nebraska. The Region VII council also has a 

committee dedicated to developing partnerships 

with universities, physician associations, and other 

organizations; its efforts largely align with the health 

equity components of the Nebraska State Health 

Improvement Plan and Division of Public Health efforts. 

A regional health equity survey is currently being 

developed in partnership in the Region VII Health 

Equity Council and the Health Equity Priority Committee 

of the Nebraska State Health Improvement Plan.

The University of Nebraska at Lincoln has established 

a Minority Health Disparities Initiative (MHDI) with 

the OHDHE; its director sits on MHDI’s advisory 

council and has presented at the university’s annual 

Minority Health Disparities Initiative Conference on 

several occasions.

Funding 

Annual budget (FY 2017) of state/

territorial minority health entity 

(SMHE) across all income sources

$4,744,168

Annual budget (FY 2017) of SMHE 

from state/territorial government $4,133,168

Largest funding source State government

Anticipated changes to budget

Reductions 

anticipated in 

2019 and 2020

In FY 2017, the OHDHE’s total budget was 

$4,744,168; of that, $4,133,168 was allocated from 

state funding sources while federal contributions 

totaled $511,000. Reductions in state general funds 

allocated to the OHDHE may take place in 2019 and 

2020 depending on tax revenues. 

Federal funding sources for minority health in FY 2017 

include a State Partnership Initiative to Address Health 

Disparities (SPI) grant from the U.S. Office of Minority 

Health ($197,209), a Preventive Health and Health 

Services Block internal funding grant ($278,000), and 

the Every Woman Matters internal funding screening 

program grant ($35,000). The SPI grant project award 

period runs from 2015 to 2020. The Every Women 

Matters funding is an internal allocation from the Every 

Women Matters program which has been awarded from 

2015 to 2017. 

State and Territorial Efforts to Reduce Health Disparities 149
Nebraska

Support for the OHDHE’s health disparities and health 

equity activities in FY 2017 break down as follows:

• Minority health initiative state funding

($1,526,000 cash funds, $31,713 general funds): 

The OHDHE provided funding for minority public 

health services in counties with a 5 percent or 

greater minority population, in Nebraska’s first and 

third congressional districts. For 2015–2017, 19 

projects received funding. Funded organizations 

included public health departments, FQHCs, tribes, 

community action agencies, and community-based 

organizations. A request for applications is published on a 2-year basis.

• FQHC state funding ($1,349,000 cash funds): 

The OHDHE distributed funds equally among FQHCs 

in the second congressional district to implement 

a minority health initiative targeting issues such 

as infant mortality, cardiovascular disease, obesity, 

diabetes, and asthma. 

• Native American Public Health Act state funding - 

$500,000 ($450,000 general funds and $50,000 

Preventative Health and Health Services Block Grant 

funding): The OHDHE funds four federally recognized 

tribes and one community-based organization to provide educational and public health services targeted 

to Native American populations. 

• Preventative Health and Health Services Block 

Grant: OHDHE receives an internal allocation of 

from the Preventative Health and Health Services 

Block Grant funding received by the Nebraska 

Department of Health and Human Services Division 

of Public Health. The funding is allocated to:

•Identify disparities among racial and ethnic 

minorities

•Increase awareness of health disparities

•Establish and maintain behavioral risk surveillance 

system for sub-groups of minority populations and 

refugees

•Improve access to culturally competent and 

linguistically appropriate health services for 

racial and ethnic minorities

•Improve data collection strategies for racial, 

ethnic and other vulnerable populations

•Expand community-based health promotion 

and disease prevention outreach efforts to 

the aforementioned populations.

State and Territorial Efforts to Reduce Health Disparities 150
Nebraska

Nebraska State Data

Total Populationa: 

1,907,116

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 10.6 89.4 88.0 4.7 0.8 2.4 4.1 100.0 NA 

Percent of population 

medically uninsureda 22.5 7.1 7.8 17.7 26.7 6.6 15.9 8.7 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 6.7 5.3 4.8 11.5 SP SP NC 5.7 5.9

Age-adjusted 

mortality rateb 465.8 716.4 697.4 964.7 825.8 479.5 NC 707.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.4 12.8 12.3 21.8 10.2 6.7 9.1 12.4 13.6

Percent with 

diabetesc 6.3 9.0 8.6 12.3 12.5 6.1 9.4 8.8 10.8

Percent with 

heart diseasec 0.4 4.1 4.1 3.4 4.0 1.1 0.9 3.8 4.3

HIV rated 223.7 NC 82.8 836.7 186.5 88.4** 269.8 131.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

58.6 67.0 66.8 69.3 55.4 62.0 60.3 66.4 72.2

Percent received 

oral health visit 

(past 12 months)c

56.9 70.2 71.0 54.4 54.0 64.8 54.0 69.2 66.5

Percent received 

flu vaccinec 38.4 45.1 45.1 36.7 42.3 47.3 40.1 44.5 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 88.4 per 100,000 population (31 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 108.5 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 151
Nevada 

Introduction to Nevada’s Health Equity Activities

Nevada had an estimated 2016 population of 2,940,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (29 percent), followed by Blacks/African Americans (9 percent), Asian Americans and NHOPI (9 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 

14 percent of the population.1 Approximately 1,236,000 Nevada residents live within a primary care health 

professional shortage area.2

The Nevada Office of Minority Health was established during the 2005 legislative session. Following the loss of state 

general funds in 2010, the Nevada State Health Division transferred responsibility for minority health activities to the 

Office of Consumer Health Assistance. In July 2017, Assembly Bill 141 became law, reestablishing the office as the 

Office of Minority Health and Equity (OMHE) within the Department of Health and Human Services (Nevada DHHS). 

This new law also requires the Nevada DHHS and the State Board of Health to appoint nine voting members to a new 

stakeholder advisory committee. (Similarly, a nine-member advisory committee provided guidance to the former Office 

of Minority Health.) The OMHE is expected to become a member of the Nevada Minority Health and Equity Coalition, 

which local and state leaders established in 2016 to prioritize health disparities.

Nevada Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health and Equity

Strategic plan in 

place to address 

minority health 

or health equity

The strategic plan that expired in 

2014 has not yet been updated.

Date strategic plan 

was last updated 2009

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

No

Key strategies 

used to achieve 

health equity

• Establishing the new Office of 

Minority Health and Equity

• Supporting the Minority Health 

and Equity Coalition

• Working to serve minority groups 

in addition to racial and ethnic 

minorities

Organizational Structure

After the Office of Minority Health lost its funding in 

2010, minority health activities were managed by the 

Office of Consumer Health Assistance. Legislation 

enacted in 2017 established the new OMHE, which 

is housed within the Nevada DHHS and is staffed 

by a sole full-time staff member: the OMHE manager. 

The Nevada Minority Health and Equity Coalition 

(“Coalition”) also supports the OMHE. With the new 

OMHE manager now overseeing both the OMHE and 

the Coalition, there is optimism that the OMHE will 

soon be better positioned to seek grants and other 

funding opportunities, which could lead to increased 

staffing in the next two years.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 152
Nevada

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Office of 

Minority Health and 

Equity is located 

within the Nevada 

Department of 

Health and Human 

Services. 

SMHE staffing (full-time equivalents) 1

Advisory committee or panel

The nine-member 

advisory committee 

and the Nevada 

Minority Health and 

Equity Coalition

Program Goals and Activities

A 5-year strategic plan related to minority health and 

health equity was updated in 2009 and expired in 2014; 

it was not updated due to lack of funding. Following 

restoration of funding in 2017, a data-driven process for 

setting minority health and equity priorities is expected 

to be re-established and to include input from the 

Nevada Minority Health and Equity Coalition. The initial 

focus of the Nevada DHHS in 2017 has been to secure 

funding for both the OMHE and the Coalition, although 

it is also working to include within the OMHE’s purview 

health disparities that affect persons with disabilities 

and members of Nevada’s lesbian, gay, bisexual, and 

transgender communities. 

Acronym List

Full Name of Agency Acronym Acronym

Nevada Department of Health and Human 

Services

Nevada 

DHHS

Office of Minority Health and Equity OMHE

Partnerships

Primary 

collaborators

• Asian Community Development 

Center 

• Asian Community Resource Center 

• CARE Coalition 

• Community Partners for Better 

Health 

• Division of Public and Behavioral 

Health 

• Nevada Donor Network 

• Planned Parenthood

• Southern Nevada Health District 

• Silver State Health Insurance 

Exchange 

• University of Nevada, Las Vegas

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding.

Efforts to re-establish a dedicated state minority health 

entity have involved several governmental and 

nongovernmental agencies and organizations, including 

the University of Nevada, Las Vegas School of 

Community Health Sciences, the Southern Nevada 

Health District, the Silver State Health Insurance 

Exchange, and the Nevada DHHS Division of Public 

and Behavioral Health. Nonprofit organizations involved 

in the process include the Asian Community Resource 

Center, the CARE Coalition (which focuses on 

substance abuse and mental health), Community 

Partners for Better Health, the Nevada Donor Network, 

and Planned Parenthood. 

The University of Nevada, Las Vegas School of 

Community Health Sciences received funding from 

the Nevada DHHS to assist in establishing the Nevada 

Minority Health and Equity Coalition. Meanwhile, the 

Nevada DHHS’ partnership with the Silver State Health 

Insurance Exchange provided enrollment support, as 

well as educational support to the provider community 

regarding the National Standards for Culturally and 

Linguistically Appropriate Services in Health and Health 

Care (National CLAS Standards). The Division of Public 

and Behavioral Health will also help ensure the 

availability of suitable educational materials to support 

implementation of the National CLAS Standards.

State and Territorial Efforts to Reduce Health Disparities 153
Nevada

All of the nonprofit agencies that serve as partners 

with the OMHE are participants in the Minority Health 

and Equity Coalition. Planned Parenthood and the CARE 

Coalition have expressed interest in leadership roles 

with the coalition and many of the other partners have 

offered to provide space for meeting locations.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$0

Annual budget (FY 2015) of SMHE 

from state/territorial government $0

Largest funding source 

State funding for the 

OMHE resumed in 

July 2017.

Anticipated changes to budget

None beyond the 

2017 resumption 

of funding 

Although the OMHE did not yet exist in FY 2015, the 

DHHS provided approximately $30,000 to the University of Nevada, Las Vegas to create the Nevada 

Minority Health and Equity Coalition. The 2017 legislation provided approximately $133,000 per year from 

Nevada general funds for the OMHE and the coalition. 

No additional budget changes are expected.

State and Territorial Efforts to Reduce Health Disparities 154
Nevada

Nevada State Data

Total Populationa: 

2,940,058

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 28.5 71.5 66.8 8.9 1.1 9.0 14.2 100.0 NA 

Percent of population 

medically uninsureda 20.9 7.5 10.4 9.5 15.7 8.2 18.3 11.3 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.8 5.5 4.3 9.2 SP SP NC 5.2 5.9

Age-adjusted 

mortality rateb 453.9 817.3 789.3 843.0 575.8 450.6 NC 762.6 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.2 12.7 11.8 14.9 6.8 12.2 9.6 11.7 13.6

Percent with 

diabetesc 9.2 11.8 11.2 16.6 10.1 7.8 10.0 11.1 10.8

Percent with 

heart diseasec 2.0 5.1 5.3 5.3 1.5 2.9 1.8 4.4 4.3

HIV rated 359.3 NC 307.7 1068.0 238.1 132.0** 441.2 371.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

62.8 72.7 71.8 80.9 51.4 65.9 63.9 70.3 72.2

Percent received 

oral health visit 

(past 12 months)c

51.8 64.4 65.3 61.8 61.6 54.9 50.1 61.3 66.5

Percent received 

flu vaccinec 22.5 35.3 35.5 20.7 24.9 46.7 22.4 32.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 132.0 per 100,000 population (271 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 231.5 

per 100,000 population (33 cases).

State and Territorial Efforts to Reduce Health Disparities 155
New Hampshire 

Introduction to New Hampshire’s Health Equity Activities

New Hampshire had an estimated 2016 population of 1,335,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (3 percent), followed by Asian Americans and NHOPI (3 percent), Blacks/African Americans 

(1 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 3 percent of the population.1 Approximately 117,000 New Hampshire residents live within 

a primary care health professional shortage area.2

The Office of Health Equity (OHE) within the New 

Hampshire Department of Health and Human 

Services (DHHS) is the state agency devoted 

to health disparities and related issues. The OHE 

is housed within the Office of the Commissioner 

to reflect the cross-divisional importance of the 

OHE priorities, policies and initiatives, and its key 

supportive function to the entire Department. 

In New Hampshire, the Division of Public Health 

Services is a part of the DHHS, as are Medicaid, 

the Division for Children Youth and Families, 

the Division of Family Assistance, the Bureau 

of Behavioral Health, and more. The DHHS had 

established the Office of Minority Health in 1999 

to improve minority health and safeguard all New 

Hampshire residents’ access to services; in 

2010, it integrated the New Hampshire Refugee 

Program to create the Office of Minority Health 

and Refugee Affairs; in 2016, the office was 

renamed the OHE (for simplicity, the name used 

throughout this summary). The OHE assures 

equitable access to effective, quality DHHS 

programs and services across all populations, 

with specialized focus on racial, ethnic, language, 

gender and sexual minorities, and individuals 

with disabilities.

New Hampshire Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

Yes. The Office of Health Equity co-led 

the New Hampshire Health and Equity 

Partnership’s efforts to create the 

Plan to Address Health Disparities and 

Promote Health Equity in New Hampshire.

Date strategic plan 

was last updated 2011

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The New Hampshire plan includes 

goals and assessment components 

to measure progress.

Key strategies 

used to achieve 

health equity

• Collaborating to increase awareness 

and understanding about health equity

• Promoting implementation of cultural 

and linguistic standards

• Promoting Community Health Workers 

and workforce diversity 

• Collaborating through the New 

Hampshire Health and Equity 

Partnership

• Facilitating the Culturally Effective 

Organizations Priority Work Group

• Facilitating the Behavioral Health Equity 

Work Group

• Collaborating with the Division of Public 

Health Services to increase access to 

services

• Assisting with the Equity Leaders 

Fellowship

• Increasing awareness and 

understanding about race, ethnicity 

and language (REaL) data collection 

and use

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 Designated HPSA Quarterly 

Summary.

State and Territorial Efforts to Reduce Health Disparities 156
New Hampshire

Organizational Structure

Although it does not have a formal advisory committee 

or panel, the OHE seeks input on initiatives and 

activities from community-based organizations, 

community leaders, other partners and stakeholders, 

and state agencies. 

Of the OHE’s 10 staff positions, 3 work exclusively 

on health equity: the OHE’s director, administrative 

secretary, and minority health program specialist 

(vacant). Three other staff members work on improving 

minority health and health equity by their focus on 

cultural and linguistic competence: the DHHS communication access coordinator; the hearing, speech and 

vision program specialist; and the cultural and linguistic competence coordinator. The three state 

refugee program staff (coordinator, health coordinator, 

and program specialist) also contribute towards 

advancing cultural and linguistic competence and 

workforce diversity.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The OHE is 

housed within the 

New Hampshire 

Department of 

Health and Human 

Services

SMHE staffing (full-time equivalents) 10

Advisory committee or panel None 

Program Goals and Activities

The OHE engages in many strategies to improve the 

health of minority populations. In 2011, the OHE 

co-founded the public-private New Hampshire Health and 

Equity Partnership to create a strategic plan, the Plan to 

Address Health Disparities and Promote Health Equity in 

New Hampshire. This document identified the following 

strategic priority areas: access to care; addressing 

environments where we live, learn, work and play; 

awareness and promotion of health equity; and 

improving data collection and use to identify and monitor 

disparities. In 2014, the partnership began to align with 

a collective impact approach and identified three priority 

areas on which to focus efforts: 

• Increase the capacity in the state for the collection 

of high quality Race, Ethnicity and Language (REaL) 

data across all systems at the state and local level 

to identify disparities and promote utilization of data 

to inform improvements, policies and procedures.

• Increase organizational cultural effectiveness and 

improve the capacity of organizations in the state 

to provide high quality services to all populations 

(especially racial, ethnic, and linguistic minorities) by 

incorporating the elements of a culturally effective 

organization.

• Increase a diversified workforce to support economic opportunities for racial, ethnic, and linguistic 

minorities and all populations in the state. 

While the OHE relies upon such data to guide its 

decision-making, its priorities are also determined based 

on available federal and state funding. 

Another strategy is to leverage opportunities to collaborate with organizations to increase awareness of health 

equity issues. Together with the New Hampshire Department of Education, for example, the OHE is promoting 

implementation of cultural and linguistic standards. It 

also collaborates with the Division of Public Health 

Services to increase access to services and assists 

with the Southern New Hampshire Area Health Education Center’s Equity Leaders Fellowship. Staff with the 

OHE also facilitate several workgroups, such as the 

Health and Equity Partnership’s Culturally Effective 

Organizations Work Group and the Behavioral Health 

Equity Work Group, a joint effort of the New Hampshire 

Health and Equity Partnership and the New Hampshire 

Children’s Behavioral Health Collaborative.

Sharing information is another core strategy the OHE 

employs to increase health equity. The OHE director 

speaks at different conferences and to various organizations, tailoring remarks for each audience. Topics of 

recent talks include: the importance of collection of 

race, ethnicity, and language (REaL) data; social determinants of health and demographics; and the impact of 

health equity work in New Hampshire.

The OHE had previously received a State Partnership 

Grant Program to Improve Minority Health (SPG) grant 

from the U.S. Office of Minority Health. It used this 

funding to develop a train-the-trainer initiative for 

community-connected organizations and consumer 

assistance entities designated by the New Hampshire 

Insurance Department. These trainers worked to 

increase awareness of health insurance options 

for underserved and minority populations. Relatedly, 

State and Territorial Efforts to Reduce Health Disparities 157
New Hampshire

the OHE also trained five access outreach workers 

to conduct culturally- and linguistically-appropriate 

information sessions about the Patient Protection and 

Affordable Care Act, and the health insurance marketplace for uninsured minority and other underserved 

populations.3 The SPG award also helped strengthen 

partnerships between the OHE and other agencies 

and organizations working to promoting health equity, 

including partially funding development of the Plan to 

Address Health Disparities and Promote Health Equity 

in New Hampshire.

Acronym List

Full Name of Agency Acronym Acronym

New Hampshire Department of Health and 

Human Services DHHS

Office of Health Equity OHE

From 2010 to 2015, the OHE received almost $12 

million in federal Administration for Children and Families Health Profession Opportunity Grant (HPOG) funds 

for its New Hampshire Health Profession Opportunity 

Project. HPOG’s objectives were to train Temporary 

Assistance for Needy Families and other low-income 

individuals in health occupations that pay well and are 

projected to be in high demand, as well as to offer 

advancement opportunities for those already engaged in 

health careers. Partners included the Division of Family 

Assistance (DFA), the Department of Labor (DOL) 

Apprenticeship Office, the Office of Workforce Opportunity/Workforce Investment Board (OWO/WIB), and 

multiple contractors, supporters, advisers, and stakeholders. After 5 years, NH’s HPOG outcomes include: 

1,311 participants enrolled; 1,051 enrolled in health 

care training; 845 participants completed health care 

training; 782 individuals employed; and 692 employed 

in health care. An additional objective was promoting 

workforce diversity; the OHE exceeded its target of 25 

percent minority enrollment with 28 percent of participants reflecting racial/ethnic diversity. 

Partnerships

Primary 

collaborators

• Behavioral Health Equity Workgroup

• Division of Public Health Services

• Brandeis Institute on Assets and 

Social Policy

• Foundation for Healthy 

Communities 

• Immigrant Integration Network

• New Hampshire Children’s 

Behavioral Health Collaborative

• New Hampshire Department of 

Education

• New Hampshire Department 

of Health and Human Services

• New Hampshire Endowment 

for Health

• New Hampshire Health and Equity 

Partnership

• New Hampshire Multicultural 

Student Affairs Consortium

• Southern New Hampshire Area 

Health Education Center

• Numerous ethnic community-based 

organizations

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding.

To further its mission of reducing health disparities, 

the OHE collaborates with many organizations and 

networks (e.g., Children’s Behavioral Health 

Collaborative, the New Hampshire Multicultural 

Student Affairs Consortium, and the Immigrant 

Integration Network). Within the state government, 

it partners with other programs within the DHHS and 

the Division of Public Health Services. For example, the 

OHE provides input and resources to state government 

efforts around health equity issues such as increasing 

minority populations’ access to services like home 

visits, breast and cervical cancer screenings, and 

maternal and child health care. The OHE also monitors 

meetings across the Division and provides input and 

resources related to health equity.

3 Information about New Hampshire’s State Partnership Grant is available on the U.S. Department of Health and Human Services, Office of 

Minority Health website. Last accessed 7/14/2017.

State and Territorial Efforts to Reduce Health Disparities 158
New Hampshire

One of its most high-profile collaborations is with 

the many partners involved in the public-private New 

Hampshire Health and Equity Partnership, as well 

as the host-agency, the Foundation for Healthy 

Communities. Comprised of advocates, communitybased organizations, public health agencies, and 

philanthropic organizations, the Partnership published 

in 2011 its Plan to Address Health Disparities and 

Promote Health Equity in New Hampshire.

4 Building on 

the recommended strategic areas outlined in the plan, 

the Partnership recently developed three priorities: 

implement culturally effective organizations, promote 

workforce diversity, and promote the collection and use 

of race, ethnicity, and language (REaL) data. 

As a result of the Health Profession Opportunity Project 

initiative, the OHE partnered with the ACF/HPOG-funded 

Brandeis Institute on Assets and Social Policy’s 

New Hampshire Employer Research Initiative. This 

collaboration significantly advanced the state’s 

understanding of employer perspectives, as well as 

strategies to promote workforce diversity.5 Multiple 

publications resulted, including the Culturally Effective 

Healthcare Organizations: A Framework for Success 

Issue Brief,

6 co-authored by the OHE director, and 

foundational to much of OHE’s work. 

The OHE works informally with the Southern New 

Hampshire Area Health Education Center (SNH AHEC), 

a community-based nongovernmental organization 

focused on underserved communities.7 Since 2001, 

this center has operated an interpretation training 

program accredited by the New Hampshire Department 

of Education; it also offers trainings on health care 

community interpretation, legal interpretation, medical 

interpretation, behavioral health interpretation, and 

infectious disease interpretation.8,9 The OHE and the 

SNH AHEC worked together to create interpretation 

trainings for behavioral health and infectious disease; 

they also partner on efforts to promote community 

health workers in the state. Additionally, the OHE 

director helped create the Equity Leaders Fellowship, 

which is administered by the SNH AHEC. By offering 

learning sessions on leadership development, 

one-on-one mentoring, and a board shadowing 

experience, this fellowship prepares individuals from 

communities of color to serve on nonprofit boards, join 

community committees, and participate in other civic 

engagement opportunities. Another informal OHE 

partner on many of its minority health activities is the 

New Hampshire Endowment for Health—a private, 

nonprofit foundation that operates statewide to “improve 

the health of New Hampshire’s people, especially those 

who are vulnerable and underserved.”10

As noted above, OHE staff also facilitate the Behavioral 

Health Equity Workgroup, a joint effort of the New 

Hampshire Health and Equity Partnership and the New 

Hampshire Children’s Behavioral Health Collaborative. 

Through this workgroup, the OHE provides technical 

assistance and coaching resources addressing cultural 

and linguistic competence and implementation of the 

National CLAS Standards. Relatedly, the OHE seeks 

to increase behavioral health equity awareness and 

understanding by facilitating discussions around many 

topics, including the collection of data on race, 

ethnicity, language, sexual orientation, gender identity 

information, and language access.

The OHE also informally partners with the New 

Hampshire Department of Education to implement 

the National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care 

(National CLAS Standards). In connection with grants 

that the department received recently from the 

Substance Abuse and Mental Health Services 

Administration, the OHE assists grantees in 

understanding and applying the National CLAS 

Standards. The OHE also helped the New Hampshire 

Department of Education develop a training video, 

Understanding and Practical Implementation of 

CLAS Standards.

11

4 Plan to Address Health Disparities and Promote Health Equity in New Hampshire. Available on the New Hampshire DHHS website. Last accessed 

7/14/2017.

5 More information is available at the Brandeis University Heller School’s website. Last accessed 7/14/2017.

6 Culturally Effective Healthcare Organizations: A Framework for Success.” Institute on Assets and Social Policy, Heller School for Social Policy 

and Management. Brandeis University, Waltham, MA. April 2015. Available on the Brandeis University Heller School website. Last accessed 

6/19/2018.

7 More information is available from the Southern New Hampshire Area Health Education Center website. Last accessed 7/14/2017.

8 Fifteen Years of Interpretation Training. Available at the Southern New Hampshire Area Health Education Center’s website. Last accessed 

7/14/2017.

9 The Trained Interpreters List is available at the Southern New Hampshire Area Health Education Center’s website. Last accessed 7/14/2017.

10 “About Endowment for Health.” Available at the Endowment for Health website. Last accessed 7/14/2017.

11 National Resource Center for Mental Health Promotion & Youth Violence Prevention. Understanding and Practical Implementation of CLAS 

Standards.

State and Territorial Efforts to Reduce Health Disparities 159
New Hampshire

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

 $5,243,233

Annual budget (FY 2015) of SMHE 

from state/territorial government $160,954

Largest funding source 

U.S. HHS 

Administration 

for Children and 

Families, Health 

Profession 

Opportunity Grants 

Initiative

Anticipated changes to budget HPOG funding ending

Supported with a mix of state and federal funding, 

the OHE had a FY 2015 budget of over $5 million. 

This includes a $132,826 through a SPG grant from 

the U.S. Office of Minority Health.12 The OHE did not 

receive SPG funding after FY 2015, nor does it anticipate budget changes in the next 2 years.

12 Information about New Hampshire’s State Partnership Grant is available on the U.S. Department of Health and Human Services, 

Office of Minority Health website. Last accessed 7/14/2017.

State and Territorial Efforts to Reduce Health Disparities 160
New Hampshire

New Hampshire State Data

Total Populationa: 

1,334,689

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 3.6 96.4 93.2 1.2 0.1 2.6 2.8 100.0 NA 

Percent of population 

medically uninsureda 8.8 6.3 6.3 20.3 1.5 6.9 4.6 6.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 3.9 4.1 SP SP SP NC 4.1 5.9

Age-adjusted 

mortality rateb 282.4 726.7 729.9 493.4 SP 386.5 NC 721.5 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 29.2 16.1 16.4 9.3 12.2 11.2 24.8 16.3 13.6

Percent with 

diabetesc 10.2 9.0 9.2 3.1 7.4 5.1 8.1 9.0 10.8

Percent with 

heart diseasec 3.0 4.2 4.2 4.3 8.0 0.6 4.3 4.2 4.3

HIV rated 485.0 NC 82.4 1089.5 0.0 38.6** 351.1 107.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

80.0 73.9 74.1 84.8 51.5 79.1 66.4 73.9 72.2

Percent received 

oral health visit 

(past 12 months)c

75.8 72.1 72.5 67.0 69.8 82.7 54.8 72.2 66.5

Percent received 

flu vaccinec 30.7 42.0 42.4 25.3 31.6 36.3 33.9 41.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 38.6 per 100,000 population (11 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 161
New Jersey 

Introduction to New Jersey’s Health Equity Activities

New Jersey had an estimated 2016 population of 8,945,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (20 percent), followed by Blacks/African Americans (13 percent), Asian Americans and NHOPI 

(10 percent), and American Indian/Alaska Native (less than 1 percent).1 Approximately 29,000 New Jersey 

residents live within a primary care health professional shortage area.2

In 1992, New Jersey established the Office of Minority and Multicultural Health (OMMH) in accordance with Public 

Law 1991, Chapter 401. Its mission is to “reduce and ultimately eliminate racial, ethnic health disparities by 

fostering equal access to programs that promote, support and enable all populations in New Jersey to achieve 

optimal health, dignity and independence.”3

New Jersey Minority Health Overview

Name of state/

territorial minority 

health entity

New Jersey Department of Health, 

Office of Minority and Multicultural 

Health

Strategic plan in 

place to address 

minority health 

or health equity

Healthy New Jersey 20204

Date strategic plan 

was last updated In process

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Performance measures are 

included in the Strategic Plan

Key strategies 

used to achieve 

health equity

• Community Health Disparity 

Prevention Program 

• Regional Health Equity Forums

• Community Outreach

• New Jersey Department of Health 

website

Organizational Structure

In 1992, legislation established the New Jersey OMMH 

as the sole office responsible for addressing minority 

health, health disparities, and health equity issues in 

the state. It resides within the New Jersey Department 

of Health, Division of Policy and Strategic Planning. 

The OMMH has five full-time employees dedicated to 

minority health and health disparity initiatives. The 

office’s executive director reports to the commissioner 

of the New Jersey Department of Health and is considered a part of its executive staff. Additional full-time 

staff includes two program specialists, one public 

health representative, and one executive secretary. 

The office does not use volunteers for its activities and 

initiatives, but often engages unpaid student interns. 

In 2014, the OMMH began a program with Rutgers 

University that matches a Master of Public Health 

student with an OMMH grantee in the community. The 

student receives practical, hands-on experience and 

helps the OMMH influence the public health workforce. 

The Office of the Commissioner maintains the OMMH 

Advisory Commission, composed of up to nine members representing community sectors such as health 

care facilities, health care professions, and the health 

insurance industry. The Governor, the Speaker of the 

General Assembly, or the President of the Senate may 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 New Jersey Department of Health Website. Last accessed 6/16/2016.

4 Healthy New Jersey 2020. State of New Jersey Department of Health Website. 2016. Last accessed 1/13/2018. 

State and Territorial Efforts to Reduce Health Disparities 162
New Jersey

appoint New Jersey residents to the advisory commission for a 3-year term. The commission meets on a 

quarterly basis to review and make recommendations 

on rules, regulations, and policies that the OMMH 

proposes. The Commission also advises the OMMH 

on grant awards, program and service development, 

and needs and priorities of minorities in New Jersey.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OMMH is housed within the 

New Jersey Department of Health, 

Division of Policy and Strategic 

Planning

SMHE staffing 

(full-time equivalents) 5

Advisory committee 

or panel OMMH Advisory Commission

Program Goals and Activities

New Jersey addresses strategies regarding minority 

health, health disparities, and health equity in Healthy 

New Jersey 2020, the State Health Improvement Plan. 

In that Plan, New Jersey identifies statewide health 

improvement priorities, increases public awareness and 

understanding of the determinants of health, provides 

measureable objectives and goals, engages multiple 

stakeholders to strengthen policies and improve 

practices, and identifies critical research, evaluation, 

and data collection needs. The Plan focuses on five 

of the state’s major public health concerns: access to 

primary care, birth outcomes, childhood immunization, 

heart disease, and obesity. The New Jersey OMMH is 

collaborating with other New Jersey Department of 

Health offices to update the plan for 2016–2020. 

Acronym List

Full Name of Agency Acronym Acronym

New Jersey Department of Health NJDOH

Office of Minority and Multicultural Health OMMH

The state is implementing many activities and initiatives to reduce health disparities and improve health 

equity. The OMMH runs the Community Health Disparity 

Prevention Program, a mini-grant program in which 

funded programs use evidence-based strategies or 

promising practices to reduce health disparities for a 

targeted population within the community. The grantees 

are required to provide activities to the community 

during National Minority Health Month. The OMMH 

provides funding to a wide variety of organizations, 

such as faith-based institutions, community organizations, local public health centers, federally qualified 

health centers (FQHCs), hospital-based programs, 

United Way organizations, and YMCAs. For example, 

the OMMH funded Faithful Families Eating Smart and 

Moving More, an obesity prevention program originally 

developed in North Carolina that promotes healthy 

eating and physical activity in faith-based communities. 

Community outreach and funding for community initiatives are essential strategies that the OMMH uses to 

address health disparities. The OMMH also sponsors 

regional health equity forums, free to the public, and 

usually held in April in conjunction with National Minority 

Health Month. Specifically, the OMMH sponsors three 

regional health equity forums—one in the northern, 

central, and southern regions of the state. At these 

forums, community partners present initiatives funded 

through the Community Health Disparity Prevention 

Program and discuss their progress (noting which 

performance metrics they have used), outcomes, 

barriers, strategies, and lessons learned. On average, 

each year, OMMH conducts six to eight forums that are 

open to the public.

The Cook/Rutledge Fellowship is one of the longestrunning community outreach endeavors of the OMMH. 

New Jersey students who are enrolled in a graduate 

school program in medicine, law, or public health can 

apply for 10-week summer fellowships that involve 

working on a joint OMMH/university project related to 

minority health and health disparities. Past fellowship 

projects have included implementing the National 

Standards for Culturally and Linguistically Appropriate 

Services (National CLAS Standards) in long-term-care 

facilities, identifying and assessing food deserts, and 

producing health data and information on minority 

populations. On average, two students receive fellowships each year; a $6,000 stipend is contingent upon 

availability of state funds.

Another key part of OMMH’s community outreach 

involves giving educational presentations at conferences 

or symposia about health disparities or related topics. 

The OMMH also sponsors its own summits or conferences. In December 2015, it hosted a forum for the 

Hepatitis B Coalition, a statewide coalition of community 

organizations and hospitals focused on health care in 

the Asian population. At the forum, coalition members 

and other interested individuals discussed programs 

in New Jersey that target the Asian population. 

State and Territorial Efforts to Reduce Health Disparities 163
New Jersey

To educate New Jersians about minority health and 

health disparities, the OMMH disseminates information 

via the New Jersey Department of Health website.5 The 

website includes a “Your Health” tab, enabling users to 

access information about multicultural health, including: 

cultural competency, minorities in health professions, 

and community outreach activities. Users can also view 

health assessment data about the state’s progress on 

leading health indicators in relation to race and ethnicity. 

Partnerships

Primary 

collaborators

• New Jersey local public health offices

• Federally qualified health centers 

(FQHCs)

• Rutgers University

• OMMH database of collaborators

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

OMMH partners with governmental and nongovernmental 

agencies and organizations. It maintains a strong 

relationship with New Jersey local public health offices 

to support minority health and promote activities to 

reduce health disparities. In 2011, it restructured the 

Community Health Disparity Prevention Program to 

include funding for local public health office programs. 

These programs provide funding to grantees that have 

a documented relationship with their local public health 

office (e.g., through a memorandum of understanding). 

Additionally, the OMMH maintains relationships 

with the New Jersey Primary Care Association, which 

represents 22 FQHCs and 129 satellite communitybased ambulatory health care facilities throughout New 

Jersey. The FQHCs are included in all of the office’s 

community outreach activities. FQHC staff, CEOs, and 

physicians also serve on OMMH’s advisory committees, 

groups, and in other initiatives.

Rutgers University is another major collaborator. The 

OMMH regularly taps into the University’s resources, 

such as the Rutgers’ Center for State Health Policy, 

which often conducts basic program evaluations and 

analyzes survey findings for the OMMH. Rutgers also 

offers many community-focused activities, including 

those through its Urban Center for Families; at the time 

of this writing, the OMMH was funding three Urban 

Center for Families’ programs. 

Another important collaboration between the OMMH 

and Rutgers involves the African-American Brain Health 

Initiative: A University-Community Partnership. Under 

this project, in August 2015, the OMMH and Rutgers 

University received a grant from the U.S. Office of 

Minority Health to implement interventions for older 

African Americans living in the low-income urban 

neighborhoods of greater Newark to reduce health 

disparities in mental health and physical activity. Together 

they have rolled out community programs to get more 

African Americans engaged in physical activity, healthy 

eating, and mental well-being.

In addition to the collaborators listed above, the OMMH 

maintains a database of over 1,000 contacts that it uses 

to disseminate information about minority health and 

health disparities at community events (e.g., health fairs 

and conferences). The database includes schools, 

hospitals, FQHCs, local public health centers, churches, 

charitable organizations, and other communitybased organizations.

Funding 

Annualized budget (FY 2014) of 

state/territorial minority health 

entity (SMHE) across all income 

sources

$1,500,000

Annual budget (FY 2014) of SMHE 

from State/territorial government State initiatives

Largest funding source State government

Anticipated changes to budget in 

FY 2015 No

The total FY 2014 funding for the New Jersey OMMH 

was $1,500,000. In 2014, the office was funded solely 

through the State of New Jersey; in FY 2015, OMMH 

also received grant funds from the U.S. Office of 

Minority Health.

5 See the New Jersey Department of Health Website. Last accessed 1/13/2018.

State and Territorial Efforts to Reduce Health Disparities 164
New Jersey

New Jersey State Data

Total Populationa: 

8,944,469

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 20.0 80.0 68.2 13.4 0.2 9.6 8.6 100.0 NA 

Percent of population 

medically uninsureda 19.6 5.0 6.4 9.2 18.6 6.7 18.6 7.9 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.6 4.7 3.7 9.5 SP 3.2 NC 4.7 5.9

Age-adjusted 

mortality rateb 455.0 694.1 680.1 789.2 140.8 311.9 NC 668.5 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 14.6 11.4 11.5 14.7 10.0 10.4 14.0 12.1 13.6

Percent with 

diabetesc 9.6 9.0 8.3 14.9 6.9 6.3 9.1 9.1 10.8

Percent with 

heart diseasec 3.8 4.0 4.0 4.2 2.2 2.4 4.4 3.9 4.3

HIV rated 723.6 NC 158.0 1674.2 103.0 44.0** 2665.6 473.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

79.3 79.7 79.0 86.7 64.9 72.0 84.8 79.4 72.2

Percent received 

oral health visit 

(past 12 months)c

65.3 76.5 77.4 67.9 59.3 74.4 69.2 74.8 66.5

Percent received 

flu vaccinec 34.0 40.7 40.9 36.9 38.6 38.5 34.3 39.5 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 44.0 per 100,000 population (310 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 372.1 per 

100,000 population (9 cases).

State and Territorial Efforts to Reduce Health Disparities 165
New Mexico 

Introduction to New Mexico’s Health Equity Activities

New Mexico had an estimated 2016 population of 2,081,000. Hispanics/Latinos are the largest racial-ethnic 

minority population (48 percent), followed by American Indians/Alaska Natives (9 percent), Blacks/African 

Americans (2 percent), and Asian Americans and NHOPI (1 percent). Persons self-identifying as multiracial 

or “other race” comprise 12 percent of the population.1 Approximately 1,048,000 New Mexico residents live 

within a primary care health professional shortage area.2

New Mexico established the Office of Health Equity (OHE) to address health disparities throughout New Mexico. Since 

racial and ethnic groups served by the OHE comprise a majority of the state’s population, the OHE tends to describe 

its goals and activities in terms of health equity and health disparities rather than minority health. The Health Equity 

Workgroup (HEWG), consisting of 19 members from all divisions within the Department of Health (DOH), advises the 

OHE on minority health, health equity, and health disparities. The HEWG has worked to support the National 

Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards). 

The objectives of the HEWG include ongoing assessment of DOH health equity initiatives, development and 

administration of the annual National CLAS Standards assessment, providing feedback for the annual health equity 

report, and identifying opportunities for collaboration on DOH health equity initiatives. Some of the OHE’s 

most important partnerships are with other groups and programs within the DOH and supported through the HEWG.

New Mexico Minority Health Overview

Name of state/territorial minority 

health entity Office of Health Equity

Strategic plan in place to address 

minority health or health equity

The DOH strategic plan emphasizes health equity, given that racial and ethnic minorities 

constitute a majority of the population. 

Date strategic plan was last 

updated 2018 

Assessment plan in place 

to measure progress toward 

reducing health disparities

 Yes, DOH uses a performance management system framework to measure progress.

Key strategies used to achieve 

health equity

• Providing medical interpreter training to staff, offering Public Health Spanish, and 

training staff department-wide on cultural competency

• Collecting, analyzing, and reporting data on disparities among racial and ethnic 

minorities and expanding focus to look more broadly at data related to determinants 

of health

• Developing a health literacy coalition with statewide stakeholders

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 166
New Mexico

Organizational Structure

The OHE is part of the Office of Policy and Accountability under the Administrative Services Division, which 

is one of eight DOH divisions. The director of the Office 

of Policy and Accountability reports directly to one of 

the Deputy Secretaries of the DOH. Along with the OHE, 

the Office for Border Health and the Office of the Tribal 

Liaison are part of the Office of Policy and Accountability, and these offices frequently collaborate. 

The OHE has three full-time staff, including the director, 

an education and outreach coordinator, and a translator. Another translator works half-time in the OHE. 

Student interns occasionally assist with OHE activities. 

Staffing allocations are not expected to change over 

the next 2 years.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of Health Equity 

is part of the Office of Policy 

and Accountability within the 

Administrative Services Division 

of the Department of Health. 

The director of the Office of 

Policy and Accountability reports 

to the Deputy Secretary of the 

Department of Health, who is an 

appointee of the governor. 

SMHE staffing 

(full-time equivalents) 3.5 

Advisory committee 

or panel Health Equity Workgroup

Program Goals and Activities

Acronym List

Full Name of Agency Acronym Acronym

Department of Health DOH

Health Equity Workgroup HEWG

Office of Health Equity OHE

The New Mexico DOH has a 3-year strategic plan 

(currently covering 2017–2019), which it updates 

annually. The plan focuses on health equity goals. 

Although the OHE is actively involved in developing this 

document, it does not have its own standalone strategic 

plan. The OHE publishes a health equity report that 

delivers timely and relevant information about the 

comparative health status of New Mexico’s populations 

by analyzing data from the Epidemiology and Response 

Division to identify disparities. While the OHE does not 

have a comprehensive plan to assess progress on its 

disparities reduction activities, its health equity report 

does demonstrate improvements. 

Some of the OHE’s strategies for reducing health 

disparities and achieving health equity include:

• Workforce training in a new Public Health Spanish 

course and Spanish Medical Terminology and 

Interpretation. 

• Building an awareness of a disease (cerebral 

cavernous angioma) which is caused by a genetic 

mutation traced to a family that settled in New 

Mexico in the early 1600’s and potentially could 

affect many Hispanic families.

• Participation on the New Mexico Office of African 

American Affairs’ New Mexico Birth Equity Collaborative strategically addressing that Black or African 

American women continue to have a higher percentage of LBW infants and the highest infant mortality rates (11.8 per 1,000 live births in 2013–2015)

• Supporting the Office of Primary Care and Rural 

Health in leading a team of diverse stakeholders 

to develop a current statewide rural health plan 

and assess rural healthcare workforce initiatives 

in New Mexico. 

Partnerships

Primary 

collaborators

• Healthy Kids, Healthy Communities 

participating organizations

• ONAPA

• Office of School and Adolescent 

Health

• Office of Primary Care and Rural 

Health

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented 

for some partnerships (e.g., for 

interpreter training on the Navajo 

Nation and health literacy projects).

The OHE does not have contracts or memoranda of 

understanding in place with most external partners. 

Contract activities are determined on an annual basis. 

However, it has held two formal, contractual 

partnerships: one with an individual who conducts 

annual medical terminology trainings for Navajo Nation 

interpreters, and a second supporting the creation 

of a health literacy coalition.

State and Territorial Efforts to Reduce Health Disparities 167
New Mexico

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$175,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $175,000

Largest funding source State government

Anticipated changes to budget None

The total FY 2015 funding for the OHE was approximately $175,000 to support staff positions. However, 

the OHE receives a portion of the funding allocated 

to the Office of Policy and Accountability from a 5-year 

Federal Preventive Health and Health Services Block 

Grant, in the amount of $214,853. That funding varies 

depending on planned activities for each year, and 

supports the OHE’s health literacy efforts, including the 

Navajo medical interpreter training, other health literacy 

contracts, National CLAS Standards training, and other 

related activities. Sources and amounts of funding 

may change in the future if the OHE is awarded additional grants.

State and Territorial Efforts to Reduce Health Disparities 168
New Mexico

New Mexico Data

Total Populationa: 

2,081,015

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 48.6 51.5 73.3 2.0 9.4 1.7 13.6 100.0 NA 

Percent of population 

medically uninsureda 10.8 7.9 7.8 9.1 20.8 3.9 10.3 9.3 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.4 5.6 4.7 SP 6.7 SP NC 5.1 5.9

Age-adjusted 

mortality rateb 727.7 766.8 743.4 672.5 887.6 428.3 NC 753.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 16.7 15.6 15.9 10.2 17.5 28.3 18.8 16.3 13.6

Percent with 

diabetesc 12.2 11.0 10.7 9.2 15.9 13.5 11.9 11.3 10.8

Percent with 

heart diseasec 3.5 4.3 4.4 0.6 2.7 1.6 4.5 4.1 4.3

HIV rated 193.3 NC 162.1 597.1 167.6 53.7** 434.0 186.5 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

64.9 63.4 64.7 65.3 61.0 64.0 59.6 64.0 72.2

Percent received 

oral health visit 

(past 12 months)c

61.7 64.7 64.5 68.8 56.3 69.1 59.6 63.5 66.5

Percent received 

flu vaccinec 38.4 42.0 40.7 37.0 44.6 42.4 35.0 40.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 53.7 per 100,000 population (14 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 87.6 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 169
New York 

Introduction to New York’s Health Equity Activities

New York had an estimated 2016 population of 19,746,000. Hispanics/Latinos (19 percent) are the largest 

racial-ethnic minority population, followed by Blacks/African Americans (16 percent), Asian Americans and NHOPI 

(9 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 12 percent of the population.1 Approximately 5,822,000 New York residents live within 

a primary care health professional shortage area.2

In 1992, legislation created the Office of Minority Health and Health Disparities Prevention (OMH-HDP) within the New 

York State Department of Health (NYSDOH).3 The OMH-HDP became operational in 1994. The NYSDOH’s mission is 

to “protect, improve and promote the health, productivity and well-being of all New Yorkers.”4

New York Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health and Health 

Disparities Prevention

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Minority Health and 

Health Disparities Prevention has 

a strategic plan that addresses 

minority health, health disparities, 

and health equity. The New York 

State Department of Health’s 

strategic plan also includes 

approaches to reducing health 

disparities. 

Date strategic plan 

was last updated 2016.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The New York State Department 

of Health has a department-wide 

performance plan with annual goals, 

objectives, and measures on a 

range of issues, including several 

that are related to minority health, 

health disparities, and health equity.

Key strategies 

used to achieve 

health equity

• Use data on racial and ethnic 

populations in program planning, 

implementation, and evaluation.

• Promote enhanced National 

Standards for Culturally and 

Linguistically Appropriate 

Services; work with partners to 

develop a curriculum for NYSDOH 

and state agency employees.

• Establish a community 

engagement model.

Organizational Structure

The 1992 legislative mandate creating the OMH-HDP 

also established the 14-member Minority Health 

Council, which serves as an advisory committee and 

provides recommendations to the NYSDOH Commissioner. The OMH-HDP provides administrative support 

to the Minority Health Council, such as coordinating 

meetings, taking minutes, and guiding recommendations and reports through the NYSDOH to the Commissioner. One OMH-HDP staff member acts as liaison 

between the NYSDOH and the Minority Health Council.

Included among the OMH-HDP’s six full-time dedicated 

staff members are the director, deputy director, state 

partnership director, First Nations health and wellness 

program director, director of administrative services, 

and an executive assistant. In addition, the National 

CLAS Standards coordinator is employed half time and 

a state partnership secretary devotes 75 percent time 

to the OMH-HDP. Minority Health Council members are 

volunteers. The OMH-HDP does not expect staff 

allocations to change.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 New York Public Health Law (Title 2F, § 240.2).

4 New York Department of Health (Revised May 2012). Mission, 

Vision, Values - New York State Department of Health. Available 

at the New York State DOH website. Last accessed 03/15/2017.

State and Territorial Efforts to Reduce Health Disparities 170
New York

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OMH-HDP is housed within 

the New York State Department 

of Health.

SMHE staffing 

(full-time equivalents) 8

Advisory committee 

or panel Minority Health Council

Program Goals and Activities

Updated annually, the OMH-HDP strategic plan 

addresses minority health, health disparities, and 

health equity. The NYSDOH’s strategic plan, publicly 

available on its website, includes approaches to reduce 

health disparities. The NYSDOH also has an annual 

performance plan that includes goals, objectives, and 

measures, with specific aspects related to minority 

health, health disparities, and health equity.

The OMH-HDP’s agenda is based both on its legislative 

mandate and the evolving priorities of the NYSDOH 

which, in part, are based upon the State Health Improvement Plan (i.e., Prevention Agenda for 2013–2018) and 

other initiatives. The OMH-HDP’s authorizing legislation 

directives include promoting, supporting, and conducting 

research; serving as a liaison to the New York State 

Minority Health Council; assisting medical schools and 

state agencies to develop comprehensive programs to 

increase health care workforce diversity; integrating and 

coordinating state health care grant and loan programs; 

promoting opportunities for strategic planning to improve 

health equity and health care services within minority 

health communities; and assessing the impact of 

programs, regulations, and policies on minority health 

services.5 Additionally, the OMH-HDP engages nongovernmental stakeholders, such as health care consumers 

and service providers, through a community engagement 

model for decision-making.

The OMH-HDP employs several strategies to address 

health equity. For example, it provides data on racial 

and ethnic populations for use in program planning, 

implementation, and evaluation. The OMH-HDP also 

works across all NYSDOH programs, state agencies, 

and community-based organizations to incorporate 

health disparities reduction initiatives and health equity 

advancement into programs, agendas, and policies. 

It also participates in several communities of practice 

(CoP), such as the NYSDOH’s health literacy CoP and 

its epidemiology and biostatistician CoP, to address 

issues related to minority health. Together with the 

NYSDOH and community partners, the OMH-HDP 

gathers and analyzes quantitative data, which it uses 

to conduct spatial analyses identifying concentrations of 

racial and ethnic minority populations (i.e., where those 

populations represent 40 percent or more of the population). These so-called Section 240 areas are geographic 

units smaller than counties or ZIP codes in which 

populations are at higher risk for health disparities. 

After identifying Section 240 areas, the OMH-HDP 

collects qualitative data in these areas through 

“listening sessions” of local residents. Using this 

community engagement model, the OMH-HDP uses 

these listening sessions both to engage individuals 

around such topics as women’s health, men’s health, 

prenatal care, homelessness, disability status, and 

LGBTQ status and to assess residents’ access to care. 

The OMH-HDP has expanded this community engagement 

model to Section 240 areas in Brooklyn, where it uses 

qualitative and quantitative data for each Section 240 

area to develop area-specific reports. In collaboration 

with the United Way, the OMH-HDP is conducting 

listening session in additional Section 240 areas. 

Moreover, the OMH-HDP is helping other offices in the 

NYSDOH expand use of this community engagement 

model, tailoring it to the needs and population of 

each office.

Acronym List

Full Name of Agency Acronym Acronym

New York State Department of Health NYSDOH

Office of Minority Health and Health 

Disparities Prevention OMH-HDP

Another key strategy that the OMH-HDP employs relates 

to the National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care (National 

CLAS Standards). For example, it reviews application 

and proposal requests to ensure that contractors 

promote and adhere to the National CLAS Standards. 

In doing so, and in partnership with the New York State 

Office of Public Health, the OMH-HDP is implementing 

an organizational cultural competency assessment of 

compliance with the National CLAS Standards, which 

helps extend the National CLAS Standards’ reach to 

all of New York’s health and human service agencies. 

5 New York Public Health Law (Title 2F, § 240.2).

State and Territorial Efforts to Reduce Health Disparities 171
New York

Partnerships

Primary 

collaborators

• New York State Office of Public 

Health 

• New York State Minority Health 

Council

• United Way

• Native American Community Services 

of Erie and Niagara Counties

• St. Regis Mohawk Tribe

• Arthur Ashe Institute for Urban 

Health

• Northwell Health

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The OMH-HDP works with the NYSDOH, state agencies, 

and community-based organizations to address a range 

of goals. For example, as part of its strategy to 

incorporate health disparities reduction initiatives 

and health equity advancement across programs, the 

OMH-HDP works with state agencies and communitybased organizations through an interagency task force 

to establish National CLAS Standards guidelines. 

The OMH-HDP also works interdepartmentally within 

the NYSDOH and the epidemiology and biostatisticians 

community of practice through an Affirmative Action 

Advisory Committee. This committee launched a health 

equity campaign, Unnatural Causes, which uses 

quantitative data to identify the root causes of health 

disparities and develop appropriate programming. 

The NYSDOH uses Unnatural Causes in its 

training activities.

As noted above, the OMH-HDP works within the New 

York State Office of Public Health to implement an 

organizational cultural competency assessment that 

evaluates compliance with the National CLAS 

Standards. At the time of data collection, a steering 

committee was developing recommendations for best 

practices, based on the findings of a pilot assessment, 

to be replicated across the NYSDOH. 

The New York State Office of Minority Health and 

Health Disparities Prevention completed the pilot, 

has relayed its findings to the NYS DOH participants 

involved in the pilot assessment, and the report 

of recommendations for replication is being drafted. 

In addition, a National CLAS Standards curriculum is 

in development and a compendium of resources and 

trainings has been drafted. These will be utilized 

towards a cultural competency training compendium 

for use by state agencies, state employees, and 

community partners who provide direct services.

For the aforementioned spatial analysis work to identify 

Section 240 areas, the OMH-HDP collaborates with the 

United Way through a formal contractual relationship. 

After engaging Brooklyn Section 240 areas to develop 

individualized area reports, the OMH-HDP teamed with 

the United Way to conduct listening sessions in other 

Section 240 areas. The United Way, which collects 

qualitative data and drafts reports on surveyed 

communities, will also help the OMH-HDP develop 

a tool kit to guide others in implementing the 

community engagement model.

Other partners work to address needs of particular 

racial and ethnic minority groups. For instance, the 

OMH-HDP has a formal contract with Native American 

Community Services of Erie and Niagara Counties 

to implement a First Nations Health and Wellness 

Initiative. The goal of this contract is to engage all 

First Nations across New York in setting priorities for 

community health outcomes. The OMH-HDP also has 

formally joined with the St. Regis Mohawk Tribe to 

establish a drop-in center that provides additional 

services to individuals who had received treatment 

in a detoxification program. Following a 1-year pilot 

project, based on community input and site visits, the 

OMH-HDP established a 5-year contract for the drop-in 

center to serve as a resource for the community.

The OMH-HDP also collaborates with the Arthur 

Ashe Institute for Urban Health to increase minority 

representation in medical and other health care 

professions by exposing young minority students to 

health sciences. Through the Mentorship in Medicine 

and Other Health Professions, the OMH-HDP has 

supported the expansion of the existing Health 

Sciences Academy (HSA) to include a Bridge Program 

that engages middle school students. The Bridge 

Program, which was piloted through this collaborative, 

is now an integral part of the HSA. 

Since 2016, OMH-HDP utilizes its Mentorship in 

Medicine and Other Health Professions initiative 

to expand the existing HSA coursework to include a 

college preparatory curriculum and other professional 

skill building (e.g., resume writing, interview skills) 

opportunities for students. 

New York State’s largest health care provider, Northwell 

Health, has an informal relationship with the OMH-HDP. 

When Northwell conducted a feasibility study to inform 

changes to its health care system structure, it worked 

State and Territorial Efforts to Reduce Health Disparities 172
New York

with the OMH-HDP to conduct hospital-based and 

community-based listening sessions with community 

partners, employers, health care consumers, and other 

stakeholders. The OMH-HDP also conducted surveys, 

town hall meetings, and caucuses that informed 

the study.

The state also benefits from federal assistance. 

For example, the U.S. Office of Minority Health awarded 

a State Partnership Initiative to Address Health 

Disparities (SPI) grant aimed at improving health 

insurance enrollment, access to care, and health 

outcomes in Newburgh. To support this initiative, the 

OMH-HPD will produce a health profile based on local 

socioeconomic, health status, and health care 

utilization data. The OMH-HDP also will design and 

implement a culturally and linguistically tailored, 

evidence-based intervention to encourage Newburgh 

residents to obtain health insurance coverage.

The OMH-HDP also has a contractual relationship with 

the State University of New York at Albany to support 

a student intern who performs work for the OMH-HDP 

and university faculty

Funding 

Annual budget (FY 2016–2017) 

of state/territorial minority health 

entity (SMHE) across all income 

sources

$779,200

Annual budget (FY 2016-2017) 

of SMHE from state/territorial 

government

$579,200

Largest funding source State government

Anticipated changes to budget Unknown

The total FY 2016–2017 funding for the OMH-HDP was 

$779,200. In FY 2016–2017, the OMH-HDP had two 

key sources of funding: the State of New York 

($579,200) and the U.S. Office of Minority Health 

(a $200,000 State Partnership Initiative to Address 

Health Disparities grant). The OMH-HDP provides 

resources to nongovernmental entities, including the 

State University of New York at Albany, the United Way, 

Native American Community Services of Erie and 

Niagara Counties, St. Regis Mohawk Tribe, and the 

Arthur Ashe Institute for Urban Health. The OMH-HDP 

does not expect funding to change in the next 2 years.

State and Territorial Efforts to Reduce Health Disparities 173
New York

New York Data

Total Populationa: 

19,746,289

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 19.0 81.0 63.5 15.7 0.4 8.5 12.0 100.0 NA 

Percent of population 

medically uninsureda 11.6 4.9 4.5 7.1 11.2 8.2 12.2 6.1 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.3 4.7 3.8 8.5 SP 3.3 NC 4.6 5.9

Age-adjusted 

mortality rateb 488.3 650.4 667.0 641.1 170.4 348.4 NC 640.7 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 14.9 13.6 13.9 15.4 13.0 10.2 22.8 13.9 13.6

Percent with 

diabetesc 11.6 10.0 9.0 13.7 10.7 10.8 15.8 10.2 10.8

Percent with 

heart diseasec 3.3 4.3 4.6 2.7 4.5 2.6 5.4 4.1 4.3

HIV rated 1731.1 NC 222.0 1908.8 122.1 110.5** 3576.5 768.8 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

74.4 75.8 73.3 82.1 75.5 79.9 74.6 75.5 72.2

Percent received 

oral health visit 

(past 12 months)c

61.6 71.1 71.4 65.1 61.8 71.9 66.8 70.1 66.5

Percent received 

flu vaccinec 35.7 40.8 41.0 35.2 31.6 45.6 33.5 40.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 110.5 per 100,000 population (1,584 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 224.8 

per 100,000 population (16 cases).

State and Territorial Efforts to Reduce Health Disparities 174
North Carolina 

Introduction to North Carolina’s Health Equity Activities

North Carolina had an estimated 2016 population of 10,147,000. Blacks/African Americans are the largest 

racial-ethnic minority population (22 percent), followed by Hispanics/Latinos (9 percent), Asian Americans and 

NHOPI (3 percent), and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or 

“other race” comprise 6 percent of the population.1 Approximately 1,903,000 North Carolina residents live within 

a primary care health professional shortage area.2

In 1992, the North Carolina General Assembly established the Office of Minority Health and the Minority Health 

Advisory Council with public law HB1340, Part 24, Sections 165-166.3 The mission of the office, whose name 

changed to the Office of Minority Health and Health Disparities (OMHHD) in 2001, is to “promote and advocate 

for the elimination of health disparities among all racial and ethnic minorities and other underserved populations 

in North Carolina.”4

North Carolina Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health and Health 

Disparities

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Minority Health and 

Health Disparities is updating an 

existing strategic plan. 

Date strategic plan 

was last updated 2012

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

There are plans to include 

measureable outcomes within 

the updated strategic plan. 

Key strategies 

used to achieve 

health equity

• Implementing the Minority 

Diabetes Prevention Program

• Organizing Health Equity “Lunch 

and Learn” events

• Promoting adoption and 

implementation of the National 

Standards for Culturally and 

Linguistically Appropriate 

Services in Health and Health 

Care (National CLAS Standards)

• Restructuring the Community 

Health Ambassadors Program

Organizational Structure

The OMHHD is located within the North Carolina 

Department of Health and Human Services (DHHS). 

Four full-time, salaried staff members work in the 

OMHHD, including the executive director, two program 

staff, and one administrative staff member. Additionally, 

the OMHHD regularly hires temporary employees. In 

March 2017, three part-time temporary employees and 

one full-time temporary employee, as well as two 

university student interns, were staffing the OMHHD. 

In 1992, the North Carolina General Assembly created 

the 15-member Minority Health Advisory Council with a 

mandate to serve racial and ethnic minority communities. Comprised of legislators, health care and human 

services professionals, and community leaders, its 

mission is to “promote and advocate for the elimination of health disparities among all racial/ethnic 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 General Assembly of North Carolina. Public Law HB 1340, Part 

24, Sections 165-166. 

4 North Carolina Health and Human Services, Office of Minority 

Health and Health Disparities. About Us. Available at the 

OMHHD’s website. Last accessed 5/8/17.

State and Territorial Efforts to Reduce Health Disparities 175
North Carolina

minorities and other underserved populations in North 

Carolina.” In addition to reviewing strategies, programs, 

laws, and regulations to ensure that health equity is 

adequately addressed, the Minority Health Advisory 

Council advises and makes policy recommendations 

to the governor and DHHS Secretary.5

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The Office of 

Minority Health and 

Health Disparities 

is located within 

the North Carolina 

Department of 

Health and Human 

Services

SMHE staffing (full-time equivalents) 4

Advisory committee or panel Minority Health 

Advisory Council

Program Goals and Activities

With input from the Minority Health Advisory Council, the 

OMHHD is working to revise an existing strategic plan 

that was last updated in 2011–2012. The plan, which 

serves as an internal resource document and is not 

publicly available, does not currently include efforts 

to monitor progress toward reducing health disparities. 

However, the OMHHD anticipates that it will incorporate 

explicit measureable outcomes and a strategy to assess 

disparity improvement into its forthcoming version.

Priorities set forth by public and private organizations 

(e.g., U.S. Office of Minority Health, Association of State 

and Territorial Health Officials, National Partnership for 

Action to End Health Disparities, Regional Health Equity 

Councils, the University of North Carolina at Chapel Hill, 

and the North Carolina American Indian Health Board) 

inform the selection of OMHHD priorities. The OMHHD 

Director co-chairs the Social Determinants of Health 

Committee of the Region 4 Health Equity Council, which 

provides the OMHHD an opportunity to align its efforts 

with regional and national priorities. 

The OMHHD is working to eliminate health disparities 

and achieve health equity through several strategies. 

The North Carolina Minority Diabetes Prevention 

Program, administered by the OMHHD in partnership 

with the Chronic Disease and Injury Section of the 

Division of Public Health, aims to increase participation 

in diabetes prevention programs among minority populations in North Carolina. Program components include 

outreach and marketing in minority communities, 

community prediabetes screenings, and lifestyle classes 

following Centers for Disease Control and Prevention 

curricula. The OMHHD has agreements with community 

partners and local health departments to implement 

program activities throughout most of the state. 

Education is another key OMHHD strategy to carry out 

its mission. Within the DHHS, the OMHHD leads Health 

Equity Lunch and Learn events—quarterly sessions that 

are open to the public and foster dialogue on health 

equity issues. These events feature invited speakers 

and may include other activities, such as viewing a 

relevant documentary film. Moreover, the OMHHD 

works with the DHHS Women, Infants and Children 

(WIC) Program and other DHHS groups to conduct health 

equity trainings. It also encourages staff to participate 

in trainings developed by the North Carolina-based 

Racial Equity Institute.

Other key activities of the OMHHD include promoting 

adoption and implementation of the National Standards 

for Culturally and Linguistically Appropriate Services in 

Health and Health Care (National CLAS Standards) and 

training community members to be health ambassadors 

in minority communities. To support efforts around 

disseminating and adopting the National CLAS Standards, OMHHD staff provide trainings to local health 

departments. The Community Health Ambassadors 

Program is an educational program in North Carolina 

that aligns with the state’s community health workers 

initiative. Its purpose is to train community members to 

be health ambassadors within minority and underserved 

communities. When the OMHHD initiated the program, 

it focused solely on diabetes, but the OMHHD has 

revamped the program to focus on health disparities 

more broadly. 

Acronym List

Full Name of Agency Acronym Acronym

Office of Minority Health and Health 

Disparities OMHHD

Department of Health and Human Services DHHS

5 North Carolina Health and Human Services, Office of Minority Health and Health Disparities. Minority Health Advisory Council (MHAC). 

Available on the OMHHD website. Last accessed 5/11/17.

State and Territorial Efforts to Reduce Health Disparities 176
North Carolina

Partnerships

Primary 

collaborators

• North Carolina DHHS

• Division of Public Health: Women 

and Children Health Section, 

Chronic Disease and Injury Section, 

Oral Health Section, Environmental 

Health Section, Epidemiology 

Section

• Local health departments

• North Carolina American Indian 

Health Board

• North Carolina Health Professions 

Diversity 

• North Carolina Colorectal Cancer 

Roundtable 

• American Heart Association 

Mid-Atlantic Affiliate

• North Carolina Oral Health 

Collaborative 

• Population Health Improvement 

Partners 

• 50 Hoops, African Americans 

in Clinical Trials 

• CareShare Health Alliance 

• Duke Raleigh Hospital 

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented 

for some partnerships.

The OMHHD works closely with the DHHS divisions and 

offices including the Division of Public Health and the 

North Carolina Office of Rural Health. For example, the 

Collaborative Improvement and Innovation Network, 

which aims to reduce infant mortality, is a key activity 

of the OMHHD partnership with the Division’s WIC 

Program. The OMHHD also teams with the Division’s 

Chronic Disease and Injury Section on initiatives, such 

as the Minority Diabetes Prevention Program, and is a 

partner in the Health Equity Learning Community. In 

addition, the OMHHD collaborates with the Division’s 

Cancer Prevention and Control Branch and the Tobacco 

Prevention and Control Branch on community outreach 

efforts and education around health equity. 

Through its partnership with the North Carolina 

American Indian Health Board, the OMHHD 

disseminates information on minority health issues 

that respond to the needs of the state’s American 

Indian population. As updated minority health data in 

North Carolina become available, the OMHHD and the 

American Indian Health Board collaborate to update 

minority health fact sheets, as well as the 2010 Racial 

and Ethnic Health Disparities in North Carolina Report 

Card, available on the DHHS website.

Funding 

Funding in FY 2015 included federal allocations 

through a State Partnership Initiative to Address Health 

Disparities (SPI) grant from the U.S. Office of Minority 

Health; however, that funding ceased in 2015. In 

FY 2015, the OMHHD provided funding to 12 organizations that were participating in the Community Focused 

Eliminating Health Disparities Initiative. Additionally, 

in FY 2015, the OMHHD was a sponsor of the North 

Carolina Health Professions Diversity Conference. 

The OMHHD anticipates changes to future funding, 

and plans to seek supplemental funding opportunities 

to support ongoing operations.

State and Territorial Efforts to Reduce Health Disparities 177
North Carolina

North Carolina State Data

Total Populationa: 

10,146,788

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 9.2 90.8 68.9 21.6 1.2 2.8 5.6 100.0 NA 

Percent of population 

medically uninsureda 28.9 8.6 9.2 11.2 20.4 10.2 22.0 10.5 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.7 7.8 5.8 11.6 SP 6.0 NC 7.4 5.9

Age-adjusted 

mortality rateb 341.4 795.0 763.6 886.8 749.0 378.3 NC 782.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 7.9 12.8 11.8 14.9 16.5 8.3 11.0 12.4 13.6

Percent with 

diabetesc 7.1 11.7 10.5 14.7 13.1 7.5 9.9 11.3 10.8

Percent with 

heart diseasec 2.6 5.0 5.4 3.8 4.2 0.6 1.5 4.7 4.3

HIV rated 360.4 NC 134.9 1045.7 188.8 67.2** 996.3 354.9 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

62.5 76.3 75.4 79.3 68.5 61.1 66.3 75.5 72.2

Percent received 

oral health visit 

(past 12 months)c

53.3 65.0 67.6 55.3 53.5 69.7 50.4 64.2 66.5

Percent received 

flu vaccinec 34.4 45.1 47.6 36.3 27.1 48.7 31.2 44.3 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 67.2 per 100,000 population (149 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 199.0 per 

100,000 population (10 cases).

State and Territorial Efforts to Reduce Health Disparities 178
North Dakota 

Introduction to North Dakota’s Health Equity Activities

North Dakota had an estimated 2016 population of 758,000. American Indians/Alaska Natives are the largest 

racial-ethnic minority population (6 percent), followed by Hispanics/Latinos (3 percent), Blacks/African Americans 

(3 percent), and Asian Americans and NHOPI (1 percent). Persons self-identifying as multiracial or “other race” 

comprise 4 percent of the population.1 Approximately 197,000 North Dakota residents live within a primary care 

health professional shortage area.2

Health equity activities in North Dakota are coordinated by the Office of Public Health Systems and Performance 

(OPHSP), which is housed within the North Dakota Department of Health (DOH) and reports to the state and deputy 

state health officer. In July 2016, oversight for special populations moved to the OPHSP from the former DOH Office 

of Special Populations. The OPHSP focuses on community health assessments, strategic plans, and quality 

improvement, and “works through collaboration and partnership to build capacity, improve performance and 

strengthen North Dakota’s public health system.”3 A statewide Health Equity Committee was established to guide 

the OPHSP on minority health, health disparities, and health equity efforts.

North Dakota Minority Health Overview

Name of state/

territorial minority 

health entity

The Office of Public Health Systems and Performance 

coordinates minority health activities.

Strategic plan in place 

to address minority 

health or health equity

No standalone plan for minority health; the State 

Health Improvement Plan addresses health 

disparities strategies. 

Date strategic plan 

was last updated N/A

Assessment plan 

in place to measure 

progress toward 

reducing health 

disparities

The Health Equity Committee is working to 

incorporate health disparities assessment data 

collection into the maternal and child health 

program’s 5-year needs assessment. 

Key strategies used to 

achieve health equity

• Chaplaincy program to address mental health 

shortages

• Social media outreach targeted to American Indians

• All-hazards tribal consultation 

• Assistance to individuals with HIV or other STDs 

• Suicide prevention efforts in the lesbian, gay, 

bisexual, transgender, and queer/questioning 

(LGBTQ+) population; the American Indian 

population; and the older adult population 

• Pregnancy Risk Assessment Monitoring System 

(PRAMS) to collect, analyze, and translate data 

from new mothers on health risk behaviors prior 

to, during, and immediately after pregnancy

Program Goals 

and Activities

Efforts to address health disparities 

are incorporated into strategic plans 

across the DOH. The State Health 

Improvement Plan includes measurable objectives to address health 

disparities in North Dakota. Several 

health issue-specific plans, such as 

the state plans for suicide, diabetes, 

maternal and child health, HIV and 

viral hepatitis, and cancer prevention, largely focus on health disparities and special populations. 

Additionally, the DOH Health Equity 

Committee has elected to adopt the 

1 American Community Survey Public Use 

Microdata, 2016.

2 Health Resources and Services 

Administration. 2018. Designated Health 

Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 

Designated HPSA Quarterly Summary.

3 Public Health Systems and Performance, 

North Dakota Department of Health. 

Available on the DOH website. Last 

accessed 5/24/2017.

State and Territorial Efforts to Reduce Health Disparities 179
North Dakota

National Stakeholder Strategy for Achieving Health 

Equity goals, established by the U.S. Office of Minority 

Health, and is also identifying strategies relevant to the 

DOH and its stakeholders. 

Acronym List

Full Name of Agency Acronym Acronym

North Dakota Department of Health DOH

Office of Public Health Systems and 

Performance OPHSP

North Dakota State University NDSU

The Health Equity Committee is currently conducting a 

strategic planning process that will inform it’s priorities. 

Initial work included categorizing and prioritizing health 

inequity factors. To strategize and prioritize going 

forward, the committee plans to create a health disparities profile; it also identified the need to coordinate 

efforts across the Department. 

With this need in mind, the OPHSP is committed to 

increasing statewide collaboration on health disparities 

issues. For example, it is working to coordinate health 

disparities assessment data collection with the maternal 

and child health grant program’s 5-year needs assessment. By broadening the initial needs assessment, the 

state will be able to identify health factors related to 

additional population health disparities. 

As American Indians are the largest minority population, the OPHSP works closely with the North Dakota 

Indian Affairs Commission and the newly established 

American Indian Public Health Resource Center in the 

North Dakota State University to identify tribal health 

priorities. The state includes four American Indian 

reservations, each containing several tribes, and the 

OPHSP targets this constituency through several 

efforts. For example, the OPSHP leads a community 

chaplaincy program that serves tribal areas with mental 

health shortages, and will be working to recruit and 

train community health representatives from the 

reservations in suicide prevention and in addressing 

other mental health issues. The trained chaplains are 

being integrated into the Critical Incident Stress 

Management volunteer referral system for deployment 

and improved utilization by community members and 

emergency responders. Specifically, volunteers conduct 

group debriefings after critical incidents or emergencies 

(e.g., shootings), and the community chaplains provide 

resources, such as individual risk assessments for 

those in need of mental health services. 

The OPHSP also led a tribal consultation session on 

hazardous event response with tribal leaders from all 

four reservations to develop consensus on how the 

DOH could best communicate with and respond to a 

hazardous event or crisis affecting tribal communities. 

The DOH’s Indian Health Board representative facilitated 

the session, which yielded strategies that have since 

been put into place—such as an Indian Affairs Commission effort to develop a customized memorandum of 

understanding with each individual tribe. 

Although minority health activities are largely coordinated by the OPHSP, other units within the DOH lead 

several specific minority health efforts. For example, the 

Tobacco Prevention and Control Program of the Division 

of Chronic Disease, the Division of Cancer Prevention 

and Control, the Division of Nutrition and Physical 

Activity, and the Division of Family Health conduct social 

media campaigns with culturally appropriate messaging 

targeted to the American Indian population. Additionally, 

the Division of Injury Prevention and Control works with 

health care systems to adopt a zero suicide policy, 

providing technical assistance and resources for suicide 

prevention education that target at-risk populations 

(i.e., lesbian, gay, bisexual, transgender, and queer/

questioning populations; American Indian communities; 

and older adults). 

The DOH Division of Disease Control strives to make 

populations across North Dakota aware of resources 

and services related to HIV and other sexually transmitted disease. The division works with local public 

health departments to increase availability and awareness of such services. The Ryan White Part B program 

supports core medical and support services to people 

at or below 400 percent of the federal poverty level who 

are living with HIV. Services include health insurance 

premium assistance, AIDS drug assistance, housing, 

and transportation, among others. 

Finally, the DOH Community Health Section facilitated 

“Health in All Policies” training to partners across North 

Dakota that addressed strategies for addressing health 

inequities across all health department work. 

State and Territorial Efforts to Reduce Health Disparities 180
North Dakota

Partnerships

Primary 

collaborators

• North Dakota Indian Affairs 

Commission

• Lutheran Social Services of North 

Dakota

• North Dakota State University’s 

American Indian Public Health 

Resource Center

• Local public health agencies

• North Dakota Medicaid

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

Governmental and nongovernmental organizations 

partner in various ways with the OPHSP to eliminate 

health disparities and advance health equity. Through 

an informal partnership, the North Dakota Indian Affair 

Commission’s Indian Health Systems Administrator 

advises the DOH and other agencies on tribal health 

issues. The administrator also serves on the DOH 

Health Equity Committee, representing the American 

Indian population of North Dakota. 

Lutheran Social Services of North Dakota, a nonprofit 

refugee resettlement organization, partners with the 

DOH through its formal contract with the state’s 

Department of Human Services. It also collaborates 

with the DOH to increase awareness and access 

to health services for HIV and other STDs. 

To increase access to health services, the OPHSP and 

the Maternal and Child Health Grant Program formally 

contracts with North Dakota State University, partnering 

with its newly established American Indian Public 

Health Resource Center. Together, they collaborate on 

such efforts as data collection, relationship building, 

and providing technical assistance to the tribes. The 

DOH looks to the center for expertise on culturally 

appropriate strategy implementation, best practices, 

and assistance in training health department staff. 

The contract specifies that the center will assist with 

assessment activities related to health inequities and 

health disparities. 

Several contracts are also in place with local public 

health government agencies, including those that 

provide direct patient care, to incorporate health 

disparity reduction goals into their work. The DOH 

is planning to identify population health metrics, 

including some measures of health equity, with these 

local agencies. 

Finally, it informally partners with North Dakota 

Medicaid to address health disparities in vulnerable 

and underserved populations across the state.

Organizational Structure

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OPHSP is housed within 

the North Dakota DOH 

SMHE staffing 

(full-time equivalents) 0.45

Advisory committee 

or panel

Healthy North Dakota Health 

Disparities Committee

After the director of the former DOH Special Populations Section retired in 2016, health equity work 

moved into the OPHSP, which primarily works on 

system development, collaboration, and coordination 

across the health department.

The OPHSP director dedicates about 15 percent of her 

time to coordinating internal minority health and health 

equity initiatives, facilitating the Health Disparities 

Committee, and reaching out to partners. Beyond this 

position, the DOH staff members of the Health Equity 

Committee each dedicates approximately 5 percent 

of time to minority health and health equity initiatives. 

A large portion of health equity efforts are contracted 

to North Dakota State University. The principal investigator on this contract spends about 30 percent time 

on DOH minority health and health equity activities. 

A university consultant and a student intern each 

spend 10 percent of their time on DOH-contracted 

health equity initiatives. 

At the time of data collection, staffing changes were 

being anticipated over the next 2 years, because 

the OPHSP only began reestablishing the program 

and contracting efforts to outside agencies in 2016.

State and Territorial Efforts to Reduce Health Disparities 181
North Dakota

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$80,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $80,000

Largest funding source State government

Anticipated changes to budget None

Total FY 2015 funding for DOH minority health activities 

was $80,000. In FY 2015, this supported the director 

of the former Special Populations Section. Funding has 

since been reallocated into contracts overseen by 

the OPHSP. 

The OPHSP provided funding to external partners, 

entities for health disparities, and health equity 

activities. The American Indian Public Health Resource 

Center receives funding to assist with tribal data 

collection and relationship building. North Dakota State 

University receives funding to assist the DOH on coordinating health equity activities. 

DOH will be hiring a position dedicated to addressing 

statewide health disparities being supported through 

various grant funds.

State and Territorial Efforts to Reduce Health Disparities 182
North Dakota

North Dakota State Data

Total Populationa: 

757,953

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 3.2 96.8 86.8 2.6 6.1 0.9 3.6 100.0 NA 

Percent of population 

medically uninsureda 27.1 7.5 5.9 27.4 29.2 1.2 12.4 8.1 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 7.3 5.9 SP SP SP NC 7.2 5.9

Age-adjusted 

mortality rateb 377.9 689.8 661.3 375.1 1440.7 429.0 NC 688.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 17.7 12.8 12.3 10.8 15.6 10.5 31.2 12.8 13.6

Percent with 

diabetesc 7.3 8.7 8.4 10.0 15.1 4.4 4.9 8.6 10.8

Percent with 

heart diseasec 7.2 4.1 4.0 3.8 5.2 0.0 8.9 4.1 4.3

HIV rated 109.6 NC 32.9 752.6 39.1 33.9** 153.6 53.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

49.2 62.7 63.1 63.8 61.1 57.9 46.7 62.6 72.2

Percent received 

oral health visit 

(past 12 months)c

42.4 66.9 68.6 51.8 42.5 45.7 55.1 66.5 66.5

Percent received 

flu vaccinec 32.5 42.2 42.0 46.7 44.5 51.7 32.2 42.1 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 33.9 per 100,000 population (3 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 183
Northern Mariana Islands 

Introduction to Northern Mariana Islands’ Health Equity Activities

The Northern Mariana Islands had an estimated 2010 population of 54,000. Asian/Pacific Islanders are 

the largest racial-ethnic minority population (85 percent). Persons self-identifying as multiracial or “other race” 

comprise 13 percent of the population.1

To improve the coordination of health care delivery, the governor signed in January 2009 the Commonwealth 

Healthcare Corporation (CHCC)—Public Law 16-51. As a public corporation, the CHCC serves as the 

Commonwealth of the Northern Mariana Islands (CNMI) hub for public health and health care services. The CHCC’s 

mission, “improving CNMI health and well-being through excellence and innovation in service,” is aligned with its 

vision, which is to “improve the quality of life for the CNMI community through its innovative preventive/urgent care 

services.”2 With most of the population belonging to a racial minority group, health equity activities are part of the 

CHCC’s routine operations.

Northern Mariana Islands Minority Health Overview

Name of state/

territorial minority 

health entity

Commonwealth Healthcare 

Corporation, Division of Public 

Health Services

Strategic plan in place 

to address minority 

health or health equity

The Commonwealth Healthcare 

Corporation Strategic Plan is 

updated periodically.

Date strategic plan 

was last updated 2014 

Assessment plan 

in place to measure 

progress toward 

reducing health 

disparities

No

Key strategies used to 

achieve health equity • Strengthening collaboration 

between public health and 

medical sectors

• Campaigning for Medicaid Equity

• Implementing sliding fee scale 

for medically uninsured

• Improving access to healthy food 

options

• Reinforcing smoke-free laws

Organizational Structure

Following Public Law 16-51, the CHCC formed in 

2009 as a public corporation with substantial 

autonomy within the territorial government. The 

CHCC has responsibility for a wide range of health 

care endeavors—from public health activities to 

clinic- and hospital-based care delivery. Its chief 

executive officer oversees daily operations of the 

CHCC and ensures compliance with government 

regulations. In January 2017, the governor signed 

into law measures that called for the creation of a 

governing board for the CHCC.3

Altogether, the CHCC has approximately 500 staff 

members, with most employees spending at least 

some portion of their workday addressing minority 

health or advancing health equity. Volunteers also 

support an array of CHCC activities and initiatives. 

Nursing students from the Northern Marianas 

College assist the CHCC with community outreach 

and health promotion activities.4 The Medical 

Reserve Corps, which is comprised of approximately 

165 volunteers (clinicians, public health professionals, and community members), supports the 

1 U.S. Census Bureau. 2010 Census Island Areas: 2010 Census Detailed Crosstabulations.

2 Commonwealth Healthcare Corporation (CHCC) Strategic Plan, 2015-2020. Available on the CHCC website. Last accessed 4/3/17.

3 Saipan Tribune. Board Gains Control of CHCC. (Jan 18, 2017). Available on the Saipan Tribune website. Last accessed 4/7/17.

4 Commonwealth of Northern Mariana Islands - Northern Marianas College. “Welcome to the Nursing Department.” Available on the Northern 

Marianas College website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 184
Northern Mariana Islands 

CHCC’s Public Health and Hospital Emergency 

Preparedness Program.5 These volunteers are trained 

to respond to public health and other emergencies 

in the CNMI.

Location of state/territorial minority 

health entity (SMHE) within state/

territorial government

The CHCC is 

largely independent 

from territorial 

government. 

SMHE staffing (full-time equivalents)

The CHCC has 

approximately 500 

employees, many of 

whom spend some 

time supporting 

population health 

initiatives. 

Advisory committee or panel

The CHCC board of 

trustees serves in 

a governing role to 

the CHCC.

Program Goals and Activities

The Commonwealth Healthcare Corporation Strategic 

Plan 2015-2020 (“CHCC Strategic Plan”) highlights six 

core strategies and related outcome goals for the years 

2015–2020. Eight operational strategies will support 

the CHCC in achieving the stated goals.6 An environmental scan; strengths, weaknesses, opportunities, 

and threats (SWOT) analysis; and an interim action 

plan helped inform the development of the draft CHCC 

Strategic Plan. The CHCC sought feedback from community members on the draft prior to finalizing the plan.7

The CHCC uses surveillance data to help identify health 

priorities. Its Health and Vital Statistics Office supports 

the CHCC in monitoring the health of the CNMI population. One of the office’s core responsibilities is to 

identify problem areas, such as infant mortality, teen 

pregnancy, and non-communicable diseases. Per legislation passed in 2016, the CHCC is working to establish 

a medical claims and clinical data warehouse to support monitoring and evaluation activities and improve 

care delivery.8

One major focus of the CHCC has been on strengthening 

the collaboration between the CHCC’s Division of Public 

Health Services, its Division of Hospital Services, and 

community clinics. Efforts have focused on sharing 

resources and personnel to expand reach and enhance 

quality of care. For example, the Division of Public Health 

Services recognized a need for public health dietetic 

services in the CNMI but lacked trained personnel, and 

therefore worked with the Division of Hospital Services 

to acquire the services of a hospital dietician.

Acronym List

Full Name of Agency Acronym Acronym

Commonwealth of the Northern Mariana 

Islands CNMI

Commonwealth Healthcare Corporation CHCC

Racial and Ethnic Approaches to Community Health 

(REACH), administered through the Centers for Disease 

Control and Prevention (CDC), is an initiative to reduce 

health disparities among racial and ethnic minority 

populations. The University of Hawaii receives CDC 

funding to support and implement REACH projects. 

Through a sub-award from the University of Hawaii, 

the CHCC’s Non-Communicable Disease Bureau of 

the Division of Public Health Services is working to 

implement REACH projects in the CNMI. The primary 

goals of the CNMI REACH projects are to increase 

access to smoke-free and tobacco-free environments, 

and increase access to healthy food options.9 To reach 

these goals, the Non-Communicable Disease Bureau is 

encouraging restaurants to offer healthy options10 and 

reinforcing the CNMI “Smoke-Free Air Act of 2008” with 

community education and outreach.11

5 Hospital and Public Health Preparedness Program. Available on the Commonwealth Healthcare Corporation website. Last accessed 

8/4/2017.

6 Commonwealth Healthcare Corporation (CHCC) Strategic Plan, 2015-2020. Available on the CHCC website. Last accessed 4/3/17.

7 Commonwealth Healthcare Corporation (CHCC) Strategic Plan, 2015-2020. Available on the CHCC website. Last accessed 4/3/17.

8 Saipan Tribune. Bill Establishing CHCC Claims, Clinical Data Warehouse Signed into Law (July 2016). Available on the Saipan Tribune 

website. Last accessed 8/4/2017.

9 CNMI R.E.A.C.H.: About R.E.A.C.H. (Racial and Ethnic Approaches to Community Health). Information about the R.E.A.C.H. program 

is available on both the REACHCNMI website and the CHCC Non-Communicable Disease Bureau’s website. Last accessed 8/4/2017.

10 CNMI R.E.A.C.H. (Racial and Ethnic Approaches to Community Health) - Health Restaurant Project. Information is available on both 

the REACHCNMI website and the CHCC Non-Communicable Disease Bureau’s website. Last accessed 8/4/2017.

11 CNMI R.E.A.C.H. (Racial and Ethnic Approaches to Community Health) – Smoke Free Air Act FAQ. Information is available on both 

the REACHCNMI website and the CHCC Non-Communicable Disease Bureau’s website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 185
Northern Mariana Islands 

Partnerships

Primary 

collaborators

• CNMI Public School System

• Commonwealth Cancer Association

• Commonwealth Diabetes Coalition

• Local churches

• CNMI Office of Homeland Security 

and Emergency Management

• CNMI Department of Fire and 

Emergency Medical Services 

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The CHCC partners with governmental and 

nongovernmental organizations to advance the 

health of the CNMI population. The CHCC works 

collaboratively with the CNMI Public School System 

to support data collection activities and public health 

community outreach activities. Students and staff from 

the CNMI Public School System work with the CHCC on 

various initiatives including teen pregnancy prevention 

and vaccination. The CHCC collaborates with the 

Commonwealth Cancer Association on cancer registry 

activities and provides trainings for their staff. Access 

to a certified diabetes educator is possible because 

of the partnership between the CHCC and the Hardt 

Eye Clinic and Diabetes Education Center. CHCC staff 

also work with local churches to disseminate diabetes 

education to church members.

The CNMI Office of Homeland Security and Emergency 

Management and the CNMI Department of Fire and 

Emergency Medical Services are also key partners for 

the CHCC. The CHCC shares resources and provides 

trainings with both entities to improve population 

health and access to care. Trainings focus on topics 

such as emergency response and infectious diseases. 

Moreover, a staff member from the CHCC serves as 

the medical director for the Department of Fire and 

Emergency Medical Services.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$56,793,610

Annual budget (FY 2015) of SMHE 

from state/territorial government

$2,000,000 for 

CHCC public health 

operations and 

activities

Largest funding source Federal government

Anticipated changes to budget Possible budget 

increase

Of the CHCC’s total FY 2015 budget, federal 

grants and programs were the primary source of 

funding (approximately $31,000,000) to support 

public health and health care service delivery. The 

remaining funding came from the organization’s 

revenue, CNMI government, and other local sources. 

During this time, the CHCC provided funding to youth 

agencies for tobacco prevention activities, and to the 

Commonwealth Cancer Association to support services 

for people and families affected by cancer, as well 

as cancer survivors. The CHCC anticipates possible 

budget increases during 2017–2019, in response to 

changes in the CNMI economy.

State and Territorial Efforts to Reduce Health Disparities 186
Northern Mariana Islands 

Northern Mariana Islands Territory Data

Total Populationa: 

53,883

Race Totals

Pacific Islander Asian

Multiracial OtherTerritory 

Total

National 

Chamorro Carolinian Total

Other 

PI Filipino Chinese Korean

Other 

Asian

Population 

Characteristics

Percent of state 

populationa 23.9 4.6 6.4 35.3 6.8 4.2 3.7 12.7 2.5 100.0 NA 

Percent of population 

medically uninsureda 11.5 17.2 27.0 48.3 64.4 61.9 48.0 17.0 20.1 33.7 16.3b

Health 

Disparities

Vital Statistics

Infant mortality ratec SP 5.9

Age-adjusted 

mortality rated 876.0 733.1

Prevalence of Selected Chronic Diseases

Asthmae NC 13.6

Diabetese NC 10.8

Heart Diseasee NC 4.3

HIVf 14.9 362.3

Preventive Services

Routine check-up 

(past 12 months)e NC 72.2

Oral health visit 

(past 12 months)e NC 66.5

Flu Vaccine Receivede NC 38.4

Note: This jurisdiction’s vital statistics, disease prevalence, and preventive services data are not available by race and ethnicity in the data sources 

compiled for this report.

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: U.S. Census Bureau. 2010 Census Island Areas: 2010 Census Detailed Crosstabulations.

b Source: U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2010.

c Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

d Source: CDC National Vital Statistics Reports, Deaths: Final Data for 2015.

e Source: Behavioral Risk Factor Surveillance System, 2016.

f Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015.

State and Territorial Efforts to Reduce Health Disparities 187
Ohio 

Introduction to Ohio’s Health Equity Activities

Ohio had an estimated 2016 population of 11,614,000. Blacks/African Americans are the largest racial-ethnic 

minority population (13 percent), followed by Hispanics/Latinos (4 percent), Asian Americans and NHOPI 

(2 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 4 percent of the population.1 Approximately 1,397,000 Ohio residents live within 

a primary care health professional shortage area.2

Health equity and access are highlighted as “core public health responsibilities” of the Ohio Department of Health 

(ODH).3 Within the ODH, the Office of Health Equity (OHE) is the primary entity responsible for addressing minority 

health, health disparities, and health equity. The OHE’s key function is to provide consultations to ODH programs 

to ensure that program activities address 

minority health and health disparities. 

In addition to the OHE, the Ohio Commission 

on Minority Health—an autonomous state 

agency outside of the ODH—focuses 

exclusively on minority health and health 

equity issues. Created in 1987 through 

Amended Substitute House Bill 171, the 

commission is “dedicated to eliminating 

disparities in minority health through 

innovative strategies and financial 

opportunities, public health promotion, 

legislative action, public policy and 

systems change.”4

Ohio Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in place 

to address minority 

health or health equity

The Ohio 2017-2019 State Health 

Improvement Plan has a strong focus on 

health equity; the Ohio Department of Health: 

Strategic Plan 2015-2016 also highlighted 

health equity as a core pillar of public health.

Date strategic plan 

was last updated

The Ohio 2017-2019 State Health 

Improvement Plan was last updated in 

February 2017; the Ohio Department of 

Health: Strategic Plan 2015-2016 was last 

updated in 2015. Strategic Plan will be 

updated in 2018. 

Assessment plan 

in place to measure 

progress toward 

reducing health 

disparities

Outcome objectives and a plan for 

evaluation are included in the Ohio 

2017-2019 State Health Improvement Plan.

Key strategies used to 

achieve health equity

• Identifying strategies in the State Health 

Improvement Plan likely to reduce 

disparities 

• Implementing a comprehensive health 

equity policy

• Identifying local social determinants 

of health through market research 

and geographic information system 

technology

• Providing cultural competency trainings

• Supporting initiatives to reduce disparities 

in infant mortality and poor birth outcomes

1 American Community Survey Public Use Microdata, 

2016.

2 Health Resources and Services Administration. 

2018. Designated Health Professional Shortage 

Areas Statistics: First Quarter of Fiscal Year 2018 

Designated HPSA Quarterly Summary.

3 Ohio Department of Health’s 2015 Strategic Plan. 

Available on the ODH website. Last accessed 

8/4/17.

4 “The Mission and Vision of the Ohio Commission 

on Minority Health.” Available on the Ohio 

Commission on Minority Health’s website. 

Last accessed 8/4/17.

State and Territorial Efforts to Reduce Health Disparities 188
Ohio

Organizational Structure

The OHE is housed within the Office of Health Policy 

and Performance Improvement of the ODH. In addition 

to its two state-supported full-time staff members (the 

director and assistant director of health equity), an 

Ohio State University grant supports a third full-time 

employee. The grant-funded staff member, a disabilities 

specialist, works with ODH programs to create strategies addressing health disparities among persons with 

disabilities. Other ODH staff who support health equity 

initiatives include the director of the Office of Health 

Policy and Improvement. Several staff from the the 

ODH’s Bureau of Maternal and Child Health and Bureau 

of Health Promotion also work to eliminate health 

disparities through initiatives led by the Ohio Equity 

Institute and Creating Healthy Communities. The Ohio 

Commission on Minority Health also has several staff 

members devoted to reducing health disparities and 

achieving health equity.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of Health Equity is 

housed under the Office of 

Health Policy and Performance 

Improvement of the Ohio 

Department of Health

SMHE staffing 

(full-time equivalents) 3

Advisory committee 

or panel None

Program Goals and Activities

The Ohio Department of Health: Strategic Plan 2015-

2016 outlines four goals and objectives: (i.e., aligning 

all ODH systems to fully support national and state 

priorities, ensuring effective decision-making processes, 

improving data infrastructure and usage, and workforce 

development). In 2016, the ODH conducted a state 

health assessment to better understand overall health 

of the state’s population, which it used to inform priority 

issues for a statewide health improvement strategy. 

Together with a broad range of stakeholders that 

comprised a SHIP advisory committee, the ODH used 

the assessment results to develop the 2017-2019 Ohio 

State Health Improvement Plan (SHIP). Specifically, the 

2017-2019 Ohio SHIP highlights three priority topics: 

mental health and addiction, chronic disease, and 

maternal and child health. For each, the advisory 

committee identified those populations experiencing 

the greatest disparities. In addition to targeted outcome 

indicators for tracking progress toward reaching state 

goals, each of the three priority topics have associated 

action plans that describe outcomes and target goals in 

more detail. The Office of Health Policy and Performance 

Improvement, which includes the OHE, is responsible for 

monitoring outcomes for each priority area and population. The OHE’s role in the SHIP development process 

was to ensure that the plan addressed minority health 

and included strategies to reduce health disparities. 

As a result, the 2017-2019 SHIP identifies crosscutting 

factors influencing health outcomes. Compared with its 

predecessors, this SHIP also represents an increased 

focus on health equity and social determinants 

of health.

Acronym List

Full Name of Agency Acronym Acronym

Ohio Department of Health ODH

Office of Health Equity OHE

Strategies included in the 2017-2019 SHIP are intended 

to guide the direction of programs across the ODH, and 

the OHE consults with individual ODH programs to 

ensure that those programs adequately address needs 

of priority populations. The OHE provides health equity 

consultations for ODH solicitations and responses 

to external funding announcements.

Other OHE-led activities include the use of market 

research data and geographic information system (GIS) 

technology to identify local social determinants of 

health. The OHE maintains licensure to gather market 

research and GIS data, and educates ODH program 

staff and subgrant awardees on using this data in their 

decision-making processes. For example, using GIS 

data, the OHE worked with an Ohio community to identify 

neighborhoods for targeted prevention efforts. In 

addition, OHE staff provide cultural competency trainings 

to staff across the ODH. The OHE also is planning a 

cultural competency assessment with all ODH offices 

and bureaus and will use its results to help develop 

individualized action plans to ensure ODH-wide compliance with the National Standards for Culturally and 

Linguistically Appropriate Services in Health and Health 

Care (National CLAS Standards). 

In response to higher-than-average infant mortality rates, 

Ohio allocates resources to eliminating disparities and 

reducing infant mortality rates. The Ohio legislature in 

2016 passed Senate Bill 332, which calls for specific 

State and Territorial Efforts to Reduce Health Disparities 189
Ohio

strategies (e.g., improved data collection) to eliminate 

disparities in infant mortality and poor birth outcomes. 

Additionally, through the ODH’s Bureau of Maternal and 

Child Health’s Ohio Institute for Equity in Health Outcomes program (also known as the Ohio Equity Institute), nine Ohio communities with high rates of infant 

mortality are partnering with the ODH to improve birth 

outcomes, particularly among African American women. 

Partnerships

Primary 

collaborators

• Ohio Commission on Minority Health

• Ohio Statewide Health Disparities 

Collaborative

• Ohio Collaborative to Prevent Infant 

Mortality

• Ohio State University, Kirwan 

Institute for the Study of Race 

and Ethnicity

• Local health departments 

and hospitals

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented for 

some partnerships (e.g., those the 

Kirwan Institute for the Study of Race 

and Ethnicity).

The OHE partners with several governmental and 

nongovernmental organizations to advance health 

equity in Ohio. For example, an OHE staff member 

serves on the Ohio Commission on Minority Health’s 

advisory board. The Commission, whose focus areas 

include infant mortality, cancer, diabetes, 

cardiovascular disease, substance abuse, violence, 

and lupus, supports Ohio Equity Institute initiatives 

aimed at reducing disparities in infant mortality through 

funding of local activities. 

Statewide coalitions also partner with the OHE to 

eliminate health disparities in Ohio. An OHE staff 

member is part of the Ohio Statewide Health 

Disparities Collaborative, which is working to improve 

race and ethnicity data collection. Another statewide 

coalition, the Ohio Collaborative to Prevent Infant 

Mortality, partners with the OHE to improve minority 

health and eliminate infant mortality disparities. 

Ohio State University’s Kirwan Institute for the Study of 

Race and Ethnicity collaborates with the OHE on health 

disparity mapping efforts. An OHE staff member works 

with the Kirwan Institute to develop heat maps that 

illustrate areas with large health disparities. Together, 

the OHE and the Kirwan Institute lead presentations 

about how to use health disparity data maps to make 

informed public health decisions. As noted above, an 

Ohio State University-funded staff member works full 

time in the OHE on issues related to persons with 

disabilities. A memorandum of understanding between 

Ohio State University and the ODH supports this 

work arrangement. 

Local health departments and hospitals are key 

partners for the ODH as it pursues SHIP priorities. 

The ODH has asked local health departments and 

hospitals to implement at least one strategy for two 

of the three priority topics in the 2017-2019 SHIP.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$870,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $0

Largest funding source Federal Block Grant

Anticipated changes to budget

The ODH has 

requested additional 

state funding for 

infant mortality work. 

In the 2017–18 

budget, the budget 

request was $4 

million to support 

Ohio Equity Institute 

health equity project. 

The FY 2017 budget for the Ohio Equity Institute was 

$2,499,870 from the State of Ohio. In Creating Healthy 

Communities and other grant programs, the ODH 

provides resources to local communities and health 

departments to address priority topics and populations 

within particular communities. The Ohio Commission 

on Minority Health also provides resources to local 

organizations to implement strategies addressing 

the commission’s focus areas.

State and Territorial Efforts to Reduce Health Disparities 190
Ohio

Ohio State Data

Total Populationa: 

11,614,373

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 3.6 96.4 81.6 12.5 0.2 2.0 3.7 100.0 NA 

Percent of population 

medically uninsureda 15.1 5.6 5.5 7.7 13.9 4.4 9.1 5.9 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 6.1 7.2 5.8 14.0 SP SP NC 7.2 5.9

Age-adjusted 

mortality rateb 448.4 838.4 824.0 952.8 293.1 393.7 NC 832.3 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 26.3 13.6 13.3 17.0 35.5 6.3 24.2 14.0 13.6

Percent with 

diabetesc 12.2 11.1 10.9 12.6 18.4 3.2 13.7 11.1 10.8

Percent with 

heart diseasec 1.6 5.0 5.2 3.3 13.7 0.6 2.3 4.9 4.3

HIV rated 422.0 NC 118.0 783.1 88.4 46.9** 584.1 212.5 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

76.6 75.5 75.1 78.7 89.3 67.2 75.8 75.5 72.2

Percent received 

oral health visit 

(past 12 months)c

65.6 68.3 69.1 63.3 66.9 71.2 68.0 68.4 66.5

Percent received 

flu vaccinec 32.7 38.9 39.0 36.5 33.1 44.9 34.0 38.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 46.9 per 100,000 population (94 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 61.7 per 

100,000 population (2 cases).

State and Territorial Efforts to Reduce Health Disparities 191
Oklahoma 

Special Note: The information in this profile is from FY 2014 and does not reflect the Oklahoma State Department 

of Health’s (OSDH) current organizational structure or health equity strategies. On October 30, 2017, then Commissioner of Health and Senior Deputy Commissioner officially submitted their resignation to the Board of Health 

(BOH) effective immediately. Since that time, many additional separations among all levels of the organization have 

occurred. The Governor approved a critical infusion of state funds in the amount of $30 million to help stabilize 

the immediate financial situation; however, it did not solve all the issues facing the agency for the long term. The 

agency continues to perform a hard reset focusing solely on its core mission of public health in the most efficient 

and effective manner. Many additional actions have been and are being taken to shore up business operations and 

ensure the continuity and fiscal soundness of the OSDH. These initial actions include a reduction in force of nearly 

200 employees; a reorganization of the agency’s leadership; and plans for the development of a new financial 

reporting system. The OSDH continues to work to implement business processes and efficiencies to meet core 

public health services and to improve financial controls.

Introduction to Oklahoma’s Health Equity Activities

Oklahoma had an estimated 2016 population of 3,924,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (10 percent), followed by American Indians/Alaska Natives (8 percent), Blacks/African Americans 

(7 percent), and Asian Americans and NHOPI (2 percent). Persons self-identifying as multiracial or “other race” 

comprise 11 percent of the population.1 Notably, Oklahoma is home to 38 federally recognized tribal nations.2

Approximately 1,312,000 Oklahoma residents live within a primary care health professional shortage area.3

Oklahoma Minority Health Overview

Name of state/territorial minority 

health entity Oklahoma State Department of Health, Office of Minority Health

Strategic plan in place to address 

minority health or health equity

A strategic plan specifically to address minority health or health equity is not available. 

However, minority health and health equity are a part of the State Health Improvement 

Plan.

Date strategic plan was last updated 2015

Assessment plan in place to 

measure progress toward reducing 

health disparities

In development

Key strategies used to achieve 

health equity

• A Healthy Baby Begins with You baby showers

• Body and Soul physical fitness and nutrition program

• Community health chats

• Interpretation/translation services for populations with limited English proficiency

• Minority Health at a Glance

1 American Community Survey Public Use Microdata, 2016.

2 Office of the Tribal Liaison Website. 2016. Available on the Oklahoma Department of Health website. Last accessed 6/16/2016.

3 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 192
Oklahoma

In 1994, the Oklahoma Office of Minority Health (OOMH) was created by the Oklahoma State Board of Health, the 

body that governs the Oklahoma State Department of Health (OSDH).4 The OOMH’s mission is to “lead Oklahoma 

in improving the health status of Oklahoma’s minority and underserved populations by partnering, developing 

policies and implementing strategies to reduce and ultimately eliminate health disparities.”5

Organizational Structure

The Oklahoma Partnerships for Health Improvement, 

formerly the Community Development Service within 

the OSDH, consists of the following divisions: Health 

Equity and Resource Opportunities (HERO), Health 

Promotion, Office of Minority Health, Office of Performance Management, and Office of Tribal Liaison.6

It also houses “Turning Point,” a conglomeration of 

73 community partnerships working to “enhance the 

health status of Oklahomans.”7 The OOMH was established as the sole office responsible for addressing 

minority health issues in the State. Its central focus 

is to eliminate health disparities within the state. 

OOMH’s sister divisions, the Office of the Tribal Liaison 

and HERO, are dedicated to addressing health equity 

and social determinants of health in Oklahoma. Due 

to the nature of minority health issues, there is considerable collaboration between the OOMH and these two 

other Partnership divisions.

Advising the OOMH is the Health Disparities Advisory 

Coalition, a working group comprised of individuals 

from a broad range of professional backgrounds and 

racial/ethnic groups. Coalition members represent, 

for example, the Clinton and Lawton Indian Hospital, 

the Latino Community Development Agency, health 

care professionals, and other community members. 

The Coalition disseminates health disparity information 

to the community, provides information about the 

status of minority health to the state, and advises 

on state efforts to ensure an adequate focus on 

disparity elimination.

Acronym List

Full Name of Agency Acronym Acronym

Oklahoma State Department of Health OSDH

Oklahoma Office of Minority Health OOMH

Oklahoma Health Equity Campaign OHEC

Health Equity and Resource Opportunities HERO

OOMH’s team of six full-time individuals who dedicate 

all efforts to minority health and health disparities 

elimination initiatives includes the OOMH director, 

a project coordinator, an outreach coordinator, two 

interpreters/translators, and an administrative assistant. The team also works closely with a full-time 

evaluator from the Community Epidemiology Department, who spends one-third of her time assisting the 

OOMH’s minority health and health disparity work. This 

staffing allocation is not anticipated to change in the 

near future. Unpaid community volunteers help to 

implement OOMH projects and activities, especially the 

A Healthy Baby Begins with You baby showers. These 

volunteers are often college interns from the public 

health programs at Oklahoma University and the 

University of Central Oklahoma. In several instances, 

student interns have become full-time paid employees 

of the OSDH.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of Minority Health is 

housed within the Partnerships 

for Health Improvement 

division of the Oklahoma State 

Department of Health

SMHE staffing 

(full-time equivalents) 6

Advisory committee 

or panel Health Disparities Coalition

4 Oklahoma State Board of Health Website. 2016. Available on the Oklahoma Department of Health website. Last accessed 12/21/2017.

5 Oklahoma Office of Minority Health Website. 2016. Available on the Oklahoma Department of Health website. Last accessed 6/16/2016.

6 Partnerships for Health Improvement Website. 2016. Available on the Oklahoma Department of Health website. Last accessed 6/16/2016.

7 “Turning Point” grew out of a pilot effort originally funded by the Robert Wood Johnson and W.K. Kellogg Foundations in 1998. See the 

Oklahoma Turning Point Initiative Website. 2016. Available on the Oklahoma Department of Health website. Last accessed 6/16/2016.

State and Territorial Efforts to Reduce Health Disparities 193
Oklahoma

Program Goals and Activities

The OOMH is developing a strategic plan to address 

minority health and health equity. It is guided in this 

effort by Oklahoma’s Health Improvement Plan. Health 

disparities play a key part in the plan by focusing efforts 

on four priority issues: tobacco use, obesity, child health, 

and behavioral health. For each of these topics, OOMH 

will develop strategic plans for reducing health disparities. The strategic plan will include an assessment plan 

to measure progress. 

Oklahoma is implementing many activities and initiatives to reduce health disparities and improve health 

equity. The A Healthy Baby Begins with You program 

is a statewide initiative led by the OOMH in conjunction 

with the OSDH, Maternal and Child Health Division, as 

well as local community partners. Together, these state 

agencies host community baby showers to increase 

knowledge and educate minority communities about 

infant mortality and low birthweight. Physicians attend 

and speak with parents, grandparents, and foster 

parents about taking care of themselves and the baby 

before and after pregnancy. Vendors and health care 

providers help participants find resources and link 

them to programs. After the shower, the OOMH conducts follow-up calls with attendees to see if they have 

used the information and resources. Approximately 10 

to 20 community showers are conducted throughout 

Oklahoma each year.

Another initiative led by the OOMH is the Body and 

Soul intervention program, which encourages physical 

fitness and proper nutrition among African American 

church members. The office contracts with four African 

American faith-based institutions and provides technical assistance to implement the program. The intervention lasts between 6 to 12 weeks and is available 

to congregation members and others in the community.

To learn about the health care needs of racial and ethnic 

minority communities and devise strategies to reduce 

health disparities, the OOMH engages the minority 

community in a series of “community health chats” 

each year. It picks chat topics based on the targeted 

community’s health needs. Along with a health care 

professional, the OOMH provides information about the 

signs and symptoms of targeted health condition, as 

well as what community members can do to prevent or 

treat it. Information from the chats helped state officials 

develop the State Health Improvement Plan. Additional 

community health chats, focus groups, and key informant interviews related to health disparities and 

minority health are planned for 2016 to assist in 

building the OOMH’s strategic plan.

To help improve health equity, the OOMH provides 

interpretation and translation services for populations 

with limited English proficiency. Two interpreters and 

translators on staff provide language assistance 

services to anyone within the office. These services 

include over the phone and in-person translation/

interpreter services as well as translation of OSDH 

documents. The office also conducts interpretation/

translation classes to ensure consistency in the 

quality of such services within the state and county 

health departments.

Finally, to educate Oklahomans about minority health 

and health disparities, the OOMH publishes a Minority 

Health at a Glance report. The report presents statistical data on major health concerns within minority 

populations in Oklahoma, and is updated annually 

with new data. 

Partnerships

Primary 

collaborators

• Langston University

• Clinton and Lawton Indian Hospital

• Latino Community Development 

Agency

• Oklahoma Health Care Authority

• Community Health Centers, Inc

Contracts or 

memoranda of 

understanding 

with any partners

Yes, memoranda of understanding 

are implemented for some 

partnerships.

The OOMH partners with governmental and nongovernmental agencies and organizations to eliminate health 

disparities and advance health equity within the state. 

A primary collaborator is Langston University, a historically black college with whom the OOMH develops 

initiatives that target the state’s African American 

communities. Additionally, many events are held on the 

University’s campus, including A Healthy Baby Begins 

with You baby showers. The OOMH also provides data 

from its Minority Health at a Glance report to the University to assist in grant-writing efforts.

Another major collaborator, the Clinton and Lawton 

Indian Hospital, connects the OOMH with Oklahoma’s 

American Indian communities. The hospital and OOMH 

work together to bring the OOMH-sponsored baby 

showers to the American Indian population. As part 

State and Territorial Efforts to Reduce Health Disparities 194
Oklahoma

of the OOMH’s Health Disparities Advisory Coalition, 

the hospital provides feedback on the office’s 

strategies and components of the Oklahoma Health 

Improvement Plan to ensure that they address the 

American Indian population’s health care needs.

The relationship with the American Indian community 

extends beyond the OOMH through the Office of the 

Tribal Liaison in the Partnerships in Health 

Improvement division of the OSDH. This office “seeks 

to demonstrate a respect for sovereignty and advocate 

for tribal nations while fostering inclusive partnerships 

using sound public health practices to achieve its 

vision – ‘Achieving Tribal-State Synergy for Optimal 

Holistic Health’ for all Oklahomans.”8 The Office of 

the Tribal Liaison’s work focuses mainly on building 

government-to-government relationships, but several 

of its activities incorporate components of minority 

health and health disparities, and thus overlap with the 

activities of the OOMH. During the development of the 

State Health Improvement Plan, the Office of the Tribal 

Liaison and the OOMH conducted community chats 

with tribes as a formal consultation regarding health 

issues, health disparities, and the health needs of the 

American Indian population. It has also collaborated 

with the tribes in distributing flu vaccinations, 

disseminating health information, and conducting 

safety inspections.

The OOMH also has an ongoing partnership with the 

Latino Community Development Agency, which assists 

in disseminating information about the office’s 

programs, such as the community health chats. 

The agency also provides representation for Latino 

community on the OOMH’s Health Disparities 

Advisory Coalition.

Funding 

Annualized budget (FY 2014) of 

state/territorial minority health 

entity (SMHE) across all income 

sources

$670,000

Annual budget (FY 2014) of SMHE 

from state/territorial government

Approximately 68% 

of Office of Minority 

Health funding 

comes from state 

initiatives

Largest funding source State government

Anticipated changes to budget in 

FY 2015 Yes

The total FY 2014 funding for the OOMH was 

$670,000. Its largest funding source was the State of 

Oklahoma, which allocated $316,075 to its operations. 

The OOMH also received a $150,000 State Partnership Grant from the U.S. Office of Minority Health. In 

addition to funding efforts relating to minority health, 

the State of Oklahoma allocated $203,437 to the 

OOMH. Since the two offices have overlapping work 

related to minority health, health disparities, and health 

equity, funding for the OOMH is included in its annual 

budget. The OOMH expects its funding allocation to 

change in FY 2015 due to the end of the State Partnership Grant. OOMH staff anticipate that the State of 

Oklahoma will allocate additional funding to maintain 

its programs.

In FY 2014, the OOMH provided funding to the faithbased institutions involved with the Body and Soul

program as well as to the community partners involved 

in the A Healthy Baby Begins with You program. The 

office spends an estimated $20,000 a year on funding 

to nongovernmental, community entities for those 

two programs.

8 Available on the Oklahoma Department of Health website.

State and Territorial Efforts to Reduce Health Disparities 195
Oklahoma

Oklahoma State Data

Total Populationa: 

3,923,561

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 10.3 89.7 72.4 7.2 7.7 2.1 10.7 100.0 NA 

Percent of population 

medically uninsureda 27.2 12.7 11.2 17.8 27.6 11.0 22.8 14.2 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 6.1 7.3 6.6 12.1 8.6 SP NC 7.3 5.9

Age-adjusted 

mortality rateb 518.6 904.0 874.5 981.3 1012.0 477.5 NC 888.4 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 9.2 14.6 13.2 19.9 18.0 4.9 16.9 14.1 13.6

Percent with 

diabetesc 8.7 12.3 11.4 13.7 16.4 7.3 11.4 11.9 10.8

Percent with 

heart diseasec 2.4 5.1 5.1 2.2 5.8 0.1 5.5 4.8 4.3

HIV rated 199.9 NC 143.7 578.2 114.3 97.3** 212.9 179.9 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

58.4 71.0 69.6 77.5 73.6 53.9 67.4 70.0 72.2

Percent received 

oral health visit 

(past 12 months)c

44.9 59.8 59.7 56.2 56.3 55.9 54.7 58.8 66.5

Percent received 

flu vaccinec 24.5 42.1 41.8 38.5 41.6 37.8 32.1 40.8 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 97.3 per 100,000 population (67 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 198.0 per 

100,000 population (8 cases).

State and Territorial Efforts to Reduce Health Disparities 196
Oregon 

Introduction to Oregon’s Health Equity Activities

Oregon had an estimated 2016 population of 4,093,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (13 percent), followed by Asian Americans and NHOPI (5 percent), Blacks/African Americans (2 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 8 

percent of the population.1 Approximately 1,072,000 Oregon residents live within a primary care health professional 

shortage area.2

In 2011, the Office of Multicultural Health and Services, which is housed within the Oregon Health Authority (OHA), 

changed its name to the Office of Equity and Inclusion (OEI) to reflect its broadened focus and goals.3 The OEI’s work 

focuses on health equity, diversity, inclusion, and civil rights. Its mission is to “work with diverse communities to 

eliminate health gaps and promote optimal health.”4

Oregon Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Equity and Inclusion

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Equity and Inclusion 

2011-2016 Strategic Plan is updated 

every 5 years. Health equity is also 

addressed in the Oregon State Health 

Improvement Plan, 2015-2019. 

Date strategic plan 

was last updated 2015

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

• The Oregon State Health 

Improvement Plan, 2015-2019

includes measures for each 

priority. 

• The Office of Equity and Inclusion 

2011-2016 Strategic Plan does 

not include an assessment 

component. 

• The Office of Health Analytics 

helps track health disparity data.

Key strategies 

used to achieve 

health equity

• Traditional Health Worker Program

• Health Care Interpreter Program

• Cultural competence continuing 

education

• Developing Equity Leadership 

through Training and Action (DELTA)

• Collection of Race, Ethnicity, 

Language, and Disability 

(“REAL+D”) data 

Organizational Structure

The OEI is one of seven units that comprise the OHA. 

Structurally, it is organized into two focal areas: health 

equity and diversity and inclusion. The OEI has 21 

full-time staff members: the OEI director, the executive 

manager for health equity, the executive manager for 

diversity and inclusion, and 18 program staff. Overall, 

75 percent of the OEI staff are dedicated to health 

equity work, while 25 percent are dedicated to diversity and inclusion. In addition to the OEI staff, many 

in the Public Health Division support health equity 

initiatives as part of their daily work. Fifteen staff who 

are members of the Public Health Division’s Health 

Equity Work Group spend 10–15 percent of their time 

on health equity activities, as does the administrator 

of the Center for Prevention and Health Promotion. At 

times, student interns and volunteers support heath 

disparity reduction activities led by the Public Health 

Division and the OEI. The Public Health Division has 

an AmeriCorps Volunteers in Service to America 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Office of Equity and Inclusion 2011-2016 Strategic Plan. Available 

on the OEI website. Last accessed 8/4/17.

4 Office of Equity and Inclusion: About Us. Available on the OEI 

website. Last accessed 8/4/17.

State and Territorial Efforts to Reduce Health Disparities 197
Oregon

(VISTA) intern, who serves as a health equity coordinator. 

A Community Advisory Council (on hiatus at time of 

data collection) advises the OEI to ensure programmatic alignment with community needs. The OHE’s 

Health Equity Policy Committee, which offers guidance 

to ensure that OEI programs and policies advance 

health equity, is transitioning from the OHE to the 

Oregon Health Policy Board, where its advisory function 

will expand to support the entire OHA. The Oregon 

Health Policy Board, a policy-making and oversight body 

for the OHA, was established in 2009 and is comprised 

of nine governor-nominated members.5

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of Equity and Inclusion 

is one of seven divisions of the 

Oregon Health Authority.

SMHE staffing 

(full-time equivalents) 21

Advisory committee 

or panel

The Community Advisory Council 

and the Health Equity Policy 

Committee advise the OEI.

Program Goals and Activities

In 2015, the OEI updated its Office of Equity and 

Inclusion 2011-2016 Strategic Plan to clarify its role, 

vision, and goals. Although it does not include a plan 

to measure progress towards meeting those goals, 

the OEI obtains relevant health disparity data from 

the Office of Health Analytics. A separate report, the 

Oregon State Health Improvement Plan, 2015-2019, 

includes health equity strategies with specific metrics 

to assess progress. The OHA’s Public Health Division 

aims to revise the State Health Improvement Plan, with 

support from an internal Health Equity Work Group, to 

ensure that strategies take into account racial-ethnic 

minority populations.

A core function of the OEI is to serve as an advisory 

body to the OHA on health equity issues. To determine 

its priorities, the OEI relies upon national and local 

health disparity data and best practices; it also receives 

input from the Public Health Division’s internal Health 

Equity Work Group, the Community Advisory Council, 

the Health Equity Policy Committee, and community 

coalitions. Because several OEI programs are mandated by state legislation, state lawmakers also help 

drive OEI’s priorities. 

Acronym List

Full Name of Agency Acronym Acronym

Office of Equity and Inclusion OEI

Oregon Health Authority OHA

One OEI disparity reduction strategy is to support and 

promote traditional health workers, such as community 

health workers, peer support specialists, personal 

health navigators, and birth doulas. The Traditional 

Health Worker Program, managed by the OEI, helps train 

and certify providers to ensure culturally responsive care 

and improve minority health. 

Language access and cultural competence are other 

focus areas of the OEI. Its Health Care Interpreter 

Program provides resources for health care interpreters 

seeking to meet qualifications for certification. Through 

this program, the OEI monitors training programs, which 

are reviewed by a committee of governor-approved 

individuals. Programs that meet the committee’s criteria 

are publicly shared—OEI staff add trainings that meet 

the criteria to an online registry.6 Relatedly, the OEI is 

required by law7 to provide support and resources aimed 

at improving the cultural competence of Oregon’s health 

care providers. As part of this mandate, the OEI also 

monitors and provides reports on provider participation 

in cultural competence-related continuing education. 

The OEI also manages Developing Equity Leadership 

through Training and Action (DELTA), a training program 

to prepare leaders in health equity and diversity. Each 

cohort includes 20–25 participants from various backgrounds and a program curriculum spanning 9 months. 

Trainings cover a range of topics such as health equity 

metrics, community engagement, and language access, 

and participants must submit a project to enhance 

health equity in their respective organizations.8

5 See the Oregon Health Policy Board: Members page on the OHA’s website. Last accessed 8/4/2017.

6 Office of Equity and Inclusion. Cultural Competence Continuing Education (CCCE): HB 2611 (2013). Available on the OEI website. Last 

accessed 8/4/17.

7 2015 ORS 413.450, Continuing education in cultural competency. Available through OregonLaws.org. Last accessed 8/4/17.

8 See the Office of Equity and Inclusion’s Developing Equity Leadership through Training and Action (DELTA) webpage. Available on the OEI 

website. Last accessed 8/4/17.

State and Territorial Efforts to Reduce Health Disparities 198
Oregon

Another priority for the OEI is promoting the collection 

of race, ethnicity, language, and disability (“REAL+D”) 

demographic data. The OHA is mandated to collect 

REAL+D data when feasible and is working to standardize its collection and analysis to efficiently identify 

and respond to health disparities. 

The Public Health Division also implements interventions designed to reduce health disparities. For 

example, as part of its statewide obesity prevention 

plan, it is working to increase access to parks and 

recreation facilities for low socioeconomic and 

minority populations. 

Partnerships

Primary 

collaborators

• Multnomah County Health 

Department

• Oregon legislative system

• Regional Health Equity Coalitions

• Community-based organizations

• Nine federally recognized tribes

• Northwest Portland Area Indian 

Health Board

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts are implemented for 

some partnerships (e.g., with several 

Regional Health Equity Coalitions and 

federally recognized tribes).

The OEI partners with various organizations to advance 

health equity in Oregon. The Multnomah County Health 

Department is a key partner, particularly around health 

care access issues. Much of the collaborative work 

aims to improve the health of both of refugee 

populations and of those enrolled in the Oregon Health 

Plan. In addition, the OEI partners with the legislature 

on health policy work. In this role, the OEI assesses 

whether new bills might have unintended 

consequences for minority populations, and whether 

any revisions in legislation could enhance health 

equity outcomes.

Regional Health Equity Coalitions collaborate with the 

OEI to advance local health equity. The coalitions focus 

on identifying and addressing regional health 

disparities, while focusing state-level priorities. One 

of the coalitions, the Oregon Health Equity Alliance, 

advocates for legislative and policy work to advance 

health equity. The OEI and the Oregon Health Equity 

Alliance are working on the Cover All Kids initiative 

to ensure health insurance coverage for all Oregon 

youth. The OEI also partners with community-based 

organizations that serve as training entities for 

traditional health workers or health care interpreters. 

To eliminate disparities and advance the health of 

Oregon’s Native American tribal populations, the Public 

Health Division partners with Oregon’s nine federally 

recognized Native American tribes and the Northwest 

Portland Area Indian Health Board. The Public Health 

Division works with tribes on public health goals, 

including emergency preparedness, child vaccinations, 

and tobacco prevention. In addition, state legislation 

mandates monthly meetings between Oregon tribal 

health leaders and OHA staff to discuss health and 

policy issues.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$3,400,000 

Annual budget (FY 2015) of SMHE 

from state/territorial government Undetermined

Largest funding source State government

Anticipated changes to budget None

Total FY 2015 funding for the OEI was approximately 

$3,400,000 from state and federal sources; this 

covers both staff salaries and OEI activities. State 

general funds are the largest source of funding for 

the OEI. During FY 2015, the OEI also received State 

Innovation Model (SIM) funding from the U.S Centers 

for Medicare and Medicaid Services to support health 

equity initiatives. The OHA’s Public Health Division’s 

budget does not include a separate line item for health 

equity activities, but $726,181 was earmarked for 

salaries of the staff who are members of the Health 

Equity Work Group. 

In FY 2015, the OEI allocated $125,000 to each of the 

six Regional Health Equity Coalitions to support local 

project implementation. During that same year, the OEI 

provided grant funding up to $2,500 per organization 

to community-based and nonprofit organizations for 

health equity projects and activities. The Public Health 

Division also provides funding to Oregon’s nine federally recognized Native American tribes for public 

health activities.

State and Territorial Efforts to Reduce Health Disparities 199
Oregon

Oregon State Data

Total Populationa: 

4,093,465

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 12.8 87.2 84.3 1.9 1.2 4.6 8.0 100.0 NA 

Percent of population 

medically uninsureda 14.9 5.3 6.1 7.5 13.5 6.3 9.8 6.5 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 3.6 5.4 4.9 SP SP SP NC 5.2 5.9

Age-adjusted 

mortality rateb 454.8 715.8 715.1 738.2 664.3 443.7 NC 705.9 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 18.2 17.0 16.9 25.5 29.2 9.4 20.5 17.3 13.6

Percent with 

diabetesc 12.4 9.2 9.2 14.7 13.3 8.0 10.6 9.4 10.8

Percent with 

heart diseasec 2.7 4.6 4.5 5.3 10.4 1.1 3.2 4.5 4.3

HIV rated 236.1 NC 181.2 761.6 124.6 84.2** 234.0 193.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

60.6 66.4 66.3 67.1 63.2 67.4 63.7 66.1 72.2

Percent received 

oral health visit 

(past 12 months)c

60.9 69.2 68.7 72.6 74.1 69.2 68.7 68.9 66.5

Percent received 

flu vaccinec 27.4 36.6 36.4 24.5 34.0 40.1 32.6 36.0 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 84.2 per 100,000 population (123 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 151.5 per 

100,000 population (19 cases).

State and Territorial Efforts to Reduce Health Disparities 200
Pennsylvania 

Introduction to Pennsylvania’s Health Equity Activities

Pennsylvania had an estimated 2016 population of 12,784,000. Blacks/African Americans are the largest racialethnic minority population (11 percent), followed by Hispanics/Latinos (7 percent), Asian Americans and NHOPI 

(3 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 4 percent of the population.1 Approximately 728,000 Pennsylvania residents live within 

a primary care health professional shortage area.2

In 2007, an executive order formally integrated the Office of Health Equity (OHE) into the Pennsylvania Department

of Health (PADOH). As mentioned in its authorizing executive order, the OHE is to be a leader in increasing public 

awareness about health disparities; address health disparities by advocating for program development; work with 

policymakers, health care providers, insurers, and communities to implement programs and policies that cause a 

sustained and measured improvement in health status of disparate and underserved populations; and collaborate 

with academic institutions, providers, community-based organizations, state agencies, and others to eliminate health 

disparities.3 The OHE focuses on racial and ethnic minorities, as well as other vulnerable populations. 

Pennsylvania Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Health Equity has 

a strategic plan regarding minority 

health, health disparities, and 

health equity.

Date strategic plan 

was last updated

The Office of Health Equity is 

developing an updated version 

of its strategic plan.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

There are currently no plans to 

integrate an assessment plan into 

the strategic plan.

Key strategies 

used to achieve 

health equity

• Public Health 3.0

• Pennsylvania Interagency Health 

Equity Team

• Implementation of National 

Standards for Culturally and 

Linguistically Appropriate Services 

in Health and Health Care 

(National CLAS Standards)

Organizational Structure

In 2007, an executive order formally integrated the 

OHE into the PADOH. An OHE Advisory Committee, 

which consists of 16 experts who volunteer from 

across Pennsylvania, provides guidance to Pennsylvania’s secretary of health on issues around health 

inequality. The Advisory Committee recommends 

activities that are evidence-based, data-driven, and 

culturally aware. It also works to increase health disparity public awareness and helps organize individuals 

and community actions to eliminate health disparities.4

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 Commonwealth of Pennsylvania Governor’s Office, Executive Order. 

Subject: Office of Health Equity. Number: 2007-04. Date: May 21, 

2007. Signed by Edward G. Rendell, Governor. Available on the 

Pennsylvania Office of Administration’s website. Last accessed 

8/4/2017.

4 Office of Health Equity Advisory Committee. Office of Health Equity 

Advisory Committee 2016-2018. Available through the Pennsylvania 

Department of Health website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 201
Pennsylvania

The OHE has one full-time staff member, the OHE 

director, who spends 100 percent time on minority 

health, health disparities, and health equity issues. 

Two PADOH staff also spend a portion of their time on 

OHE initiatives and activities, as do two unpaid student 

interns. The OHE anticipates possible staff increases 

in the next two years.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OHE is housed within the 

Pennsylvania Department of 

Health

SMHE staffing 

(full-time equivalents) 1

Advisory committee 

or panel

Office of Health Equity Advisory 

Committee

Program Goals and Activities

The OHE is updating its strategic plan for addressing 

minority health, health disparities, and health equity—

initially developed in 2010. Once complete, the OHE’s 

document will be integrated into ongoing PADOH-level 

strategic planning. One part of the OHE’s strategic plan 

will be a health equity report, which will include factors 

related to social determinants of health. In setting its 

priorities, the OHE is informed by several key sources, 

including data from the Robert Wood Johnson Foundation’s County Health Rankings and the Behavioral Risk 

Factor Surveillance System. County Health Rankings, 

available online,5 assess essential health factors 

including obesity, smoking, high school graduation 

rates, access to healthy foods, unemployment, income 

inequality, teen births, and the quality of air and water.6

The Behavioral Risk Factor Surveillance System is a 

national survey that collects data on chronic health 

conditions, health-related risk behaviors, and preventive services use. Other contributors to the OHE’s 

priority-setting process include the PADOH and 

other stakeholders. 

Acronym List

Full Name of Agency Acronym Acronym

Pennsylvania Department of Health PADOH

Office of Health Equity OHE

The OHE has several major strategies to improve the 

health of minority populations and eliminate disparities: Public Health 3.0, a new Pennsylvania Interagency 

Health Equity Team, and implementation of the 

National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care 

(National CLAS Standards). Public Health 3.0 is a 

national initiative to build innovative partnerships to 

address all aspects of life that promote well-being and 

health. It promotes cross-sector environmental, policy, 

and systems-level actions to affect the social determinants of health and advance health equity.7 The OHE 

uses the County Health Rankings and the Behavioral 

Risk Factor Surveillance System data to identify regions 

with the worst health outcomes. It then hosts periodic 

meetings in these areas, engaging with cross-sector 

partners to assess progress toward improved health 

outcomes. Between meetings, the OHE works with 

several community organizations within these regions 

to obtain information on health outcomes and provide 

technical assistance. 

Also as part of its strategy, the OHE is developing 

the Pennsylvania Interagency Health Equity Team. 

A replication of the Federal Interagency Health Equity 

Team,8 the Pennsylvania Interagency Health Equity 

Team has representation from state agencies with 

the goal of increasing cross-sector equity. First convened 

in 2017, the Pennsylvania Interagency Health Equity 

Team seeks to share data on inequalities across 

sectors to develop collaborative projects to address 

previously unrecognized gaps and to align activities 

across agencies.

The OHE is also implementing National CLAS 

standards and is working within the PADOH to meet 

all of the National CLAS Standards. In addition, 

together with the PADOH, the OHE is working toward 

national accreditation. 

5 “County Health Rankings and Roadmaps: Building a Culture of Health, County by County.” Funded by the Robert Wood Johnson Foundation. 

Available online. Last accessed 8/4/2017.

6 “County Health Rankings and Roadmaps-About.” Funded by the Robert Wood Johnson Foundation. Available online. Last accessed 8/4/2017.

7 “Public Health 3.0.” Office of Disease Prevention and Health Promotion. Available through the Health People 2020 website. Last accessed 

8/4/2017.

8 “Federal Interagency Health Equity Team.” National Partnership for Action to End Health Disparities. Available on the U.S. Office of Minority 

Health Website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 202
Pennsylvania

Partnerships

Primary 

collaborators

• Department of Aging

• Department of Agriculture

• Department of Community 

and Economic Development

• Department of Conservation 

and Natural Resources

• Department of Corrections

• Department of Education

• Department of Health

• Department of Human Services

• Department of Labor and Industry

• Department of Transportation

• Pennsylvania Association of 

Community Health Centers

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding.

The OHE partners with a wide range of organizations, 

both within and outside of state government, in 

its efforts to advance health equity. As part of the 

Pennsylvania Interagency Health Equity Team, the 

OHE informally collaborates with representatives 

from the following state agencies: Department of 

Aging, Department of Agriculture, Department of 

Community and Economic Development, Department 

of Conservation and Natural Resources, Department 

of Corrections, Department of Education, Department 

of Health, Department of Human Services, 

Department of Labor and Industry, and Department 

of Transportation. These agencies work together to 

share data and develop collaborative projects. For 

instance, as part of the Diversity Day project, the 

Pennsylvania Interagency Health Equity Team seeks 

to encourage minority population use of Pennsylvania’s 

state parks by coordinating cultural competency 

trainings for park staff. It also has been working with 

the Pennsylvania Parks and Forest Foundation to hold 

a health summit and to develop the Diversity Day 

project. The OHE is collaborating with transportation 

stakeholders to have health be a consideration in local 

transportation planning.

To support the WalkWorks Program—which focuses on 

increasing physical activity to combat childhood obesity 

and other chronic conditions and establishes safe 

walking routes throughout Pennsylvania—the OHE 

informally collaborates across departments and 

sectors. The OHE’s WalkWorks partners include the 

PADOH, Department of Conservation and Natural 

Resources, Department of Transportation, University of 

Pittsburgh Graduate School of Public Health, and other 

governmental and nongovernmental organizations.9

The OHE also works with the Department of 

Transportation to encourage health considerations in 

local transportation planning and to assess the need 

for more crosswalks, sidewalks, and bike lanes in 

at-risk communities. 

In addition, the OHE shares information and data 

with the Department of Conservation and Natural 

Resources and the Department of Education to help 

identify and address opportunities for improvement 

initiatives. It also collaborates with the Pennsylvania 

Association of Community Health Centers to share 

opportunities, promote health equity activities, and 

provide related trainings.

Funding 

Annual budget (FY 2017) of state/

territorial minority health entity 

(SMHE) across all income sources

$137,000

Annual budget (FY 2017) of SMHE 

from state/territorial government $137,000

Largest funding source State government

Anticipated changes to budget Potential for Increase

The total FY 2015 funding for the OHE was $137,000. 

The Pennsylvania state government fully funds the OHE 

and the OHE does not fund nongovernment organizations. The OHE anticipates possible funding increases 

in the next 2 years.

9 “WalkWorks.” Available on the Pennsylvania Department of Health website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 203
Pennsylvania

Pennsylvania State Data

Total Populationa: 

12,784,227

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 7.0 93.0 80.9 11.0 0.3 3.3 4.5 100.0 NA 

Percent of population 

medically uninsureda 14.8 5.6 5.5 9.1 9.4 6.3 12.3 6.3 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 6.3 5.8 5.2 10.8 SP 4.7 NC 6.2 5.9

Age-adjusted 

mortality rateb 547.7 771.4 762.9 927.7 206.4 383.6 NC 770.1 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 24.4 14.3 13.4 22.0 25.5 9.8 24.0 14.6 13.6

Percent with 

diabetesc 12.2 11.2 11.0 15.7 3.7 5.1 8.5 11.2 10.8

Percent with 

heart diseasec 3.3 4.7 4.8 5.2 1.9 0.5 4.0 4.6 4.3

HIV rated 870.6 NC 119.1 1474.8 203.1 71.1** 1224.2 314.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

72.8 73.7 73.0 83.0 66.1 62.4 64.5 73.6 72.2

Percent received 

oral health visit 

(past 12 months)c

64.3 66.9 68.6 56.9 60.3 8.0 58.7 67.0 66.5

Percent received 

flu vaccinec 32.4 43.6 43.1 42.8 39.6 47.2 30.8 42.9 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 71.1 per 100,000 population (250 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 707.9 per 

100,000 population (22 cases).

State and Territorial Efforts to Reduce Health Disparities 204
Puerto Rico 

Introduction to Puerto Rico’s Health Equity Activities

Puerto Rico had an estimated 2016 population of 3,411,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (99 percent), followed by Blacks/African Americans (12 percent).* Persons self-identifying as multiracial 

or “other race” comprise 21 percent of the population.1

The Puerto Rico Department of Health (DOH) is responsible for preserving and promoting the health of all Puerto 

Ricans. Its responsibilities range from public health service coordination to managing several hospitals and clinics 

where DOH staff provide direct patient care. Given Puerto Rico’s racial and ethnic composition, activities targeting 

health equity activities are standard practice throughout DOH programs. 

Puerto Rico Minority Health Overview

Name of state/

territorial minority 

health entity

Puerto Rico Department of Health

Strategic plan in 

place to address 

minority health 

or health equity

Department of Health Strategic 

Plan, 2011-2018

Date strategic plan 

was last updated 2011

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Department of Health Strategic 

Plan, 2011-2018 includes strategic 

goals and an evaluation plan. 

Key strategies 

used to achieve 

health equity

• Improving access to health care

• Conducting municipality visits

• Delivering specialized services 

to crime victims

• Leading HIV and tuberculosis 

programs 

• Obtaining federal funding to 

support public health activities

Organizational Structure

Charged with preserving and promoting the health and 

well-being off all Puerto Ricans, the DOH is responsible 

for a wide range of health care activities. The Department is organized into 11 units: Auxiliary Secretariat 

for Family Health and Integrated Services, Assistant 

Secretary for Health Promotion, Assistant Secretary 

for Medical Services and Nursing, Assistant Secretary 

of Environmental Health and Public Health Laboratories, Assistant Secretary for Planning and Development, Secretariat of Health Facilities Accreditation, 

Office of Preparation and Coordination of Response in 

Public Health, Research Office, Office of Epidemiology 

and Research, Commission for Suicide Prevention, 

and Food and Nutrition Commission of Puerto Rico.2

A council advises the Secretary of Health on issues 

related to the health of Puerto Ricans.

In total, the DOH employs 4,833 staff members, 

including clinicians who provide direct patient care and 

administrators who support operations at public hospitals and clinics. Most DOH employees spend at least 

some portion of their workday addressing minority 

health issues and advancing health equity. Its staff 

is funded with a combination of state and federal 

* Note: The Hispanic/Latino ethnic category is not mutually exclusive with racial categories.

1 American Community Survey Public Use Microdata, 2016.

2 Puerto Rico Department of Public Health. Operational Units. Available on the Commonwealth of Puerto Rico Department of Health’s website. 

Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 205
Puerto Rico

funding. A proposed voluntary retirement plan, under 

consideration because of budgetary concerns, is 

expected to decrease DOH staff—particularly directcare nurses.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The DOH reports to the Secretary 

of Health, who oversees the 

Department and reports to the 

Governor of Puerto Rico.

SMHE staffing 

(full-time equivalents)

The DOH has 4,833 employees, 

including hospital and clinic 

health care providers. Many 

support population health 

initiatives.

Advisory committee 

or panel

Yes. A council directly advises the 

Secretary of Health. 

Program Goals and Activities

The Puerto Rico Department of Health Strategic Plan, 

2011-2018 includes strategic objectives to promote 

health equity, reduce disparities, and improve overall 

population health. It includes specific strategic goals 

and anticipated evaluation activities, including the 

frequency of assessments monitoring progress on 

those goals. 

To identify departmental priorities, the DOH reviews 

available data and program reports and engages with 

a wide array of stakeholders. The DOH solicits feedback during strategic planning efforts on the current 

priorities of community members, academics, religious 

groups, and partner organizations. In 2015, the 

Governor of Puerto Rico signed an executive order that 

brought attention to health equity. Since then, several 

laws have been enacted to protect health and reduce 

health disparities. 

A separate report, the Puerto Rico Healthy People 2020 

Strategic Plan, which was last updated in 2012, also 

guides the DOH in selecting and addressing priorities.3

The Healthy People 2020 plan focuses on priority 

health conditions; nutrition and physical activity; 

maternal, infant, and child health; mental health and 

substance abuse; and older adults. For each priority 

area, the Healthy People 2020 plan lists strategies 

to achieve the stated goals. In addition, the DOH has 

a 10-year (2016 through 2026) comprehensive health 

plan for the Commonwealth.

Acronym List

Full Name of Agency Acronym Acronym

Department of Health DOH

One key priority for the DOH is reducing disparities in 

access to health care. Representatives from the DOH 

and other agencies visit municipalities at least annually, allowing DOH staff to both learn about constituent 

communities and educate residents about the services 

offered through DOH programs. The DOH seeks to 

provide a broad range of interventions for particularly 

vulnerable, underserved, and special populations. 

For example, the DOH sponsors an office that focuses 

exclusively on treatment and assistance for crime 

victims. In addition to providing direct medical intervention for crime victims, its staff collaborate with the 

Puerto Rico Department of Education to conduct 

tailored educational programming for various audiences 

on prevention of violence, sexual assault, and 

other crimes. 

Other interventions include the DOH’s HIV program 

and Ryan B White Programs, which aim to prevent 

the spread of HIV and treat HIV-positive individuals. 

Staff from the Family Health and Integrated Services 

Unit of the DOH conduct outreach to promote HIV 

testing in the homeless population; the lesbian, gay, 

bisexual, and transgender population; and others at 

high risk of HIV. Likewise, staff from the Family Health 

and Integrated Services Unit lead a tuberculosis 

program that targets at-risk populations. Program staff 

provide educational resources and tuberculosis testing 

to communities and conduct epidemiologic investigations upon disease detection. 

Another core focus for DOH staff working on health 

equity issues involves obtaining external financial 

support. Staff throughout the DOH work to identify 

funding opportunities that can address health needs 

and reduce health disparities in Puerto Rico. Such 

opportunities often relate to chronic disease prevention, emerging diseases, and community outreach. 

The DOH includes professionals to assist staff in 

responding to federal funding opportunities that 

could support or expand DOH initiatives. 

3 Puerto Rico Health People 2020 Strategic Plan: Promoting Healthy Living. Available on the Commonwealth of Puerto Rico Department 

of Health’s website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 206
Puerto Rico

Partnerships

Primary 

collaborators

• American Red Cross

• Association of State and Territorial 

Health Officials

• Centers for Disease Control and 

Prevention

• Centers for Medicare & Medicaid 

Services

• Health Resources and Services 

Administration

• Puerto Rico Medical Association

• Schools of medicine, pharmacy, 

and public health 

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The DOH partners with governmental and nongovernmental organizations to promote health equity 

in Puerto Rico. Federal partners include the Centers for 

Disease Control and Prevention, the Health Resources 

and Services Administration, and the Centers for 

Medicare and Medicaid Services. These agencies 

provide the DOH with funding, technical assistance with 

program implementation, and guidance on emerging 

issues. The Association of State and Territorial Health 

Officials assists the DOH with training staff and 

accreditation processes and the American Red 

Cross assists on blood banking and disaster 

prevention activities. 

In addition to these national partners, the DOH 

collaborates with organizations based within Puerto 

Rico, including academic institutions and nonprofit 

groups. The DOH has contracts in place with the local 

medical school, pharmacy school, and public health 

school. Joint activities include research on the 

incidence of the Zika virus in pregnant women and its 

sequelae in children. To prevent the spread of the Zika 

virus, the DOH is working with a nonprofit organization 

to educate women of childbearing age about 

transmission and prevention.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$741,431,000 

(includes budget for 

direct patient care 

services)

Annual budget (FY 2015) of SMHE 

from state/territorial government

$354,691,000 

(includes revenue 

from direct patient 

care services)

Largest funding source 

Territorial government 

and patient care 

revenues (which 

includes federal 

Medicare and 

Medicaid dollars)

Anticipated changes to budget Unknown

In FY 2015, funding to support all DOH activities and 

operations, including clinical support, totaled 

$741,431,000. Territorial government allocations and 

patient service revenue constituted the largest source 

of funding, followed by the federal government. The 

DOH contracts with local, nonprofit organizations to 

provide services to special populations, such as 

HIV-positive individuals and drug users. Funding 

supports nonprofits conduct outreach and provide 

education in at-risk communities.

State and Territorial Efforts to Reduce Health Disparities 207
Puerto Rico

Puerto Rico Territory Data

Total Populationa: 

3,411,307

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 98.6 1.4 66.9 11.6 0.3 0.1 21.1 100.0 NA 

Percent of population 

medically uninsureda 8.7 6.4 5.7 8.1 5.5 23.4 7.5 6.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP NC NC NC NC NC NC 7.0 5.9

Age-adjusted 

mortality rateb NC NC NC NC NC NC NC 624.7 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 17.5 26.4 17.7 19.0 SP SP 17.1 17.5 13.6

Percent with 

diabetesc 15.3 20.4 16.5 9.6 SP SP 14.8 15.3 10.8

Percent with 

heart diseasec 7.8 6.1 8.3 7.8 SP SP 6.8 7.7 4.3

HIV rated NC NC NC NC NC NC NC 564.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

82.3 78.3 84.3 84.6 SP SP 79.0 82.3 72.2

Percent received 

oral health visit 

(past 12 months)c

69.5 74.7 71.7 76.9 SP SP 64.8 69.5 66.5

Percent received 

flu vaccinec 25.3 11.9 26.7 26.4 SP SP 22.8 25.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015.

*Native Hawaiian and other Pacific Islander

State and Territorial Efforts to Reduce Health Disparities 208
Rhode Island 

Introduction to Rhode Island’s Health Equity Activities

Rhode Island had an estimated 2016 population of 1,056,000. Hispanics/Latinos (15 percent) are the largest 

racial-ethnic minority population, followed by Blacks/African Americans (6 percent), Asian Americans and NHOPI 

(4 percent), and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” 

comprise 9 percent of the population.1 Approximately 162,000 Rhode Island residents live within a primary care 

health professional shortage area.2

The Rhode Island Department of Health (RIDOH) Health Equity Institute (HEI) was created explicitly to advance health 

equity. Its mission is to “promote access to comprehensive, high quality services so that all Rhode Islanders may 

achieve their optimal state of health.”3 Located within the RIDOH Director’s Office, the HEI seeks to advance health 

equity across all RIDOH programs and policies. 

Rhode Island Minority Health Overview

Name of state/

territorial minority 

health entity

Health Equity Institute

Strategic plan in 

place to address 

minority health 

or health equity

Rhode Island Department of Health 

Strategic Framework

Date strategic plan 

was last updated 2016

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Rhode Island Department 

of Health Strategic Framework

includes measurable objectives.

Key strategies 

used to achieve 

health equity

• Championing population health 

goals

• Supporting the Health Equity Zone 

project

• Supporting community health 

workers as change agents

Organizational Structure

Within the RIDOH, the HEI is located in the Director’s 

Office. HEI has 11 full-time staff members, including a 

director, a Minority Health lead, a disability and health 

program manager, a Health Equity Zone manager, a 

refugee health coordinator, a minority youth mentoring 

manager, a maternal and child health program manager, an evaluator/epidemiologist, an outreach worker, 

a communications manager, and a systems coordinator. The HEI anticipates staffing allocations to 

change following expiration of grants. The Commission for Health Advocacy and Equity was legislatively 

established and serves as an advisory council both 

to the RIDOH generally and the HEI in particular.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Information about the Health Equity Institute is available from the Rhode Island Department of Health’s website. Last accessed October 22, 

2017.

State and Territorial Efforts to Reduce Health Disparities 209
Rhode Island

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Health Equity Institute is 

housed within the Rhode Island 

Department of Health Director’s 

Office

SMHE staffing 

(full-time equivalents) 11

Advisory committee 

or panel

Commission for Health Advocacy 

and Equity

Program Goals and Activities

The Rhode Island Department of Health Strategic 

Framework serves as the RIDOH’s “blueprint” for 

reducing health disparities and achieving health 

equity. It identifies three leading priorities or directives 

to help the state achieve its population health goals: 

(1) address the social and environmental determinants 

of health, (2) eliminate health disparities and promote 

health equity, and (3) ensure access to quality health 

services, including vulnerable populations. Each of 

the RIDOH’s 23 population health goals and targets is 

associated with a specific RIDOH area or program and 

has been incorporated into an Integrated Population 

Health Plan as part of Rhode Island’s State Innovation 

Model (SIM) Test Grant Operational Plan. The RIDOH 

also developed metrics associated with each population health goal to measure improvement over time. 

Disparities identified through data analyses of metric 

data help determine specific health equity priorities 

for the RIDOH. 

To that end, a key HEI strategy is to support the RIDOH 

in championing Rhode Island’s population health goals. 

The HEI works with RIDOH programs and staff to 

increase their capacity to address disparities and 

advance health equity. In an effort to support this 

strategy, the HEI developed a health equity training 

series, featuring training videos and facilitated discussions with RIDOH staff. 

Acronym List

Full Name of Agency Acronym Acronym

Health Equity Institute HEI

Rhode Island Department of Health RIDOH

Another major HEI strategy involves supporting the 

Health Equity Zone project, which aims to prevent 

chronic diseases, improve birth outcomes, and improve 

the social and environmental conditions in nine geographic areas throughout Rhode Island. Within each 

Health Equity Zone, the HEI helps build a network of 

municipal leaders, residents, businesses, transportation and community planners, law enforcement, 

education systems, and health systems that collaborate on developing and implementing action plans 

for their communities. 

The HEI also leads an effort to support community 

health workers as change agents. To facilitate implementation of this strategy the HEI worked with the 

Rhode Island Certification Board to create a Certified 

Community Health Worker credential aimed at standardizing education and scopes of practice, integrating 

community health workers into the health system, and 

improving visibility and job stability. A larger goal of the 

certification credential is to develop a labor force 

capable of reducing disparities by linking clinical issues 

to community social determinants of health. 

Partnerships

Primary 

collaborators

• Brown University School of Public 

Health

• Health Equity Zone partners 

• Rhode Island College

• Rhode Island Department of Health 

divisions and programs

• Rhode Island Executive Office 

of Health and Human Services

• Rhode Island Parent Information 

Network

• University of Rhode Island

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The HEI partners with a variety of governmental, 

nongovernmental, academic, and other organizations to 

advance health equity in Rhode Island. For example, to 

support the community health worker certification 

program, the RIDOH engaged in a formal partnership 

with Rhode Island College. The RIDOH and the HEI also 

work closely with the Rhode Island Parent Information 

Network, a contracted organization that hires, trains, 

State and Territorial Efforts to Reduce Health Disparities 210
Rhode Island

and supports community health workers. To support its 

efforts, the RIDOH has established formal partnerships 

with other academic institutions, as well, including the 

Brown University School of Public Health and the 

University of Rhode Island. Other HEI collaborators 

include the Rhode Island Executive Office of Health 

and Human Services and many divisions and programs 

within the RIDOH. Each Health Equity Zone engages a 

collaborative of diverse partners that include municipal 

leaders, residents, businesses, transportation, local 

housing authorities, health care partners including 

mental health community centers, payers, hospitals, 

community planners, law enforcement, education 

systems, among others.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$3,725,000

Annual budget (FY 2015) of SMHE 

from state/territorial government $425,000

Largest funding source Federal government

The total FY 2015 funding for the HEI was $3,725,000. 

The HEI received several federal grants in FY 2015, 

including a State Partnership Initiative to Address 

Health Disparities (SPI) grant ($200,000); a Title V 

Maternal and Child Health Services Block Grant 

Program ($1,700,000); a federal Preventive Health 

and Health Services Block Grant ($800,000); and a 

Systems Integration Project for Children and Youth with 

Special Healthcare Needs grant ($300,000). The HEI 

received $425,000 in state funding in FY 2015, and 

approximately $300,000 from Medicaid administrative 

funds. The HEI provided $2,400,000 to the Health 

Equity Zone project in FY 2015.

State and Territorial Efforts to Reduce Health Disparities 211
Rhode Island

Rhode Island State Data

Total Populationa: 

1,056,426

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 15.0 85.1 81.0 6.2 0.5 3.6 8.7 100.0 NA 

Percent of population 

medically uninsureda 10.5 3.1 3.2 6.1 21.9 4.0 11.4 4.2 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 5.5 5.1 SP SP SP NC 5.9 5.9

Age-adjusted 

mortality rateb 417.5 705.4 708.5 471.8 641.4 356.5 NC 690.1 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 17.9 15.5 16.0 15.3 11.0 10.5 18.0 15.9 13.6

Percent with 

diabetesc 8.3 10.1 10.2 9.6 17.4 3.0 8.9 9.9 10.8

Percent with 

heart diseasec 2.4 4.2 4.3 1.7 1.3 3.4 4.2 4.1 4.3

HIV rated 540.9 NC 155.1 1100.8 189.9 126.1** 424.0 259.5 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

78.7 82.5 83.1 74.6 87.7 81.1 79.0 82.3 72.2

Percent received 

oral health visit 

(past 12 months)c

66.9 77.8 78.9 66.0 71.2 75.1 58.9 76.6 66.5

Percent received 

flu vaccinec 39.4 47.6 47.6 41.2 54.8 53.2 35.6 46.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 126.1 per 100,000 population (38 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 174.5 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 212
South Carolina

Introduction to South Carolina’s Health Equity Activities

South Carolina had an estimated 2016 population of 4,961,000. Blacks/African Americans are the largest racialethnic minority population (27 percent), followed by Hispanics/Latinos (6 percent), Asian Americans and NHOPI 

(2 percent), and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial 

or “other race” comprise 4 percent of the population.1 Approximately 2,231,000 South Carolina residents live 

within a primary care health professional shortage area.2

The South Carolina Department of Health and Environmental Control (DHEC)’s Office of Health Equity (OHE) was

created to address minority health and health disparities. Located within the Health Services Division of the DHEC, 

the OHE reports directly to the division’s chief of staff. 

South Carolina Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Health Equity does not 

have an updated strategic plan. The 

Health Services Division is deciding 

whether to incorporate health equity 

strategies into the Health Services 

Division’s strategic plan or create a 

standalone strategic plan for the Office 

of Health Equity.

Date strategic plan 

was last updated

The Office of Health Equity does not 

have a standalone strategic plan. 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Office of Health Equity does not 

have an assessment plan in place.

Key strategies 

used to achieve 

health equity

• Increase awareness of health 

disparities 

• Re-engage community partners

• Provide trainings on cultural 

competency and the National 

Standards for Culturally and 

Linguistically Appropriate Services in 

Health and Health Care

• Improve breast and cervical screening 

of African and Native American women

• Increase minority participation in the 

AIDS Drug Assistance Program and 

HIV/AIDS medical care and treatment

Organizational Structure

Housed within the DHEC’s Health Services Division, the OHE reports to the Health Services 

Division chief of staff, who reports to the division’s 

director. The OHE has two staff members who work 

full time on minority health initiatives: a cultural 

competency consultant and an equity and disparities consultant. Plans are underway to fill the 

currently vacant OHE program director position 

in the near term. Approximately 10 percent of the 

Health Services Division’s chief of staff effort is 

on minority health initiatives. Student interns 

support the OHE at times. In addition, employees 

throughout the DHEC work to advance health 

equity as part of their daily work, including staff 

within the Bureau of Community Health and 

Chronic Disease Prevention and the Bureau 

of Maternal and Child Health.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 Designated HPSA Quarterly 

Summary.

State and Territorial Efforts to Reduce Health Disparities 213
South Carolina

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of Health Equity is 

located within the Health Services 

Division of the South Carolina 

Department of Health and 

Environmental Control.

SMHE staffing 

(full-time equivalents) 3

Advisory committee 

or panel None

Program Goals and Activities

In 2016, the Health Services Division embarked on a 

priority-setting initiative with support from an external 

contractor. The effort culminated in a report that 

highlighted priorities for the division, including OHE 

priorities. Subsequently, the Health Services Division 

began selecting priorities and discussing whether the 

OHE should create a stand-alone health equity strategic plan. The Health Services Division plans to 

establish methods for measuring outcomes associated 

with each identified priority to track progress. Some 

grant activities require health equity data monitoring.

Acronym List

Full Name of Agency Acronym Acronym

Office of Health Equity OHE

Department of Health and Environmental 

Control DHEC

Although the OHE does not have its own strategic plan, 

the office is leading various health equity strategic 

planning activities. For example, the OHE participated 

in a 2-day session focused on health disparities and 

OHE priorities. During the session, the OHE engaged 

external and internal stakeholders, and received 

technical assistance from the Association of State 

and Territorial Health Officials. The purpose of the 

session was for the OHE to gather information to 

drive development of a stand-alone strategic plan 

or a plan for integrating OHE strategic initiatives into 

the more comprehensive strategic plan of the Health 

Services Division. 

Organizations that play an ongoing role in identifying 

health equity priorities include the Alliance for a 

Healthier South Carolina, the South Carolina Commission for Minority Affairs, and the South Carolina 

Institute of Medicine and Public Health. 

To improve the health of minority populations and 

eliminate disparities, the OHE promotes public awareness of health disparities and works with staff across 

the DHEC to ensure that efforts are appropriate for 

targeted populations. DHEC “lunch and learn” events 

educate staff about health disparities and how DHEC 

efforts help to achieve health equity. During National 

Minority Health Month, the OHE develops content for 

the DHEC’s public blog to raise awareness of health 

disparities. The OHE aims to re-engage community 

partners, such as the Urban League. Re-engagement 

opportunities allow the OHE and the Health Services 

Division to update partners on current activities and 

request ongoing support. 

OHE staff members lead efforts to educate DHEC staff 

on cultural competency and the National Standards 

for Culturally and Linguistically Appropriate Services 

in Health and Health Care (National CLAS Standards). 

All DHEC staff are required to complete an online 

training module—developed by the OHE—that focuses 

on cultural competency. In addition, the OHE is responsible for providing National CLAS Standards trainings 

to staff responsible for direct client services.

Several initiatives led by bureaus and programs outside 

of the OHE also aim to improve minority health. These 

include the Best Chance Network, the Minority Aids 

Initiative, and chronic disease prevention initiatives. 

The Best Chance Network, led by the Division of Cancer 

Prevention and Control, is a breast cancer and cervical 

cancer early detection program that provides free 

screenings for eligible women in South Carolina.3

Program activities include targeted outreach and 

education to improve screening rates among African 

American and Native American women. The STD/HIV 

Division’s Minority AIDS Initiative aims to increase 

participation of minority populations in the Aids Drug 

Assistance Program, as well as boost engagement 

of minority populations in HIV/AIDS medical care and 

treatment services. The Bureau of Community Health 

and Chronic Disease Prevention is working to address 

3 “Best Chance Network: South Carolina’s Breast and Cervical Cancer Early Detection Program.” South Carolina Department of Health 

and Environmental Control. Available on the DHEC website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 214
South Carolina

disparities in chronic diseases. For example, the 

Bureau is implementing targeted obesity prevention 

efforts in five South Carolina counties with high rates 

of disparities in obesity prevalence in minority populations. The Bureau is working to increase access 

to healthy food and physical activity opportunities 

in these communities. 

Partnerships

Primary 

collaborators

• University of South Carolina, Institute 

of Medicine and Public Health

• South Carolina Office of Rural Health

• South Carolina Birth Outcomes 

Initiative

• Alliance for a Healthier South 

Carolina

• South Carolina Cancer Alliance

• Diabetes Advisory Council of South 

Carolina

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented for 

some partnerships (e.g., OHE has a 

contract with the University of South 

Carolina, Institute of Medicine and 

Public Health).

The OHE partners with several organizations to 

advance health equity in South Carolina. The University 

of South Carolina, Institute of Medicine and Public 

Health plays a key role in facilitating conversations 

around obesity prevention with partners across the 

state. Working with DHEC, the Institute of Medicine 

and Public Health supports the implementation of 

SCaleDown, South Carolina’s statewide obesity action 

plan.4 The OHE also works closely with the South 

Carolina Office of Rural Health on access to health 

care and related issues, including development 

of a state plan for rural health.

The OHE has an ongoing collaboration with the Birth 

Outcomes Initiative, a collaborative comprised of 

various organizations and state agencies. As part 

of the broader initiative aimed at improving birth 

outcomes, the OHE focuses on birth outcome 

disparities through its role on the initiative’s health 

disparities committee. The Alliance for a Healthier 

South Carolina is another significant partner for the 

OHE. Made up of executive leaders from various 

organizations across the state, the alliance focuses 

on improving the health of all South Carolinians.5

OHE staff are members of the alliance’s Health 

Equity Acceleration Team, which is working to advance 

health equity. 

The South Carolina Cancer Alliance has a health equity 

workgroup that aims to eliminate cancer disparities. 

Workgroup activities focus on identifying and 

addressing the needs of priority populations. A DHEC 

staff member who is a member of the South Carolina 

Cancer Alliance implements cancer-prevention activities 

in communities. To improve equity with regard to 

diabetes, the OHE participates in the Diabetes Advisory 

Council of South Carolina. The OHE and the South 

Carolina Commission for Minority Affairs provide 

technical assistance and consultation to the council 

to ensure program plans take into account 

health equity.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$220,538

Annual budget (FY 2015) of SMHE 

from state/territorial government $220,538

Largest funding source State government

Anticipated changes to budget Unknown

Funding for minority health and health equity initiatives 

is included in overall DHEC funding. For FY 2015, 

$220,538 supported the salaries for the OHE’s three 

full-time staff members. Federal funding specific to 

minority health was not available to the OHE in FY 

2015; funding to address state health disparities 

was embedded in federal grants with a broader scope. 

The OHE did not provide funding to organizations to 

carry out health disparities work in FY 2015. Changes 

to the sources or amount of funding for health equity 

activities over the next 2 years is uncertain.

4 “SCale Down” website. Available on the South Carolina Institute of Medicine and Public Health website. Last accessed 8/4/2017.

5 Alliance for a Healthier South Carolina: About Us. Available at the Healthier SC website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 215
South Carolina

South Carolina State Data

Total Populationa: 

4,961,119

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 5.5 94.5 67.3 27.0 0.3 1.6 3.8 100.0 NA 

Percent of population 

medically uninsureda 30.4 9.0 9.2 11.2 13.5 11.4 21.2 10.2 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 7.1 4.8 11.3 SP SP NC 6.9 5.9

Age-adjusted 

mortality rateb 357.8 841.6 802.1 939.3 352.4 386.2 NC 829.8 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 12.6 13.4 12.9 15.4 9.5 2.0 14.9 13.5 13.6

Percent with 

diabetesc 3.8 13.1 11.7 16.7 20.8 5.7 10.0 13.0 10.8

Percent with 

heart diseasec 0.9 4.6 5.3 3.3 3.6 0.0 2.8 4.6 4.3

HIV rated 393.3 NC 143.7 1024.2 78.0 56.3** 790.3 394.6 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

60.9 69.2 67.0 74.3 63.7 56.0 63.7 68.7 72.2

Percent received 

oral health visit 

(past 12 months)c

55.1 61.2 64.2 52.3 50.0 70.8 50.5 60.6 66.5

Percent received 

flu vaccinec 25.1 38.6 41.6 31.0 34.8 31.0 23.1 38.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 56.3 per 100,000 population (35 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 135.6 per 

100,000 population (3 cases).

State and Territorial Efforts to Reduce Health Disparities 216
South Dakota

Introduction to South Dakota’s Health Equity Activities

South Dakota had an estimated 2016 population of 865,000. American Indians/Native Americans are the largest 

racial-ethnic minority population (9 percent), followed by Hispanics/Latinos (4 percent) and Black/African American 

(2 percent). Persons self-identifying as multiracial or “other race” comprise 3 percent of the population.1

Approximately 36 percent of South Dakota’s population resides within a health professional shortage area.2

One of the least densely populated states in the nation, South Dakota is comprised of mostly rural or frontier 

areas. With many residents living 60 or more miles from a health care facility and only one city/county health 

department in the entire state, the South Dakota Department of Health (DOH) relies heavily on statewide 

cooperative extension services and community-based agencies to improve access to care. It also collaborates 

extensively with tribal entities to share data and information. The South Dakota Office of Tribal Relations also 

facilitates communication and collaboration between the state and tribal entities, and the Division of Health and 

Medical Services (DHMS) targets services and tailors programs to reach immigrant and refugee groups, which are 

also among the state’s priority populations. 

South Dakota Minority Health Overview

Name of state/

territorial minority 

health entity

N/A

Strategic plan in 

place to address 

minority health 

or health equity

A strategic plan specifically to 

address minority health or health 

equity does not exist. 

Date strategic plan 

was last updated

However, one goal in the 

Department of Health strategic 

plan is to improve access to care 

and quality of care for everyone in 

South Dakota.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Department of Health strategic 

plan is being developed.

Key strategies 

used to achieve 

health equity

• Partnering with tribal entities 

to improve health of Native 

Americans

• Improving access to care in rural 

communities

Organizational Structure

South Dakota does not have an office solely 

dedicated to minority health, health disparity, 

or health equity issues. Instead, activities that 

advance health equity are embedded in initiatives 

sponsored by the various offices comprising the 

DOH’s Division of Health and Medical Services 

(DHMS)—e.g., the Office of Chronic Disease 

Prevention and Health Promotion, the Office of 

Infectious Diseases, and the Office of Family and 

Community Health. Because such activities are 

embedded in ongoing work activities for most 

DHMS employees, staffing allocations for health 

equity work is difficult to tease apart from other 

staffing needs. Mid-level staff with the state DOH 

commit a large portion of their time to specific 

initiatives (e.g., the tobacco disparity coordinator), 

but no senior staff are exclusively dedicated to 

health equity and minority health initiatives. 

However, the DOH uses volunteers for some health 

equity activities (e.g., the coalition affiliated with 

the Office of Chronic Disease Prevention and 

Health Promotion are volunteers). The state DOH 

1 American Community Survey Public Use Microdata, 2016.

2 Health Services and Resources Administration, Year 2015 population HPSA estimates by state.

State and Territorial Efforts to Reduce Health Disparities 217
South Dakota

also employs paid interns, most of whom are college 

students who work during the summer.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

No entity is solely responsible for 

minority health, health disparities, 

and health equity in South Dakota

SMHE staffing 

(full-time equivalents) N/A

Advisory committee 

or panel None

Program Goals and Activities

The South Dakota DOH is developing its first formal 

strategic plan. Its anticipated goals include improving 

quality, accessibility, and effective use of health care 

for all South Dakotans. Specific offices within the DOH 

have developed action plans, and these include 

references to minority or disparate populations. These 

action plans integrate objectives related to minority 

health, health disparities, and health equity. In particular, emphasis is placed on initiatives for American 

Indian populations. 

Many DOH initiatives focus on reducing health 

disparities affecting its American Indian population. 

For example, the South Dakota DOH has prioritized 

tobacco-related activities and is working with tribal 

partners to establish smoke-free policies in public 

places on tribal lands. It is also working to create 

direct referrals from the Indian Health Service’s 

electronic health records to the South Dakota “Quit 

Line,” and to implement other targeted screening 

and prevention efforts. Other activities that address 

minority health, health disparities, and health equity 

are embedded in the department’s broader initiatives. 

For example, the state’s DOH is tailoring approaches 

specifically for foreign-born, low-income, and rural 

populations to improve access to care. 

Acronym List

Full Name of Agency Acronym Acronym

South Dakota Department of Health DOH

DOH’s Division of Health and Medical 

Services DHMS

The DOH prioritizes activities based on needs identified 

through surveillance and other data collection efforts. 

Tribal entities play a role in strategic planning; tribal 

entities and the State DOH have a mutual goal to 

enhance and coordinate—and not duplicate—services 

for American Indian populations. 

Partnerships

Primary 

collaborators

• Tribal entities, including the Northern 

Plains Indian Health Service

• Social service agencies, including 

the South Dakota Department 

of Social Services

• Cooperative Extension

• Community health care association 

and community health centers

• Office of Rural Health

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships (e.g., data 

sharing agreements).

South Dakota’s DOH partners with tribal entities across 

the state, including the Northern Plains Indian Health 

Service and tribal epidemiology centers. Key 

partnership activities include data sharing with tribal 

epidemiology centers and regular communication with 

tribal health entities about emerging disease trends 

across the state.

Other significant partners include a community health 

care collaborative, community-based social service 

agencies, and the Statewide Cooperative Extension. 

South Dakota’s DOH works with these agencies to 

improve the health of rural, low-income, and immigrant 

populations. In addition, the department collaborates 

with the Sioux Falls City Health Department, which is 

the only city/county health department in the state. 

The Cooperative Extension is critical in expanding the 

reach of services to underserved, rural areas of the 

state where the department’s activities normally do not 

reach. The Office of Rural Health and the Department 

of Social Services also collaborate on initiatives that 

involve minority health and health equity.

State and Territorial Efforts to Reduce Health Disparities 218
South Dakota

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources No separate SMHE 

and no specific 

budget designated 

for minority health, 

health disparities, or 

health equity

Annual budget (FY 2015) of SMHE 

from state/territorial government

Largest funding source 

Anticipated changes to budget

In South Dakota, funding is not tied specifically to 

advance minority health, health disparities, or health 

equity initiatives. Rather, many of the activities that 

address health disparities are embedded in larger 

initiatives administered by state DOH. The department’s FY 2015 budget was $91,329,147, of which 

$7,925,518 came from the state general funds, 

$43,291,140 came from federal funds, and 

$40,112,489 came from other funds. Two of the 

offices that administer a significant number of activities 

aimed at reducing health disparities are the Office of 

Chronic Disease Prevention and Health Promotion and 

the Office of Infectious Disease, both of which are 

almost entirely funded by the federal government. 

South Dakota receives grants for American Indian 

health; the amount of money applied toward other 

disparate populations is unclear.

State and Territorial Efforts to Reduce Health Disparities 219
South Dakota

South Dakota State Data

Total Populationa: 

865,454

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 3.7 96.3 84.9 1.5 9.3 1.5 2.8 100.0 NA 

Percent of population 

medically uninsureda 17.5 8.3 5.8 20.0 31.1 5.6 13.8 8.6 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 7.3 5.9 SP 12.5 SP NC 7.3 5.9

Age-adjusted 

mortality rateb 358.7 724.3 678.1 322.9 1386.9 451.3 NC 719.5 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 18.8 9.0 8.8 5.0 13.1 SP 16.7 9.3 13.6

Percent with 

diabetesc 4.7 8.0 7.9 1.5 11.8 SP 8.9 8.0 10.8

Percent with 

heart diseasec 4.3 4.9 5.2 1.1 4.6 SP 2.2 4.9 4.3

HIV rated 146.2 NC 45.8 1017.3 150.7 42.1** 119.0 73.3 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

57.0 70.3 71.3 80.8 60.8 SP 46.5 70.0 72.2

Percent received 

oral health visit 

(past 12 months)c

58.6 71.0 72.3 75.6 53.6 SP 51.0 70.6 66.5

Percent received 

flu vaccinec 33.3 48.7 49.5 34.8 47.6 SP 27.4 48.4 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 42.1 per 100,000 population (4 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 220
Tennessee

Introduction to Tennessee’s Health Equity Activities

Tennessee had an estimated 2016 population of 6,651,000. Blacks/African Americans are the largest racial-ethnic 

minority population (17 percent), followed by Hispanics/Latinos (5 percent), Asian Americans and NHOPI (2 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 3 percent of the population.1 Approximately 2,449,000 Tennessee residents live within a primary care 

health professional shortage area.2

Created to address the health of minority populations in Tennessee, the Office of Minority Health and Disparities 

Elimination (OMHDE) works to advance health equity and include social determinants of health in public health 

strategies. Its mission is to “promote health policies, programs, and services designed to improve health and quality 

of life by preventing and controlling the disproportionate burden of disease, injury, and disability among racial and 

ethnic minority populations.”3 It also provides subject matter expertise to programs across the Tennessee 

Department of Health (DOH). The Office of Rural Health (ORH) is closely connected with the OMHDE and contributes 

to disparity elimination efforts. 

Tennessee Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health and Disparities 

Elimination

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Minority Health and Disparities 

Elimination has a stand-alone strategic plan 

that serves as an internal resource.

Date strategic plan 

was last updated The strategic plan is updated periodically. 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

No

Key strategies 

used to achieve 

health equity

• Introducing the National Standards for 

Culturally and Linguistically Appropriate 

Services in Health and Health Care

• Offering small grant opportunities to address 

health disparities

• Providing subject matter expertise to efforts 

across the Tennessee Department of Health

• Championing inclusion of social 

determinants of health in public health 

strategies

• Increasing the visibility of the Office of 

Minority Health and Disparities Elimination

Organizational Structure

Housed within the DOH Office of the Deputy 

Commissioner for Population Health, the 

OMHDE is closely linked to the ORH. Although 

the OMHDE does not have a formal advisory 

committee or panel, the Tennessee Black 

Caucus of State Legislators may discuss 

priorities and activities with OMHDE staff. 

The OMHDE has five full-time staff members, 

each of whom dedicates 100 percent time 

to minority health and disparity elimination. 

Staffing includes the director of the OMHDE, 

a director of capacity building, a director 

of faith-based and community initiatives, 

a Hispanic community engagement coordinator, and an administrative assistant. 

Additionally, the ORH has six staff members 

who dedicate at least 25 percent time 

to minority health initiatives.

1 American Community Survey Public Use Microdata, 

2016.

2 Health Resources and Services Administration. 

2018. Designated Health Professional Shortage 

Areas Statistics: First Quarter of Fiscal Year 2018 

Designated HPSA Quarterly Summary.

3 Information is available on the Tennessee Department 

of Health’s website. Last accessed 10/15/2017.

State and Territorial Efforts to Reduce Health Disparities 221
Tennessee

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Office of Minority Health and 

Disparities Elimination is housed 

within the Office of the Deputy 

Commissioner for Population 

Health.

SMHE staffing 

(full-time equivalents) 5

Advisory committee 

or panel None

Program Goals and Activities

The OMHDE’s strategic plan, which is updated periodically, serves as an internal tool guiding the office’s 

disparities-related priorities and activities. Although 

no official assessment plan is in place, the OMHDE 

informally monitors health outcome data to assess 

how DOH and OMHDE programmatic efforts affect the 

health of minority populations. The annually-updated 

DOH-wide Tennessee State Health Plan includes strategies for improving population health with a focus on 

four key drivers of health status: excessive caloric 

intake, tobacco and nicotine use, physical inactivity, 

and substance use disorders. During its development 

and subsequent updates, the DOH’s Division of Health 

Planning solicited public input and engaged key stakeholders to enhance its understanding of health issues 

across the state. The DOH also maintains a closely 

aligned, department-wide strategic plan, and is 

exploring how to incorporate social determinants 

of health into future planning efforts. 

Efforts to educate DOH’s section leaders and others 

about the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care 

(National CLAS Standards) fall within the purview of the 

OMHDE. In addition to assessing DOH leadership’s 

familiarity with the National CLAS Standards, the 

OMHDE has been documenting complementary section 

activities and plans to share results of its data collection and subsequent analysis with the leadership team. 

Recognizing the disproportionate effects of violence on 

minority health, the OMHDE is spearheading efforts to 

bring attention to the issue as a public health concern. 

Staff with the OMHDE have been initiating conversations with community partners, law enforcement 

entities, and other state agencies to better understand 

drivers and inhibitors of violence; they are also documenting strategies implemented across the state to 

reduce its prevalence. Additionally, the OMHDE is 

exploring how to improve sources of violence data in 

Tennessee. The OMHDE plans to convene stakeholders 

from five hotspot counties to ascertain the range of 

anti-violence strategies such communities currently 

employ and will seek feedback on how the OMHDE 

can support violence-reduction efforts. 

To ensure that the health needs of racial and ethnic 

minority populations are adequately included across 

the DOH’s public health activities, the OMHDE’s staff 

serve as a department-wide program planning resource 

by contributing minority health subject matter expertise 

on public health activities. For example, the OMHDE 

worked with the Office of Communicable and Environmental Diseases and Emergency Preparedness to 

identify culturally responsible language to share for 

vulnerable and immigrant populations around Zika virus 

prevention and control. The OMHDE also organizes 

community engagement efforts, promotes the disaggregation of data to more precisely identify disparities 

affecting population subgroups, and raises awareness 

about the social determinants of health within the 

DOH. As the only state government agency exclusively 

focusing on racial and ethnic minority populations, the 

OMHDE also works to increase its visibility throughout 

state government. 

Acronym List

Full Name of Agency Acronym Acronym

Office of Minority Health and Disparities 

Elimination OMHDE

Office of Rural Health ORH

Department of Health DOH

Efforts to reduce health disparities in rural regions of 

the state also fall within the purview of the ORH. For 

example, the ORH developed and distributes a ruralurban fact sheet, which includes racially disaggregated 

health outcomes data. The ORH also identifies health 

professional shortage areas and helps address issues 

with access to health care. 

State and Territorial Efforts to Reduce Health Disparities 222
Tennessee

Partnerships

Primary 

collaborators

• Community-based and faith-based 

organizations

• Historically Black colleges 

and universities

• Knox County Health Department, 

Metro Public Health Department, 

Shelby County Health Department

• Memphis Breast Cancer Consortium

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The OMHDE partners with many organizations to 

reduce health disparities and improve minority health. 

It offers competitive funding opportunities to 

community-based and faith-based organizations and 

has distributed more than 30 small ($10,000) awards 

to organizations across the state. The Memphis Breast 

Cancer Consortium, for example, received OMHDE 

funding to provide African American women across the 

state with information about breast cancer prevention. 

Per the state’s new funding requirements, eligible 

activities must specifically address issues related 

to both social determinants of health and DOHdetermined priority health outcomes. Local health 

departments can also receive small ($2,500) OMHDE 

grants to address health disparities through primary 

prevention efforts. The OMHDE also works with local 

health departments (e.g., those in Knox and Shelby 

counties and the Metro Public Health Department) 

to share information, resources, and facilitate 

connections with community-based and faithbased organizations.

Tennessee’s five historically Black colleges and 

universities are frequent partners of the OMHDE which, 

for example, has awarded $40,000 to each of these 

institutions to address at least one DOH health priority 

on its campus. Initiatives must be student-driven and 

supported by faculty and staff, providing an opportunity 

to engage young African Americans and enhance the 

health sciences career pipeline. 

To improve access to care and reduce disparities 

in rural regions of the state, the ORH partners with 

the Tennessee Hospital Association to place needed 

providers in health professional shortage areas. 

The ORH also partners with the Tennessee Primary 

Care Network, a network of safety net clinics funded 

by the DOH, to conduct trainings and disseminate 

educational materials.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$1,360,700

Annual budget (FY 2015) of SMHE 

from state/territorial government $1,360,700

Largest funding source State government

Anticipated changes to budget Unknown

The FY 2015 OMHDE budget of $1,360,700 was 

entirely comprised of state funding. State allocations 

have been relatively consistent at this level for 4 years. 

In FY 2015, the OMHDE awarded 30 grants of $5,000 

to community-based and faith-based organizations to 

support health disparities elimination activities in local 

communities. The OMHDE also provided funding to 

local health departments to address health disparities. 

In FY 2015, the ORH received state funding to support 

safety net clinics ($12,000,000) and funding from the 

State Loan Repayment Program ($315,000), with 

matching funds from the U.S. Health Resources and 

Services Administration ($315,000). The ORH provided 

funding to federally qualified health centers 

($6,000,000) and faith-based and charitable care 

organizations ($6,000,000), and provided funding 

to support health care professionals through the State 

Loan Repayment Program.

State and Territorial Efforts to Reduce Health Disparities 223
Tennessee

Tennessee State Data

Total Populationa: 

6,651,194

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 5.2 94.8 78.0 16.7 0.3 1.9 3.2 100.0 NA 

Percent of population 

medically uninsureda 31.4 8.2 8.7 10.8 16.6 9.6 17.5 9.4 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.0 7.0 6.0 10.4 SP SP NC 7.0 5.9

Age-adjusted 

mortality rateb 351.9 895.4 877.7 981.7 257.8 392.4 NC 886.3 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 16.0 15.9 15.8 18.2 12.7 8.5 19.7 16.2 13.6

Percent with 

diabetesc 8.4 12.9 13.0 11.8 15.3 12.9 12.3 12.8 10.8

Percent with 

heart diseasec 2.6 5.5 6.0 2.8 10.6 5.0 2.5 5.4 4.3

HIV rated 353.4 NC 139.3 1016.3 64.1 69.8** 782.0 297.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

56.0 71.3 70.1 75.8 58.1 78.8 52.9 70.6 72.2

Percent received 

oral health visit 

(past 12 months)c

51.9 59.8 61.1 54.7 32.2 67.4 45.5 59.4 66.5

Percent received 

flu vaccinec 23.6 37.0 38.7 26.1 53.8 49.0 25.1 36.7 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 69.8 per 100,000 population (65 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 260.2 per 

100,000 population (7 cases).

State and Territorial Efforts to Reduce Health Disparities 224
Texas

Introduction to Texas’ Health Equity Activities

Texas had an estimated 2016 population of 27,863,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (39 percent), followed by Blacks/African Americans (12 percent), Asian Americans and NHOPI (5 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 8 percent of the population.1 Approximately 5,729,000 Texas residents live within a primary care health 

professional shortage area.2

The Texas Office of Minority Health was established in 1993 as a stand-alone entity within what was then the Texas

Department of Health. In 2011, it became the Center for Elimination of Disproportionality and Disparities (CEDD) 

within the Texas Health and Human Services Commission (THHSC). The CEDD, which is the state’s minority health 

entity, includes an Office of Minority Health and Health Equity (OMHHE). The THHSC oversees several state 

departments responsible for health and human services, and within that structure, the CEDD can readily partner 

with state agencies. The State Advisory Coalition for Addressing Disproportionality and Disparities addresses related 

policy and practice changes within the THHSC. 

Texas Minority Health Overview

Name of state/

territorial minority 

health entity

Center for Elimination of 

Disproportionality and Disparities

Strategic plan in 

place to address 

minority health 

or health equity

Health equity priorities are 

integrated into the Texas Health 

and Human Services Commission’s 

strategic plan.

Date strategic plan 

was last updated 2014 

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

Yes. The assessment plan is part 

of the annual operational plan. 

Key strategies 

used to achieve 

health equity

• Education and outreach

• Leadership development to build 

capacity for addressing health 

inequities

• Partnerships and crosscollaboration

• Data analysis

• Policy and practice

Organizational Structure

In support of its mission to eliminate disproportionality 

and disparities, the CEDD provides oversight to the 

OMHHE, as well as the Regional Equity Initiatives that 

involve regional equity specialists throughout Texas. 

The CEDD has a director and seven mid-level staff 

who dedicate about 80 percent time to minority health 

and health equity initiatives. An eighth mid-level staff 

person contributes about 50 percent time to grant 

application activities in support of minority health 

and health equity initiatives. In total, eight staff members contribute at least half their time to minority 

health activities. Beyond these positions, the CEDD 

regularly engages unpaid interns to help with minority 

health activities. As of 2017 there are no concrete 

plans to increase the number of staff working on 

minority health and health equity initiatives.

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 225
Texas

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The CEDD is a center within 

the Texas Health and Human 

Services Commission 

SMHE staffing 

(full-time equivalents) 8 

Advisory committee 

or panel

State Advisory Coalition for 

Addressing Disproportionality and 

Disparities

Program Goals and Activities

Since 2010, health equity strategies have been 

integrated into the THHSC strategic plan, which covers 

a period of approximately 5 years and was last updated 

in 2014. The CEDD’s annual operational plan includes 

an assessment plan to measure progress toward 

reducing disparities. At the time of data collection, 

Texas had no stand-alone strategic plan for minority 

health or health equity.

In setting priorities for minority health, health disparities, 

and health equity, the CEDD focuses on two factors: 

1) the data-driven strategic priorities identified by the 

State Advisory Coalition for Addressing Disproportionality and Disparities and 2) the U.S. Office of Minority 

Health’s strategic priorities. Partners that are engaged 

with communities also provide input about priorities.

Acronym List

Full Name of Agency Acronym Acronym

Texas Health and Human Services 

Commission THHSC

Center for Elimination of Disproportionality 

and Disparities CEDD

Office of Minority Health and Health Equity OMHHE

The CEDD’s disparity reduction strategies focus on 

revising practices to improve outcomes. Key to practice 

change is the CEDD’s support for health professionals 

and community members. One support strategy is 

education and outreach among health professionals 

and community members. Within the CEDD, the 

OMHHE leads education and outreach using training 

modules and presentations on the National Standards 

for Culturally and Linguistically Appropriate Services 

(National CLAS Standards), health equity, and social 

determinants of health at state and local conferences. 

The OMHHE has an online training on the CLAS for use 

by Medicaid-supported organizations, health professionals, and social workers. It also shares presentations on health inequities and social determinants of 

health to providers and community members. A related 

CEDD strategy involves building capacity among 

healthcare professionals and others to help address 

health inequities by conducting trainings for THHSC 

employees statewide. 

In addition, the Regional Equity Initiative, another 

element of the CEDD’s work, uses “equity specialists” 

to work in communities across Texas. One equity 

specialist partners with state and community stakeholders in each of the state’s 11 regions. These 

specialists offer technical assistance and training 

to local providers and help foster collaborations to 

eliminate disparities in health as well as other areas 

(e.g., education and juvenile justice). Equity specialists 

help identify and analyze data to identify disparities, 

establish regional advisory committees to help explore 

underlying causes, and work to support communities 

in ameliorating inequities.

Cross-agency collaboration with disease- or conditionspecific teams throughout the Texas Department of 

State Health Services and the THHSC is a key strategy 

the CEDD employs in its efforts to achieve health 

equity. For example, the CEDD joins efforts with child 

welfare agencies to achieve infant mortality reduction 

goals among minority populations. It also works with 

the Texas Emerging and Acute Infectious Disease 

Branch to address disparities in HIV/AIDS incidence 

and prevalence. Since 2014, the CEDD has worked 

with Texas Medicaid and the Texas Children’s Health 

Insurance Program (CHIP) to adjust cultural competency efforts to mirror the National CLAS Standards. 

Several of these cross-collaborations serve African 

Americans and Hispanics in east and south Texas.

Additionally, the CEDD continues to emphasize quality 

data collection and analysis to help drive policy 

changes around health disparity elimination. The 

CEDD has developed a how-to guide for identifying and 

monitoring reductions in disparities and is analyzing 

qualitative and quantitative data to inform program 

modification. It established a data evaluation workgroup in early 2016, which has sought to establish 

a central data repository so that various health agencies in the state can use consistent data to compare 

programs and services. The CEDD also has sought 

to identify relevant THHSC policies and to participate 

in workgroups responsible for performance metrics. 

State and Territorial Efforts to Reduce Health Disparities 226
Texas

Partnerships

Primary 

collaborators

• Local health departments

• Other state agencies

• Universities

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented for 

some partnerships (e.g., those with 

several city health departments).

The CEDD’s primary partners are city and county health 

departments, other state agencies, and universities. 

For example, it works with local health departments 

to build capacity, obtain state partnership grants, and 

refine the public health accreditation process. The 

CEDD has a memorandum of understanding with three 

city health departments that are involved in grants 

primarily directed at efforts to reduce obesity.

Since the state health department is within the same 

organizational system as the CEDD there is no formal 

contract in place with the state health department; 

instead the CEDD has a collaborative partnership 

agreement with the state health department

The CEDD also works with the Texas Juvenile Justice 

Department, Texas Medicaid, and Texas CHIP to 

address health equity issues. For example, the CEDD 

helps test for HIV/AIDS on behalf of the Texas Juvenile 

Justice Department. Partnerships with Medicaid and 

CHIP focus primarily on women’s health programs; 

those agencies have primary responsibility for 

interacting with clients and communities and the 

CEDD plays a supporting and guiding role to help 

the agencies better address health inequity. 

State universities, particularly their public health and 

social work departments, also work closely with the 

CEDD to explore opportunities for research and to 

collaborate with internship programs.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

Approximately 

$600,000

Annual budget (FY 2015) of SMHE 

from state/territorial government Unknown

Largest funding source Federal Government

Anticipated changes to budget Possibly in 2018, 

but unknown

The total FY 2015 funding for the CEDD was approximately $600,000. In FY 2015, the largest single 

source of funding was a U.S. Office of Minority Health 

grant (approximately $200,000). The remaining funding 

(approximately $400,000) came from a mix of state 

general revenue and other federal and state grants, 

including a grant from the federal Substance Abuse 

and Mental Health Services Administration to fund 

the Texas System of Care. Some funds came from 

other state agencies through the previously mentioned 

collaborative partnership agreements. The CEDD 

provided approximately $110,000 of the U.S. Office 

of Minority Health grant to city health departments 

and external evaluators, and approximately $20,000 

to universities for health disparities activities in 

FY 2015. The funds appropriated through the Texas 

general revenue could change in 2018 with the release 

of the next legislative rider.

State and Territorial Efforts to Reduce Health Disparities 227
Texas

Texas State Data

Total Populationa: 

27,862,596

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 39.1 60.9 74.4 12.1 0.5 4.7 8.4 100.0 NA 

Percent of population 

medically uninsureda 26.8 11.0 16.9 15.4 22.6 11.0 24.7 17.2 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.3 6.0 5.2 9.9 SP 3.7 NC 5.7 5.9

Age-adjusted 

mortality rateb 606.2 772.3 732.1 883.1 146.6 366.7 NC 730.6 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 8.7 14.7 12.7 17.8 13.2 6.5 12.9 13.1 13.6

Percent with 

diabetesc 12.0 10.7 10.9 14.7 16.5 7.8 4.7 11.2 10.8

Percent with 

heart diseasec 2.3 4.5 4.1 3.4 1.8 2.3 2.4 3.8 4.3

HIV rated 324.3 NC 212.8 1150.2 53.4 78.8** 1279.1 368.9 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

62.3 73.9 69.3 79.9 64.8 68.7 73.6 70.7 72.2

Percent received 

oral health visit 

(past 12 months)c

54.1 64.6 61.5 64.2 55.7 65.7 54.9 61.8 66.5

Percent received 

flu vaccinec 31.9 40.7 38.7 32.9 43.4 47.6 29.8 38.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 78.8 per 100,000 population (810 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 139.5 per 

100,000 population (25 cases).

State and Territorial Efforts to Reduce Health Disparities 228
U.S. Virgin Islands

Introduction to U.S. Virgin Islands’ Health Equity Activities

The U.S. Virgin Islands (USVI) had an estimated 2010 population of 105,000. Blacks/African Americans are 

the largest racial-ethnic minority population (76 percent), followed by Hispanics/Latinos (17 percent). Persons 

self-identifying as multiracial or “other race” comprise 2 percent of the population.1

Public health, clinical care, and environmental health services fall within the purview of the USVI Department of 

Health (DOH), which also provides emergency medical response services and functions as the USVI regulatory body 

for health care providers and facilities. Although a departmental reorganization is in progress, no office within the 

USVI DOH is dedicated solely to minority health, health disparities, or health equity issues. However, given that most 

of the USVI’s population represents a racial or ethnic minority group, a focus on minority populations is embedded 

in all DOH programs. 

U.S. Virgin Islands Minority Health Overview

Name of state/

territorial minority 

health entity

N/A

Strategic plan in 

place to address 

minority health 

or health equity

The Department of Health is 

developing a territorial health 

strategic plan; an update of the 

territorial Healthy People plan is 

also anticipated.

Date strategic plan 

was last updated

Healthy Virgin Islands 2010

was last updated in 2003.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

An overarching plan to measure 

progress toward reducing health 

disparities is not available, but 

the Department of Health does 

measure outcomes for selected 

programs.

Key strategies 

used to achieve 

health equity

• Health education and outreach

• Department of Health staff 

trainings

Organizational Structure

Most of the DOH’s approximately 450 staff members 

spend at least some portion of each day working to 

improve population health and achieve health equity. 

For example, DOH staff members focusing on such 

activities as diabetes prevention, tobacco cessation 

and prevention, and communicable disease control 

engage in health equity work, even when it is not 

explicitly part of the job description. With DOH budget 

cuts anticipated, the DOH may need to reduce 

staff size.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The U.S. Virgin Islands 

Department of Health is one 

of several departments housed 

under the Office of the Governor.

SMHE staffing 

(full-time equivalents)

The U.S. Virgin Islands 

Department of Health has 

approximately 450 employees, 

many of whom spend some time 

supporting population health 

initiatives.

Advisory committee 

or panel

Plans are in place to establish a 

public health advisory committee.

1 American Community Survey Public Use Microdata, 2016.

State and Territorial Efforts to Reduce Health Disparities 229
U.S. Virgin Islands

Program Goals and Activities

Acronym List

Full Name of Agency Acronym Acronym

U.S. Virgin Islands USVI 

Department of Health DOH

To garner insights into how best to meet patient needs, 

staff with the DOH engage in conversations with health 

care facilities staff to better understand why patients 

are seeking care. Another strategy to assess needs 

is to improve the territory’s health data infrastructure, 

which is one of the DOH’s current goals. Such improvements, including a transition to electronic vital records, 

would ensure that the department has access to 

validated, accurate, and detailed data. An important 

step towards this objective was the USVI’s 2016 

participation in the Behavioral Risk Factor Surveillance 

System. Analyses of the resulting survey data will help 

guide the DOH’s priority setting. 

The DOH is working to establish a public health 

advisory committee to offer the department guidance 

on priority setting and programmatic activities. On an 

ad-hoc basis, specific DOH programs engage an 

advisory committee comprised of nongovernmental 

stakeholders. Such committees offer guidance on 

particular issues of interest, such as mental health, 

substance abuse, chronic disease prevention, and HIV/

AIDS. Although the DOH has no overarching territorial 

strategic plan currently, it is working with a contractor 

to develop such a blueprint. The resulting plan will 

focus on public health and health care delivery and will 

clarify which DOH divisions are responsible for activities of the department, USVI hospitals, and federally 

qualified health centers (FQHCs). The plan will highlight 

how health care entities should collaborate to improve 

health care delivery and overall health. That same 

contractor will also update the DOH’s Healthy People 

plan; its previous iteration, Healthy Virgin Islands 2010: 

Improving Health for All, was last updated in 2003. 

A major focus of the DOH is to increase awareness of 

disease prevention and preventive care, public health 

issues, and healthy lifestyle behaviors through 

health-related information dissemination and outreach. 

In addition to publishing newspaper articles, broadcasting both television- and radio-based public service 

announcements, and posting information on the DOH 

website and Facebook pages, the DOH organizes health 

fairs to provide information, health tests, and immunizations. The DOH also conducts additional outreach 

efforts on such topics as communicable disease 

prevention, tobacco cessation, and heart disease 

management. With support from the U.S. Centers for 

Disease Control and Prevention and the Association 

of State and Territorial Health Officials, the USVI will 

participate in the Million Hearts State Learning Collaborative to reduce the risk of heart attack and stroke 

through blood pressure monitoring and control.2

Building public health capacity through organizational 

changes and staff trainings has been another priority 

for the DOH. In 2013–2014, the departure of a major 

employer in the territory led to a significant reduction 

in DOH staff size. Since then, the DOH has worked to 

restore the department’s organizational capacity and 

expertise, enabling it to enhance its programmatic 

activities. It continues to build capacity around program 

planning and management, as well as monitoring and 

evaluation. While the DOH reviews outcomes for 

selected initiatives, no overarching assessment plan is 

currently in place to monitor progress toward reducing 

health disparities. 

Partnerships

Primary 

collaborators

• Federally qualified health centers

• Local hospitals

• University of the Virgin Islands

• U.S. Virgin Islands: Department of 

Agriculture, Department of Education, 

Department of Planning and Natural 

Resources

• Women’s Coalition of St. Croix 

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships.

The DOH partners with organizations committed to 

eliminating health disparities and improving the health 

of the USVI population. For example, two FQHCs are 

key partners in extending service reach and providing 

health education within communities. FQHC staff often 

join DOH staff at health fairs and community events 

to provide on-site counseling, immunizations, and 

screening. Dedicated space within the FQHCs allows 

the DOH to provide services that the FQHC otherwise 

2 Association of State and Territorial Health Officials. Heart Disease and Stroke: State Learning Collaborative to Improve Blood Pressure 

Control. Available on the ASTHO website.

State and Territorial Efforts to Reduce Health Disparities 230
U.S. Virgin Islands

would not be able to provide. In addition, the DOH 

works with FQHCs in designing and conducting 

community health surveys. 

USVI hospitals also partner with the DOH to improve 

access to health services. A memorandum of 

agreement between the DOH and a USVI hospital is 

in place. Under this agreement, the DOH assists the 

hospital with its 24-hour mental health hotline.

The University of the Virgin Islands, another prominent 

partner, leads public health trainings with DOH staff 

and conducts surveys on specific topics. In 2017, the 

DOH collaborated with its School of Nursing, as well 

as the St. Croix campus of Barry University’s physician 

assistant training program, to provide health services 

free of charge at the USVI’s Agricultural Fair.3

Several community-based organizations also partner 

with the DOH. The Women’s Coalition of St. Croix, for 

example, collaborates with the department on sexual 

assault and domestic violence prevention efforts. In 

some cases, the DOH provides funding to communitybased organizations, which funds salaries of 

community workers that implement specific 

health initiatives. 

Examples of territorial government agencies with which 

the DOH partners include the USVI Department of 

Agriculture, which oversees the Special Supplemental 

Nutrition Program for Women, Infants, and Children. 

Through this partnership the two departments 

distribute vouchers, redeemable for fresh fruits and 

vegetables, to low-income individuals. They also 

collaborate on efforts to engage farmers about public 

health laws governing agricultural activities, as well 

as to improve the distribution of fresh fruits and 

vegetables and to educate community members on 

the importance of eating fresh fruits and vegetables. 

In partnership with the USVI Department of Education, 

the DOH embarked on joint efforts to secure schoolbased health education programs, as well as school 

food service program regulations. The DOH also 

collaborates with the USVI Department of Planning 

and Natural Resources to disseminate information 

about water and beach safety to the public.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

The DOH receives 

approximately 

$15,000,000–

$20,000,000 

for a broad range 

of activities that 

advance health 

equity. 

Annual budget (FY 2015) of SMHE 

from state/territorial government N/A

Largest funding source Federal government

Anticipated changes to budget Possible budget cuts

The total FY 2015 funding for the DOH to support 

operations and service delivery was approximately 

$50,000,000, with roughly 30–40 percent of funding 

contributing to activities that help advance health 

equity in the USVI. Approximately $30,000,000 of 

the overall FY 2015 DOH funding came from federal 

sources. Most federal grants are ongoing, but the 

DOH anticipates cessation of funding for addressing 

the Zika virus and additional budget cuts in the 

coming years.

3 United States Virgin Islands Department of Health. DOH to Provide Free Services at Agriculture Fair. Available on the DOH website.

State and Territorial Efforts to Reduce Health Disparities 231
U.S. Virgin Islands

U.S. Virgin Islands Terrirtory Data

Total Populationa: 

27,862,596

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black or 

African 

American Multiracial Other

Territory 

Total

National 

Total

Population Characteristics

Percent of state 

populationa 17.4 82.6 15.6 76.0 2.1 6.2 100.0 NA 

Percent of population 

medically uninsureda 41.5 28.6 28.2 30.9 32.9 35.5 30.8 16.3b

Total Populationa: 

27,862,596

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black or 

African 

American

American 

Indian/ 

Alaska 

Native

Asian or 

Pacific 

Islander

Multiracial 

or Other

Territory 

Total

National 

Total

Health Disparities

Vital Statistics

Infant mortality rateb SP NC NC NC NC NC NC SP 5.9

Age-adjusted 

mortality rateb NC NC NC NC NC NC NC 531.0 733.1

Prevalence of Selected Chronic Diseases

Percent with asthmac 18.0 8.8 12.5 10.1 SP 8.6 SP 10.4 13.6

Percent with 

diabetesc 9.5 13.2 6.3 13.5 SP 24.0 SP 12.8 10.8

Percent with 

heart diseasec 0.4 2.3 6.3 1.6 SP 0.0 SP 2.0 4.3

HIV rated SP NC SP SP SP SP SP 635.5 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

53.4 72.0 60.7 69.8 SP 77.6 SP 69.2 72.2

Percent received 

oral health visit 

(past 12 months)c

44.8 52.9 48.9 52.3 SP 50.6 SP 51.4 66.5

Percent received 

flu vaccinec 13.0 15.9 22.8 13.6 SP 23.4 SP 15.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: U.S. Census Bureau. 2010 Census Island Areas: 2010 Census Detailed Crosstabulations. 

b Source: U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2010

c Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. 

d Source: CDC National Vital Statistics Reports, Deaths: Final Data for 2015.

e Source: Behavioral Risk Factor Surveillance System, 2016.

f Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015

State and Territorial Efforts to Reduce Health Disparities 232
Utah

Introduction to Utah’s Health Equity Activities

Utah had an estimated 2016 population of 3,051,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (14 percent), followed by Asians/Pacific Islanders (3 percent), Blacks/African Americans (1 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 

8 percent of the population.1 Approximately 747,000 Utah residents live within a primary care health professional 

shortage area.2

The Office of Health Disparities (OHD) replaced the Center for Multicultural Health during the 2011 legislative 

session, in compliance with Senate Bill 33. While the center focused on coordinating efforts to address racial and 

ethnic health disparities, the OHD has a broader mission of reducing disparities by geography and income as well as 

by race and ethnicity. At the end of 2016, the OHD began reporting directly to the Utah Department of Health (UDOH) 

Deputy Director (previously it had reported to the Division of Family Health and Preparedness). The OHD also 

coordinates a Health Disparities Advisory Council, which consists of community partners and other agencies that 

work with racial and ethnic minorities. 

Utah Minority Health Overview

Name of state/territorial minority 

health entity Utah Office of Health Disparities

Strategic plan in place to address 

minority health or health equity

The strategic plan has expired; a new strategic plan with health disparities integrated 

into the broader health department plan is under development. It will be released in 

December 2017.

Date strategic plan was last 

updated

The strategic plan was being updated at the time of the data collection for this 

report. The stand-alone OHD plan, last updated in 2013, covered 2013–2015; 

the Department-wide plan covered 2013–2016. 

Assessment plan in place 

to measure progress toward 

reducing health disparities

Yes 

Key strategies used to achieve 

health equity

• Promoting access to primary care among underserved communities

• Promoting access to dental care among underserved communities

• Reducing adverse birth outcomes among Pacific Islanders

• Promoting National Standards for Culturally and Linguistically Appropriate Services 

in Health and Health Care

• Increasing awareness of health disparities through data reports

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 233
Utah

Organizational Structure

The OHD has functioned in its current role since 2011. 

It was established to reduce racial and ethnic disparities, but also seeks out opportunities to address 

health disparities by geography and income. Three 

full-time staff members, including the OHD director 

and two program specialists, dedicate all of their 

time to minority health, health disparities, and health 

equity initiatives. Eight interns support them, though 

they each spend less than half of their time on such 

initiatives. Other staffing assistance includes approximately five individuals who work for either the UDOH 

Family Dental Plan or the UDOH Oral Health Program, 

and three to five volunteers from the University of Utah 

who spend between 5 and 10 percent of their time on 

OHD strategic initiatives. A part-time employee may 

also be hired.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OHD is at the department 

level of the Utah Department 

of Health; reports directly to 

the Deputy Director

SMHE staffing 

(full-time equivalents) 3 

Advisory committee 

or panel

Health Disparities Advisory 

Council

Program Goals and Activities

Utah has maintained a strategic plan addressing health 

disparities since 2008. The OHD is transitioning from 

a stand-alone strategic plan for health disparities 

alone to one that is integrated into the broader UDOH 

strategic plan. The stand-alone strategic plan has been 

updated every 3 to 5 years; the latest version covered 

2013–2015. The most recent department-wide strategic 

plan spanned 2017–2020. An evaluation plan also is 

in place for activities, including those related to federal 

grant awards, that the OHD oversees. 

Funding sources and data are the primary factors 

driving the selection of minority health, health disparities, and health equity goals. Some goals reflect priorities associated with federal funding, as well as priorities 

mandated by the Utah legislature. Other goals have 

emerged from working with the UDOH Center for Health 

Data to examine primary data collected from the community (obtained in part from assessments performed 

with nongovernment partners) and secondary data from 

public health databases.

Acronym List

Full Name of Agency Acronym Acronym

Utah Department of Health UDOH

Office of Health Disparities OHD

The OHD is working on many strategies to achieve 

health equity and eliminate health disparities. Two 

strategies aim to promote access to primary care and 

dental care among underserved communities. The OHD 

is collaborating with multiple partners, including the 

state Medicaid program and community health centers, 

to focus on two geographic areas (the neighborhood of 

Glendale and the City of South Salt Lake) with a high 

proportion of medically underserved individuals, most 

of whom are racial and ethnic minorities. Community 

partners conduct outreach and identify individuals in 

need, while UDOH agencies conduct screenings and 

refer individuals to primary care services. Another 

strategy focuses on promoting the National Standards 

for Culturally and Linguistically Appropriate Services in 

Health and Health Care (National CLAS Standards) at 

medical and dental clinics within these two communities. Specifically, the OHD assessed providers’ level 

of knowledge about the National CLAS Standards and 

then developed online trainings to increase awareness among providers throughout the state who serve 

patients with limited English proficiency. In addition, 

the OHD is in the process of piloting evidence-based 

methods to reduce adverse birth outcomes among 

Pacific Islanders and Hawaiian Natives by developing 

a culturally appropriate educational program. It also 

has in place a strategy to increase awareness of health 

disparities by publishing data analyses and reports 

on such topics as health status by race and ethnicity, 

health disparity trends among racial and ethnic minorities, and the top 15 languages spoken in local health 

districts and counties. 

State and Territorial Efforts to Reduce Health Disparities 234
Utah

Partnerships

Primary 

collaborators

• Federal Office of Minority Health 

• City of South Salt Lake 

• Salt Lake County Health Department 

• UDOH Family Dental Plan 

• UDOH Oral Health Program 

• UDOH Bureau of Maternal and Child 

Health 

• UDOH Bureau of Health Promotion

• UDOH Medicaid Program 

• UDOH Media Relations

• Utah Health Policy Project 

• Communities United 

• Association for Utah Community 

Health, Community Health Centers

• Community Building Community 

• National Tongan American Society 

• Somali Community Self-Management 

Agency 

• Queen Center 

• University of Utah School of Dentistry 

Residency Program 

• Fortis College Dental Hygienist 

Training Program 

• Latter-day Saint Humanitarian Center 

• UDOH Utah Indian Health Advisory 

Board

Contracts or 

memoranda of 

understanding 

with any partners

Contracts are in place with all 

partners that receive funding from 

the OHD. This includes:

• UDOH Family Dental Plan

• UDOH Office of Public Information 

and Marketing

• Utah Health Policy Project

• Communities United

• Association for Utah Community 

Health, Community Health Centers 

• Community Building Community

• National Tongan American Society

• Somali Community SelfManagement Agency

• Queen Center

The OHD partners with several government organizations at the federal, state, county, and city levels, as 

well as with nongovernment organizations, academic 

institutions, faith-based organizations, and a community board. It puts in place contracts to manage funding 

provided to or received from partners. Contracts are 

currently in place with nongovernment partners, as well 

as partners at the state government level that receive 

OHD funding. Most of the initiatives covered by such 

contracts address the OHD’s strategies promoting 

access to primary or dental care among underserved 

communities and reducing adverse birth outcomes 

among Pacific Islanders. 

In addition to these contractual arrangements, the 

OHD has informal agreements with local governments, 

academic institutions, a faith-based organization, and 

a community board. These informal partnerships are 

not always tied to specific initiatives and strategies, 

but help the OHD address minority health more broadly. 

Among public health institutions is the UDOH Oral 

Health Program, which conducts training related to 

promoting access to dental care among underserved 

communities. The Latter-Day Saint Humanitarian 

Center, meanwhile, assists the OHD with outreach 

among refugee populations, while the Health Access 

Project assists OHD’s targeted communities to establish medical homes. The OHD also collaborates closely 

with other UDOH programs such as the Family Dental 

Plan and the UDOH American Indian Liaison.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$384,500

Annual budget (FY 2015) of SMHE 

from state/territorial government $163,500

Largest funding source 

Federal grant from 

federal Office of 

Minority Health

Anticipated changes to budget 

Possible (as reported 

at the time of data 

gathering)

Total FY 2015 funding for the OHD was $384,500. 

In FY 2015, it had three key funding sources: a grant 

from the federal Office of Minority Health ($175,000), 

Utah general revenue funding ($163,500), and a federal Maternal and Child Health Block Grant ($46,000). 

Awarded in FY 2015, the Maternal and Child Health 

Block Grant funded an initiative to reduce adverse 

birth outcomes disparities among Pacific Islanders; 

the other two sources of funding are ongoing. In turn, 

the OHD provided $97,000 to other organizations in FY 

2015, including six nongovernment partner agencies 

($75,000), a private entity for social interactive video 

development ($18,000), and the Utah Government 

Office of Marketing and Media ($4,000).

State and Territorial Efforts to Reduce Health Disparities 235
Utah

Utah State Data

Total Populationa: 

3,051,217

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 13.8 86.2 86.5 1.1 1.0 3.4 8.1 100.0 NA 

Percent of population 

medically uninsureda 22.0 6.7 7.5 7.1 25.2 10.4 20.3 8.8 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.5 4.9 5.0 SP SP SP NC 5.0 5.9

Age-adjusted 

mortality rateb 548.1 725.1 719.9 672.3 701.7 515.1 NC 730.6 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 9.9 14.4 14.1 27.3 9.9 7.9 17.9 14.1 13.6

Percent with 

diabetesc 6.2 7.4 7.1 9.0 16.0 6.4 6.4 7.2 10.8

Percent with 

heart diseasec 1.6 2.6 2.6 0.0 3.3 1.6 0.7 2.4 4.3

HIV rated 201.1 NC 92.7 1028.3 100.8 95.4** 164.7 116.4 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

60.5 62.7 62.7 55.0 62.5 63.2 61.5 62.6 72.2

Percent received 

oral health visit 

(past 12 months)c

63.5 74.9 74.9 67.1 47.0 65.9 62.3 73.6 66.5

Percent received 

flu vaccinec 27.7 37.4 37.2 19.7 35.5 33.5 30.2 36.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 95.4 per 100,000 population (56 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 23.7 per 

100,000 population (5 cases).

State and Territorial Efforts to Reduce Health Disparities 236
Vermont

Introduction to Vermont’s Health Equity Activities

Vermont had an estimated 2016 population of 625,000. The largest racial-ethnic minority populations are Hispanics/

Latinos (2 percent), followed by Asian Americans and NHOPI (1 percent), Blacks/African Americans (1 percent), and 

American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 3 

percent of the population.1 Approximately 12,000 Vermont residents live within a primary care health professional 

shortage area.2

The Office of Health Equity (OHE) is located within the Vermont Department of Health (VDOH). Both the OHE and 

the VDOH seek to improve health equity by addressing avoidable inequalities, particularly for those who have 

experienced socioeconomic disadvantage and social injustice.3 Because all offices and programs within the VDOH 

share a responsibility to address health equity, the OHE collaborates with other VDOH divisions. 

Vermont Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

The Vermont Department of 

Health Strategic Plan 2014-20184

identifies health equity as a 

strategic goal.

Date strategic plan 

was last updated 2016

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Office of Health Equity 

monitors progress through the 

Social Determinants of Health/

Health Equity Scorecard.5

Key strategies 

used to achieve 

health equity

• Collecting diversity data

• Building community partnerships

• Fostering cultural competence 

throughout the Vermont 

Department of Health

Organizational Structure

Located within the planning unit of the VDOH Commissioner’s Office, the OHE does not have a committee 

or panel advising on minority health or health equity 

issues. The OHE’s director, its only staff member, 

dedicates half of her time to disparity reduction 

initiatives. However, because the topic is an overarching VDOH priority, staff throughout the department 

dedicate time to advancing health equity.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OHE is housed within the 

Vermont Department of Health.

SMHE staffing 

(full-time equivalents) 0.5

Advisory committee 

or panel None

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Vermont Department of Health’s Health Equity website. Last accessed 7/31/17.

4 Vermont Department of Health‘s Strategic Plan 2014-2018 (2014). Available on the VDOH website. Last accessed 7/31/17.

5 Social Determinants of Health: Health Equity Scorecard (2017). Available on the VDOH website. Last accessed 7/31/17.

State and Territorial Efforts to Reduce Health Disparities 237
Vermont

Program Goals and Activities

Acronym List

Full Name of Agency Acronym Acronym

Office of Health Equity OHE

Vermont Department of Health VDOH

Health equity is one of six goals identified in the 

Vermont Department of Health Strategic Plan 2014-

2018. Last updated in 2016, the plan outlines three 

strategic directions to help realize this objective: 

(1) reduce health disparities in communities that 

experience a disproportionate burden of disease, 

(2) recruit and retain qualified candidates from diverse 

backgrounds, and (3) translate documents for people 

with limited English proficiency. The plan, as well as 

accompanying performance scorecards that the VDOH 

uses to monitor progress on its goals, are publicly 

available on the VDOH’s website. Each scorecard tracks 

statewide population data and program performance 

measures; one specifically focuses on social determinants of health and health equity.

The VDOH Commissioner’s Office sets health equity 

goals and uses data to drive decision-making. To that 

end and in collaboration with the Division of Health 

Surveillance, a major OHE strategy is to assist in data 

collection and analysis. For example, the OHE works with 

each division of the VDOH to examine data for potential 

disparities and inequities; it also has enhanced Healthy 

Vermonters 2020,6 the state’s Health Assessment Plan, 

by adding five new data elements focusing on social 

determinants of health. The OHE will continue to 

advocate for inclusion of health disparities measurement in future updates of the State Health Assessment 

Plan and State Health Improvement Plan.

In line with the VDOH strategic plan, the OHE works to 

foster cultural competence throughout the department. 

The National Standards for Culturally and Linguistically 

Appropriate Services in Health and Health Care, which 

emphasize structural and systemic changes to improve 

cultural competence, provide the framework for these 

efforts. New hires are required to complete online 

cultural competency training within 60 days of hire. 

The department is expanding and revising this training, 

and is developing additional ongoing educational opportunities for staff engagement related to cultural competence. In addition, both the OHE and the VDOH support 

best practices to recruit and retain candidates from 

diverse backgrounds. Both the department and the 

OHE are also committed to language access efforts, 

per the VDOH Strategic Plan’s directive to translate 90 

percent of the VDOH’s translation committee-identified 

health documents and related materials by 2017. 

Partnerships

Primary 

collaborators

• Burlington Local Health Office

• Pride Center of Vermont

• Refugee Health Committee

• Vermont Agency of Human Services

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding

Partnerships are at the core of the OHE’s work. 

As such, it collaborates with both governmental 

and nongovernmental entities committed to achieving 

health equity. One natural partner is the Refugee 

Health Committee, which is chaired by the OHE 

director in her capacity as the VDOH’s Refugee Health 

Program’s refugee health coordinator. The committee 

meets bimonthly to address community needs, 

issues, and concerns related to refugee health. 

Its membership includes health workers, community 

organizations, representatives from the U.S. Committee 

for Refugees and Immigrants (Vermont’s resettlement 

agency), and others. The OHE director’s dual role with 

the Refugee Health Program has also strengthened 

the VDOH’s relationship with the refugee resettlement 

agency working in Vermont. In addition, the OHE has 

been meeting with the Sudanese Foundation of 

Vermont to better understand needs and interests 

affecting the health of Vermont’s Sudanese community. 

The OHE also partners with the Burlington Local Health 

Office, one of 12 district offices reporting to the VDOH, 

to support interpreter training and emergency 

preparedness. Burlington’s office oversees the state’s 

most diverse region, which has the largest health 

disparities and is a key site for refugee resettlement. 

The OHE also leads several Equal Employment 

Opportunity efforts for the VDOH’s parent entity, the 

Vermont Agency of Human Services, and facilitates 

health equity-related partnerships for other VDOH 

divisions. For example, the OHE has helped establish 

a relationship between the Vermont Tobacco Control 

Program and the Pride Center of Vermont to develop 

6 State Health Assessment Plan: Healthy Vermonters 2020 (2012). Available on the VDOH website. Last accessed 7/31/17.

State and Territorial Efforts to Reduce Health Disparities 238
Vermont

smoking cessation efforts targeting the lesbian, gay, 

bisexual, and transgender (LGBT) populations. In fact, 

the OHE also established its own partnership with the 

Pride Center of Vermont to address issues related to 

HIV, hepatitis C, and alcohol and drug abuse in LGBT 

communities. Although some VDOH programs and 

offices have formal relationships with the Pride Center 

of Vermont to address these issues, the OHE itself 

does not have a contract or memorandum of 

understanding with any partners.

Finally, the OHE partners with a variety of organizations 

focusing on rural and agricultural communities. 

For example, the OHE participates in the Farm Health 

Task Force,7 which aims to build and sustain a 

healthy farm workforce through targeted informationsharing and outreach efforts related to farm safety, 

migrant and immigrant farm worker health, and 

practitioner education.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

N/A

Annual budget (FY 2015) of SMHE 

from state/territorial government N/A

Largest funding source N/A

Anticipated changes to budget None

The OHE receives no direct funding from the state 

or other sources for its operations. The OHE director/

refugee health coordinator position is funded through 

grants to address specific health issues that disproportionately affect minorities (e.g., substance use disorders and emergency preparedness).

7 Information about the Vermont Farm Health Task Force is available on the Champlain Valley Area Health Education Center’s website. 

Last accessed 7/31/17.

State and Territorial Efforts to Reduce Health Disparities 239
Vermont

Vermont State Data

Total Populationa: 

624,594

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 2.0 98.1 94.2 0.9 0.5 1.2 3.2 100.0 NA 

Percent of population 

medically uninsureda 0.3 3.6 3.4 19.6 0.0 2.1 3.6 3.5 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 4.5 4.7 SP SP SP NC 4.6 5.9

Age-adjusted 

mortality rateb 319.2 715.2 717.1 636.9 SP 480.5 NC 712.8 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 18.9 15.5 15.6 15.9 22.6 5.5 17.0 15.5 13.6

Percent with 

diabetesc 3.6 8.4 8.3 6.2 25.0 6.4 9.2 8.4 10.8

Percent with 

heart diseasec 1.1 3.7 3.6 0.0 19.1 3.0 4.7 3.7 4.3

HIV rated 604.5 NC 101.9 1068.4 0.0 103.2** 337.0 123.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

68.2 70.2 70.4 63.0 66.7 75.6 62.9 70.3 72.2

Percent received 

oral health visit 

(past 12 months)c

65.1 72.3 72.7 55.1 40.6 83.7 65.1 72.2 66.5

Percent received 

flu vaccinec 48.4 41.5 42.2 29.2 34.5 25.4 40.4 41.7 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 103.2 per 100,000 population (9 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 609.8 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 240
Virginia

Introduction to Virginia’s Health Equity Activities

Virginia had an estimated 2016 population of 8,412,000. Blacks/African Americans are the largest racial-ethnic 

minority population (19 percent), followed by Hispanics/Latinos (9 percent), Asians/Pacific Islanders (7 percent), 

and American Indians/Alaskan Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 6 percent of the population.1 Approximately 1,528,000 Virginia residents live within a primary care health 

professional shortage area.2

The Virginia Department of Health’s (VDH) Office of Health Equity (OHE) includes the Division of Multicultural Health 

and Community Engagement, the Division of Rural Health, the Division of Social Epidemiology, and the Primary Care 

Office. The OHE’s initiatives and activities address minority health, health disparities, and health equity. Its mission 

is to identify health disparities and their root causes, and to promote equitable opportunities to be healthy.3 The OHE 

director also serves as a senior adviser on minority health to the Virginia State Health Commissioner. 

Virginia Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

At the time of data collection, both the 

Virginia Department of Health and the 

Office of Health Equity were developing 

strategic plans that address minority 

health, health disparities, and health 

equity as part of the larger goal of 

improving the health of all Virginians.

Date strategic plan 

was last updated 2014

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Virginia Department of Health 

strategic plan evaluates inequality and 

disparities at a community level. 

Key strategies 

used to achieve 

health equity

• Policies: Improve internal policies 

to bolster the Virginia Department 

of Health infrastructure to address 

health equity.

• Education: Educate staff of the 

Virginia Department of Health and 

other government agencies, and 

inform the public about health equity.

• Programming: Support faith-based 

community programs to promote 

health prevention, and school-based 

programs to increase high school 

graduation rates.

Organizational Structure

The OHE includes the Division of Multicultural 

Health and Community Engagement, the Division 

of Rural Health, the Division of Social Epidemiology, 

and the Primary Care Office. Its purview includes 

minority health, health disparities, and health equity 

in the context of other initiatives and activities. The 

OHE director serves as a senior adviser on minority 

health to the Virginia State Health Commissioner. 

In addition, the Commissioner’s Advisory Committee 

on Health Disparities and Health Equity serves as a 

resource on minority health, health disparities, and 

health equity. Its tasks are to identify the limits of 

current services, programs, regulations, and laws; 

review disease prevention and health promotion 

strategies; support legislation and policies to 

improve health service delivery and accessibility; 

and make recommendations to the Virginia State 

Health Commissioner.4

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. 

Designated Health Professional Shortage Areas Statistics: 

First Quarter of Fiscal Year 2018 Designated HPSA Quarterly 

Summary.

3 Virginia Department of Health. Division of Multicultural Health 

and Community Engagement. Available on the VDH website.

4 Virginia Department of Health, Office of Health Equity. 

Commissioner’s Advisory Council on Health Disparity and 

Health Equity. Available on the VDH website.

State and Territorial Efforts to Reduce Health Disparities 241
Virginia

The OHE has 13 full-time staff members, 2 part-time 

staff members, and 8 contractors. Its staff members 

work on all activities in the OHE’s four units. The OHE 

staff include an office director, a director of multicultural health and community engagement, a director 

of primary care and rural health, a social epidemiology 

and shortage designations manager, a senior policy 

adviser, a Partners in Prayer and Prevention coordinator, a social epidemiologist, a social epidemiologist/

spatial analyst, two health workforce coordinators, a 

health equity specialist, a community health specialist, 

a rural health specialist, a health workforce specialist, 

a social epidemiologist assistant, a communications 

specialist, a human resource analyst, and a program 

support technician. The OHE’s Division of Multicultural 

Health and Community Engagement also has one 

unpaid intern. The OHE does not expect staffing 

to change in the next 2 years.

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OHE is housed within the 

Virginia Department of Health.

SMHE staffing 

(full-time equivalents) 13

Advisory committee 

or panel

Commissioner’s Advisory Council 

on Health Disparity and Health 

Equity

Program Goals and Activities

The OHE was developing a strategic plan at the time of 

data collection. The VDH strategic plan for 2014–2016 

addressed health equity as part of its goal to improve 

the health of all Virginians. It included an assessment 

process, with associated metrics, and addressed health 

equity by evaluating inequalities and disparities at a 

community level across Virginia. The OHE strategic 

plan will align with the VDH strategic plan. The OHE’s 

priorities are informed by a state health equity report, 

communicating with stakeholders, and analyzing 

health data. The Virginia Health Opportunity Index, a 

composite of 13 environmental, social, demographic, 

and educational indicators that relate to each community’s well-being, was established by the OHE and helps 

identify areas needing intervention. It includes metrics 

calculated at census tract and county levels.5

Acronym List

Full Name of Agency Acronym Acronym

Virginia Department of Health VDH

Office of Health Equity OHE

Division of Multicultural Health and 

Community Engagement DMHCE

The OHE employs a range of strategies to achieve 

health equity. One is to bolster the VDH infrastructure 

through internal policymaking to advocate for health 

equity. By integrating health equity into strategic planning processes, such as the State Health Improvement 

Plan or the VDH strategic plan, the OHE believes that 

the VDH is better prepared to engage in health equity 

activities in Virginia.

Another strategy relates to enhancing cultural competency. Specifically, the OHE educates VDH staff and 

local health department staff on health equity issues 

using a cultural competency training series. During 

quarterly training sessions, VDH staff can attend in 

person or by videoconference. The OHE also educates 

the broader public through speaking engagements 

on health equity and social determinants of health.

Through its programming strategy, the OHE is collaborating in a faith-based community program called 

Partners in Prayer and Prevention, which derived from 

a previous initiative called Congregations for Million 

Hearts. Partners in Prayer and Prevention facilitates 

partnerships with faith and interfaith organizations, 

marginalized communities, and the VDH. The OHE 

initially focused on targeted distribution of VDHapproved information on prevention of the Zika virus.6

However, the OHE later expanded this strategy to target 

chronic diseases. 

5 Virginia Department of Health, Office of Health Equity. Virginia Health Opportunity Index. Available on the VDH website.

6 Virginia Department of Health. Partners in Prayer and Prevention (P3). Available on the VDH website.

State and Territorial Efforts to Reduce Health Disparities 242
Virginia

Partnerships

Primary 

collaborators

• American Heart Association

• Danville Public Schools

• Pittsylvania/Danville Health District

• Virginia Oral Health Coalition

• Virginia Commonwealth University 

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships

The OHE collaborates with several partners to address 

minority health, health disparities, and health equity 

issues. As part of its education strategy, the OHE 

disseminates information (e.g., via newsletter) about 

educational opportunities and community events 

(e.g., town halls or trainings) sponsored both by governmental and nongovernmental organizations across 

Virginia. For instance, the Virginia Commonwealth University’s Center on Health Disparities holds a monthly 

Health Disparities Roundtable lecture and discussion 

series, which the OHE recounts in its newsletter.

It also has informal partnerships across several activities with Virginia Commonwealth University’s Center on 

Health Disparities, Center on Society and Health, and 

Department of Family Medicine and Population Health. 

The Center on Health Disparities develops the capacity 

of students, staff, faculty, and community partners 

to identify and develop interventions to reduce health 

disparities.7 Staff from the OHE sits on the Center on 

Health Disparities’ steering committee and assists with 

the center’s community engagement programs. The 

University’s Center on Society and Health studies the 

implications of social factors on health8 and is working 

with the Department of Family Medicine and Population 

Health and the Robert Graham Center for Policy Studies 

in Family Medicine and Primary Care to merge census 

and electronic health records data, connecting economic 

and social challenges with patients’ health.9 The Center 

on Society and Health informally advises the OHE on 

data analysis, such as the Virginia Health Opportunity 

Index. The OHE also engages other academic institutions as stakeholders when identifying priorities.

Informal collaborations between the OHE and the American Heart Association grew out of the OHE’s work with 

Congregations for Million Hearts, a faith-based initiative 

for raising awareness about reducing the risks of stroke 

and heart disease.10 The OHE seeks to align that initiative (now known as Partners in Prayer and Prevention) 

with the American Heart Association’s EmPOWERED to 

Serve program, which works with multicultural communities to increase healthy living behaviors.

The OHE informally collaborates with the Virginia Oral 

Health Coalition, and recognizes that oral health is 

unavailable and/or inaccessible to many vulnerable 

individuals and communities. To advance oral health 

equity, an OHE representative sits on the Virginia Oral 

Health Coalition’s clinical advisory board, and attends 

and presents at various community, regional, and board 

meetings. The OHE director presented at the annual 

Virginia Oral health Summit in 2016.11

Some of the OHE’s partnerships are more formal. 

For example, the OHE formally collaborates with the 

Pittsylvania/Danville Health District and Danville Public 

Schools. Danville has Virginia’s lowest on-time graduation rate, and its graduation rate is much lower among 

boys and African Americans than girls and members 

of other racial and ethnic groups. The collaboration 

supports implementation of the Youth Health Equity 

Leadership Initiative, which provides targeted ninthgrade students with leadership and self-efficacy skills, 

with the goal of improving the on-time graduation rate 

among racial and ethnic minority youth.12

7 Virginia Commonwealth University Center on Society and Health, About the Center on Society and Health website.

8 Virginia Commonwealth University Center on Society and Health. About the Center on Society and Health website. 

9 Virginia Commonwealth University Center on Society and Health. (2017). Community Vital Signs website.

10 Virginia Department of Health. Congregations for Million Hearts. Available on the VDH website.

11 Virginia Oral Health Coalition. 2016 Virginia Oral Health Summit. Available at the Virginia Oral Health’s website.

12 U.S. Department of Health and Human Services Office of Minority Health. Grant Program; STATE PARTNERSHIP INITIATIVE TO ADDRESS 

HEALTH DISPARITIES (SPI). 

State and Territorial Efforts to Reduce Health Disparities 243
Virginia

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$2,900,000

Annual budget (FY 2015) of SMHE 

from state/territorial government Unavailable

Largest funding source Unavailable 

Anticipated changes to budget None

The total FY 2015 funding for the OHE was 

$2,900,000. The OHE funds activities related to its 

four units, including rural health, primary care, social 

epidemiology and data analysis, and multicultural 

health and community engagement. The OHE received 

a grant for $200,000 from the U.S. Office of Minority 

Health to implement the Youth Health Equity Leadership Initiative with the Pittsylvania/Danville Health District and Danville Public Schools.13 The OHE does not 

expect funding to change in the next 2 years. The OHE 

does not provide funding to nongovernmental entities.

13 U.S. Department of Health and Human Services Office of Minority Health. Grant Program; STATE PARTNERSHIP INITIATIVE TO ADDRESS 

HEALTH DISPARITIES (SPI). 

State and Territorial Efforts to Reduce Health Disparities 244
Virginia

Virginia State Data

Total Populationa: 

8,411,808

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 9.0 91.0 68.0 19.0 0.3 6.5 6.3 100.0 NA 

Percent of population 

medically uninsureda 25.6 7.3 7.8 10.0 6.8 8.1 19.6 9.0 10.2

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.0 6.2 4.8 10.1 SP 4.0 NC 5.9 5.9

Age-adjusted 

mortality rateb 342.2 728.4 708.5 850.8 292.6 360.6 NC 715.5 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 11.2 13.5 13.2 15.7 15.0 10.2 12.8 13.5 13.6

Percent with 

diabetesc 4.3 11.0 10.5 14.9 10.8 3.9 5.0 10.6 10.8

Percent with 

heart diseasec 0.7 3.9 4.0 4.0 7.0 0.3 3.4 3.8 4.3

HIV rated 338.0 NC 135.5 949.6 83.5 58.2** 498.7 307.7 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

67.7 76.1 74.7 83.7 66.4 75.0 63.4 75.9 72.2

Percent received 

oral health visit 

(past 12 months)c

59.7 72.3 73.7 66.2 50.9 76.2 57.3 71.6 66.5

Percent received 

flu vaccinec 33.6 43.5 45.0 38.4 30.1 40.0 40.2 43.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 58.2 per 100,000 population (258 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 160.7 per 

100,000 population (8 cases).

State and Territorial Efforts to Reduce Health Disparities 245
Washington

Introduction to Washington’s Health Equity Activities

Washington had an estimated 2016 population of 7,288,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (12 percent), followed by Asian Americans and NHOPI (9 percent), Blacks/African Americans (4 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 

11 percent of the population.1 Approximately 3,230,000 Washington residents live within a primary care health 

professional shortage area.2

In 2006, the Washington State Legislature created the Governor’s Interagency Council on Health Disparities (GICHD) 

to eliminate racial, ethnic, and gender-based health disparities by race, ethnicity, and gender in the state. Of its 17 

members, 14 represent state agencies or consumer groups and 3 are appointed by the governor.3 The GICHD makes 

policy recommendations regarding cultural competency and other health equity issues and develops the State Policy 

Action Plan to Eliminate Health Disparities. Additionally, the Washington State Department of Health’s (DOH) Health 

Equity Workgroup was established in 2014 to lead and support initiatives to achieve health equity. 

Washington Minority Health Overview

Name of state/territorial 

minority health entity Governor’s Interagency Council on Health Disparities

Strategic plan in place to 

address minority health 

or health equity

Governor’s Interagency Council on Health Disparities: State Action Plan to Eliminate 

Health Disparities

Date strategic plan was last 

updated December 2016

Assessment plan in place 

to measure progress toward 

reducing health disparities

There is no formal assessment plan, but the Governor’s Interagency Council on Health 

Disparities plans to collect data on 16 key indicators. 

Key strategies used to 

achieve health equity

Governor’s Interagency Council on Health Disparities:

• Health impact reviews

• Implementing National Standards for Culturally and Linguistically Appropriate Services 

in Health and Health Care 

DOH Health Equity Workgroup:

• Building infrastructure and workforce to support health equity (e.g., improving data 

collection with the Health Disparity Tool, forging partnerships)

• Evaluating the impact of proposed legislation on health equity and tribal health 

• Educating DOH staff, partners, and the public about health equity and diversity

• Requiring diversity and inclusion training for all DOH staff

• Promoting use of DOH’s Health Disparities Index 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 Governor’s Interagency Council on Health Disparities: About Us. Available on the state’s “healthequity” website. Last accessed 

8/5/17Health Equity. Available on the VDH website.

State and Territorial Efforts to Reduce Health Disparities 246
Washington

Organizational Structure

The GICHD, established by state legislation, is independent and completely distinct from the DOH. Its 

co-chairs are gubernatorial appointees, and all 17 

volunteer members who commit time to Council activities. Several staff members from the State Board of 

Health support the GICHD (e.g., the GICHD manager 

is employed by the State Board of Health and devotes 

100 percent time to minority health and health equity 

activities). Several staff from the Washington State 

Board of Health also support the Council as part of 

their day-to-day responsibilities. In addition, the DOH 

has three staff members who spend 100 percent time 

on health equity activities.

Ad hoc advisory committees help the GICHD develop 

policy recommendations. For each GICHD-identified 

priority topic area, the legislature mandates the formation of an advisory committee—comprised of members 

from different races, ethnicities, genders, and organization affiliations—to aid the GICHD in developing 

policy recommendations. Once the GICHD issues policy 

recommendations for the topic area, the advisory committee disbands. 

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The GICHD is an independent 

body, distinct from the DOH.

SMHE staffing 

(full-time equivalents) 3 (plus 17 volunteers)

Advisory committee 

or panel

By statute, ad-hoc advisory 

committees must be convened 

to guide the GICHD in providing 

policy recommendations to the 

governor and legislature.

Within the DOH, the Health Equity Workgroup includes 

diverse staff from across the department. Official 

responsibilities of five workgroup members explicitly 

identify health equity, and each devotes a portion of 

their time to health equity activities. They include: a 

director of community relations and equity (40 percent), 

a chief of civil rights and risk management (60 percent), a tribal liaison (100 percent), a community relations and equity consultant (100 percent), and a health 

equity consultant (100 percent). Other DOH staff spend 

time supporting minority health through their work 

on broader health initiatives. Volunteers and student 

interns occasionally support the DOH and the Health 

Equity Workgroup on minority health efforts.

Program Goals and Activities

The GICHD developed its first State Action Plan to 

Eliminate Health Disparities in 2010, which it updated 

in December 2016.4 The Action Plan includes recommendations for the governor and legislature to eliminate health disparities. The GICHD’s authorizing statute 

lists 16 diseases and conditions that the Council must 

address. To establish its priorities, the GICHD obtains 

input from various sources, including its authorizing 

legislation, topical briefings, and community input. 

Although the GICHD does not have a formal assessment plan to measure progress toward reducing health 

disparities, it plans to monitor data on the 16 diseases 

and conditions specified in the statute. Health equity 

is also a guiding principle of the DOH’s 2017–2019 

Strategic Plan, which identifies health disparity reduction and ensuring health equity among two of its six 

core goals.5

Established by the Secretary of Health in 2014, the 

Health Equity Workgroup is comprised of staff representing DOH divisions and has an internal work plan 

that specifies strategies and activities to reduce health 

disparities. The work plan aligns with the GICHD’s 

recommendations and federal priorities for reducing 

health disparities. Available health disparity data, along 

with community input, help drive priority setting within 

the DOH. 

The GICHD promotes health equity through state action 

planning and other ongoing activities. In collaboration 

with the Washington State Board of Health, the GICHD 

supports health impact reviews for proposed legislation 

and budgetary changes. These health impact reviews 

assess how a bill would likely affect health and health 

disparities. The governor or any state legislator can 

request a health impact review for any legislative proposal or budgetary change.6

4 Governor’s Interagency Council on Health Disparities: State Action Plan to Eliminate Health Disparities. Available on the Governor’s Interagency 

Council on Health Disparities’ website. Last accessed 8/5/2017.

5 Department of Health Strategic Plan: September 2016-August 2019. Available on the Washington State Department of Health website. 

Last accessed 8/5/2017.

6 Washington State Board of Health. Health Impact Reviews. Available on the DOH website. Last accessed 8/5/17.

State and Territorial Efforts to Reduce Health Disparities 247
Washington

Acronym List

Full Name of Agency Acronym Acronym

Governor’s Interagency Council on Health 

Disparities GICHD

Department of Health DOH

Another priority for both the GICHD and the DOH is 

implementation of the National Standards for Culturally 

and Linguistically Appropriate Services in Health and 

Health Care (National CLAS Standards). In partnership 

with the DOH, the GICHD developed online training 

modules about the National CLAS Standards that are 

specific to Washington and appropriate for health care 

providers and state agency staff. The GICHD is encouraging state agencies to adopt and implement the 

National CLAS Standards. Within the DOH, the Center 

for Public Affairs is leading efforts to implement the 

Standards. Specifically, the Center for Public Affairs 

is consulting with staff across the DOH to develop 

program-specific plans for the National CLAS Standards 

implementation, identify existing cultural or linguistic 

barriers, and determine how program staff can overcome obstacles with available resources. 

The GICHD also views promoting equity in state 

government as a strategy to achieve health equity. 

In its State Action Plan to Eliminate Health Disparities, 

the GICHD urged the governor to consider issuing 

policies to, for example, diversify the government 

workforce to better reflect state demographics, 

improve the “cultural humility” of state employees, 

and ensure that state-supported organizations promote 

health equity.7

In addition to the GICHD’s efforts, the DOH’s Health 

Equity Workgroup is responsible for identifying and 

supporting strategies that promote health equity. 

For example, to better evaluate the impact of proposed legislation on health equity and tribal health, 

the Health Equity Workgroup successfully promoted 

the inclusion of two new questions to the standard bill 

analysis template—one addressing health equity and 

one addressing tribal health. Health Equity Workgroup 

members then assessed how these new questions 

are used by conducting interviews with senior leaders 

and reviewing how legislative analysts answered these 

questions. In response to their findings, workgroup 

members developed targeted training and resource 

materials. The Health Equity Workgroup plans to continue investigating the health equity and tribal health 

components of the bill analysis template as part of 

continuing quality improvement efforts. 

To promote health equity dialogue among DOH staff, 

the Health Equity Workgroup organizes a lecture series, 

Health Equity & Diversity (HED) Talks, in which guest 

speakers discuss health equity or diversity issues with 

DOH staff. The HED Talks occur three times per year, 

and each is followed by an opportunity for DOH staff 

to meet and discuss presentation content in small 

groups. Other activities supported by the Health Equity 

Workgroup include staff training and promoting the 

use of the Health Disparities Index—a part of the DOH 

Washington Tracking Network’s Information by Location tool.

Partnerships

Primary 

collaborators

• Community-based organizations 

• Racial and ethnic state commissions

• State agencies

• State Board of Health

• Tribal entities

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships

Organizations represented within the GICHD membership are key GICHD partners in the effort to achieve 

health equity. These include state agencies (i.e., 

Department of Agriculture, Department of Commerce, 

Department of Early Learning, Department of Ecology, 

Department of Health, Department of Social and 

Health Services, Health Care Authority, Office of Superintendent of Public Instruction, State Board of Health, 

and Workforce Training and Education Coordinating 

Board). Commissions represented within the GICHD 

membership (i.e., American Indian Health Commission, 

Commission on African American Affairs, Commission 

on Asian Pacific American Affairs, and Commission 

on Hispanic Affairs) also collaborate heavily with 

the GICHD. 

7 Governor’s Interagency Council on Health Disparities: State Action Plan to Eliminate Health Disparities. Available on the Governor’s Interagency 

Council on Health Disparities’ website. Last accessed 8/5/2017.

State and Territorial Efforts to Reduce Health Disparities 248
Washington

Several community-based organizations partner 

with the DOH to advise and implement programs. 

For example, to address disparities around chronic 

disease prevention, the DOH collaborates with the 

Center for MultiCultural Health, El Centro de la Raza, 

and Asian Pacific Islander Coalition Advocating Together 

(APICAT). The Gay City Health Project, which serves the 

lesbian, gay, bisexual, transsexual, and questioning 

community, works with the DOH on activities related to 

HIV/AIDS disparities, as well as tobacco and marijuana 

use prevention. 

To facilitate coordination and partnership with Washington’s tribal entities, a DOH staff member serves 

as a full-time tribal liaison, meeting monthly both 

with the Secretary of Health and tribal health leaders 

to discuss health issues and priorities. The American 

Indian Health Commission and the Seattle Indian 

Health Board are also key partners in addressing 

equity issues affecting the state’s Indian populations. 

Contractual work with the American Indian Health 

Commission focuses primarily on chronic disease 

prevention and maternal and child health.

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

$137,000 to support 

the Governor’s 

Interagency Council 

on Health Disparities

Annual budget (FY 2015) of SMHE 

from state/territorial government $137,000

Largest funding source State

Anticipated changes to budget Unknown

In FY 2015, the State Board of Health received 

$137,000 from the state to support the GICHD. 

Funding for GICHD support has been steady at this 

level since FY 2012. Additionally, since FY 2012, the 

state has allocated $94,000 to the State Board of 

Health for health impact reviews. In FY 2015, no federal funding supported GICHD operations or activities.

The DOH did not have dedicated funding for health 

equity work in FY 2015. Minority health and health 

equity work is part of broader DOH activities funded 

by state and/or federal sources and, therefore, cannot 

be disaggregated. While some DOH staff are fully 

dedicated to minority health and health equity initiatives, many other staff support minority health through 

population health initiatives that integrate health 

equity approaches, creating a challenge in determining 

total budgetary resources for staff salaries. The DOH 

provides funding to several partner organizations to 

advance health equity, including the Center for MultiCultural Health, the American Indian Health Commission 

for Washington State, the Seattle Indian Health Board, 

Gay City Health Project, El Centro de la Raza, and the 

Asian Pacific Islander Coalition Against Tobacco.

State and Territorial Efforts to Reduce Health Disparities 249
Washington

Washington State Data

Total Populationa: 

7,288,000

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 12.4 87.6 75.7 3.7 1.3 8.8 10.5 100.0 NA 

Percent of population 

medically uninsureda 16.5 4.5 4.9 6.7 14.8 5.1 13.5 6.0 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 4.6 4.7 4.6 8.5 SP 4.2 NC 4.9 5.9

Age-adjusted 

mortality rateb 464.0 679.6 686.4 729.9 844.4 413.4 NC 672.0 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 12.9 15.1 15.4 18.8 27.4 6.9 14.8 14.9 13.6

Percent with 

diabetesc 7.3 9.6 9.6 13.3 14.7 6.4 7.9 9.4 10.8

Percent with 

heart diseasec 1.5 3.9 4.2 2.3 4.2 1.4 2.2 3.7 4.3

HIV rated 273.8 NC 173.2 878.3 167.9 82.5** 389.8 208.3 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

58.5 65.7 65.2 71.5 61.3 66.1 61.3 65.2 72.2

Percent received 

oral health visit 

(past 12 months)c

57.1 70.1 70.0 64.0 56.5 72.7 61.9 69.2 66.5

Percent received 

flu vaccinec 33.0 40.9 41.3 29.9 36.7 40.7 33.1 40.3 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 82.5 per 100,000 population (412 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 143.4 per 

100,000 population (54 cases).

State and Territorial Efforts to Reduce Health Disparities 250
West Virginia

Introduction to West Virginia’s Health Equity Activities

West Virginia had an estimated 2016 population of 1,831,000. Blacks/African Americans are the largest racial-ethnic 

minority population (4 percent), followed by Hispanic/Latinos (1 percent), Asian Americans and NHOPI (1 percent), 

and American Indians/Alaska Natives (less than 1 percent). Persons self-identifying as multiracial or “other race” 

comprise 2 percent of the population.1 Approximately 628,000 West Virginia residents live within a primary care 

health professional shortage area.2

The Department of Health and Human Resources (DHHR), Bureau of Public Health’s (BPH) Office of Minority Health 

(OMH) was established in 2014. The OMH addresses barriers to health care, risk reduction, healthier lifestyle 

choices, health care service usage, health promotion, and disease prevention.3 Its mission is to “eliminate health 

disparities for vulnerable populations as defined by race/ethnicity, socio-economic status, geography, age, disability 

status, and among other populations identified to be at-risk for health disparities.”4

West Virginia Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Minority Health

Strategic plan in 

place to address 

minority health 

or health equity

The Office of Minority Health 

plans to develop a strategic plan 

regarding minority health, health 

disparities, and health equity.

Date strategic plan 

was last updated N/A.

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

The Office of Minority Health’s 

strategic plan will include an 

assessment plan.

Key strategies 

used to achieve 

health equity

• Reduce and eliminate tobacco 

use in targeted minority 

populations.

• Reduce and eliminate obesity 

and diabetes as well as promote 

healthy lifestyles.

• Address behavioral health and 

substance abuse.

Organizational Structure

The OMH addresses the health of minority populations by bringing a focus on health equity issues to the 

DHHR’s health promotion efforts. The Minority Health 

Advisory Team, established by the OMH, is comprised 

of professionals from public and private sector organizations and advises the OMH around the development 

of programs and services necessary to eliminate health 

disparities. It is also assisting the OMH in developing its 

first Minority Health Strategic State Plan. The OMH has 

one full-time staff position (currently vacant) who serves 

as the BPH’s minority health coordinator and dedicates 

100 percent time to health equity initiatives. The OMH, 

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated 

Health Professional Shortage Areas Statistics: First Quarter of 

Fiscal Year 2018 Designated HPSA Quarterly Summary.

3 West Virginia Department of Health and Human Resources, 

Bureau of Public Health, Office of Minority Health. (July 2013). 

Office of Minority Health CHARTER.

4 West Virginia Department of Health and Human Resources, 

Bureau for Public Health, Office of Minority Health. Activities 

Report 2016 (July 1, 2015 – June 30, 2016).

State and Territorial Efforts to Reduce Health Disparities 251
West Virginia

BPH, and DHHR also have volunteers who work on 

minority health, health disparities, and health equity. 

Staff allocations are not expected to change. 

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OMH is housed within the 

West Virginia Department of 

Health and Human Resource, 

Bureau of Public Health’s Health 

Improvement Section

SMHE staffing 

(full-time equivalents) 1 (vacant)

Advisory committee 

or panel Minority Health Advisory Team

Program Goals and Activities

Overarching goals of the OMH are to promote and 

strengthen health data collection; increase awareness 

of major health issues affecting vulnerable populations; 

establish and strengthen coalitions and partnerships 

to solve health problems; develop practices, programs, 

and policies that achieve health equity; and provide 

training, seminars, and technical assistance.5

The OMH plans to develop a strategic state plan, which 

will include a process to evaluate progress towards 

specific goals. In the meantime, the DHHR strategic 

plan identifies priorities that contribute to the OMH’s 

goals and activities. The OMH also prioritizes activities 

based upon analyses of health data. One such analysis 

has identified vulnerable populations not previously 

recognized. The OMH is also addressing data improvement efforts. For instance, the DHHR conducts a 

behavioral health risk factors survey,6 but until recently, 

it had not consistently collected gender identity and/or 

sexual orientation information. Emerging evidence from 

recent data analyses indicate that the lesbian, gay, 

bisexual, or transsexual (LGBT) populations are among 

the most vulnerable in the state. Such evidence allows 

the OMH to set priorities to address health disparities 

affecting LGBT communities. 

Acronym List

Full Name of Agency Acronym Acronym

Department of Health and Human 

Resources DHHR

Bureau for Public Health BPH

Office of Minority Health OMH

The OMH makes use of several strategies to improve 

minority health and health equity in the state. Such 

strategies target particularly vulnerable minority populations. For example, to reduce tobacco use, the OMH 

collaborates with the Division of Tobacco Prevention, 

along with other state and federal programs, to provide 

services and educate targeted minority populations 

across the state. 

In 2014, West Virginia had the second-highest prevalence of obesity (i.e., 36 percent of its population) 

and the fourth-highest prevalence of diabetes (i.e., 14 

percent of its population) nationally.7 As part of its 

strategy to address obesity and diabetes, the OMH 

collaborates with the Division of Health Promotion and 

Chronic Disease and the Bureau for Medical Services, 

among other organizations, to assist individuals with diabetes, prediabetes, and obesity by connecting Medicaid 

recipients with diabetes self-management programs and 

diabetes prevention programs, among other aspects of 

the program. The OMH also has increased awareness of 

oral health, physical activity, and nutrition through education, and by providing screening information.

5 West Virginia Department of Health and Human Resources, Bureau of Public Health, Office of Minority Health. (July 2013). Office of Minority 

Health Charter.

6 Crouch, Gupta, Williams, & Christy (2014). West Virginia Behavioral Risk Factor Surveillance System Report 2014. Available on the DHHR 

website. Last accessed 5/12/2017.

7 West Virginia Department of Health and Human Resources, Bureau of Public Health (2014). West Virginia Behavioral Risk Factor Surveillance 

System Report 2014. Available on the DHHR website. Last accessed 5/12/2017.

State and Territorial Efforts to Reduce Health Disparities 252
West Virginia

Partnerships

Primary 

collaborators

State agencies:

• Bureau for Medical Services

• Division of Health Promotion 

and Chronic Disease

• Division of Primary Care

• Division of Rural Health and 

Recruitment

• Division of Tobacco Prevention

• Oral Health Program

Other organizations:

• Adolescent Health Coalition

• American Cancer Society

• Association of State and Territorial 

Health Officials

• Bonnie’s Bus

• Coalition for a Tobacco-Free West 

Virginia

• Healthy Steps

• Marshall Medical Outreach

• Mountains of Hope Cancer Coalition

• Susan G. Komen West Virginia

• Try This West Virginia

• West Virginia Association of Free 

Clinics

• West Virginia Breast and Cervical 

Cancer Screening Programs

• West Virginia Cancer Registry

• West Virginia Health Right

• West Virginia Immunization Network

• West Virginia Oral Health Coalition

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships

The OMH works with both governmental and nongovernment organizations to eliminate health disparities. 

For example, the OMH collaborates with the Coalition 

for a Tobacco-Free West Virginia to reduce tobacco use 

among minority populations and to identify particularly 

at-risk minority populations. Together, the OMH and 

the Coalition for a Tobacco-Free West Virginia conduct 

outreach with minority communities and provide educational resources related to tobacco use. The OMH also 

collaborates with the Division of Tobacco Prevention 

which, in turn, collaborates with other federal, state, 

and nongovernmental partners. The Division of Tobacco 

Prevention offers cessation services and distributes 

education materials designed for targeted at-risk 

groups, including pregnant women, African Americans, 

those over age 55, LGBT populations, and low-income 

communities. 

To improve health behaviors and related outcomes, the 

OMH collaborates with Try This West Virginia, an effort 

to increase awareness of nutrition, physical activity, 

and oral health in minority communities. Efforts are 

coordinated with a faith-based initiative, Healthy Bodies 

Healthy Spirits, which seeks to increase physical 

activity and healthy nutrition habits. 

The OMH also collaborates with the Division of Health 

Promotion and Chronic Disease and other organizations as part of its strategy to reduce and eliminate 

diabetes and obesity among minority populations. To 

address socioeconomic health disparities, the Division 

of Health Promotion and Chronic Disease collaborates with the Bureau for Medical Services to connect 

Medicaid beneficiaries to nongovernmental and federal 

diabetes prevention and self-management programs. 

Recognizing the significant barriers to achieving oral 

health among all West Virginians, the OMH collaborates with the West Virginia Oral Health Coalition and 

the BPH’s Oral Health Program. The West Virginia Oral 

Health Coalition seeks to provide oral health access 

to uninsured adults, implement a multidisciplinary 

oral health plan, cover adult restorative procedures 

by expanding Medicaid benefits, and change the oral 

health culture in West Virginia.8

Reducing disparities in cancer care is another focus 

of the OMH. The OMH collaborates extensively with the 

Mountains of Hope Cancer Coalition (which represents 

health care professionals, community advocates, volunteers, cancer survivors, the American Cancer Society, 

and the BPH) to promote cancer prevention among 

minority communities, educate individuals with cancer, 

and assist cancer patients with their care. For example, 

the two organizations work to increase cancer awareness through community outreach with Bonnie’s Bus 

and Susan G. Komen West Virginia. They also partner 

with the Association of State and Territorial Health 

Officials to implement the Healthy Steps initiative in 

Harrison and Kanawha Counties. In addition, the OMH 

collaborates with the West Virginia Cancer Registry and 

the West Virginia Breast and Cervical Cancer Screening 

Program to increase breast cancer awareness among 

minority women. 

8 West Virginia Oral Health Coalition: About Us. Available on the West Virginia Oral Health Coalition’s website. Last accessed 5/12/2017.

State and Territorial Efforts to Reduce Health Disparities 253
West Virginia

The OMH has developed other partnerships to address 

specific concerns. For example, it partners with the 

Division of Primary Care to ensure that racial and 

ethnic minorities have access to health care services 

through community health centers, school-based health 

centers, and satellite centers. Through a collaboration 

with the Division of Rural Health and Recruitment, 

the OMH also works to advance health equity among 

rural populations in West Virginia. Further, the OMH 

collaborates with the Adolescent Health Initiative, a 

longstanding coalition supported through the DHHR, 

to educate and improve minority adolescent health 

through community organizations.9

Finally, the OMH is also engaged in decision-making 

and policy development to expand an influenza initiative; for this effort, it partners with the West Virginia 

Health Right, the West Virginia Immunization Network, 

and the West Virginia Association of Free Clinics, 

among others.

Funding 

Annual budget (FY 2017) of state/

territorial minority health entity 

(SMHE) across all income sources

$90,000

Annual budget (FY 2017) of SMHE 

from state/territorial government $90,000

Largest funding source State government

Anticipated changes to budget Unknown

Total FY 2015 funding for the OMH was $90,000, all 

of which is allocated by the state. The OMH provided 

less than $10,000 in minigrants to advance health 

equity. It is unclear if OMH funding will remain stable 

or decline in the future.

9 Adolescent Health Initiative. Adolescent Health Initiative Home Page. Available on the DHHR website. Last accessed 5/12/2017.

State and Territorial Efforts to Reduce Health Disparities 254
West Virginia

West Virginia State Data

Total Populationa: 

1,831,102

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 1.4 98.6 93.1 3.9 0.1 0.8 2.1 100.0 NA 

Percent of population 

medically uninsureda 16.0 5.3 4.9 15.2 10.9 7.4 9.4 5.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 7.1 6.7 SP SP SP NC 7.1 5.9

Age-adjusted 

mortality rateb 266.0 948.3 945.5 1049.4 SP 202.9 NC 943.3 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 4.7 16.3 16.0 18.8 21.9 SP 23.8 16.2 13.6

Percent with 

diabetesc 11.9 15.0 14.9 15.2 15.9 SP 12.5 15.0 10.8

Percent with 

heart diseasec 2.1 8.0 8.1 4.5 10.0 SP 12.2 8.0 4.3

HIV rated 391.4 NC 81.9 729.2 29.5 54.8** 541.4 113.3 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

73.5 79.1 78.9 80.8 89.8 SP 77.3 79.0 72.2

Percent received 

oral health visit 

(past 12 months)c

55.1 57.8 58.1 57.3 49.5 SP 45.4 57.8 66.5

Percent received 

flu vaccinec 26.2 44.8 44.8 43.3 42.6 SP 29.6 44.6 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 54.8 per 100,000 population (7 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 255
Wisconsin

Introduction to Wisconsin’s Health Equity Activities

Wisconsin had an estimated 2016 population of 5,779,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (7 percent), followed by Blacks/African Americans (6 percent), Asians/Pacific Islanders (3 percent), 

and American Indians/Alaska Natives (1 percent). Persons self-identifying as multiracial or “other race” comprise 

5 percent of the population.1 Approximately 1,401,000 Wisconsin residents live within a primary care health 

professional shortage area.2

Housed within the Wisconsin Department of Health Services’ (DHS) Division of Public Health (DPH), the Minority 

Health Program (MHP) was created to provide “statewide leadership for policy measures that aim to improve 

the health of vulnerable populations in Wisconsin.”3 It is charged with coordinating DPH efforts to reduce health 

disparities, administering community grants, and implementing a public health information campaign. It also 

publishes a Minority Health Report and provides administrative support to the Minority Health Advisory Group. 

Wisconsin Minority Health Overview

Name of state/territorial 

minority health entity

Wisconsin Department of Health Services, Division of Public Health, Office of Policy 

and Practice Alignment, Minority Health Program

Strategic plan in place to 

address minority health 

or health equity

The Wisconsin Department of Health Services developed a strategic state health plan, 

Healthiest Wisconsin 2020: Everyone Living Better, Longer,

4 which identifies eliminating 

health disparities and achieving health equity as crosscutting priorities. 

Date strategic plan was last 

updated Healthiest Wisconsin 2020: Everyone Living Better, Longer was last updated in 2010. 

Assessment plan in place 

to measure progress toward 

reducing health disparities

The Wisconsin Department of Health Services is developing performance measures 

intended to track progress toward reducing health disparities.

Key strategies used to 

achieve health equity

• Increasing the Wisconsin Division of Public Health’s capacity to eliminate health disparities

• Advising on data collection and standardization efforts

• Implementing the National Standards for Culturally and Linguistically Appropriate Services in 

Health and Health Care and developing a plan for individuals with limited English proficiency

• Providing grant funding to support the work of community-based organizations serving 

socially disadvantaged minority populations

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

3 The Wisconsin Department of Health Services, Division of Public Health, Minority Health Program webpage. Available on the Wisconsin DHS 

website. Last accessed 8/4/2017.

4 Healthiest Wisconsin 2020: Everyone Living Better, Longer. A State Health Plan to Improve Health Across the Life Span, and Eliminate Health 

Disparities and Achieve Health Equity. Available on the Wisconsin DHS website. Last accessed 8/4/2017.

State and Territorial Efforts to Reduce Health Disparities 256
Wisconsin

Organizational Structure

The Department of Health Services is comprised of 

nine distinct divisions, including the DPH. Within the 

DPH are eight bureaus and offices, including the Office 

of Policy and Practice Alignment, which oversees the 

MHP. Its current advisory committee is the Minority 

Health Advisory Group, which consists of 15 community 

representatives with diverse backgrounds from across 

the state.

In 2015, the DPH and the MHP developed a plan to 

restructure the MHP’s staffing and funding structure. 

This required replacing the MHP’s three previous staff 

positions (an office manager, a policy analyst, and a 

program director) with three new positions intended to 

align with the DPH’s strategies for addressing health 

disparities. The new staff positions include an outreach 

coordinator, a training officer, and an epidemiologist. 

Many DPH staff outside of the MHP also dedicate time 

to minority health activities. 

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The Minority Health Program is 

housed within the Department 

of Health Services, Division of 

Public Health, Office of Policy and 

Practice Alignment.

SMHE staffing 

(full-time equivalents) 3

Advisory committee 

or panel Minority Health Advisory Group

Program Goals and Activities

Eliminating health disparities and achieving health 

equity are key priorities identified in the DHS strategic 

state health plan, Healthiest Wisconsin 2020: Everyone 

Living Better, Longer. The DHS is required to produce 

a state health plan every 10 years. Beginning in 2015, 

the DHS began developing a new health improvement 

plan through the Wisconsin Health Improvement 

Planning Process. The new health improvement plan 

will build on Healthiest Wisconsin 2020 and will 

be updated every 5 years. In addition to the DHS’s 

strategic state health plan, the MHP has a stand-alone 

operational plan that focuses on how it can support 

the DPH in its efforts to advance health equity.

The DHS aligns health equity priorities with other statewide priorities. Various DHS divisions and programs 

are involved in priority setting for the MHP, as are nongovernmental groups such as local health departments 

and the Great Lakes Inter-Tribal Council. Within the 

DPH, some bureaus create “equity action teams” 

that establish health equity priorities specific to their 

bureaus. The MHP has played a key role in setting 

health equity priorities and encouraging the DHS to link 

priorities to actionable disparities. The MHP also has 

been working with the DHS to develop performance 

measures intended to monitor progress on its efforts. 

The DHS and its partners will report on progress to the 

Wisconsin Public Health Council, which was created 

to monitor and advise on implementation of the state 

health plan, and will also track progress on a publicly 

available website. 

Acronym List

Full Name of Agency Acronym Acronym

Wisconsin Department of Health Services DHS

Wisconsin Division of Public Health DPH

Minority Health Program MHP

To align with the DHS’s health equity priorities, the DPH 

adopted a crosscutting approach in which each DPH 

bureau shares a responsibility for eliminating health 

disparities and advancing health equity. The MHP 

serves primarily as a resource within the DPH, supporting the bureaus and programs on activities related 

to minority health and health disparities. Accordingly, 

many of the MHP strategies aim to increase the 

DPH’s capacity to advance health equity. One strategy 

involves coordinating with other DPH programs and 

partners. Many of the bureaus and programs within 

the DPH have dedicated staff focusing on minority 

health and health equity activities. For example, the 

Wisconsin AIDS/HIV Program works on specific initiatives targeting minority populations, such as increased 

HIV testing and outreach in communities of color, and 

cultural competency training for health care providers. 

The Tobacco Prevention and Control Program is another 

example; it funds smoking prevention initiatives that 

target specific racial and ethnic minority populations 

where disparities exist. The MHP’s role is to help 

build partnerships, such as establishing a community 

of practice—an internal group intended to act as an 

equity advisory team within the DPH. The overall goal 

of these partnerships is to make it easier for the DPH’s 

bureaus and programs to reduce health disparities. 

State and Territorial Efforts to Reduce Health Disparities 257
Wisconsin

In addition to building partnerships, the MHP also 

advises the DPH and its partners on data collection 

and data analysis efforts. Toward the goal of improving 

the quality of data used to identify disparities, the MHP 

provides training to improve data collection efforts, 

such as the collection of vital records data, and is 

helping to standardize the way disparities data are 

used throughout the DPH.

Another strategy of the MHP focuses on the National 

Standards for Culturally and Linguistically Appropriate 

Services in Health and Health Care (National CLAS 

Standards). The MHP promotes National CLAS Standards implementation within the DPH and among its 

partners. To support this strategy, the MHP provides 

training, develops resources, and maintains a webpage to disseminate information on the National CLAS 

Standards. The MHP also developed a National CLAS 

Standards Pledge. DHS programs and partners that sign 

this pledge agree to adopt, promote, and implement 

the National CLAS Standards; promote health equity; 

and help to eliminate health disparities. The MHP also 

helped develop the DPH’s Language Access Plan to 

ensure that its programs, services, and activities are 

accessible to individuals with limited English proficiency.

Community-based organizations working to address 

the social determinants of health can apply for grant 

awards issued by the MHP. Four such programs are 

targeted to:

1. Support community health workers across different 

ethnic groups in their efforts to identify the most 

prominent social determinants of health

2. Promote skills learning for unemployed and underemployed individuals

3. Improve health literacy within the Hmong population 

living in north-central Wisconsin

4. Promote peer breastfeeding support for African 

American women.

Partnerships

Primary 

collaborators

• CORE/El Centro

• Great Lakes Inter-Tribal Council

• Hmong American Center

• Local health departments

• Racine Kenosha Community Action 

Agency

• Urban League of Greater Madison

• Wisconsin Division of Public Health 

bureaus and programs

Contracts or 

memoranda of 

understanding 

with any partners

Yes, contracts or memoranda of 

understanding are implemented 

for some partnerships

A key priority of the MHP is to advance health equity by 

expanding DPH partnerships. The MHP works collaboratively with grantees to support that goal. The grantee 

organizations—CORE/El Centro, Hmong American 

Center, Racine Kenosha Community Action Agency, and 

Urban League of Greater Madison—provide quarterly 

progress reports to the MHP. The MHP also conducts 

site visits with grantees and, moving forward, will be 

working to align grant programs with statewide priorities. 

In addition to working with community-based organizations, the MHP collaborates with local health departments and a variety of DPH sections, including the 

Bureau of Communicable Diseases and the Bureau of 

Community Health Promotion. The MHP also works with 

the Great Lakes Inter-Tribal Council in efforts to eliminate health disparities and advance health equity.

State and Territorial Efforts to Reduce Health Disparities 258
Wisconsin

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

~$250,000

Annual budget (FY 2015) of SMHE 

from state/territorial government ~100,0000

Largest funding source Federal government

Anticipated changes to budget Unknown

In FY 2015, the total funding for the MHP was approximately $250,000. The MHP received approximately 

$100,000 from the State of Wisconsin and approximately $150,000 from a 2-year State Partnership 

Initiative to Address Health Disparities (SPI) grant from 

the U.S. Office of Minority Health. The last year of the 

SPI grant was FY 2015. The MHP provided funding to 

four grantees in 2015. Each grantee received $25,000 

over 2 years. 

As part of the MHP’s restructuring, the State of Wisconsin increased the amount of funding allocated to 

the MHP in 2016. The increase in funding came from 

Wisconsin general revenue and was intended to fund 

MHP’s three full-time staff positions in an effort to 

bring more stability to the program.

State and Territorial Efforts to Reduce Health Disparities 259
Wisconsin

Wisconsin State Data

Total Populationa: 

5,778,709

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 6.7 93.3 85.5 6.2 0.9 2.8 4.6 100.0 NA 

Percent of population 

medically uninsureda 16.3 4.7 4.6 9.4 16.4 7.0 13.6 5.4 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb 5.5 5.8 4.4 14.9 SP 6.4 NC 5.8 5.9

Age-adjusted 

mortality rateb 450.7 724.1 702.4 1009.6 848.1 468.3 NC 720.9 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 9.6 11.9 11.8 15.2 18.4 4.6 13.2 11.9 13.6

Percent with 

diabetesc 5.6 10.0 9.7 13.4 20.3 0.0 7.3 9.7 10.8

Percent with 

heart diseasec 1.3 4.8 4.9 2.4 8.1 0.8 1.2 4.6 4.3

HIV rated 304.6 NC 64.9 772.0 76.6 63.9** 305.4 122.0 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

64.8 71.8 71.1 85.9 69.4 58.4 67.8 71.5 72.2

Percent received 

oral health visit 

(past 12 months)c

55.0 73.8 75.0 60.0 48.8 62.4 61.2 73.1 66.5

Percent received 

flu vaccinec 34.0 36.2 36.5 29.7 20.9 47.1 32.8 36.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 63.9 per 100,000 population (78 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 67.1 per 

100,000 population (1 case).

State and Territorial Efforts to Reduce Health Disparities 260
Wyoming

Introduction to Wyoming’s Health Equity Activities

Wyoming had an estimated 2016 population of 529,000. Hispanics/Latinos are the largest racial-ethnic minority 

population (10 percent), followed by American Indians/Alaska Natives (3 percent), Asians/Pacific Islanders 

(1 percent), and Blacks/African Americans (1 percent). Persons self-identifying as multiracial or “other race” comprise 

4 percent of the population.1 Approximately 159,000 Wyoming residents live within a primary care health professional 

shortage area.2

Established in 2006, the Wyoming Office of Health Equity (OHE) was originally called the Wyoming Office of 

Multicultural Health. Its goals are to minimize health disparities among underserved populations—through 

networking, partnerships, education, collaboration, and advocacy—and to promote culturally competent programs 

aimed at improving health equity. Internal and external advisory committees advise the OHE on minority health, health 

disparities, and health equity. The internal advisory committee, the Health Equity Workgroup (HEW), was created in 

2014 as part of its strategic plan and meets regularly. The Multicultural Health Advisory Committee has been the 

external advisory body since 1980; due to funding constraints, it no longer meets regularly. 

Wyoming Minority Health Overview

Name of state/

territorial minority 

health entity

Office of Health Equity

Strategic plan in 

place to address 

minority health 

or health equity

Integrated into the Public Health 

Division’s strategic map.

Date strategic plan 

was last updated 2013

Assessment 

plan in place to 

measure progress 

toward reducing 

health disparities

No

Key strategies 

used to achieve 

health equity

• Building capacity for language 

interpretation

• Building internal capacity to 

address health equity

• Increasing awareness and 

education

• Building infrastructure with Native 

American tribes

Organizational Structure

Within the Department of Health’s (DOH) Division of 

Public Health, the OHE is housed in the Rural and Frontier Health Unit. One mid-level staff person has a sole 

commitment to the OHE and chairs the HEW, which 

consists of DOH employees who volunteer to serve on 

the workgroup. The OHE does not include volunteers or 

interns, but external volunteers work on health equity 

community projects. There are no plans to increase the 

number of staff working on minority health and health 

equity initiatives. 

Location of state/

territorial minority 

health entity (SMHE) 

within state/territorial 

government

The OHE sits within the Rural and 

Frontier Health Unit of the DOH’s 

Division of Public Health.

SMHE staffing 

(full-time equivalents)

1 staff committed to OHE 

activities

Advisory committee 

or panel

Health Equity Workgroup and 

Multicultural Health Advisory 

Committee

1 American Community Survey Public Use Microdata, 2016.

2 Health Resources and Services Administration. 2018. Designated Health Professional Shortage Areas Statistics: First Quarter of Fiscal Year 

2018 Designated HPSA Quarterly Summary.

State and Territorial Efforts to Reduce Health Disparities 261
Wyoming

Program Goals and Activities

The OHE does not have a stand-alone strategic plan, 

but the Public Health Division of the Wyoming DOH has 

a strategic map that includes a cultural competency 

component. The Public Health Division’s strategic map, 

drafted in 2012 and updated in 2013, led to the 2014 

creation of the HEW, which is responsible for determining OHE’s actions and tasks. A plan to assess progress on meeting OHE’s goals is not yet available. Staff 

at multiple levels within the DOH use a health equity 

assessment tool to set minority health priorities. 

To increase awareness of and address health disparities and health equity issues, the OHE has several priority areas. For example, to build capacity for language 

interpretation, the OHE offers two trainings in different 

parts of the state that focus on medical communication and apply to interpreters speaking any language. 

The OHE plans to launch a website that will connect 

individuals with local interpreters. To support building 

internal capacity to address health equity, the OHE is 

performing an assessment within the DOH and developing web-based classes for employees to address 

identified knowledge gaps. Dispersed employees can 

participate in these webinars. A DOH administrator 

requires a baseline training for all employees and 

drives all programs to address social determinants of 

health in the populations they serve. Monthly speakers 

are invited to present to DOH staff on health equity 

topics, such as collecting data on social determinants 

of health. To support tribal infrastructure around health 

disparity reduction, the OHE helps a tribal coalition 

build capacity and address goals. This tribal coalition, 

which meets monthly, has worked to develop education 

about the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care 

(National CLAS Standards). Collectively these initiatives 

benefit programs within the DOH, particularly those 

that serve economically disadvantaged populations, 

the elderly, individuals with mental health conditions, 

and American Indians. 

Acronym List

Full Name of Agency Acronym Acronym

Wyoming Department of Health DOH

Office of Health Equity OHE

Health Equity Workgroup HEW

Partnerships

Primary 

collaborators

• Wind River Indian Reservation

• Transportation services

• County governments

• Police departments

Contracts or 

memoranda of 

understanding 

with any partners

No partnerships include formal 

contracts or memoranda of 

understanding

The OHE partners with tribal agencies and other local 

governmental agencies to achieve health equity objectives. For example, it works with agencies within the 

Wind River Indian Reservation to inform them of grant 

opportunities and trainings. The OHE also provides 

technical assistance for the Reservation’s health equity 

conference and is helping them to analyze data on 

health disparities. Reservation agencies also participate 

in a roundtable on health disparities. To address access 

barriers to health care, the OHE works with local transportation providers that serve tribal residents and other 

at-risk populations. The OHE assists county transportations departments with grant applications by providing 

supporting data. 

In addition, the OHE works with county governments on 

nurse training and other initiatives. The OHE requires 

county-level public health response coordinators to 

track at-risk individuals as part of emergency response. 

Finally, the OHE works with local police departments 

to conduct cultural competency trainings and performs 

other support functions on an as-needed basis.

State and Territorial Efforts to Reduce Health Disparities 262
Wyoming

Funding 

Annual budget (FY 2015) of state/

territorial minority health entity 

(SMHE) across all income sources

The Rural and 

Frontier Health 

Unit received state 

general revenue 

funding and applies 

some of this funding 

to the OHE, but none 

is designated for the 

OHE specifically. 

Annual budget (FY 2015) of SMHE 

from state/territorial government Not applicable

Largest funding source State government

Anticipated changes to budget None

The Rural and Frontier Health Unit applies available 

funding to the OHE, but OHE activities do not receive 

a specific amount. In FY 2015, Wyoming general revenue was the sole source of funding for the Rural and 

Frontier Health Unit. The DOH, which expects reduced 

funding overall in the future, does not plan to set aside 

funding specifically for the OHE; the amount of funding 

that the Rural and Frontier Health Unit may apply to the 

OHE could decline.

State and Territorial Efforts to Reduce Health Disparities 263
Wyoming

Wyoming State Data

Total Populationa: 

528,626

Ethnicity Race Totals

Hispanic 

or Latino

Not 

Hispanic 

or Latino White

Black 

or African 

American

American 

Indian/ 

Alaska 

Native

Asian 

American 

and 

NHOPI*

Multiracial 

or Other

State 

Total

National 

Total

Population 

Characteristics

Percent of state 

populationa 9.7 90.3 92.0 0.9 2.5 1.1 3.5 100.0 NA 

Percent of population 

medically uninsureda 17.9 10.5 10.4 7.6 40.3 7.0 12.3 11.2 8.9

Health 

Disparities

Vital Statistics

Infant mortality rateb SP 4.8 4.7 SP SP SP NC 4.9 5.9

Age-adjusted 

mortality rateb 521.0 732.4 723.0 352.8 957.3 SP NC 728.8 728.8

Prevalence of Selected Chronic Diseases

Percent with asthmac 13.1 14.1 13.4 SP 28.1 SP 21.8 14.0 13.6

Percent with 

diabetesc 9.7 8.1 7.9 SP 10.6 SP 12.4 8.3 10.8

Percent with 

heart diseasec 3.5 4.0 4.1 SP 2.2 SP 2.3 4.0 4.3

HIV rated 134.2 NC 45.8 417.3 107.2 44.4** 96.5 59.3 362.3

Preventive Services

Percent received 

routine check-up 

(past 12 months)c

55.5 65.7 65.9 SP 63.9 SP 57.3 65.1 72.2

Percent received 

oral health visit 

(past 12 months)c

59.3 67.5 68.4 SP 51.4 SP 53.5 67.1 66.5

Percent received 

flu vaccinec 31.8 35.2 35.7 SP 31.6 SP 29.6 35.2 38.4

Key NA = Not applicable, NC = Not collected by the data source, SP = Suppressed due to small numbers.

a Source: American Community Survey Public Use Microdata, 2016.

b Source: CDC Wonder Online Database for vital statistics. Infant mortality rate is the number of deaths per 1,000 births in 2015. Age-adjusted 

mortality rate is the number of deaths per 100,000 population in 2016.

c Source: Behavioral Risk Factor Surveillance System, 2016.

d Source: CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2015. Note that Hispanic individuals do not 

appear in any race categories in this dataset.

*Native Hawaiian and other Pacific Islander

**The CDC NCHHSTP Atlas’s racial classifications separate Asian and Pacific Islander into distinct racial categories. HIV data in table reflects infection 

rate among Asians of 44.4 per 100,000 population (2 cases); HIV infection rate among Native Hawaiians and Other Pacific Islanders is 0.0 per 

100,000 population (0 cases).

State and Territorial Efforts to Reduce Health Disparities 264
U.S. Department of

Health and Human Services

Ofce of Minority Health

Office of Minority Health

Tower Oaks Building

1101 Wootton Parkway, Suite 600

Rockville, MD 20852

Phone: 240-453-2882

Fax: 240-453-2883

Email: info@minorityhealth.hhs.gov

Web: http://www.minorityhealth.hhs.gov