Visioning with Vulnerable Populations to Gather Primary, Real-Time Data, and Promote Health Equity

The Marshall County Health Department (MCHD) is located in Marshall County in far Western Kentucky and serves a population of approximately 31,000 individuals. The population is 97.74% white with 20.3% of the population being under 18 years and 22.5% over 65. The public health issue faced with the development of this model practice is the real-time equitable collection of data, specifically qualitative data from specific populations. The goals were to gather real-time data from a subpopulation of the community and use this to not only help develop our community health assessment but to hold sustainability so we can measure trends and patterns over time.

To accomplish this, we expanded on the visioning described in the Mobilizing for Action through Planning and Partnerships (MAPP) process. The MCHD partnered with the local public school system to engage students in obtaining their vision of a healthy community. The objective was to visit one middle school and collect data from 50 students; however, through partnerships, we completed these visioning sessions in all nine of the public schools in Marshall County and collected data from over 200 students. The students were asked to draw a picture and write a few sentences describing their vision of a perfectly healthy community.  We not only exceeded our goal, but we gathered qualitative data from all age ranges from elementary to high school.

Subgroups were chosen at each school. For the two middle schools, The BETA club, the largest independent, non-profit, educational youth organization in America, and The Explore Learning Pathways students were chosen to participate. The Explore program is a specialized learning platform for select students at the middle school. For the elementary schools, participants in Team Ultra (offered to grades 3-5) were chosen. Team Ultra teaches students about physical activity, nutrition, and upstanding character. The students at the high school were part of the Marshall Mission, which works to improve diversity and inclusion within the school and serve as student ambassadors.

The public health impact of this relates to the essential public health service of Assess and Monitor Public Health. By gathering data on what a healthy community means to this subgroup we can better understand the needs and adapt our programs, services, and partnerships.

This took community engagement on the partnership level (with the local public schools), but also with the children from whom the data was gathered. Youth are considered a vulnerable population; however, they have a voice, and it needs to be heard. According to the Mid-America Regional Council (MARC) children are considered medically vulnerable. The UNICEF Convention on the rights of the Child states, Children are not just objects who belong to their parents and for whom decisions are made, or adults in training. Rather, they are human beings and individuals with their own rights”. By using this subgroup in the population, we gathered qualitative data from a group often overlooked. We wanted to take steps such as contacting the schools and carefully choosing subgroups of students to participate in eliminating health inequities and promoting the equitable collection of data. Groups were chosen due to diversity in learning, participation in specific programs, and the diversity of the programs.

The largest milestone was our reach. Our goal was to reach 50 students in the Explore Learning Pathways group; however, we reached 227 total students during the 1^st round of this practice in the 2021-2022 school year. We increased those numbers to 314 responses on the 2^nd round of visioning sessions in the 2022-2023 school year. The specific factors of this success were not only the partnership with the local public school system but also our partnerships at the MCHD through the health educators of Team Ultra. The health educators were trained on the presentation to students by the Public Health Program Specialist and then gathered the data from that group of students.

Overall, this promotion was a success. Going from a goal of 50 students to over 200. We wanted to make great strides in reducing health inequities in data collection, specifically for the Community Health Assessment. We were not only able to gather visioning data from students but the participation in our community health assessment survey doubled for the under-18 age group from the last survey conducted in 2019.

https://www.marshallcohealthdepartment.com/2020/

The approximate population in Marshall County under 18 is 6,975 children, of these approximately 5,487 are school-aged (over 5 and under 18). During the 1^st round of visioning sessions, 227 responses were gathered across 9 public schools (6 elementary, 2 middle schools, and 1 high school) which accounts for approximately 5% of the total school-aged population. During the 2^nd round of visioning sessions, we gathered an additional 87 for a total of 314 responses which increased our reach to approximately 6% of the student population. This process was an expansion of the visioning discussed in the MAPP process.

The MAPP process describes the visioning process and states that some communities engage children in the process by asking for visual depictions of a healthy community. To expand on this idea, we created a standard form, with each school's logos depicted at the top. The Public Health Program Specialist and the Health Education Department visited each subgroup at each public school to present the assignment. Not only did we ask them for a healthy community vision, but we also educated them on the Social Determinants of Health, and what health equity means and could look like in their community. The children were then asked to anonymously draw a picture of their perfectly healthy community” and write a few sentences describing their drawing. 

In years past during the collection of data for the CHA, there was not an overwhelming effort to collect data from children. As previously stated, children are considered a vulnerable population and often overlooked in data collection efforts despite the wealth of knowledge they can provide. UNICEF Convention on the Rights of the Child states, that children are not just objects who belong to their parents and for whom decisions are made, or adults in training. Rather, they are human beings and individuals with their own rights.” With this statement in mind, we wanted to make strides to ensure that we collected as much data from this group as possible.

 The steps we took to incorporate health equity in data collection was the selection of participants and age groups. Each group (BETA, Explore, Marshall Mission, and Team Ultra) is comprised of a diverse group of students, in age, background, and social standing. The decision to use these groups to administer the visioning sessions was made by speaking with teachers at each school and the health education department at the MCHD, which oversees Team Ultra. We gathered data from students as young as 3^rd grade, and as old as seniors in high school. The visioning document used was created so that no matter what age, literacy level, or ability everyone participated by drawing or writing a description (or both). We captured input from students of different races, sexual orientations, and ability levels which was reflected in the drawings the students submitted.

Although visioning with youth is not a new concept, we went a step further to educate on public health and health equity, standardize/formalize the process, and incorporate health equity initiatives into the practice. We not only created a standard form, but we reached a diverse group of students and gather data from each grade (3^rd and above). This Practice is not evidence-based. 

The original goal was to collect real-time data from school-aged children to complete our Community Health Assessment. We started with the goal of 50 students at one local middle school.  After the 1^st session succeeded (we collected 101 responses with the 1^st group). We reached out to the other public schools in the county. One by one each school agreed to let us come in and conduct these sessions.

The original visioning sessions were conducted between December 2021 and February 2022. The second round was conducted in October 2022. We conducted the 2^nd round much faster due to the relationship we had built previously with the schools and teachers from the previous year. This was important because we had built rapport with not only the public school system in reference to the visioning sessions but also individual teachers. There were also students at the 2^nd visioning session that remembered them from the year before. This was helpful because they were able to assist other students with the assignment, and already had a grasp on the concept of visioning.  

The MCHD was responsible for the creation and administration of the visioning sessions. The Public Health Program Specialist administered to both middle schools and the high school, while the health education team at the MCHD administered to the elementary schools through Team Ultra. Part of this administration included education on the Social Determinants of Health and health equity.

There were no start-up costs for this project. The only expense was the printing of the documents (approximately 3.00) and the time of the health department employees administering the sessions. This makes this initiative a cost-effective way to gather data not only from school-aged children but other vulnerable and marginalized populations.

The data was collected by the Public Health Program Specialist and the health education department at the MCHD. The data analysis was conducted by Dr. Miranda Terry through Tennessee State University.

The 1^st round of visioning sessions was evaluated using a two-phase qualitative coding process. Inductive analysis was used during the initial coding phase as codes were developed from the data itself. The 2^nd phase was coding for patterns in the data. The top ten features identified by the participants of what makes a healthy community were: (1) farmer's markets/access to healthy food (2) cheap or free healthcare or medicines (3) nicer and more accepting people in the community with less homophobia, transphobia, sexism, racism, and ableism (4) mental health (5) clean environment (6) bike paths/walking paths (7) bigger parks for all ages and abilities (8) cheap or free gym or recreation center (9) homeless shelter (10) better school food.

The data findings were used as part of the data presentation for our 2022 Community Health Assessment. Because of these visioning sessions and other data collected, 3 of the ten issues identified were used as part of our Community Health Improvement Plan. Those issues were: (1) access to healthy food (2) acceptance (3) mental health.

 During the 2^nd round of visioning sessions, students were made aware that last year's results were being used in our Community Health Improvement Plan, that their opinion did matter, and they were making a difference. We feel this helped with getting more honest responses and better participation the 2^nd time these sessions were conducted, especially with the students who had completed them the year before.  

The data gathered during the 2^nd round of visioning sessions was also analyzed using a two-phase qualitative coding process. The top five features identified by the participants of what makes a healthy community were: (1) farmer's markets/access to healthy food/ gardens (2) pick up trash/ no pollution/ clean water/ clean environment (3) nicer and more accepting people in the community with less homophobia, transphobia, sexism, racism, and ableism (4) exercise/ physical activities and (5) plant more trees/ no deforestation.

We are confident in the sustainability of our practice. The 1^st round of visioning sessions spanned over 3 months, and we completed the 2^nd round in one month with more participation. This was thanks to the teachers and the local schools and the health education department at the MCHD. The anonymity of the project also helps sustain this project, because students know there is no retaliation or a way to trace their responses back to them. This helps us get more honest responses.  

Financially, this is a low-cost initiative. This will help with the sustainability of the practice, even if funding is cut, other than the cost of employee time it cost less than 5.00 to print the material needed for the project. It will cost more if you have a larger group you are trying to reach, however, it is still a low-cost intervention strategy.

Most teachers were still at the schools from last year; however, several were new and had to explain the process to them so we could come in and continue this project. Every new teacher was excited and willing to let us come in and conduct these sessions. This is thanks to the relationship of the MCHD with the local public school system, and the Public Health Program Specialist for contacting each school to arrange a time for the visioning sessions.

Although participation was up this year, we had fewer from one of the middle schools. This was because students were left with the forms and asked to complete them and turn them into the teacher within the week. The previous year, they completed while the MCHD was present that day. Next year, we will have them complete them while we are present, to have a higher participation rate.

Overall, we learned two lessons (1) Teachers move schools, so you must be ready to explain the process and importance every year. (2) we had better results when students were asked to complete while we were there, instead of leaving the assignment to pick up later we discovered this at one middle school and a high school.  

These visioning sessions started as a one-time, one-school, 50-student goal and has turned into something that we plan to continue every school year. We want to watch trends and patterns in our youth and discover what is affecting them as a whole. We increased our participation by 1% from last year, and our goal is to reach at least 10% of the student population within the next two years.