Community Health Data & Health Equity Indicators
Understanding the health landscape of our community is essential to designing effective interventions. This page presents key health indicators, chronic disease prevalence data, social determinants of health metrics, and neighborhood-level disparity analyses for Hennepin County, Minnesota. Data sources include the Minnesota Department of Health, the CDC BRFSS, Hennepin County Public Health, and our own program evaluation research conducted in partnership with the University of Minnesota School of Public Health.
Chronic Disease Burden in Hennepin County
Chronic diseases are the leading causes of death, disability, and healthcare expenditure in Hennepin County and across the United States. According to the CDC, six in ten American adults have at least one chronic disease, and four in ten have two or more. The following data points illustrate the scope of the challenge in our service area and inform our programmatic priorities.
Hennepin County adult obesity rate (BMI of 30 or higher) as reported by the 2023 BRFSS. This represents a 4.7 percentage-point increase over the 2018 rate of 33.5%.
Percentage of Hennepin County adults diagnosed with diabetes (type 1 or type 2). An additional 8.7% have prediabetes (A1C 5.7–6.4%) and are at elevated risk for progression.
Percentage of adults with diagnosed hypertension (blood pressure of 130/80 mmHg or higher). Hypertension is the leading modifiable risk factor for cardiovascular disease and stroke.
Tobacco Use
The adult cigarette smoking rate in Hennepin County is 12.8%, slightly below the statewide average of 14.1%. However, significant disparities exist across racial and ethnic groups. Among American Indian adults, the smoking rate is 38.2%. Among adults with household incomes below 200% of the federal poverty level, the rate is 26.4%, more than double the county average. E-cigarette use among high school students in Minneapolis Public Schools reached 19.7% in 2023, a public health concern given the addictive nature of nicotine and emerging evidence of pulmonary harm. These disparities inform Health Promotion Project's targeted tobacco cessation programming and our delivery of culturally adapted interventions in communities with the highest tobacco burden.
Mental Health
An estimated 21.3% of Hennepin County adults report experiencing frequent mental distress (14 or more mentally unhealthy days in the past 30 days). This rate has increased steadily from 16.8% in 2019, reflecting a nationwide trend exacerbated by the COVID-19 pandemic and its social and economic aftereffects. Among adults aged 18 to 25, the rate is 29.1%. Access to mental health services remains unevenly distributed, with communities of color, immigrant populations, and residents of north Minneapolis reporting the greatest unmet mental health needs. Health Promotion Project addresses mental wellness through our MBSR program, integrated behavioral health referrals, and community health worker-led stress management education embedded in all prevention curricula.
Health Equity Indicators
Health equity means that everyone has a fair and just opportunity to be as healthy as possible. In Hennepin County, health outcomes vary dramatically by race, ethnicity, income, geography, and immigration status. These disparities are not the result of individual choices; they are driven by structural inequities in housing, education, employment, food access, and healthcare systems. Understanding these disparities is the first step toward eliminating them.
Racial & Ethnic Disparities in Chronic Disease
The following data from the Minnesota Department of Health Center for Health Equity illustrate the scope of racial and ethnic health disparities in our service area. These figures represent age-adjusted prevalence rates for adults aged 18 and older.
| Health Indicator | White | Black/African American | Hispanic/Latino | Asian American | American Indian |
|---|---|---|---|---|---|
| Diabetes Prevalence | 8.2% | 16.8% | 14.3% | 10.1% | 18.7% |
| Hypertension | 29.4% | 42.1% | 28.7% | 26.3% | 39.8% |
| Obesity (BMI 30+) | 33.1% | 48.7% | 41.2% | 14.6% | 52.3% |
| Current Smoker | 10.4% | 21.6% | 13.8% | 8.9% | 38.2% |
Source: Minnesota Department of Health, Center for Health Equity; CDC Behavioral Risk Factor Surveillance System (BRFSS), 2023. Values in red indicate rates significantly above the county average.
Social Determinants of Health: Neighborhood-Level Analysis
The neighborhoods where Health Promotion Project concentrates its programming are characterized by multiple overlapping social determinants of health challenges. The following data from the American Community Survey (ACS) and Hennepin County Public Health illustrate the structural context in which chronic disease disparities develop and persist.
Cedar-Riverside / West Bank
- Poverty Rate: 52.3% (county average: 11.4%)
- Uninsured Adults: 18.7%
- Limited English Proficiency: 41.2%
- Food Insecurity: 34.8%
- Primary Languages: Somali, Oromo, Amharic
North Minneapolis (Near North / Camden)
- Poverty Rate: 38.1%
- Uninsured Adults: 14.2%
- Life Expectancy Gap: 10.4 years below county average
- Food Desert Classification: USDA-designated
- Primary Languages: English, Hmong
Phillips / Powderhorn
- Poverty Rate: 34.6%
- Uninsured Adults: 21.3%
- Limited English Proficiency: 28.4%
- Primary Languages: Spanish, Somali, Karen
- Immigrant/Refugee Population: 44.1%
Brooklyn Park / Brooklyn Center
- Poverty Rate: 19.8%
- Uninsured Adults: 11.6%
- Limited English Proficiency: 22.7%
- Primary Languages: Hmong, Liberian English, Somali
- Median Household Income: $52,400 (county: $79,600)
How This Data Shapes Our Work
Health Promotion Project uses this community health data to make evidence-informed decisions about where to locate programs, which languages to prioritize, which health conditions to target, and how to design culturally responsive interventions. Our approach is guided by the socio-ecological model, which recognizes that individual health behaviors are shaped by interpersonal, community, organizational, and policy-level factors.
Data-Driven Site Selection
We prioritize program delivery in neighborhoods with the highest chronic disease burden, the greatest barriers to healthcare access, and the largest gaps between available services and community need. This data-driven approach ensures that our limited resources reach the populations where they can have the greatest impact on reducing preventable disease and premature mortality.
Culturally Adapted Curricula
Neighborhood-level language and demographic data inform our decisions about which languages to offer programming in and how to adapt educational materials for cultural relevance. For example, our diabetes prevention nutrition education for Somali participants incorporates traditional Somali dietary patterns and cooking methods, rather than requiring participants to adopt unfamiliar Western dietary frameworks. Similarly, our physical activity programming for Hmong elders emphasizes culturally familiar movement practices rather than gym-based exercise models.
Addressing Root Causes
Because chronic disease disparities are driven by structural inequities rather than individual choices, our programming extends beyond health education to address the social determinants that shape health outcomes. Our community health workers conduct social determinants of health assessments for every participant, identifying barriers related to housing instability, food insecurity, transportation access, employment, immigration status, and health insurance coverage. We then coordinate referrals to a network of partner organizations providing direct services to address these upstream determinants of health.
Continuous Quality Improvement
We update our community health needs assessment every three years in alignment with the Hennepin County Community Health Improvement Plan (CHIP) cycle. Interim data reviews are conducted annually to ensure that our programmatic priorities remain aligned with the evolving health needs of our service area. All program evaluation data is shared publicly through our Annual Impact Report and is made available to community partners, funders, and the academic research community to advance the evidence base for community-based health promotion interventions.