1 COMMUNITY HEALTH ASSESSMENT OF BERKELEY COUNTY, WEST VIRGINIA by Shepherd University Department of Nursing Education senior students in NURS 413, Community Health Care, in collaboration with The Berkeley County Health Department Shepherd University Department of Nursing Education Spring, 2007
2 1 CONTENTS CHAPTER 1 A DESCRIPTION OF THE COMMUNITY...2 CHAPTER 2 DATA COLLECTION AND INITIAL INTERPRETATION...4 Windshield Survey...4 Demographic Data...6 Epidemiology...17 Key Informant Interviews...25 General Public Surveys...28 CHAPTER 3 DATA ANALYSIS AND IDENTIFICATION OF COMMUNITY NEEDS AND RESOURCES Priority Issue 1: Affordable Health Care...35 Priority Issue 2: Lack of Specialty Services...38 Priority Issue 3: Health Prevention and Promotion...42 CHAPTER 4 CONCLUSIONS AND RECOMMENDATIONS APPENDIX A WINDSHIELD SURVEY RAW DATA APPENDIX B LIST OF KEY INFORMANTS APPENDIX C BERKELEY COUNTY KEY INFORMANT SURVEY APPENDIX D GENERAL PUBLIC SURVEY APPENDIX E PRIORITY MATRIX APPENDIX F SHEPHERD UNIVERSITY DEPARTMENT OF NURSING EDUCATION FACULTY AND STUDENTS WHO PARTICIPATED IN THIS ASSESSMENT REFERENCES... 70
3 2 CHAPTER 1 A DESCRIPTION OF THE COMMUNITY Berkeley County, West Virginia, is located in the Eastern Panhandle of the state and is bordered by Washington County, Maryland, and the Potomac River to the north; Frederick County, Virginia, to the south; and the West Virginia counties of Jefferson and Morgan to the east and west, respectively. The 321 square mile county s close proximity to Washington, DC and Baltimore, Maryland, has contributed to the rapid growth of its population, which increased by 23% during the period from April 1, 2000 to July 1, 2005 (Map Stats, 2007). Berkeley County is located within the Appalachian mountain system that runs north and south along the eastern region of the United States. The county encompasses three ridges and valleys: North Mountain, Third Hill Mountain, and Sleepy Creek Mountain. Altitude ranges from 300 to 2,200 feet elevation, with the higher regions located primarily in the western part of the county (Doherty, 1972). Rivers and streams in the county include the Potomac River along its northern boundary, Back Creek and Cherry Run in the western part of the county, and Opequon Creek in the east, as well as numerous natural springs. During the 20 th century, the full extent of the area s natural wealth became known, and writers described it as full of natural treasures such as iron ore, mineral water, sulfur, sandstone,[and] potter s clay, as well as a fertile area for producing wheat, barley, oats, and corn (Doherty, 1972, p. 4). The county currently includes numerous fruit orchards. Historically, Berkeley County has been a county of both Virginia and West Virginia. In 1734, Frederick County, Virginia, was formed from part of Spotsylvania County because of the difficulty of the distant commute for residents to meeting places and court appointments (Gardiner & Gardiner, 1938). In 1772, Berkeley County was formed from part of Frederick
4 3 County. At the time it was formed, Berkeley County also occupied the present day areas of both Jefferson and Morgan Counties (Gardiner & Gardiner, 1938, p. 16). The areas within the county on which our assessment focused were Martinsburg, Hedgesville, and Inwood. Martinsburg, the county seat, has a population of about 15,000 with a density of 2,976 per square mile over a city area of 5.1 square miles, according to the United States Census (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). The city is located in the center of the county, with the small towns of Hedgesville to the northwest and Inwood to the south.
5 4 CHAPTER 2 DATA COLLECTION AND INITIAL INTERPRETATION This chapter will describe our findings regarding Berkeley County gathered from windshield surveys, epidemiological and demographic data, and key informant and general public interviews. We collected windshield survey data by direct observation, and we conducted face to face or telephone interviews with key informants and members of the general public. Windshield Survey Senior nursing students of the Shepherd University Department of Nursing Education conducted windshield surveys of the Hedgesville, Martinsburg, and Inwood areas of Berkeley County between January 17 and 28, 2007, at various times of day. The purpose of the surveys was to objectively identify areas of concern without physical interaction and to get an overview of the unique aspects of the county s population centers. Berkeley County is bordered by Maryland, Virginia, and two other West Virginia counties, Jefferson and Morgan. Interstate 81, a four to six lane interstate highway with plenty of shoulder room, runs through the middle of the county from north to south. Other major roads include state routes 9, 45, and 51, and U.S. routes 11 and 340. Conditions on these roads vary; some have no shoulders or have potholes and cracks, and some are extremely narrow and curvy. Within the major population centers of Martinsburg and Hedgesville, there are sidewalks, traffic signals, and well marked traffic signs. In and near Martinsburg, public buses provide access to limited areas of the county. Trains have a large presence in the community, with numerous railway crossings and a passenger station located in north Martinsburg. The West Virginia Regional Airport in south Berkeley County serves small aircraft.
6 5 Health care access is primarily located in Martinsburg, at or near the campus of City Hospital Inc., a West Virginia University East partner, with many physicians offices and ancillary services located nearby. The Veterans Affairs Medical Center is located in south Martinsburg. Hedgesville and Inwood have a limited number of primary, secondary, or tertiary health care settings, consisting of family physicians, dentists, counselors, and pharmacies. Businesses seen in the county include bars and clubs (especially prominent in south Berkeley), grocery stores, restaurants, gas stations, and banks. Utility companies, media outlets such as radio stations and billboards, campgrounds, and industrial parks containing factories and other businesses also are a part of the county s landscape. Housing in Berkeley County varies greatly by location, style, age, and condition. We saw many new developments all over the county, primarily outside of the major population centers. Within these population centers the homes tend to be older and small, but there are some older, larger homes on or near farms in the rural areas of the county. Many Christian places of worship are scattered throughout the county, including Baptist, Catholic, Methodist, Presbyterian, and independent churches, a Jehovah s Witness meeting hall, and other denominations, mostly in the population centers. In Martinsburg there is also a synagogue, which has since announced its closing. We did not see any mosques during the windshield survey. Houses of worship vary from large to small, and new to old depending on location, age, and denomination. Public service and federal offices are present in the community; most being centrally located in and around Martinsburg. Services we observed in the county include volunteer fire stations, state and city police stations, post offices, military recruitment offices, a jail, a recycling center, an animal control agency, and the county health department. Schools are primarily
7 6 located near the major population centers of the county and include public and private elementary, intermediate, middle, and high schools, as well as a vocational school, a community college, and college branch offices. These buildings are primarily brick, and differ in age. Major concerns that arose from these observations were health care accessibility throughout the county, numbers of general and specialty practitioners, and safety issues such as poor upkeep of secondary roads, lack of sidewalks, and lack of fencing around some private pools and community areas. Another concern was the easy availability of alcoholic beverages, especially in south Berkeley County. For a more in depth look at the windshield survey data, see Appendix A. Demographic Data In this section we will compare demographic characteristics of the United States (US), West Virginia (WV), and Berkeley County. The overall population for the US in 2000, according to the U.S. Census Bureau, was 281,421,906. During the year 2000, the Census Bureau stated that the population of WV was 1,808,344, which rose to 1,816,856 in The population of Berkeley County in 2000 was 75,905, which the Census Bureau estimated rose to 93,394 in 2005 (Map Stats, 2007). As Table 2 1 shows, population gender was similar for the US, WV, and Berkeley County, with slightly more females than males in each population (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). e g t a n e r c e P Table 2 1: Gender Berkeley Co. West Virginia United States MALES FEMAL ES
8 7 As shown in Table 2 2, the largest population group was between the ages of 25 and 54. The age distribution of the populations of Berkeley County, WV, and the US are similar (Berkeley County Quickfacts from the U.S. Census Bureau, 2007), but compared to both the US and WV, a greater percentage of Berkeley County residents were in the 25 to 54 age group. Whites were the predominant race in all areas, as shown in Table 2 3. There were higher percentages of Whites in WV and Berkeley County than in the US, and a higher percentage of Blacks in Berkeley County and the US when compared with the state of WV. The percentage of Hispanics living in the US and in Berkeley County was higher than that in WV (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). Table 2 3: Race 100 e 80 t a g n 60 e r c 40 e P 20 0 WHITE BLACK Other HISPANIC Berkeley County West Virginia United States
9 8 According to the 2000 U.S. Census, the percentages of residents born in Berkeley County (98%) and WV (99%) were higher than the U.S. average (90%). The 2000 U.S. Census also found English to be the predominant language spoken in most Berkeley County homes. Spanish was the second most common language, with a greater percentage of Spanish speaking households in Berkeley County than in the state as a whole (Berkeley County Quickfacts from the U.S. Census Bureau, (2007). According to the 2000 U.S. Census, the average household size in Berkeley County was 2.53 people per household, slightly higher than the WV average of 2.38 people. Both these averages were slightly smaller than the average household size for the US, which was 2.59 people. As shown in Table 2 4, the average family size for Berkeley County was 2.99 people, similar to the WV average of 2.91 people. However, the average family size was slightly smaller than the US average of 3.14 people per family (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). 3.2 f o e r a l s u 3 b i d u m v 2.8 N I n d 2.6 Table 2 4: Average Family Size Average Family Size Berkeley County West Virginia United States In Berkeley County, 37% of households included individuals under the age of 18, a percentage similar to that of the US (36%) and higher than the WV average (31%). However, WV had a higher percentage of households with individuals age 65 and over (28%) than the US (23%) and Berkeley County (21%). In 2005, the Census Bureau reported that 25% of people
10 9 living in Berkeley County were under the age of 18; the WV average was 21%. Almost 11% of individuals living in Berkeley County were over the age of 65, less than the WV average of 15% (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). Berkeley County and WV had a greater number of people who own their houses than the national average. In Berkeley County and WV, 74 % of residents reported living in their own houses, compared with the national average of 66%. The number of housing units for Berkeley County reported in 2005 was 39,522, compared to WV, which had 872,223 housing units in 2005 (Berkeley County Quickfacts from the U.S. Census Bureau. (2007). Table 2 5 shows that the US had a higher percentage of individuals attending or graduating from college than WV and Berkeley County. Berkeley County had a slightly higher percentage of individuals with a 12 th grade or lower educational level than individuals in WV and US (Berkeley County Quickfacts from the U.S. Census Bureau. 2007). Table 2 5: Educational Attainment Berkeley County West Virginia United States t s n e i d s r e f o e g t a e n r c e P
11 10 According to the 2000 U.S. Census, 23% of Berkeley County residents ages 15 years and older had never been married. This percentage was below the state average (24%) and national average (27%). The population of Berkeley County residents 15 years and older who were married was 57%, slightly higher than averages for the state (56%) and nation (54%). The population of Berkeley County residents who were divorced during the 2000 census was 12%, which was slightly higher than the rates for WV (10%) and the US (10%). Table 2 6 illustrates the distribution of marital status throughout the three regions (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). Table 2 6: Marital Status t 40 n e r c 30 e P Never Married Married Separated Widowed Divorced Marital status Berkeley County West Virginia United States The 2000 U.S. Census also revealed that 45% of grandparents in Berkeley County cared for one or more grandchild under the age of 18. This was lower than the state average of 49% and higher than the national average of 42% as shown in Table 2 7 (Berkeley County Quickfacts from the U.S. Census Bureau, 2007)..
12 11 Table 2 7: Grandparents as Caregivers t e n r c e P Residency Berkeley County West Virginia United States The increasing number of grandparents as caregivers is believed to be correlated with the teen pregnancy rate. According to the National Campaign to Prevent Teen Pregnancy (n.d.), in 2000, WV ranked 16 th in the nation in pregnancies occurring between the ages of 15 to 19. West Virginia s pregnancy rate was 67 per 1,000 teens compared to the 2000 US rate of 87 per 1,000. According to the West Virginia Adolescent Pregnancy Prevention Initiative (n.d.), 158 Berkeley County teens between the ages of were pregnant in Possibly because of the Veterans Affairs Medical Center located in Martinsburg, the percentage of veterans older than 18 was higher in Berkeley County (17%) than the state (15%) and national (13%) averages. The 2000 U.S. Census also revealed that the percentage of disabled residents ages 5 to 64 was higher for Berkeley County (32%) than the state (28%) and nation (27%). In contrast, the percentage of disabled residents over 64 years of age in Berkeley County was slightly lower than that of the state and nation. Table 2 8 illustrates the distribution in all three areas (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). The unemployment percentages in 2007 for Berkeley County, WV, and US were estimated to be 4.7, 5.4, and 4.5 respectively, as shown in Table 2 9. West Virginia had a higher unemployment rate than the US and Berkeley County (Map Stats, Feb. 2007).
13 12 50 e 40 g t a 30 n 20 r c e e P 10 0 Table 2 8: Disabled Residents 5 to to Age in Years Berkeley County West Virginia United States 6 Table 2 9: Unemployment Status e g t a n e r c e P Area Berkeley County West Virginia United States The distribution, as shown in Table 2 10, between classes of workers in Berkeley County was similar to the US and WV. However, the percentage of private wage and salary workers was slightly higher across the US. Both Berkeley County and the state of West Virginia had a higher percentage of government workers than the nation, but WV was higher than Berkeley County (Berkeley County Quickfacts from the U.S. Census Bureau. 2007). According to the 2000 U.S. Census (2007), residents of Berkeley County spent on average 4 to 5 minutes longer commuting to work than US and WV residents, possibly because of the availability of well paying, high tech jobs in the Washington, DC, and Baltimore Table 2 10: Type of Worker
14 Percentage Berkeley County West Virginia United States 10 0 Private Government Self employed Unpaid metropolitan areas. As shown in Table 2 11, family income in the US was higher than that for WV and Berkeley County, although Berkeley County s median family income is higher than the WV median family income (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). n i n 100,000 i a e r s d m l a e o 50,000 o m c i n d 0 Table 2 11: Median Income Comparison Area Berkeley County West Virginia United States
15 14 More recent statistics from 2003 showed the median family income in Berkeley County was $43,300, compared with $32,967 in WV (Map Stats, Feb. 2007). According to the 2000 U.S. Census, more WV residents than county or U.S. residents reported living below the poverty line, as shown in Table The 2003 data listed individual poverty status for WV as 16%; US, 3%; and Berkeley County, 12% (Map Stats, 2007). Table 2 12: Poverty Status e l i n r t y e v o p w l o e b e g t a n e e r c P Families Individuals Berkeley County West Virginia United States Medicare, the federal program that provides health insurance for people 65 years of age and older, disabled individuals, and people with chronic kidney failure, is divided into two parts: Part A, otherwise known as Hospital Insurance, and Part B, also called Supplementary Medical Insurance, which covers services. Members are enrolled in either part A, part B, or both. The percent of WV residents enrolled in Medicare remained consistent from However, the percent of change for the U.S. residents has continued to increase as shown in Table 2 13 (Medicare Enrollment Reports, 2005).
16 15 The number of enrolled beneficiaries in Medicare parts A and B in the US declined slightly in 2004; a decline in enrolled individuals was also present in WV in 2004 and in Table 2 14 summarizes Berkeley County Medicare Enrollment in 2003 (Medicare Enrollment Reports, 2005). According to the 2000 Census, the median value of homes in Berkeley County ($99,700) was slightly less than the median value of homes in the US ($119,600). The median value of homes in WV was the lowest, at $73,000. More recent statistics from 2003 showed the U.S. median household value had risen to $140,000 and the WV median value had risen to $78,200 (Percentage of million dollar homes nearly doubles since 2000, 2005).
17 16 Table 2 15 shows that over 50% of homes in the US and WV used electricity as the primary heating source. In Berkeley County, the two most common home heating fuels were electricity (54%) and fuel oil (23%). Gas heat was the third most common heating source in WV. The high prevalence of electrical heating sources in Berkeley County could be a result of the rapid growth in the region, including the increased rate of new housing developments being built. Table 2 15 compares major home heating sources in Berkeley County, WV, and the US (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). As shown in Table 2 16, the 2000 U.S. Census revealed that 4% of Berkeley County residents do not have telephone service. This is higher than the West Virginia and U.S. overall percentages of 3.5% and 2.4%, respectively. However, at 0.4%, the percentage of Berkeley County housing without complete plumbing and kitchen facilities is slightly less than the percentages of West Virginia residences (0.5%) and U.S. residences (0.7%). Fewer Berkeley
18 17 County residences lack complete plumbing and kitchen facilities than the US and WV overall percentages; however, Berkeley County residents are more likely to have no residential phone service (Berkeley County Quickfacts from the U.S. Census Bureau, 2007). Epidemiology The epidemiologic focus of this study was based on data from the website of the West Virginia Department of Health and Human Resources (WVDHHR). Among the data groups from this source were selected causes of death in Berkeley County from 1992 to 2001; cancer incidence among county residents from 1999 to 2000; infant and fetal mortality, birth statistics, and fertility rates, all from 1997 to 2001; and a comparison of behavioral prevalences in the county between 1994 and Monthly reports showing communicable disease statistics from the first 8 months of 2006 were used as the most recent set of information related to communicable disease in Berkeley County. These data sources were chosen because they are the most recent and authoritative sources available.
19 18 Data on infectious diseases from January to August, 2006, showed 5 cases of campylobacteriosis, 10 cases of chickenpox, 407 cases of influenza like illness, 3 cases of acute Hepatitis B, 1 case of H. influenza, 3 cases of animal rabies, 2 cases of aseptic meningitis, 1 case of neisseria, 14 cases of Streptococcus pneumonaie, 3 cases of salmonellosis, 2 cases of group B strep, and 1 case of toxic shock syndrome (West Virginia Monthly High Incidence Communicable Disease Infectious Disease Epidemiology Program [IDEP] Surveillance Data, January August, 2006). From January 1 to September 30, 2006, there were 1350 confirmed reportable disease cases (Confirmed and Probable Cases by Month reported to WVEDSS, 2006). Statistics from the WVDHHR website showed that the top five causes of death in Berkeley County from 1992 to 2001 were heart disease, malignant cancer, stroke, chronic obstructive pulmonary disease, and injuries. All of these rates were significantly higher than national averages. Table 2 17 is a comparison of death rates from selected leading causes in Berkeley County, WV, and the US, from (Berkeley County selected causes of deaths, , 2004).
20 19 According to the WVDHHR website, heart disease caused deaths per 100,000 people in Berkeley County. This rate was 22.5% greater than the overall U.S. rate of 279 deaths from heart disease per 100,000 people (Berkeley County selected causes of deaths, , 2004). The second leading cause of death in the county in the years studied was malignant cancer, which caused deaths per 100,000 people in the county, compared to a rate of deaths per 100,000 people in the nation. The leading cause of cancer deaths in Berkeley County was lung cancer, with a death rate of 72.7 deaths per 100,000 people, compared to a rate of 57.6 deaths per 100,000 in the nation. This rate was 26.2 % higher than the national average. In Berkeley County, colon cancer was the next highest cause of cancer deaths, with a rate of 26 deaths per 100,000 in the county, a rate 42.1% higher than the national average of 18.3 deaths per 100,000. Breast cancer, with a rate of 29.1 deaths per 100,000 in Berkeley County, was only 3.1% higher than the national average of 28.2 per 100,000, and prostate cancer fell 16.1% below the national rate, with 28.4 deaths per 100,000 people in the county, compared to 33.9 deaths per 100,000 in the US (Berkeley County selected causes of deaths, , 2004). Because lung and colon cancer death rates are lowered by behavioral changes (stopping smoking and colorectal screenings, respectively), this information carries important public health implications for the county. Stroke (cerebrovascular disease) was the third leading cause of death in the county from , causing 67.5 deaths per 100,000 residents. The national average death rate from stroke was 61.6 deaths per 100,000 persons (Berkeley County selected causes of deaths, , 2004.)
21 20 Chronic obstructive pulmonary disease (COPD) followed stroke as the fourth leading cause of death in Berkeley County, causing 50.6 deaths per 100,000 county residents, a rate 22.3% higher than the U.S. average of 41.4 deaths per 100,000 (Berkeley County selected causes of deaths, , 2004.) Research has shown that smoking tobacco contributes to 80 to 90% of all COPD cases. In Berkeley County, 32% of residents smoked, making the county seventh in the state for number of smokers (1999 Berkeley County behavioral prevalences, 2004). Injuries accounted for 424 deaths in Berkeley County during the period reviewed. Of these, 272 were unintentional, including 129 motor vehicle accidents and 143 other non vehicle accidents. Unintentional injuries accounted for 39.9 deaths per 100,000 county residents, a rate 12% higher than the national average of 35.6 deaths per 100,000. Intentional injuries, including 113 suicides and 39 homicides and deaths from legal intervention, accounted for 152 deaths in Berkeley County, a rate of 21.4 deaths per 100,000, compared to 18.4 per 100,000 nationally. While homicide and legal interventions caused a death rate of 5.5 per 100,000 people in Berkeley County, a rate 24.1% lower than the national average of 7.2 per 100,000, suicide rates were very high in the county. In the period studied, 16 persons per 100,000 took their own lives, a rate 41.2% higher than the national average of 11.3 persons per 100,000 (Berkeley County selected causes of deaths, , 2004). Other top causes of death in the county were diabetes, pneumonia, and influenza. Diabetes caused 26.2 deaths per 100,000 people, 10.2% higher than the national average of 23.8 deaths per 100,000. Pneumonia and influenza claimed 30.8 people per 100,000 in the county, a rate 8.1% lower than the national average of 33.5 deaths per 100,000 (Berkeley County selected causes of deaths, , 2004).
22 21 Information from the WVDHHR website also showed that Berkeley County had an infant mortality rate 19.5% higher than the national average. From 1997 to 2001, 8.5 infant deaths occurred per 100,000 population, compared to a US average of 7.1. Table 2 18 compares other related birth statistics for the county and the nation (Berkeley County infant and fetal mortality, 2004; Berkeley County selected birth statistics, 2004; WV Healthy People 2010, 2001.) Table 2 18: Comparison of selected birth statistics per 100,000 people for Berkeley County, the US, and WV Healthy People 2010 target rates. Fetal deaths, however, occurred at a rate 17.5% lower than the national average, with 5.5 deaths occurring per 100,000, compared to 6.7 in the nation (Berkeley County Infant and fetal mortality, , 2004). In that same period, there were 395 low birth weight babies born, a number similar to the national average. In Berkeley County, 144 mothers received no prenatal care, 1,423 mothers used tobacco (a rate 124.8% higher than the national population based average), and 1,208 mothers had less than 12 years of education (Berkeley County selected birth statistics, 2004).
23 22 Many behavioral factors contributing to non infectious illness and death in the county are highlighted in Table Over one third of county residents (37.1%) were physically inactive, nearly one fourth (23.8%) were obese, and 27.5% had hypertension. Nearly one third of county residents smoked cigarettes and 8% used smokeless tobacco, while 7.4% were binge drinkers. In addition, one in five county residents ages 18 to 64 had no health insurance, and 14.5% had difficulty seeing a physician because of cost (1999 Berkeley County behavioral prevalences, 2004). Inactivity, hypertension, obesity, tobacco, and alcohol use are significant contributors to heart disease, cancer, stroke, and COPD, the four leading causes of death in Berkeley County. Fiscal disparities such as lack of insurance and inability to pay for care can be relevant factors to poor preventative, prenatal, and children s health care. Healthy People 2010 (2000), a public health planning document published by the U.S. Department of Health and Human Services, has made specific recommendations and set objectives related to many of the diseases that are primary causes of death in the US. West Virginia Healthy People 2010 (2001), a related
24 23 document published by the WVDHHR, outlined similar objectives for West Virginia residents. These objectives are summarized and compared to Berkeley County actual rates in Table 2 20, below (Berkeley County selected causes of deaths, , 2004; West Virginia Healthy People 2010, 2001; Healthy People 2010, 2000). Table 2 20: Comparison of Objectives and Data 400 l e p o e 300 P 0 200, r e P 0 Heart Disease Cancer Stroke COPD Injury Berkeley Co. Death Rates WV Healthy People 2010 Targets Healthy People 2010 Targets With regard to cardiovascular disease, Healthy People 2010 (2000) objectives set a goal of no more than 166 deaths per 100,000 people (p ). West Virginia Healthy People 2010 (2001) targeted no more than 200 deaths from heart disease per 100,000 residents (p. 70). Healthy People 2010 objectives related to cancer target no more than overall deaths per 100,000 residents (p 3 10), with no more than 44.9 of those from lung cancer, no more than 22.3 from breast cancer (p. 3 12), no more than 13.9 from colorectal cancer (p. 3 14), and no more than 28.8 from prostate cancer (p. 3 17). The Flagship Objectives of West Virginia Healthy People 2010 did not set overall cancer death target rates, but did set goals of reducing lung cancer to no more than 59 per 100,000 West Virginia residents (p. 18), breast cancer to no more than 21 per 100,000 West Virginia females (p. 19), and prostate cancers to no more than 19.5 per 100,000 West Virginia males (p. 19). In addition, West Virginia Healthy People 2010
25 24 recommended increased screenings for cervical and colorectal cancers (p. 20), and increased counseling regarding tobacco use cessation and diet modification (p. 17). Implementing such measures could impact future death rates from cancer in the county. Reducing the national death rate from stroke to no more than 48 per 100,000 persons was the goal of Healthy People 2010 (2000, p ), while reducing the stroke death rate to no more than 45 per 100,000 residents was set by West Virginia Healthy People 2010 (2001, p. 72). COPD death rates in the U.S. should be reduced to 60 per 100,000, according to Healthy People 2010 (2000 pp ). West Virginia Healthy People 2010 (2001) recommended a target of no more than 50 deaths from COPD per 100,000 people (p. 152). National Healthy People 2010 (2000) goals call for reducing deaths per 100,000 people from unintentional injuries to no more than 17.5 (p ) and from intentional injuries to no more than three homicides and five suicides (p.15 43). Without specifying an overall target rate for deaths from unintentional injuries, West Virginia Healthy People 2010 (2001) set several related objectives, such as reducing vehicle and ATV crash deaths (p ) by requiring seat belts, child safety restraints, and helmets for bikers and motorcyclists. The state initiative also did not set a specific overall goal of reducing deaths from intentional injuries and violence, but set related goals to reduce deaths from domestic violence (p. 93), as well as reducing sexual assault (p. 94) and child maltreatment (p. 95). Comparing actual disease rates in Berkeley County with goals set by Healthy People 2010 and West Virginia Healthy People 2010 indicated possible areas of direction for health care in the county in the future. Both Healthy People 2010 and West Virginia Healthy People 2010 also contained a number of recommendations and objectives aimed at improving health care in
26 25 the nation and the state, respectively, which could be implemented to provide longer, healthier lives to Berkeley County residents, while eliminating health care disparities in the region. Key Informant Interviews To obtain information from the community about the state of health care in Berkeley County, we conducted two series of interviews, one with members of the general public and another with select key informants. The key informants represented a broad cross section of public and private organizations including, but not limited to, health care agencies, school system administrators, religious leaders, and elected officials present throughout Berkeley County. A listing of key informants who participated in our survey is found in Appendix B. We asked key informants two open ended questions, which were: 1. What additional health care services would you like to see available in Berkeley County? 2. What do you think are the three priority health care needs for this area of Berkeley County? The results of the 30 individual key informant interviews are summarized below. The first question, about desired additional health care services, resulted in a variety of key informant responses. Of the 30 key informants interviewed, 97% (29) said they would like to see broader transportation access to health care facilities, increased access to specialized health care services such as dental and vision care, and improved and expanded behavioral and substance abuse rehabilitation and treatment facilities within the area. Ninety three percent (28) of the key informants interviewed also indicated a desire for increased numbers of and access to specialized health care providers such as women s health services, adult and pediatric dentists, physicians specializing in chronic diseases such as diabetes and respiratory disorders, and nutritionists for county residents. Collectively, all of the key informants stated a desire to
27 26 increase access to existing facilities for working residents through the use of flexible business hours. Three key informants noted that standard 9 a.m. to 5 p.m. health care office business hours were not convenient for most working residents, requiring them to miss work in order to visit a health care provider or agency. All 30 key informants expressed a desire to expand preventative health care like nutritional and obesity education and to increase no cost health care and wellness screenings for children, adults, and elderly adults. The second interview question asked key informants to identify the three top priority health care needs for community residents. These three priorities included: access and availability of health care for underinsured, uninsured, and working poor individuals, broader specialized health care services and providers, and improving preventative health care screening and wellness for all community residents. All 30 key informants noted that the lack of affordable health care was a major issue of concern and that providing health care for all residents, either through public programs (Medicaid and Medicare) or private agencies was a priority community health issue. All key informants identified the necessity of providing health care access for uninsured, underinsured, and insured members of the community. Although all of the key informants interviewed recognized that there were agencies available to provide some measure of health care services, they pointed out the limitations and shortfall those agencies face in providing coverage to community residents. Also, not all key informants (7 of 30) were familiar with the resources and programs available to assist community residents. Key informants identified the need for broader, specialized health care services as a second priority health care need for Berkeley County. All 30 key informants identified the lack
28 27 of access and availability of general and specialized health care services such as pediatric and adult dental and vision specialists and women s health services as a priority community need. Four key informants suggested that improving and expanding the community s emergency medicine and emergency department facilities should be a priority issue. Additionally, 3 of 30 key informants cited the lack of a nutritional specialist to address obesity across the lifespan as significant absence with regard to improving community health. The third priority health care need for Berkeley County cited by key informants was the need for preventative health care for both well and chronically ill community members. All 30 key informants emphasized the need for improved and expanded community preventative health care. One key informant noted that the community suffered from generational health care illiteracy, suggesting that health care professionals must do a better job of educating community members about healthy behaviors. This health care education, encompassing issues such as smoking cessation, moderating alcohol consumption, healthy eating habits, maintaining an active lifestyle, and safe sexual practices must be provided in a tailored, culturally competent method to improve community health. Four key informants suggested prioritizing more preventative and aggressive health care screenings for hypertension, obesity, diabetes, and malnutrition or poor nutrition for all community residents. In summary, the top four issues identified by key informants were: access to affordable health care services to all community residents (30 of 30 informants), access and availability to general and specialized health care providers, including dental and vision providers (30 of 30 informants), improved and expanded community preventative and wellness health care (30 of 30 informants), and
29 28 improved community health care education (13 of 30 informants). General Public Surveys In small groups, senior BSN students from our Community Health nursing class at Shepherd University surveyed the general public at local businesses and schools in Hedgesville, Inwood, and Martinsburg from March 1 to 16, We obtained a total of 400 completed surveys. We identified the participants genders and ages based on observation, and asked each individual five survey questions. Each individual s responses were recorded on a separate survey sheet. All responses were then collected and will be presented in aggregate form. A copy of the survey can be found in Appendix C. The survey questions included: What county do you live in? What county do you work in? In what county do you get your health care? What health care services would you like to see available in Berkeley County? What do you think is the biggest health care need in Berkeley County? Martinsburg A total of 125 responses were received for the survey done in Martinsburg. Of the respondents, 72 (57.6%) were women and 53 (42.4%) were men. For the purposes of the survey, age groups were divided into teen, young adult (ages 20 to 39), adult (ages 40 to 59), and older adult (ages 60 and over). Of women, 16 (12.85% of total) were teens, 23 (18.4% of total) were young adults, 21 (16.8% of total) were adults, and 12 (9.6% of total) were older adults. Among men, 9 were teens (7.2% of the total), 10 were young adults (8% of total), 27 were adults (21.6% of total), 5 were older adults (4% of total), and 2 men did not specify their age (1.6% of total).
30 29 Ten of the respondents lived in West Virginia counties other than Berkeley County: six in Jefferson, three in Morgan, and one in Hampshire. One respondent lived in Warren County, Virginia, while five did not specify their county of residence. Forty respondents did not state that they work in Berkeley County, comprising 21 who were not currently working, either because they were teens or because they were retired, 9 others who did not specify in what county they work, and 10 who worked in other counties. Of those, one respondent worked in Frederick County, Maryland, one in Fairfax County, Virginia, and one in Warren County, Virginia, while six worked in Jefferson County, West Virginia, and one worked in a combination of three counties, including Berkeley. Most respondents obtained their health care within Berkeley County. Of those who did not, four went to Maryland: two to Washington County, one to Carroll County, and one to Frederick County. Nine respondents got their health care in nearby Virginia: nine in Frederick County, one in Fairfax County, and one in Warren County. Residents who got health care in West Virginia counties other than Berkeley included two in Morgan and three in Jefferson. Seven respondents did not specify where they received their health care. Respondents were asked what health care services they would like to see in Berkeley County. Among female and male teens, 6 of 25 respondents said they would like to see some sort of sports related medical treatment facility: physical therapy, sports injury clinic, and trainers were among the answers. Teens also stated a need for specialists, including allergy specialists, to prevent lengthy trips elsewhere for such services. Young adult women mentioned that they would like to see more children s specialists, orthodontists, dentists, obstetric and gynecological specialists, and specialists in general. Adult women stated that they would like to see more clinics, more general practitioners, a women s center, fertility specialists, a wellness center,
31 30 acupuncture, and free medical services. Older adult women said they would like to see more specialists, clinics for low income residents, and better eldercare facilities. Young adult men expressed a desire for lower cost health care options, specialists, and sports medicine facilities. Adult men also noted that they d like to see more facilities for low income residents, more dentists and other specialists, and more programs to teach health promotion and illness prevention. All other men (older adult and unspecified) said they d like to see more specialists, better technology and emergency care, more health education, and expanded nursing education programs. Respondents were also asked what they believe is the biggest health care need in Berkeley County. Among 25 male and female teens, 6 responded that the county s biggest health care need is treatment for orthopedic or athletic injury needs. Teens also indicated a need for mental health promotion, dental and medical insurance, birth control, free care, allergy treatment, and a better hospital and emergency room. Young adult women said the county s biggest need is more dentists and specialists, child and prenatal care, cancer treatment, obesity and weight management concerns, insurance for the poor and elderly, health promotion, and treatment for substance abuse including tobacco. Adult women saw the most important needs as education and health promotion, clinics and affordable health care, obesity, dental care, specialized care for groups including cardiac patients, substance abusers, and mentally ill individuals. Older women identified lower costs and better benefits, obesity and smoking, diabetic care, communication between Martinsburg City Hospital and Winchester Hospital, specialized care, and eldercare as outstanding needs. Young men ranked costs, obesity, sexually transmitted diseases (STDs), dental needs, and smoking as prime concerns. Among adult men, costs, insurance, physicians accepting new patients and insurance, obesity, smoking, homelessness, eldercare, cardiac care,
32 31 substance abuse, pediatric needs, and specialized care were identified as primary county needs. Older men pointed out needs for more emergency care, care for elderly and disabled residents, and more physicians. Hedgesville In Hedgesville, 124 persons responded to the survey; 53 (42.7%) were male and 71 (57.3%) were female. Eight respondents (6.45%) were teenagers, 45 (36.3%) were young adults, 45 (36.3%) were adults, and 26 (21%) were older adults. Of the total number of participants, 112 were residents of Berkeley County; the 12 who did not claim Berkeley County residency included 7 from Morgan County; 1 each from Allegany County, Maryland, and Rockingham County, Virginia, and Stephens City, Virginia; and 2 who did not specify. In terms of work location, 47 individuals surveyed did not work in Berkeley County, including 16 who worked in Maryland: 12 in Washington County, 2 in Montgomery County, and 2 in Frederick County. Five respondents worked in Virginia: two in Fairfax, one in Stephens City, one in Loudon County, and one in Arlington. One person who answered the survey worked in Morgan County, West Virginia; another worked in Washington, DC. Fourteen were retired, six were unemployed, one was disabled, and three did not specify. Of the participants, 79 received their health care within Berkeley County, 34 traveled outside Berkeley County for health care, and 11 did not specify where they obtained their health care. When asked about health care services wanted in Berkeley County, 78 participants listed specific concerns, and other participants listed items in general. With regard to specialists needed in the area, 25 individuals listed specific types, with 17 people citing a need for dental care. Cardiac specialized care followed, with a total of nine participants listing it, and five people mentioned a need for cancer specialists. Two people stated a need for neonatal care; dialysis,
33 32 pain management, obstetrics and gynecology, chiropractic, and dermatology were each listed by one individual. Besides specialty care, respondents next cited concern was the lack of physicians located in the Hedgesville area, with 23 participants listing this as a main concern. The need for medical practices to accept more insurance carriers and Medicaid was also an issue listed by 20 individuals. Lack of health education was mentioned by 18 respondents, of whom 7 specified obesity, 4 mentioned substance abuse, 2 stated the need for safe sex education, 3 cited teen pregnancy, and 2 noted HIV awareness. Of those surveyed, nine people expressed concern regarding health care options for the elderly in this area. Three people mentioned the necessity of better emergency department facilities at City Hospital and three mentioned the cost of health care. Other issues that were only mentioned by one person each totaled 17 miscellaneous categories. The data compiled by these surveys done in Hedgesville can be categorized into three main concerns: more area specialists in general, more family practice physicians located in the Hedgesville area, and payment issues related to area medical or dental practices not accepting certain insurance carriers, Medicare or Medicaid, or uninsured or underinsured clients. Inwood A total of 151 participants answered the general public survey in the Inwood community. Of those participants, 80 (52.9%) were female and 71 (47.1%) males, 7 (4.9%) teenagers, 57 (40.4%) young adults, 58 (41.1%) adults, and 29 (20.5%) older adults. Out of the participants interviewed, 127 (90.0%) lived in Berkeley County. When asked if they worked or received health care in Berkeley County 94 (66.6%) responded that they lived in Berkeley County; 108 (76.5%) received their health care in Berkeley County. Survey respondents were asked what health care services they would like to see in Berkley County. Of the respondents, 18 wanted increased dental care services, 13 wanted more
34 33 affordable health care services and more free clinics, 15 wanted more health prevention education, 17 wanted more primary physicians and specialists in the area, 9 people wanted more vision screenings, 14 wanted walk in clinics, 10 wanted a better or upgraded hospital, and 6 wanted comprehensive health care. Needs cited by four or fewer respondents each were more rehabilitative services, better child care, more pharmacy help, more single mom support, more labs or x ray facilities, more urgent care facilities, assistance for the elderly and disabled, sleep clinics, increased activity choices, more legal support for medical staff, diabetic care, increased food choices, cancer research, and counseling services. Several statements indicated either that the respondent didn t know what services were needed or that he or she believed that health care in the county was adequate. Next, members of the general public were asked what they believed to be Berkeley County s biggest health care need. Responses indicated that the largest need was affordable health care, listed by 27 respondents, followed by more education programs for all ages, health problems, and preventative education. Of those surveyed, 17 people believed the biggest health care need was more physicians and specialists in Berkeley County, 13 people identified obesity help as a health care need, and 11 people identified alcoholism and drunk driving prevention and assistance a large need for the county. Ten people said they believe that teen pregnancy prevention was a significant need, and nine people named a need for dental care. Other concerns suggested by the general public that totaled fewer than nine responses each were more public transportation, pharmacy assistance, a newer or better hospital, more cardiac care, better emergency care, more mental health care, increased state funding, increased vision programs, more activities for children, more information about and prevention of sexually transmitted diseases, assistance for gambling addiction, elderly care, illegal drug use rehabilitation programs,
35 34 hypertension programs, more insurance, diabetes programs, smoking cessation, and violence awareness. In conclusion, out of the 400 respondents, 223 (55.6%) were female and 177 (44.4%) were male. Regarding ages of the participants surveyed, 40 (10.3%) were teenagers ages 12 19, 135 (34.6%) were young adults ages 20 39, 151 (38.7%) were adults ages 40 59, 72 (18.2%) were older adults ages 60 and over, and the ages of 2 (.5%) were not specified. The largest issues identified throughout the community were lack of affordable health care, lack of specialists, need for health promotion and education, need for assistance and rehabilitation programs to deal with substance and alcohol abuse, and lack of resource awareness.
36 35 CHAPTER 3 DATA ANALYSIS AND IDENTIFICATION OF COMMUNITY NEEDS AND RESOURCES Upon completion of the community assessment, we identified a list of problems and evaluated each problem on six criteria, which included community awareness, motivation to resolve the problem, nurses ability to influence the problem, the availability of expertise, severity of outcomes if left unresolved, and the quickness in which each problem can be solved. Each category was given a rating using a scale of 1 5, 1 being none and 5 being extensive. We then totaled up scores for each category of the problem and used the total number to determine the problem s priority. The top five problems identified using the total score were prevention and promotion of health, substance abuse, access to affordable health care, awareness of resources, and lack of specialists. See Appendix D for a copy of the matrix. We further narrowed the top five problems to three, by placing the problem list on the board and voting for the two that were the highest priority for the community. The resulting top three priority problems were lack of affordable health care, lack of specialists, and illness prevention and health promotion. Each top priority issue was then analyzed to identify its contributing factors and data supporting the relationship. Concluding each section are potential partnerships that may be formed to solve this issue. Priority Issue 1: Affordable Health Care This section of the paper will discuss the first priority issue, lack of access to affordable health care. The following table provides an overview of factors contributing to the problem, offers supporting data, and concludes with goals and objectives.