2014-15 Community Health Report Ashe County Promoting safe & healthy living, preventing disease,& protecting the environment 2014-15 Community Health Assessment [March 23, 2015] 0 2014-15 Acknowledgments This report is a result of a collaboratve efort of Ashe County. We acknowledge individuals and to organizatons who helped play an integral role in the development and implementaton of community health assessment plans. See Appendix A for a detailed list of individuals. Appalachian District Board of Health Ashe Health Alliance Ashe Memorial Hospital Western Youth Network Authorship acknowledgments Community health opinion report: Stephanie Bunch, Rachel Miller, David Willard, Jennifer Greene, Gretchen Summerville, Paty Parsons, Nancy Kautz Secondary data report: Jennifer Greene, Stephanie Bunch, Rachel Miller, Melissa Bracey, David Willard, Nancy Kautz Secondary data presentaton report: Jennifer Greene, Stephanie Bunch, Rachel Miller, Melissa Bracey Community health report development: Jennifer Greene, Stephanie Bunch, Rachel Miller Public Health Director: Beth Lovete, RN, BSN, MPH Special thanks to Isabel Spencer for her work to translate the community health opinion survey Jan Jones of Second Harvest Food Bank for her contributons of invaluable data about food insecurity Lori Wats of Smoky Mountain Center and Ashe County Coaliton for the Homeless for important contributons of local homelessness data © Appalachian District Health Department, [March 23, 2015]. Unauthorized editng of this report without express and writen permission is strictly prohibited. Report contents, excerpts and links may be used, provided that full and clear credit is given to Appalachian District Health Department and/or original sources with appropriate and specifc directon to the original content. 2014-15 Community Health Assessment [March 23, 2015] 1 Table of Contents Executive Summary ........................................................................................................................................ 5 Health Priorities Selected ............................................................................................................................... 9 Introduction/Background ...................................................................................................................................... 10 Process & Methods ...................................................................................................................................... 11 Community health opinions…………………………………………………………………………………………………………………………..14 Ashe County Demographics………………………………………………………………………………………………………………………….15 Grandparents caring for children……………………………………………………………………………………………………..18 Free/Reduced Lunch Partcipaton Trend………………………………………………………………………………………….18 Income & Economy……………………………………………………………………………………………………………………………………….19 Unemployment…………………………………………………………………………………………………………………………………20 Poverty and housing…………………………………………………………………………………………………………………………21 Food insecurity & hunger………………………………………………………………………………………………………………….22 Educaton……………………………………………………………………………………………………………………………………………………..24 Crime & Safety……………………………………………………………………………………………………………………………………………..25 Sexual Assault………………………………………………………………………………………………………………………………….25 Domestc Violence……………………………………………………………………………………………………………………………26 Child Abuse & Neglect……………………………………………………………………………………………………………………..26 Juveniles served by JCPC………………………………………………………………………………………………………………….27 Healthcare Resources…………………………………………………………………………………………………………………………………..28 Uninsured……………………………………………………………………………………………………………………………………….28 2015 Enrollment in Federal Health Insurance Marketplace……………………………………………………………..28 Unduplicated Medicaid Eligibles……………………………………………………………………………………………………..29 Healthcare Practtoners………………………………………………………………………………………………………………….29 County Health Ranking………………………………………………………………………………………………………………………………..30 Environmental Health………………………………………………………………………………………………………………………………….31 Life expectancy by locaton……………………………………………………………………………………………………………..31 Rabies……………………………………………………………………………………………………………………………………………..31 2014-15 Community Health Assessment [March 23, 2015] 2 Air & Water Quality…………………………………………………………………………………………………………………………..32 Water Protecton Permits………………………………………………………………………………………………………………….32 Environmental Epidemiology……………………………………………………………………………………………………………33 Childhood blood lead levels………………………………………………………………………………………………………………33 Access to healthy foods and recreaton……………………………………………………………………………………………..33 Maternal and Child Health……………………………………………………………………………………………………………………………34 Pregnancy Outcomes……………………………………………………………………………………………………………………….34 Infant Mortality……………………………………………………………………………………………………………………………….34 Low Birth Weight & Percent Mothers Smoking During Pregnancy……………………………………………………34 Child death rate……………………………………………………………………………………………………………………………….34 Leading Causes of Death………………………………………………………………………………………………………………………………35 Age-adjusted leading causes 2009-2013…………………………………………………………………………………………..35 Leading causes of death by age group……………………………………………………………………………………………..36 Mortality trends since last community health assessment report……………………………………………………37 Gender disparites in heart disease mortality………………………………………………………………………………….38 Adult diabetes…………………………………………………………………………………………………………………………………………….39 Obesity for adults and children 2-4 years…………………………………………………………………………………………………….40 Percent of adults with a diagnosed chronic disease…………………………………………………………………………………….41 Total Cancer Mortality………………………………………………………………………………………………………………………………..41 Total Cancer Incidence………………………………………………………………………………………………………………………………..42 Lung Cancer Mortality & Incidence…………………………………………………………………………………………………42 Prostate Cancer Mortality & Incidence…………………………………………………………………………………………..43 Breast Cancer Mortality & Incidence………………………………………………………………………………………………44 Colorectal Cancer Mortality & Incidence………………………………………………………………………………………..45 Chronic Lower Respiratory Disease……………………………………………………………………………………………………………46 Heart Disease & Stroke……………………………………………………………………………………………………………………………..47 Leading Risk Factors………………………………………………………………………………………………………………………………….48 Tobacco Use…………………………………………………………………………………………………………………………………49 Physical Actvity & Nutriton…………………………………………………………………………………………………………50 2014-15 Community Health Assessment [March 23, 2015] 3 Communicable disease……………………………………………………………………………………………………………………………..51 Sexually Transmited Infectons……………………………………………………………………………………………………51 Behavioral Health…………………………………………………………………………………………………………………………………….52 Suicide Trend……………………………………………………………………………………………………………………………….53 Suicide by means…………………………………………………………………………………………………………………………54 Substance Abuse…………………………………………………………………………………………………………………………55 Other Unintentonal Injury Mortality………………………………………………………………………………………………………56 Unintentonal Poisoning Deaths………………………………………………………………………………………………….56 Unintentonal Motor Vehicle Injury Mortality………………………………………………………………………………………….57 Alcohol Related Motor Vehicle Crashes………………………………………………………………………………………..57 Community assets that support health……………………………………………………………………………………………………..58 Special populatons to remember……………………………………………………………………………………………………………..60 Veterans………………………………………………………………………………………………………………………………………60 Children……………………………………………………………………………………………………………………………………….61 Elderly…………………………………………………………………………………………………………………………………………61 Populatons with special healthcare needs…………………………………………………………………………………..61 People without health insurance…………………………………………………………………………………………………..61 People who speak a language other than English at home……………………………………………………………62 People who are geographically isolated……………………………………………………………………………………….62 People who are food insecure……………………………………………………………………………………………………..62 People who are homeless……………………………………………………………………………………………………………63 Priority health concerns………………………………………………………………………………………………………………………….64 Next steps for the coaliton……………………………………………………………………………………………………………………..65 Healthy NC 2020………………………………………………………………………………………………………………………………………66 References & Appendices…………………………………………………………………………………………………………………………67 Appendix A: Acknowledgments and community partner list Appendix B: Community Opinion Survey databook & survey instruments Appendix C: Secondary databook with references Appendix D: Community Resource Guide 2014-15 Community Health Assessment [March 23, 2015] 4 Executive Summary The status of health in Ashe County is one of community importance since health afects the community in so many ways. There are many strengths in the county, as pointed out by community members responding to the community opinion survey such as beauty of the rural community ofered by natural resources, willingness of so many residents to care for others, and community connectedness through collaboraton and social support ofered through friends, neighbors, and faith communites. Community collaboraton led to the development of a comprehensive plan including fve main elements in two key phases. The frst phase of the process described in this report include the collecton and analysis community input through an opinion survey, community leader input, and community secondary data review. During this phase, the Ashe Health Alliance adopted a community input survey that was distributed broadly in two ways: electronically by email, website postng, and social media, and through traditonal hard copy formats in various community locatons including the health department and WIC clinic, county library, Ashe Memorial Hospital, and many others. Appalachian District Board of Health members also provided input about the questons included and distributon points for a community leadership survey disseminated only in electronic formats for inital data collecton. In additon, Ashe Health Alliance members took eforts to disseminate hard copies and/or electronic links to the survey from the period of mid- November-January 31, 2015. The inital goal of responses for the community opinion survey disseminated in the county was 500, and the goal was achieved at about 97% with 488 responses overall. The community leadership survey had lower response, with 28 overall, but this has been reviewed as an inital step towards collectng leadership input that will be broadened in the second phase of data collecton. The group utlized community convenience sampling methods for the community input due to resources available. At the November, 2015 meetng, the Ashe Health Alliance members adopted a tmeline for completng the assessment. In additon, they reviewed and approved a radio public service announcement to run on local staton, WKSK 580AM to promote the survey. Paper copies were distributed to members at this meetng, and members worked diligently to ensure a broad representaton was included. At the January, 2015 meetng, Ashe Health Alliance members reviewed preliminary results from the community opinion survey and approved an extension to the end of January, 2015 to get closer to the response goal of 500 or more. Winter weather posed challenges in contnuing eforts for the next phase of data review planned for February, 2015, and but the group contnued to work diligently to meet established deadlines by the NC Division of Public Health for fling the community health report. Ashe Health Alliance members received a powerpoint presentaton to guide the selecton of community health priorites. The priority selecton criteria was outlined (as is described in health priorites secton) and members used 3 stckers to vote for their top priorites. Data review included socioeconomic data like populaton numbers and growth trends, race/ethnic profle of the community, and a review of leading causes of death and illness in the county using trends. Similarities between secondary data and community opinions Overall, the analysis of community data along with community opinions indicate that, for many areas, the community members who partcipated in the survey highlighted key areas of concern that mirrored that in the community statstcs from secondary sources. The community opinion data refects those that partcipated in the survey seem in- tune with the concerns related to substance abuse, chronic disease, and behavioral health needs. In additon, those responding also seem aware of the importance of caring for the aging populaton in the community. Chronic diseases claiming most lives and causing the most illness call for preventive measures. The leading cause of death in the county is heart disease, followed by a close second in cancer, with most cancer deaths atributed to lung cancer. If all leading causes of death for the county are combined, over 60% are due to preventable chronic disease. This is important since we know that 3 primary risk factors: poor nutriton, lack of physical 2014-15 Community Health Assessment [March 23, 2015] 5 actvity, and tobacco use are linked to them. We also know that from review of the mortality statstcs, chronic diseases ofen afect some groups more than others. For example, we know that though heart disease is a leading cause of death overall, more men die from heart disease every year when compared to women. Community members who partcipated in the survey pointed out the connecton between poor eatng habits, being overweight, lack of exercise, and tobacco use as impactul aspects of overall community health problems. In additon, most supported the noton of providing indoor and outdoor recreatonal and actve living opportunites in the community, along with tobacco free environments like workplaces, parks, and other public venues beyond indoor areas of restaurants and bars. Tobacco use is the leading cause of preventable death in the US and is a major risk factor linked to the majority of deaths in the county. Tobacco use is a well-known risk factor for many community health problems that are noted within the secondary data like low and very low birthweight due to a higher percentage of women who smoked during pregnancy, a high number of people who have died from chronic lower respiratory disease/chronic obstructve pulmonary disease (CLRD/COPD), and that lung cancer and heart disease are leading causes of morbidity and mortality in the community. It is important to remember the demographic who responded to the survey when reviewing this analysis, but this majority support somewhat mirrors that of other statewide policy eforts that have had support, even among some former or current tobacco users. Along with traditonal forms of tobacco use, another trend that is emerging in the community is electronic nicotne delivery systems (ENDS), which may be beter known as e-cigaretes or some other form. There is much that is unknown about the potental harms that may come as a result of the use of ENDS, but the Ofce on Smoking and Health of the Centers for Disease Control and Preventon note: “Smoking is by far the leading cause of preventable death in the U.S., causing nearly 500,000 premature deaths each year, including 42,000 deaths caused by secondhand smoke exposure (DHHS, 2014). In North Carolina, 24.6% of young adults aged 18-30 are current cigarette smokers (DHHS, 2014). If smoking persists at the current rate, the 2014 Surgeon General’s report projects that 5.6 million of today’s American children will die prematurely from a smoking-related illness, including 180,000 North Carolina youth aged 0-17 (DHHS, 2014, p.694). “ –Tim McAffee, MD, MPH, Director, Office of Smoking and Health, Centers for Disease Control and Prevention, US DHHS. Tobacco preventon and control tools are available for healthcare providers, workplaces, and public policy makers at local, state, and natonal levels. Local governments do have authority to adopt and enforce tobacco free policies in public places that can protect those most vulnerable from exposure and further efforts to reduce the illness and deaths related with diseases linked to tobacco use. Alcohol, Tobacco and Prescription drugs Community members recognize alcohol, tobacco, and other drug use as one of the major health problems and one of the major risky behaviors that impact health in the county. The importance of substance abuse review is not only the potental harmful efects of misuse or abuse of substances, but also because alcohol and other drugs can be linked to other health problems that we are among the leading causes of death: all other unintentonal injuries, suicide, and unintentonal motor-vehicle injury deaths. In close review of these causes, we see that some trends have increased, th including that of all other unintentonal injuries, which is now the 4 leading cause of death. Suicide deaths show a decreasing trend. Tobacco and alcohol are important substances to consider along with prescripton drugs since each is linked to injury-related or chronic disease-related deaths that are among the leading causes of mortality for the county. According to the data detailed in the Substance Abuse secton, we note that community members pointed out their top 3 substance abuse concerns as methamphetamine use (80%), prescripton drug misuse or abuse (60%), alcohol use 2014-15 Community Health Assessment [March 23, 2015] 6 (46%), and tobacco use (43%). Ranked slightly lower, were driving afer using drugs or alcohol (25%) and marijuana use (25%). Prescripton drug misuse is a key factor to review when looking at deaths due to all other unintentonal injuries since many are due to unintentonal poisoning. Eforts have begun to address this concern with the Project Lazarus program, but contnued eforts are likely needed to contnue to adopt a community wide model that addresses prescripton overdose, response to overdose using Naloxone rescue kits by emergency responders or family members of individuals believed to be at-risk, as well as other methods like prescripton lockboxes, drop box locatons, and community-wide awareness. Operaton Medicine Cabinet or Medicine Take back days ofen coordinated by law enforcement and community partners ofer great exposure in the community to safely dispose of medicines. Alcohol use also warrants additonal review since it is linked to 7% of all crashes compared to 4.9% in NC and 5.5% in Macon County. In NC, 28% of all fatal crashes were related to alcohol in 2013, and 0% were alcohol related in Ashe County for 2012 and 2013, but in prior years, it ranged from 25% to 67% (UNC HSRC, 2013). Simple, yet comprehensive approaches can also be applied to addressing alcohol use, especially that among underage users, which community members who partcipated in the survey believe that most access alcohol from peers or siblings (51%), while others equally believe access is gained from alcohol lef accessible (23%), or accessing it at partes (23%), and fewer believed access came from home with parents that approve (16%). Substance abuse is an important component when considering community behavioral health needs and gaps as well as th unintentonal injury deaths. All other unintentonal injury deaths ranks 4 among the leading causes of death for the county, and represents nearly double the number of deaths in the county in comp arison to suicide. Additonally , alcohol and other substances may increase risk of depression, which may increase risk for suicide. The data reviewed for the most recent period available, 2003 -2007 from the NC Ofce of Chief Medical Examiner, shows that of the suicide deaths of 15 year olds or older county residents, 40% had some alcoh ol present at the tme, and of those, nearly a third had a blood alcohol content (BAC) above the legal limit of 0.08 g/dL. In additon, handguns were the most ofen reported means of suicide during the same tme period with at least 10% more suicides by mea ns of handguns when compared to NC and Macon County during this data period (NC SCHS, NC OCME). Behavioral health and suicide Behavioral health is a broad area including substance abuse described above, but may also encompass community needs for behavioral healthcare supports like counseling and other therapies. Overall, suicide contnues to be among th the leading causes of death, tying 7 place with diabetes and septcemia (NC SCHS, 2014). The suicide rate viewed over fve-year aggregate trends from 2001 —2005 to 2009-2013 indicates a decreasing trend to a rate of death of 18.2 per 100,000 (NC SCHS, 2014). Though this is higher than NC overall with a rate of 12.2 per 100,000, Ashe has a lower suicide rate compared to 20 per 100,000 in Macon County (NC SCHS, 2014). Over the period of 2008 -2012, there were 28 Ashe County residents who died by suicide: 18 were male and 10 were female (NC SCHS, 2013). It is important to understand factors that may infuence or give context important in understanding and addressing this community health concern . We know from the community opin ion survey, most respondents (74 %) recognize that suicide is a problem in the county , while another 14% don’t know if a problem exists . Most ofen, if someone was made aware a person had extreme sadness or were contemplatng suicide, they would refer them to a doctor, health department, or other clinic or a pastor or another church member. Consideraton for community health improvement should include a greater understanding about whether or not the healthcare and faith community are prepared and equipped with tools they need should someone refer a person near or in crisis to them for help. In additon, further eforts to understand potental beh avioral health needs of youth should be explored through use of other tools like the 2014-15 Community Health Assessment [March 23, 2015] 7 Youth Risk Behavior Survey, so youth needs can be assessed since suicide among youth and young adults has become a natonal problem. Aging population trends and projected needs of the elderly Some community members (28%) recognized the needs of aging problems by notng it among the top 3 health problems that have the greatest impact on the community. There were many needs identfed for older adults in the community, but among them, transportaton and medicaton assistance programs were identfed as most important by survey partcipants, 67% and 70%, respectvely. Ashe County has a higher median age of 45.5 years compared to 37.6 years in NC and high percentage of older adults in the county, with 15.5% age 55-64 and another 23% who are age 65 and older (NC LINC, 2013). Altogether, that is nearly 40% of the populaton age 55 or older. This is an area that should be further assessed to ensure a broad sector of community members understand what is already planned or what needs further support to implement or sustain initatves for this populaton group. Special populations in the community Community members at the greatest risk for health problems are described briefy in this report. Notably, those who are youngest, oldest, and without healthcare coverage are important groups, as are those who do not speak English as a frst language. Ashe County homes that speak a language other than English at home are 4.6% compared to 7% in Macon County and 10.9% in NC overall (US Census Bureau, 2013). Socioeconomic factors that have impacts on the community Economy impacts health, as is evidence through unemployment rates, poverty, and household income levels well below that of NC. Economic development eforts aimed at growing employment are an important component to supportng long term health in the community. Though the unemployment rate for the county is decreasing, it is 7.6% compared to 6.6% in Macon County and 6.3% in NC (NC Department of Commerce, 2014) If I could change one thing to support health in my community Community members partcipatng in the community opinion survey were asked what they would change if they could impact one thing to improve health in the community. Major themes emerging from those write-in responses were around addressing healthcare coverage and afordability (73),improving physical actvity optons including indoor and outdoor recreaton opportunites (56), increase and/or improve medical care services (49, of which 10 are specifcally related to mental health services available), increase healthy food optons and/or nutriton behaviors (35), furthering educaton, with most specifcally about educaton for preventve health eforts (27), and addressing substance abuse concerns (23, of which most were about tobacco control/preventon followed by youth preventon eforts related to substance use). 2014-15 Community Health Assessment [March 23, 2015] 8 Health priorities selected Health priorites were selected by the Ashe Health Alliance in February, 2015 as described in methods secton. These priorites are not all-inclusive, but highlight priority areas this group will be working to beter understand and develop community improvement eforts to improve upon them. However, other key areas highlighted in this report will be reviewed as well to make sure all groups working to support health have the ability to also engage. Substance Use and Abuse Drugs, alcohol, and tobacco; including misuse or abuse of prescripton drugs and use of e-cigaretes or other devices for nicotne delivery Physical activity and nutrition Access to physical actvity or recreaton, accessing healthy foods, and making healthy choices for eatng healthy and making physical actvity easier for all Chronic Disease Management and Awareness Obesity, Heart disease, chronic lower respiratory disease/COPD, stroke, cancer, diabetes, and hypertension Next steps for community health improvement planning The group’s next steps in addressing important health priorites are briefy described below in the graphic. Since each priority requires both the use of evidence-based interventons (where they exist) and community context, and because some sectors of the populaton were not adequately heard during the community opinion survey process, the next steps will be conductng 4 to 5 community listening sessions in community locatons selected by the coaliton. At each listening session, community members will learn some about their community’s health, but most of the tme will be spent on gathering input from community members about solutons or reactons to proposed solutons using evidence based strategies. This process will take place in the spring of 2015. Results from community listening sessions will lead the group towards the development of a comprehensive community health improvement plan that will be used for the next two to three years to implement and measure results. This report is planned to be released during a community- wide forum, date to be determined, during the summer, 2015. 2014-15 Community Health Assessment [March 23, 2015] 9