2013 Hunterdon County Community Health Needs Assessment

Transcription

1 2013 Hunterdon County Community Health Needs Assessment June 2013

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3 2013 Hunterdon County Community Health Needs Assessment Prepared by: Joanna Chua, MPH, CHES Program Coordinator Hunterdon Regional Community Health Adopted: June 28, 2013

4 2013 Hunterdon Community Health Needs Assessment

5 TABLE OF CONTENTS ACKNOWLEDGEMENTS... i EXECUTIVE SUMMARY... ii INTRODUCTION... 1 COMMUNITY... 2 MOBILIZING ACTION THROUGH PLANNING AND PARTNERSHIPS... 4 COMMUNITY HEALTH STATUS ASSESSMENT... 5 Demographics... 5 Population... 5 Age... 7 Race/Ethnicity... 8 Disability... 9 Social and Economic Factors Educational Attainment Employment Income and Poverty Marital Status Housing Crime Physical Environment Air Quality Access to Healthy Food Transportation Clinical Care Healthcare Access and Utilization Oral Health Physician Supply Preventive Services Hospital Utilization and Access Health Outcomes Mortality Leading Causes of Death Cancer Morbidity Maternal and Child Health Mental Health Cardiovascular Disease Other Chronic Diseases Health Behaviors Obesity, Physical Activity and Nutrition Substance Use and Abuse Hunterdon Community Health Needs Assessment

6 Substance Abuse Treatment Bullying Sexual Activity COMMUNITY THEMES AND STRENGTHS ASSESSMENT Introduction Methodology Results FORCES OF CHANGE ASSESSMENT Introduction Methodology Results LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT57 Introduction Methodology Results PRIORITIZATION Assets and Resources CONCLUSIONS REFERENCES APPENDICES Appendix A: List of Partnership for Health Members Appendix B: County Health Rankings Model Appendix C: Focus Group Code Book Appendix D: Data Summary by Health Issue Appendix E: Data Summary by Health Factor Hunterdon Community Health Needs Assessment

7 LIST OF FIGURES Community Health Status Assessment FIGURE 1: Population Trends and Projections... 6 FIGURE 2: Population, by Municipality... 6 FIGURE 3: Population Density (per square mile), by Municipality... 7 FIGURE 4: Age Demographics... 7 FIGURE 5: Race/Ethnicity... 8 FIGURE 6: Percentage with a Select Disability... 9 FIGURE 7: Educational Attainment FIGURE 8: Percentage of High School Graduate or Higher, by Municipality FIGURE 9: Unemployment Rate FIGURE 10: Unemployment Rate, by Municipality FIGURE 11: Median Income, by Municipality FIGURE 12: Percentage of Individuals below Poverty Level FIGURE 13: Individuals below Poverty Level, by Municipality FIGURE 14: Number of People on Government Assistance Programs FIGURE 15: Marital Status FIGURE 16: Percentage of Municipalities with Gang Presence FIGURE 17: Violent and Non-Violent Crime Rate per 1,000 population FIGURE 18: Percentage of Adults Health Care Coverage FIGURE 19: Percentage of Adults Who Did Not See a Doctor Due to Cost FIGURE 20: Percentage of Adults Who Have Never Seen a Doctor for a Routine Checkup FIGURE 21: Hunterdon Hispanics Usual Source of Care FIGURE 22: Percentage of Adults Who Have Seen a Dentist in the Past Year FIGURE 23: Percentage of Adults Who Have Had a Permanent Tooth/Teeth Removed due to Tooth Decay or Gum Disease, by Age FIGURE 24: Physician Density per 100,000 population, by Primary Care and Select Internal Medicine Specialty FIGURE 25: Physician Density by 100,000 population, by Other Select Specialty FIGURE 26: Percentage of Adults Who Use Selected Preventive Services FIGURE 27: Percentage of Adults Who Use Selected Preventive Services FIGURE 28: ED Visits and Hospital Admissions per 1,000 population FIGURE 29: Hospital Utilization for Mental/Behavioral Conditions per 1,000 population FIGURE 30: Premature Death: Years of Potential Life Lost based on 3-Year Averages Hunterdon Community Health Needs Assessment

8 FIGURE 31: Leading Causes of Death per 100,000 population FIGURE 32: Cancer Incidence per 100,000 population, by Site FIGURE 33: Cancer Mortality per 100,000 population, by Site FIGURE 34: Method of Delivery FIGURE 35: Percentage with Prenatal Care in the 1 st Trimester, by Mother s Race/Ethnicity.. 33 FIGURE 36: Percentage of Babies Born with Low Birth Weight, <2,500g FIGURE 37: Depression and Suicide Among Youth FIGURE 38: Percentage of Adults with Cardiovascular Health Issues FIGURE 39: Percentage of Adults with Asthma and Diabetes FIGURE 40: Percentage of Adults Who are Obese (BMI 30) FIGURE 41: Percentage of Adults Who are Obese or Overweight (BMI 25) FIGURE 42: Percentage of Adults Who Engage in Binge Drinking FIGURE 43: Alcohol Consumption, Binge Drinking and Marijuana Use Among High School Students, Past 30 Days FIGURE 44: Perception of Parental and Peer Disapproval of Substance/Drug Use FIGURE 45: Percentage of High School Students Lifetime Use of Drugs FIGURE 46: Lifetime Substance Use Among Middle School Students FIGURE 47: Percentage of Adults Who Currently Smoke Cigarettes FIGURE 48: Percentage of High School Students Who Smoke, Past 30 Days FIGURE 49: Distribution of Substance Abuse Treatment Admissions, by Primary Drug FIGURE 50: Percentage of High School Students Bullied FIGURE 51: Sexual Behaviors Among High School Students Community Themes and Strengths Assessment FIGURE 52: Leading Factors that Contribute to Quality of Life FIGURE 53: Leading Factors that Reduce Quality of Life FIGURE 54: Leading Recommendations to Improve Quality of Life Local Public Health System Assessment FIGURE 55: Rank ordered performance scores for each Essential Service, by level of activity (With range) Prioritization FIGURE 56: Top Health Issues with Corresponding Seriousness and Ability to Impact Scores Hunterdon Community Health Needs Assessment

9 LIST OF TABLES Community Health Status Assessment TABLE 1: Per Capita and Median Household Income TABLE 2: Median Value of Housing and Gross Rent TABLE 3: Crime Rate per 1,000 population TABLE 4: Rates of Juvenile (per 1,000 children) and Adult (per 1,000 adults) Arrests due to Substance Use TABLE 5: Maternal and Child Health TABLE 6: Binge Drinking of 12 th Graders, by Gender TABLE 7: Student Perception that Substance/Drug Use is Not Harmful TABLE 8: Percentage of High School Students Who Used Drugs 40 Times or More TABLE 9: Percentage of High School Seniors (Under 18 years) Who Reported Purchasing Cigarettes from Convenience Store or Gas Station, by Gender TABLE 10: Percentage of High School Students Reported Having Ever Been Bullied in the Past 12 Months, by Gender Local Public Health Assessment TABLE 11: Summary of performance scores by Essential Public Health Service (EPHS) Prioritization TABLE 12: Master List of Top Health Issues with Corresponding Seriousness and Ability to Impact Scores Hunterdon Community Health Needs Assessment

10 ACKNOWLEDGEMENTS Funding for this project was provided through a grant from the Robert Wood Johnson Foundation s New Jersey Health Initiatives program. Special thanks to the many community members who participated in the 6 focus groups and the 14 community stakeholders who participated in the Forces of Change Assessment, for their valuable input. Lastly, thank you to all members of the Hunterdon County Partnership for Health for your support and active participation throughout the whole Community Health Needs Assessment process Hunterdon Community Health Needs Assessment i

11 EXECUTIVE SUMMARY INTRODUCTION The Hunterdon County Partnership for Health is a county-wide initiative that involves more than 30 community service providers, agencies and organizations sharing a common interest in promoting and improving the health, well-being and quality of life of Hunterdon County residents. Since its inception in 1995, this healthier community initiative has led the completion of 4 county-level Behavioral Risk Factor Surveillance System (BRFSS) surveys and the development of a 2007 Community Health Improvement Plan (CHIP). In 2011, Hunterdon Healthcare System (HHS), in collaboration with the Hunterdon County Department of Health, applied for and received a grant from the Robert Wood Johnson Foundation s (RWJF) New Jersey Health Initiatives program. This two-year grant operationalized through Hunterdon Regional Community Health (HRCH), an affiliate of Hunterdon Healthcare System, has enabled the Partnership for Health to lead another round of Community Health Needs Assessment (CHNA) activities. The objectives of the 2013 Hunterdon County Partnership for Health Community Health Needs Assessment are as follows: 1. Develop a comprehensive community health profile that would provide a snapshot of the health and healthcare-related needs of Hunterdon County residents 2. Identify and prioritize health issues/needs 3. Have a CHNA report that would fulfill the new IRS requirement for non-profit hospital and that can be used by other community stakeholders who are interested in using it for their strategic planning METHODOLOGY The CHNA conducted utilized the Mobilizing for Action through Planning and Partnerships (MAPP) framework, which consists of the following 4 assessments: 1. Community Themes & Strengths Assessment Conducted 6 focus groups to identify factors affecting quality of life of residents of Hunterdon County. 2. Local Public Health System Assessment Surveyed 18 individuals to identify the strengths, limitations, gaps and needs of the current public health system in Hunterdon County. 3. Forces of Change Assessment Conducted a brainstorming session with 14 community stakeholders to identify factors, events and trends that influence or will influence the community s health and the delivery and operation of public health services. 4. Community Health Status Assessment Analyzed 13 primary and secondary data sources to develop a comprehensive quantitative data-based county health profile Hunterdon Community Health Needs Assessment ii

12 Throughout the CHNA process, input from members of the Partnership for Health and other community residents, service providers and stakeholders -- especially those representing the underserved, low-income and minority populations -- was taken into account. After consideration and analysis of both qualitative and quantitative data from the 4 individual assessments, members of the Partnership for Health developed a master list of health issues in the county and voted on what should be prioritized. KEY FINDINGS I. COMMUNITY HEALTH STATUS ASSESSMENT A. Demographic and Socioeconomic 3 rd least densely populated county in NJ. Larger proportion of residents have a college or graduate/professional degrees (48%) compared to NJ overall. Higher than state average median income. However, large variation exists across the 26 municipalities. Dramatic 281% increase in food stamp usage between 2007 and Predominantly white, non-hispanic residents. The 2 nd largest race/ethnicity is Hispanics. Larger proportion of residents aged years compared to NJ. Increasing elderly (65 years and above) population. Smaller percentage of residents who are unemployed compared to NJ. Percentage of individuals in Hunterdon living below poverty is lower than NJ. B. Healthcare Access and Utilization Among adult Hunterdon residents, 93.2% have some form of health insurance coverage compared to just 87.2% in NJ. However, only 37.9% of Hunterdon Hispanics have some form of health insurance coverage. Larger percentage of Hunterdon Hispanics reported not having a primary care provider and cited cost as a major barrier to seeing a doctor compared to the general Hunterdon County population. Lower total physician density (per 100,000 population) compared to NJ. However, Hunterdon has a higher ratio of primary care and family physicians compared to the state. Percentages of reported use of preventive services in Hunterdon are higher among women over 40 years of age receiving mammogram and adults over 50 who received sigmoidoscopy or colonoscopy. However, percentage of men over 40 years of age receiving a Prostate-Specific Antigen test is lower than the state average Hunterdon Community Health Needs Assessment iii

13 C. Maternal and Child Health Larger percentage of pregnant women receiving prenatal care in the first trimester compared to state average. However, percentage among Hunterdon Hispanics is significantly lower. Birth rate is significantly lower than NJ and there are higher percentage of C-sections and multiple births in Hunterdon. D. Health Status and Health Outcomes Top reported causes of death were cancer, diseases of the heart and cerebrovascular diseases/stroke, although mortality rates due to these diseases were lower than NJ s rates. Breast and prostate cancers, followed by melanomas of the skin were the most common types of cancer. Lung/bronchus, prostate and colon/rectum cancers were the most frequently reported causes of cancer deaths. Lower percentage of obese and overweight adults compared to NJ. However, prevalence is increasing. E. Substance Abuse and Mental Health Alcohol and marijuana are the most frequently used substance among high school students. Prevalence of binge drinking among Hunterdon adults and percentage of adult heavy drinkers are higher than state average. Lifetime heroin use among Hunterdon high school students is higher than NJ. Lower percentage of adults and youths smoking cigarettes compared to their NJ counterparts. Majority of residents admitted for substance abuse treatment are due to alcohol followed by heroin/opiates. Larger percentage of high school students reported having been bullied on school property compared to NJ s average. II. COMMUNITY THEMES AND STRENGTHS ASSESSMENT A. Factors contributing to quality of life (Strengths) Rural Character Participants cited that parks, open spaces, and other natural resources enhance the beauty of the county while encouraging physical activity by providing opportunity to engage in various outdoor recreation activities. Accessibility and Availability of Healthcare and Social Services Participants mentioned that the county has a lot of available healthcare and social services available for all its residents, and in particular the more vulnerable population, such as the children, seniors, lower income and the growing Latino population. They also pointed out that the focus on preventive care has a positive impact on the community s overall health and well-being Hunterdon Community Health Needs Assessment iv

14 Safety of the Community Respondents identified safety and low crime rate as factors that draw a lot of people to choose to live and raise a family in Hunterdon. Excellent School System Access to high quality education was also frequently cited by focus group participants as one of the main strengths and appeal of the county. Strong Civic Support and Engagement Respondents stated that volunteerism and community support in the county is very strong. Community members and local businesses not only donate money, but more importantly they volunteer their time, knowledge and expertise. B. Factors reducing quality of life (Weaknesses) High Cost of Living Respondents frequently mentioned the high property tax and relatively higher cost of services as factors that reduce quality of life in Hunterdon. High cost of living makes it challenging for a lot of residents to make ends meet and continue to live in the county. This especially affects lower income and/or younger residents. Limited Services and Programs for Latinos Participants cited that although there are more services and programs for Latinos now than before, it is still not enough to adequately meet their need. Language and cultural differences and low health literacy continue to be barriers in accessing needed healthcare services. Mental Health Issues Participants noted that the success-driven culture and naturally competitive environment in the county put tremendous pressure on children, adolescents and adults, which in turn leads to stress and anxiety. Limited Affordable Transportation Options Due to the rural nature of the county, transportation was considered by many to be a major barrier to accessing healthcare and social services for many residents, in particular the elderly, low-income and disabled. Large Low Income Population Participants cited that income affects everything access to care, proper nutrition, opportunities to participate in organized recreational activities, and many more. They stated that in Hunterdon there is a growing number of hidden poor. These are individuals/families who are now struggling to make ends meet, yet do not seek assistance because they are embarrassed or they do not know where to go. III. FORCES OF CHANGE ASSESSMENT 1. Economic Crisis The economic downturn was a major factor among the participants. It has affected and will continue to affect the health and well-being of the Hunterdon community and the delivery of services by the healthcare and local public health systems. In addition, these tough economic times not only affect residents finances, but also their health. The financial stress of figuring out a way to maintain the lifestyle they are used to may have a harmful effect on their mental health as well as their children. 2. Healthcare Affordability and Uninsured Population Although the impact of the healthcare reform on healthcare delivery, affordability and accessibility remains 2013 Hunterdon Community Health Needs Assessment v

15 uncertain, participants believe that these are important issues that need to be addressed as they significantly influence the health of the community. 3. Aging Population and End-of-Life Care The changing demographic, the growing elderly population in particular, will contribute to an increase in demand for specific healthcare, social and supportive services, such as home care, and end-of-life and palliative care. Participants agreed that the public health system and the hospital will need to determine ways to fill the gaps and provide the needed care and services. 4. Substance Abuse, Mental Illness and Gang Activity Participants cited that substance abuse and its high prevalence of comorbidity with mental illness continue to be a pervasive problem in Hunterdon. In addition, because of the high demand for and profitability of drugs, gang activity is increasing in Hunterdon. Increasing accessibility to treatment services for substance abuse and mental illness is imperative to meet the persistent need. Emphasis on prevention efforts is also critical to curb this problem. 5. Government Policies and Priorities The differing priorities of federal, state and local governments are creating confusion and affecting availability and accessibility of services and programs in the county. Focus on the federal level is prevention and public health. However, decreasing budget has led to shifting of priorities away from health and human services and decreasing funding and staffing of various public health services at the local level. IV. LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT Overall, the Hunterdon County public health system which consists of the hospital, local health department, community-based agencies, faith-based organizations, schools and other public health entity, is performing at an optimal level. It should be noted that assessment participants responded the best they could with the information they have. However, the results captured at this point in time may not accurately reflect the current performance of the local public health system due to the uncertainties of how changes in the county Division Public Health Services would impact the county s public health infrastructure and delivery of the 10 Essential Public Health Services. PRIORITY ISSUES Members of the Hunterdon County Partnership for Health reviewed the assessment findings and voted on the following to be its priority health issues based on 2 criteria: (1) seriousness of the issue, which included size and consequence, and (2) ability to impact or make a difference: 1. Obesity/Overweight Although percentage of overweight and/or obese adults in Hunterdon is lower than the state and nation, it has been increasing over the past 15 years. In addition, being overweight or obese substantially increases risk of developing certain chronic diseases such as heart disease and diabetes. 2. Substance Abuse Substance abuse continues to be a pervasive issue in Hunterdon that cuts across age and gender. 3. Latino Health Disparities There is a stark disparity in access to and utilization of healthcare services between the Hunterdon Latinos and the general Hunterdon 2013 Hunterdon Community Health Needs Assessment vi

16 population. They are also more likely to have poorer health outcomes and exhibit more risky behaviors compared to the general Hunterdon population. 4. Aging-related Issues The growing elderly population and their more specialized needs, such as home health and end-of-life care, are challenges that need to be addressed. Gaps in provision of and coordination of services need to be looked at and closed. NEXT STEPS Action teams were formed around each of the 4 identified health issues. Each team will meet and discuss in further detail their respective health issue. They will define attainable goals and objectives and develop clear strategies to address the health issues. All of which will be captured in the 2013 CHIP. The next step in this process will be to use the developed strategies to take action and impact the identified health issues Hunterdon Community Health Needs Assessment vii

17 INTRODUCTION The Hunterdon County Partnership for Health, Hunterdon s healthier community initiative, was co-founded in 1995 by Robert Wise, President and CEO of Hunterdon Healthcare System, John Beckley, former Hunterdon County Health Department director and Bernadette West, PhD, then Executive Director of Local Advisory Board (LAB) III, a central New Jersey regional health planning organization. The Partnership for Health is a county-wide initiative that involves more than 30 community service providers/agencies sharing a common interest in promoting and improving the health, well-being and quality of life of Hunterdon County residents. This is reflected in the Partnership for Health s vision statement of achieving health as defined by the World Health Organization (WHO): Every individual of Hunterdon County has a state of optimal physical, mental, spiritual, and social well-being which allows the individual to pursue the most fulfilling life possible, and not merely a life absent of disease or infirmity. Health and what influences it has evolved with the recognition of the social determinants of health. It is now understood that health is not a result of just one factor but is shaped, promoted and protected by a multitude of factors in our environment including where we live, work, learn and play. These factors include income, education, housing, access to quality healthcare and to healthy food, employment, and transportation, among others. To better understand the health of the community and barriers to achieving health, the Partnership for Health has taken the lead in conducting a wide range of community surveys and needs assessments designed to measure and track community health indicators over the years. More specifically, the Partnership for Health has led the completion of 4 county-level Behavioral Risk Factor Surveillance System (BRFSS) surveys in 1995, 2000, 2005 and Data from these surveys provided a picture of the community s health over the past 15 years. In 2007, a Community Health Improvement Plan (CHIP) was developed to focus on the Top 5 public health issues identified for Hunterdon County at that time (1) Mental Health, (2) Weight/Physical Activity, (3) Cardiovascular Disease, (4) Drugs, Alcohol & Tobacco, and (5) Access to Healthcare. Action teams, made up of experts and other passionate individuals, were formed to work together, and develop goals, objectives and strategies to address these top 5 health issues. In 2011, Hunterdon Healthcare System (HHS), in collaboration with the Hunterdon County Department of Health, applied for and received a grant from the Robert Wood Johnson Foundation s (RWJF) New Jersey Health Initiatives program. This two-year grant operationalized through Hunterdon Regional Community Health, an affiliate of HHS, has enabled the Partnership for Health to lead another round of Community Health Needs Assessment (CHNA) activities. This new assessment will provide an updated look into the most pressing health issues of the Hunterdon community Hunterdon County Community Health Needs Assessment - 1 -

18 CHNA is an essential step in the community health improvement process because it allows the Partnership for Health and its members, including Hunterdon Medical Center, to develop and implement more targeted and cost-effective strategies designed to improve the health status of the population they serve. With the collaborative efforts of the members of the Partnership for Health [see Appendix A for list of members] supported by the RWJF grant staff and outside consultants, a comprehensive 2013 Hunterdon County Partnership for Health CHNA process began in November 2011 and concluded in February 2013 with the following objectives: 1. Develop a comprehensive community health profile that would provide a snapshot of the health and healthcare-related needs of Hunterdon County residents 2. Identify and prioritize health issues/needs 3. Have a CHNA report that would fulfill the new IRS requirement for non-profit hospitals and at the same time can be used by other community stakeholders for their strategic planning The scope and focus of the CHNA was designed to not only be on health outcomes, but also on behaviors, socio-economic status and other environmental factors that impact health, following the University of Wisconsin Population Health Institute s County Health Rankings model [see Appendix B]. This report discusses the findings from the Assessment and will be used to guide the community s and Hunterdon Medical Center s health improvement planning process. COMMUNITY Hunterdon County, established in 1714 is a square mile rural-suburban community located in Western New Jersey. Hunterdon is surrounded by Warren County, Morris County, Somerset County and Mercer County and part of Pennsylvania. Although the 8 th largest county in NJ by total land area, it is the 18 th most populated with 128,349 residents in [1] It is the 3 rd least densely populated county in New Jersey with a population density of per square miles. [2] Historically agricultural, Hunterdon has been transitioning into a more commercial, industrial and residential community. The county, consisting of 26 municipalities, is the home of Hunterdon Medical Center (HMC), the only hospital in Hunterdon. HMC is a 178-bed teaching hospital that treats over 8,600 inpatients annually and has 292,000 outpatient visits per year. [3] Its Emergency Department sees approximately 33,000 patients each year. [3] Since opening its doors in 1953, HMC has focused on primary care and community wellness, and emphasized the importance of providing quality care while achieving a high level of patient satisfaction. This is reflected in its mission and vision statements. Mission: Hunterdon Healthcare System delivers compassionate and exceptional care that improves the health of the community Hunterdon County Community Health Needs Assessment - 2 -

19 Vision: Hunterdon Healthcare System is recognized as a national model for offering community focused health improvement that is consumer-centered and driven by a passion for excellence. Map of Hunterdon County and its Municipalities LEBANON TWP HAMILTON BORO GLEN GARDNER BORO CALIFON BORO TEWSKBURY TWP BLOOMSBURY BORO HOLLAND TWP BETHLEHEM TWP HIGHBRIDGE BORO UNION TWP CLINTON TOWN LEBANON BORO CLINTON TWP ALEXANDRIA TWP READINGTON TWP MILFORD BORO FRANKLIN TWP FRENCHTOWN BORO KINGWOOD TWP RARITAN TWP FLEMINGTON BORO DELAWARE TWP EAST AMWELL TWP STOCKTON BORO WEST AMWELL TWP LAMBERTVILLE CITY 2013 Hunterdon County Community Health Needs Assessment - 3 -

20 MOBILIZING ACTION TRHOUGH PLANNING AND PARTERNSHIPS The CHNA conducted utilized the Mobilizing for Action through Planning and Partnerships (MAPP) framework, which was developed by the National Association of County and City Health Officials in partnership with the Public Health Practice Program Office of the Centers for Disease Control and Prevention, as a tool to guide community health improvement. MAPP is a process that is driven by the community and is rooted on partnership development, assessment of needs and assets, and strategic planning on how to use available resources to address the prioritized health needs or concerns. The MAPP process consists of 4 assessments: 1. Community Themes & Strengths Assessment 2. Local Public Health System Assessment 3. Forces of Change Assessment 4. Community Health Status Assessment Throughout the CHNA process, input from members of the Partnership for Health and other community residents, service providers and stakeholders -- especially those representing the underserved, low-income and minority populations -- was taken into account. Furthermore, consultants were hired to provide expertise, additional support and assistance in conducting the CHNA. Consultants included John Beckley, MPH, Steven Godin, PhD, MPH, and Holleran Consulting. John Beckley has over 35 years of experience in the field of public health and was Hunterdon County s health officer/director for 26 years (September 1985-December 2011). He facilitated the Forces of Change brainstorming session. Steven Godin is a professor of Health Studies and director of the MPH Program at East Stroudsburg University. He has over 20 years of experience in community and public health and he facilitated the focus groups. In addition, both John Beckley and Steven Godin provided strategic guidance and support throughout the process. Holleran is a public health research and consulting firm with 20 years of experience in conducting community health assessments. The firm facilitated the prioritization and implementation planning session and analyzed the 2010 Hunterdon County BRFSS and 2012 Hunterdon County Youth Risk Behavior Survey Hunterdon County Community Health Needs Assessment - 4 -

21 COMMUNITY HEALTH STATUS ASSESSMENT The Community Health Status Assessment (CHSA) aims to develop a picture of the health status of the community by gathering data on various health indicators and comparing it to previous year, state or national data. This information was compiled, analyzed and presented in graphs and tables that are easily understandable. Data for the CHSA was obtained from the following primary and secondary sources: A. Primary 1. Hunterdon County Behavioral Risk Factor Surveillance System, 2010 (HC BRFSS) a health-related landline telephone survey of Hunterdon County adult residents conducted between August 23 and October 15, 2010 with a final sample size of 1,104. Survey questions were adopted from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) study. Phone interview and data analysis were done by Holleran. 2. Hunterdon County Youth Risk Behavior Survey, 2012 (HC YRBS) a health-related paper and pencil survey of Hunterdon County high school students conducted in October 2012 with a final sample size of 2,002. Survey questions were adopted form the CDC Youth Risk Behavior Surveillance (YRBS) study. Data analysis was done by Holleran. 3. United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011 a health-related survey of Hispanic/Latino residents of Hunterdon County conducted between May and July 2011 with a final sample size of 352. Survey questions were adopted from the CDC BRFSS. Data analysis was done by Steve Godin, MPH, PhD. B. Secondary 1. US Census Bureau, American Community Survey, County Health Profiles: Hunterdon County, County Health Rankings, NJ Middle School Risk and Protective Factor Survey, American Drug and Alcohol Survey, NJ Household Survey on Drug Use and Health, Gangs in NJ: Municipal Law Enforcement Response to the 2010 NJSP Gang Survey, NJ Department of Labor and Workforce Development 10. NJ Center for Health Statistics DEMOGRAPHICS Population According to the 2010 US Census, Hunterdon County is home to 128,349 residents, well below the Hunterdon County Planning Board 2002 projection of 136,919. [4] The rate of population growth in the county has been steadily declining since the 1960s. However, the 5.2% population growth between 2000 and 2010 was the lowest since the 1960s. It is estimated that the influx of people coming to reside in Hunterdon will continue to level off over the next 2 decades. Of 2013 Hunterdon County Community Health Needs Assessment - 5 -

22 the 128,349 residents, there is an even distribution of males and females, 49.9% and 50.1%, respectively. [5] FIGURE 1: Population Trends ( ) and Projections ( ), Hunterdon County 140, , , , , , , , , ,776 Population 80,000 60,000 87,361 40,000 20, Data Source: NJ Department of Labor and Workforce Development, Projections of Total Population by County: New Jersey, 2010 to The most populated municipalities are the townships of Clinton, Raritan and Readington. Raritan and Readington are also the largest municipalities by land area in the county, 37.5 and 47.7 square miles, respectively. [2] However, population density is the highest in Flemington Borough and Lambertville City and lowest in the townships of Delaware and Kingwood. FIGURE 2: Population by Municipality, Hunterdon County (2010) 25,000 20,000 Population 15,000 10,000 5,000 0 Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union West Amwell Source: US Census Bureau, 2010 Census 2013 Hunterdon County Community Health Needs Assessment - 6 -

23 FIGURE 3: Population Density (per square mile) by Municipality, Hunterdon County (2010) Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union West Amwell Source: Hunterdon County: Facts and Figures, Population Density by County and Municipality, 2010 Age The proportion of children (under 18 years), adults (18-64 years) and elderly (65 years and over) residing in Hunterdon is relatively similar to that of New Jersey and the rest of the country. The similarity does not end there. As seen in all parts of the country, some more than others, the proportion and number of elderly are growing. And this is a trend that is expected to continue. According to the Pew Research Center, there will be an average of 10,000 individuals celebrating their 65 th birthday every day until [6] FIGURE 4: Age Demographics, Hunterdon County (2010) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 12.7% 13.5% 13.0% 34.6% 29.1% 27.6% 26.4% 35.4% 36.5% 23.5% 23.5% 24.0% Hunterdon County New Jersey USA Elderly, 65 years Adult, years Adult, years Children, <18 years Source: U.S Census Bureau, 2010 Census; County Health Profiles: Hunterdon County Health Research and Educational Trust of New Jersey/New Jersey Hospital Association Hunterdon County Community Health Needs Assessment - 7 -

24 In Hunterdon County, the percentage of elderly rose from 10% in 2000 to 12.7% in In addition, the percentage of adults aged years is much higher than the state average, 34.6% and 27.6%, respectively. It is projected that by 2030, elderly, aged 65 years and over will make up over 24% of Hunterdon s population. [7] The aging population and increased longevity, one of the forces of change identified in the FOCA, will certainly have an impact on the health of the community as well as the provision of healthcare and social services. Prevalence of chronic conditions increases with age leading to higher utilization of healthcare services among the elderly. It is expected that the complex care needs of this growing population, both primary and specialty care, will pose challenges to healthcare planning and delivery. Race New Jersey is one of the most diverse states in the country. However, diversity is not spread uniformly throughout the state. Hunterdon is made up of predominantly white, non-hispanic residents (87.7%), a much higher proportion than NJ (59.3%). However, the county has seen tremendous growth in the number of people of a different race/ethnicity in recent years. The Hispanic community in particular, regardless of race, has increased by almost 200% in the past decade, from 2.8% in 2000 to 5.2% in [5] Asians are the 3 rd largest race/ethnic group in Hunterdon and makes up 3.2% of the county population, increasing from 1.2% in [5] This increasing diversity is evident not only in Hunterdon, but across the nation as well and is projected to continue to grow over the next few decades. [8] FIGURE 5: Race/Ethnicity, Hunterdon County (2010) Black, non-hispanic, 2.5% Asian, non-hispanic, 3.2% White, non-hispanic, 87.7% Other race, non- Hispanic, 0.2% Two or More Races, non-hispanic, 1.0% Hispanic/Latino of any Race, 5.2% Source: US Census Bureau, 2010 Census 2013 Hunterdon County Community Health Needs Assessment - 8 -

25 The increasing diversity affects the primary language spoken at home. Although much lower than the state average of 12.1%, the Limited English Proficiency (LEP) population in the county has increased from 2.2% in 2000 to 4.1% in Spanish (4.3%) is the second most common language spoken at home, far behind English (88.9%). Among the LEP population, those speaking Spanish increased from 0.9% in 2000 to 1.9% in [5] The growing diversity - racially, ethnically, culturally and linguistically is an asset to the community, as exposure to these differences has been suggested to promote tolerance, understanding and open-mindedness. [9] However, demographic changes also create challenges for the community as well as the healthcare system. The ability of service providers to effectively and appropriately communicate with the community they serve is vital. Language and differences in cultural norms, beliefs and attitudes, especially about health, can act as barriers to accessing health and social services, and will necessitate increased awareness, understanding and sensitivity of these differences among service providers. Disability As with other communities, having services available and accessible to persons with disabilities is of utmost importance. In 2009, the percentage of Hunterdon County residents with one or more disabilites is lower than the state average. Most common forms of disabilities are difficulties with independent living, mobility and cognitive function. FIGURE 6: Percentage with a Select Disability, Hunterdon County (2009) With and Independent Living Difficulty 3.5% 3.5% With a Self-care Difficulty 1.8% 1.8% With an Ambulatory Difficulty With a Cognitive Difficulty 3.5% 3.5% 3.6% 3.6% With a Vision Difficulty With a Hearing Difficulty 1.9% 1.4% 2.6% 2.5% Total Population with Any Disability 7.9% 10.1% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% New Jersey Hunterdon County Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County Hunterdon County Community Health Needs Assessment - 9 -

26 SOCIAL AND ECONOMIC FATORS Educational Attainment As the demographic data shows in Figure 7, Hunterdon County residents ages 25 years and older have high educational attainment with very little variation across the 26 municipalities [Figure 8]. The municipalities of Union (78.3%) and Flemington (84%) have the lowest percentage of the adults 25 years or older who have a high school diploma or higher. A higher percentage of Hunterdon County residents graduated from college and/or obtained postsecondary education when compared to NJ as a whole, 48% and 34.5%, respectively. [5] FIGURE 7: Educational Attainment, Hunterdon County (2009) Less than 9th Grade, 2.3% 9th-12th Grade, No Diploma, 3.8% Graduate/ Professional Degree, 20.2% Bachelor's Degree, 27.8% High School Graduate, 22.4% Some College, No Degree, 16.2% Associate's Degree, 7.3% Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 In addition, Hunterdon is known for its excellent public school system, with high school graduation rates higher than the state average. [10] The high educational attainment of both adults and youths in the county, is a key contributor to overall quality of life.studies have shown that educational attainment is strongly correlated with an individual s health. It is suggested that better educated individuals are more likely to have access to healthcare and are more health literate. Therefore they have better health outcomes and are more likely to contribute positively to their community. [11] 2013 Hunterdon County Community Health Needs Assessment

27 FIGURE 8: Percentage of High School Graduate or Higher by Municipality, Hunterdon County (2010) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union East Amwell Source: US Census Bureau, American Community Survey 5-Year Estimate Employment Although considered one of the wealthiest counties in the country, residents of Hunterdon have not escaped the impact of the economic downturn. The unemployment rate almost doubled from 4.1% in 2002 to 7.0% in The similarity in the trend of the unemployment rate between Hunterdon County and the state is unmistakable. In the past 10 years, the largest rise in unemployment in Hunterdon County occurred between 2008 and 2010, similarly observed across the state. FIGURE 9: Unemployment Rate, Hunterdon County and New Jersey ( ) 10.0% 9.6% 9.5% 8.0% 6.0% 5.8% 4.9% 4.7% 5.5% 7.2% 7.0% Hunterdon County 4.0% 2.0% 4.1% 3.4% 3.3% 3.8% New Jersey 0.0% Source: US Department of Labor, Bureau of Labor Statistics; NJ Department of Labor and Workforce Development, Labor Force Estimates Note: Rate based on individuals 16 years old and over in the civilian workforce Hunterdon County Community Health Needs Assessment

28 Although the overall unemployment rate is lower in Hunterdon County than the state, there are 7 municipalities in the county (Bethlehem, Bloomsbury, Hampton, High Bridge, Holland, Lebanon Township and Stockton) that are experiencing unemployment rates higher than the state average. FIGURE 10: Unemployment Rate by Municipality, Hunterdon County ( ) 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Alexandria Bethlehem Bloomsbury Califon Source: US Census Bureau, American Community Survey, 5-Year Estimates In 2009, a majority of (47.3%) Hunterdon County workers were employed in management, professional and related occupations, much higher than the state average of 39.3%. This maybe a result of the continuing transition of the county from being a historically agricultural industry to a more professional, white-collar industry. This shift was noted in the FOCA as a factor that affects and will continue to affect the economy because of the different skill set individuals entering the workforce are required to have in order to find employment. Income and Poverty Clinton Town Clinton Township Delaware East Amwell Flemington In 2011, Hunterdon ranked the 4 th wealthiest out of 3,141 counties in the United States with a median income of $99,099, behind only Loudon County, Fairfax County and Arlington County, all in Virginia. [12] The American Community Survey (ACS) estimates that the median income in Hunterdon was even higher at $103,879. In either case, this is significantly higher than the state and national average, $71,180 and $52,762, respectively. TABLE 1: Per Capita and Median Household Income, Hunterdon County, New Jersey and USA ( ) Hunterdon County New Jersey USA Per Capita Income $49,521 $35,678 $27,915 Median Household Income $103,879 $71,180 $52,762 Source: US Census Bureau, American Community Survey, 5-Year Estimates Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union East Amwell Hunterdon County New Jersey 2013 Hunterdon County Community Health Needs Assessment

29 However, a different picture emerges when median income data is analyzed by municipality. Variation across the county is evident, validating focus group and forces of change participants perception that income disparity exists within the county, and that the gap between the haves and have-nots continues to grow. Median income ranges from as low as $53,333 in Flemington to $165,000 in Tewksbury. [13] A self-sufficiency standard study done in 2008 indicated that in order for a family of 4 consisting of 2 adults, 1 preschooler and 1 school-age child to make ends meet (i.e. have their basic needs like shelter, food, clothing and healthcare) in Hunterdon County, they must make at least $72,200 annually, 2 nd highest in NJ, behind Somerset. [14] Of the 26 municipalities, 4 have a median income that is either just at this threshold or below it Glen Gardner ($72,000), Stockton ($67,083), Frenchtown ($66,111) and Flemington ($53,333). [13] This self-sufficiency study also concluded that an adult living by himself/herself in Hunterdon County needs to make at least $29,139 to make ends meet. [14] In 2009, 11.1% of households were making less than $25,000. [13] FIGURE 11: Median Income, by Municipality, Hunterdon County ( ) Source: US Census Bureau, American Community Survey, 5-Year Estimates In spite of its general affluence, 3.6% of Hunterdon County residents are living in poverty, based on the Federal Poverty Level. Although this rate is substantially lower than the state and national average, it went up from 2.6% in 2000 to a 5-year estimate of 3.6% between 2007 and In addition, it is important to note that the poverty thresholds are updated for inflation using the Consumer Price Index (CPU-I), but are not adjusted based on geographic location which influences cost of living. [14, 15] In a location such as Hunterdon where cost of living is higher than average, the above numbers actually underestimate the level of poverty Hunterdon County Community Health Needs Assessment

30 FIGURE 12: Percentage of Individuals Below Poverty Level, Hunterdon County, NJ, USA 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 14.3% 12.4% 9.4% 8.5% 3.6% 2.6% USA New Jersey Hunterdon County Source: US Census Bureau, 2000 Census; US Census Bureau, American Community Survey Once again there is variation across the county, with certain municipalities experiencing greater poverty compared to others. In Flemington for example, 16.1% of individuals are living in poverty, significantly higher than the state average of 9.4% [Figure 13]. In Delaware Township on the other hand, only 0.7% of individuals are living in poverty. In addition, the percentage of Hunterdon County residents 65 years and older living below poverty decreased from 4.2% in 2000 to 3.4% in [13, 16] However, among children under 18 years, it increased from 2.1% to [13, 16] 4.3% in the same time period. FIGURE 13: Individuals Below Poverty Level, by Municipality, Hunterdon County ( ) 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Source: US Census Bureau, American Community Survey Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union East Amwell Hunterdon County New Jersey 2013 Hunterdon County Community Health Needs Assessment

31 Although the number of county residents on government assistance programs is much lower than other counties, it has increased considerably during [Figure 14]. Increase in food-stamp usage, now known as Supplemental Nutrition Assistance Program (SNAP), was most notable. It saw a surge of 281% between 2007 and FIGURE 14: Number of People on Government Assistance Programs, Hunterdon County TANF SNAP EAP WIC Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 The rising poverty among affluent communities is seen across the country. In fact, food stampusage increased by more than 200% in 6 out of the 10 wealthiest counties across the country. [17] According to the Hunger and Homelessness Survey, unemployment, poverty, low wages and high housing costs are the most common reasons for the increasing requests for emergency food assistance. [18] Hidden poverty was a term used by focus group participants to refer to individuals who were financially well-off but are now experiencing financial difficulties. A lot of them are either too embarassed to ask for help or do not know where to get help, as they never had to do so before. The big concern was how to reach this population to help them when we don t know who they are and they do not want to be identified. Although at a different degree compared to those with lower income, wealthy people are affected by the bad economy as well. They too are experiencing hardship as their standard of living has dramatically changed, explained one focus group participant. Marital Status With regards to marital status, Hunterdon County s population has a larger percentage of people who are currently married and not separated compared to the state and the nation. It also has a lower percentage of people who have never been married or are separated/divorced. The proportion of families living in a household with both husband and wife present in Hunterdon is 62.8%, significantly higher than the state s average of 51.1%. [5] The difference in 2013 Hunterdon County Community Health Needs Assessment

32 the family unit between the county and the state is even more apparent among children under the age of 18. The rate of children living in a husband-wife family per 1,000 is in Hunterdon compared to statewide. [5] In addition, the county has much lower singleparent households when compared to the state. [19] This data reinforces the perception among focus group participants that Hunterdon County is a family-oriented community. FIGURE 15: Marital Status, Hunterdon County, New Jersey, USA ( ) 70.0% 60.0% 50.0% 59.5% 50.5% 49.8% 40.0% 30.0% 32.9% 26.5% 31.5% 20.0% 10.0% 9.2% 12.7% 10.2% 0.0% Never Married Currently Married Separated/Divorced Source: US Census Bureau, American Community Survey 5-Year Estimate Housing Hunterdon County New Jersey USA Focus group participants mentioned that the high cost of living, particularly housing and property tax, is one of the downsides of living in Hunterdon, and actually results in fewer people wanting to move and live in the county. Although the median value of housing slightly dropped between 2005 and 2009, the median gross rent has continued to increase and is actually above the state average. TABLE 2: Median Value of Housing and Gross Rent, Hunterdon County and New Jersey Hunterdon County New Jersey Median Value Housing $245,000 $433,000 $430,200 $348,300 Median Gross Rent $867 $1,061 $1,210 $1,108 Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 Housing is expensive for both home owners and renters. Among the occupied housing units in Hunterdon, there are more home owners than renters, 85.4% vs. 14.6%. [13] Among 2013 Hunterdon County Community Health Needs Assessment

33 homeowners with mortgages, 79.3% have a selected monthly owner cost of $2,000 or more compared to the state average of 67.2%. [13] In addition, 42.9% of homeowners and 52.8% of renters spend 30% or more of their income on housing. [13] This data validates focus group participants sentiment that housing expense is a huge financial burden for Hunterdon residents, both homeowners and renters. Homelessness is also an issue that affects the county, males more so than females. In 2010, 137 individuals were homeless at some point in time, a figure that is probably grossly undersestimated due to the difficulty in collecting this data. [5] Of the 137 individuals, 63 were males and 38 were females. [5] Focus group participants cited that Hunterdon has very limited affordable housing options and lacks homeless shelters, especially for men. Crime Safety is one of the measures used by the County Health Rankings model to rate the health of a community because a safer community is associated with a healthier community. During the focus groups, most participants acknowledged that the county is a very safe place to live. This qualitative information was supported by quantitative data that showed the county having a very low violent crime rate of 61 crimes per 100,000 people. [20] This is the lowest county rate in NJ. However, it was brought to the Partnership for Health s attention during the Forces of Change discussion that while not as prevalent compared to other counties, gang activity is increasing in Hunterdon, and should be closely monitored in the future. There was a considerable jump in gang presence between 2007 and [21] This has been one of the priorities of the County Prosecutor who is taking proactive steps to ensure and maintain the safety of the Hunterdon community. FIGURE 16: Percentage of Municipalities with Gang Presence, New Jersey and its 21 Counties Source: Gangs in NJ: Municipal Law Enforcement Response to the 2010 NJSP Gang Survey, Hunterdon County Community Health Needs Assessment

34 The overall crime rate (violent and non-violent crimes) has been slowly but steadily declining since Included among violent crimes are murder, rape robbery and aggravated assault. Non-violent crimes include burglary, larceny-theft, and motor vehicle theft. [5] Juvenile arrests are predominantly due to drug abuse violations (2.67 per 1,000 juveniles) and larceny-theft (1.24 per 1,000 juveniles). [5] Among adults, the highest rates of arrests are due to driving under the influence (6.39 per 1,000 adults) and drug abuse violations (5.97 per 1,000 adults). [5] FIGURE 17: Violent and Non-Violent Crime Rate per 1,000 Population, Hunterdon County and New Jersey Violent Crime Rate Hunterdon County Non-Violent Crime Rate New Jersey Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 TABLE 3: Crime Rate per 1,000 Population, Hunterdon County and New Jersey Hunterdon County New Jersey Overall Crime Rate per 1,000 population Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 Although Hunterdon is relatively safe and has a low overall crime rate of 2.27 per 1,000 population, [5] the most common offenses resulting in arrest were related to substane use/abuse, both among youths and adults. Rate of arrests due to Driving Under the Influence are higher among juveniles and adults are higher in the county compared to state average Hunterdon County Community Health Needs Assessment

35 TABLE 4: Rates of Juvenile (per 1,000 children) and Adult (per 1,000 adults) Arrests due to Substance Use (2009) Driving Under the Influence Hunterdon County New Jersey Juvenile (under 18 years) Adults (18 years and older) Drug Abuse Violations Juvenile (under 18 years) Adults (18 years and older) Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 PHYSICAL ENVIRONMENT Air Quality The physical environment where we live, work and play affects our individual health and the health of the community. The quality of air we breathe is especially important as exposure to harmful air pollution, such as high ozone levels and fine particulate matter, has been linked to poor health outcomes. According to the 2012 County Health Rankings, there were 11 days in 2007 when the ozone level in Hunterdon was unhealthy. [20] Although similar to the state s average annual number of unhealthy air quality days due to ozone, this is much higher than the national benchmark of zero. In addition, there was 1 day in 2007 when air quality was unhealthy due to fine particulate matter, again more than the national benchmark of zero. [20] Poor air quality is a persistent issue in the county. It was brought up during the focus group, with one participant attributing it as one of the main reasons for the high prevalence and incidence of asthma in the county, especially among youths. Access to Healthy Food According to the 2012 County Health Rankings, 6% of Hunterdon County residents experienced both financial and geographical barriers to accessing healthy foods such as fresh fruits and vegetables. [20] However, this data does not provide an accurate picture of the food environment in the county because it is based solely on the number of and distance to grocery stores. It does not include other venues where healthy food can be purchased such as local farms, which are very common in Hunterdon. Although places are far and transportation continues to be a challenge for some residents, and more work needs to be done to reduce the barriers to accessing these healthy foods, a majority of its residents have access to farm stands and farmers markets Hunterdon County Community Health Needs Assessment

36 Transportation Another factor that was frequently mentioned during focus group sessions to be reducing the quality of life in Hunterdon was transportation. Public transporation options within the county are very limited, which makes it difficult for a significant segment of the community to engage in community activities and access services. This especially impacts the low-income, the elderly, the disabled and other individuals with transportation challenges. Although the county offers affordable transportation through the LINK, it requires a lot of planning to schedule a trip and offers very little flexibility and has a limited capacity. HART Commuter Information Services, a non-profit agency, has been educating the community and service providers about ways to maximize the resources currently in place and to minimize transportation challenges. However a lot of work still needs to be done in this area as it severely limits access to the many services and resources in the county, such as healthcare. CLINICAL CARE Healthcare Access and Utilization Access to quality and timely health care is critical for an individual to achieve the best possible health outcome, as it impacts the individual s overall physical, social and mental well-being. Access to primary care is of a particular importance as it is the first step in preventing, diagnosing and treating an illness. Common barriers to accessing healthcare include high cost, lack of insurance coverage, lack of transportation and language difficulties. All of these barriers, at varying levels, are present in Hunterdon County. Access to quality care was mentioned frequently in focus group sessions to be one of the community s strengths. In Hunterdon, 93.2% of its adult residents reported having some form of health insurance, be it health insurance, or prepaid plans such as HMOs or government plans such as Medicare or Medicaid. [22] This is considerably higher than state and national averages, 87.2% and 84.7%, respectively. [22] However, disparity exists especially among the Hispanic community, the fastest growing ethnic group in the county. Only 37.2% of Hispanic adults living in Hunterdon County reported having some form of health insurance, substantially lower than the general population, [23] which translates to reduced access to both preventive and treatment services. This is one of many areas where disparities exist between the Hispanic community and the general population of Hunterdon County. With the passage of the Affordable Care Act (ACA) in 2010, in particular the individual mandate provision, it is expected that the number of uninsured will decrease significantly. This will result largely from an expansion of Medicaid eligibility and a new individual mandate provision. However, a significant proportion of the population, such as undocumented immigrants, will remain uninsured, as they will not gain coverage through the ACA Hunterdon County Community Health Needs Assessment

37 FIGURE 18: Percentage of Adults Health Care Coverage Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011; Healthy People 2020 As noted earlier, the lack of health insurance or being underinsured can severely impact an individual s decision of whether or not to seek needed care. Approximately 5% of Hunterdon County residents reported not seeing a doctor or receiving needed medical care due to cost. [22] This is much lower than the state and national averages of 12.7% and 14.9%, respectively. [22] However, among the Hispanic county residents surveyed, 34.9% reported not being able to see a doctor in the past year due to cost. [23] This is 7 times greater than the general population surveyed in the 2010 BRFSS, once again showing extreme disparity. FIGURE 19: Percentage of Adults Who Did Not See a Doctor Due to Cost 40.0% 34.9% 30.0% 20.0% 12.7% 14.9% 10.0% 5.0% 0.0% Hunterdon County 2010 Hunterdon Hispanics 2011 New Jersey 2009 US 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, Hunterdon County Community Health Needs Assessment

38 In addition to financial barriers, 31.3% of Hispanics surveyed reported that they could not get needed health care in the past year because of language barriers. [23] And not surprisingly, this problem was even more significant among Hispanics with less than a high school diploma compared to those with more education. This data illustrates the demand and need for more Spanish-speaking and culturally competent healthcare providers. Studies show that language barriers contribute to health disparities and result in poorer health conditions, less patient satisfaction and less utilization of preventive services while overutilizing emergency department [24, 25] services. Almost half of Hispanics surveyed reported having never seen a doctor for a routine checkup. [23] This finding is especially alarming when compared to the county, state and national data, in which apprxoimately only 1% reported never having seen a doctor for a routine checkup. [22] FIGURE 20: Percentage of Adults Who Have Never Seen a Doctor for a Routine Checkup 50.0% 45.2% 40.0% 30.0% 20.0% 10.0% 0.0% 0.6% Hunterdon County 2010 Hunterdon Hispanics % New Jersey % US 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011 Absence of health insurance is also a strong predictor of not having a regular or usual source of care. [26] And as seen in the Figure 20, a larger percentage of Hispanics report being uninsured. Therefore, it is not surprising to see that a lower percentage of Hispanics have a usual source of care compared to the general population, 57.3% and 89.9%, respectively. [22, 23] Among Hispanics who reported having a usual source of care, 54.4% indicated that it is a doctor s office or HMO. [23] However, 7.7% indicated that they considered the hospital emergency room as their usual source of care. [23] This is concerning not only because Emergency Department (ED) utilization is more expensive, but also because having a usual source of care is associated with increased use of preventive services and reduced hospitalizations. [27] 2013 Hunterdon County Community Health Needs Assessment

39 FIGURE 21: Hunterdon Hispanics Usual Source of Care (2011) 60.0% 54.4% 50.0% 40.0% 30.0% 20.0% 23.1% 10.0% 6.2% 7.7% 4.6% 4.1% 0.0% Doctor's Office or HMO Clinic or Health Center Hopsital Outpatient Department Hopspital Urgent Care Other Place Emergency Center Room Source: United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011 The health disparity seen among the Hunterdon Hispanic community is a result of multiple factors mentioned above healthcare affordability, language and cultural differences and the accessibility of services geared towards this population. Quantitative and qualitative data support the need to focus on and address these glaring issues. If ignored, they will exacerbate the problem and will severely curtail progress in improving the health of the entire Hunterdon community. Oral Health According to David Satcher, MD, former surgeon general, great strides have been made in the field of oral health such as the fluoridation of drinking water, which has resulted in a dramatic reduction in dental caries. [28] However, improvements are still needed, specifically in increasing education and enhancing awareness among the general public about the importance of oral health in achieving overall good health and quality of life. Similar barriers to accessing medical care exist for accessing dental care lack of insurance, high cost, lack of transportation and not knowing where to go for affordable services. Additional barriers do however exist, such as fear and/or apprehension which 8.2% of Hunterdon adults claimed to be the main reason for not visiting a dentist in the past year. [22] However, cost is overwhelmingly the primary barrier for Hunterdon county residents (31.6%) and among Hunterdon Hispanics in particular (65.2%). [22, 23] And predictably, oral health problems disproportionately impact the more vulnerable populations the poor, children, elderly and racial/ethnic minorities. In Hunterdon, access to dental care is even more limited to those with lower income and Hispanics [Figure 22]. Dental problems are more evident among the elderly. However, access is not as a big issue for them as 80.1% of the elderly in Hunterdon reported visiting the dentist in the past year. [22] 2013 Hunterdon County Community Health Needs Assessment

40 FIGURE 22: Percentage of Adults Who Have Seen a Dentist in the Past Year, Hunterdon County (2010) 100.0% 80.0% 84.6% 88.0% 80.1% 60.0% 45.0% 40.0% 20.0% 22.2% 0.0% Income < $25,000 Income $25,000- $49,999 Income $50,000 Hunterdon Hispanics Hunterdon Elderly (65 years and older) Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011 FIGURE 23: Percentage of Adults Who Have Had a Permanent Tooth/Teeth Removed due to Tooth Decay or Gum Disease by Age, Hunterdon County (2010) 80.0% 70.0% 68.5% 60.0% 50.0% 49.6% 40.0% 30.0% 20.0% 20.4% 19.9% 32.7% 10.0% 0.0% 0.0% years years years years years 65 years and older Source: Hunterdon County Behavioral Risk Factor Surveillance System, Hunterdon County Community Health Needs Assessment

41 Physician Supply While there is a projected shortage of primary care providers in NJ and the rest of the nation, [29] Hunterdon is in a better shape, as its main focus has always been on primary care and preventive services. Hunterdon boasts a 687:1 ratio of population to primary care physicians (includes family medicine, internal medicine, pediatrics, and obstetrics/gynecology), substantially better than the state ratio of 919:1. [20] This is believed to be one of the reasons why Hunterdon is ranked the healthiest county in NJ in FIGURE 24: Physician Density per 100,000 Population by Primary Care and Select Internal Medicine Specialty (2008) Family Medicine Pediatrics (General) Internal Medicine (General) Cardiology Geriatrics Obstercis/Gynecology Hunterdon County New Jersey Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 Although the county has a large number of primary care physicians, there is a perceived shortage of certain specialties in Hunterdon, most notably pediatric specialists, according to a focus group participant who said, parents have to go outside the county to see a specialist for their child Hunterdon County Community Health Needs Assessment

42 FIGURE 25: Physician Density by 100,000 Population by Other Select Specialty (2008) Total Physicians Psychiatry Surgery (General) Surgery (Specialties) Facility-based Emergency Medicine Hunterdon County New Jersey Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 Note: Facility-based physicians include radiology, pathology and anesthesiology Preventive Services Early detection of cancer increases chances for successful treatment and therefore survival. Accessibility and affordability of these preventive services are important. In Hunterdon, percentages of reported use of preventive services are generally higher than the state average with the exception of men over 40 years receiving a Prostate-Specific Antigen test. Among women 40 years and over, 80% received a mammogram in the past 2 years compared to the state average of 72%. Looking at women 50 years and over (as per the United States Preventive Service Task Force recommendation), 81% from Hunterdon received a mammogram in the past 2 years, essentially meeting the Healthy People 2020 target of 81%. Among adults 50 years and over, 68% of Hunterdon residents reported receiving a sigmoidoscopy or colonoscopy test compared to just 64% statewide Hunterdon County Community Health Needs Assessment

43 FIGURE 26: Percentage of Adults Who Use Selected Preventive Services (2010) Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020 Among the Hunterdon Hispanic community, use of preventive services is not nearly as frequent. Hispanics are less likely to be screened for blood cholesterol and for breast and colorectal cancers. Again, not having access to these preventive/early diagnostic tests contribute to the poorer health status of the Hispanics in the community. The data shows the need to better understand and address the barriers the Hunterdon Hispanic community is experiencing regarding accessing these preventive services. FIGURE 27: Percentage of Adults Who Use Selected Preventive Services 100.0% 88.7% 80.0% 71.2% 71.8% 68.2% 60.0% 40.0% 20.0% 28.0% 34.6% 0.0% Screen Blood Cholesterol Mammography Colonoscopy/Sigmoidoscopy Hunterdon County 2010 Hunterdon Hispanics 2011 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, Hunterdon County Community Health Needs Assessment

44 Hospital Utilization and Access Emergency department (ED) visit rates for all age groups are lower than the statewide rates. Hospital admission rates of Hunterdon County residents of all age groups combined is lower than state average as well. Hospital admissions and ED visits are highest among the elderly. FIGURE 28: ED Visits and Hospital Admissions, per 1,000 Population (2010) ED Visits Hospital Admissions Hunterdon Children (<18 years) Hunterdon Adults (18-64 years) Hunterdon Elderly ( 65 years) Hunterdon County (Total) New Jersey (Total) Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 ED visits and hospital admission rates for mental and behavioral conditions are also lower than statewide rates. However, ED visits and hospital admissions for mental/behavioral health conditions increased from 2006 to Also, the rate of ED visits among Hunterdon children (10.1 per 1,000), is higher than that of the state as a whole (8.9 per 1,000). [5] FIGURE 29: Hospital Utilization for Mental/Behavioral Conditions per 1,000 Population (2010) ED Visits Hospital Admissions Hunterdon Children (<18 years) Hunterdon Adults (18-64 years) Hunterdon Elderly ( 65 years) Hunterdon County (Total) New Jersey (Total) Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County Hunterdon County Community Health Needs Assessment

45 The most common conditions of children who visit the ED are head injuries (9.56 per 1,000 children) and depression/mood disorders (7.94 per 1,000 children). [5] Among adults aged 18 to 64 years, anxiety disorders including Post Traumatic Stress Disorder (16.92 per 1,000 adults aged years) and alcohol dependence (16.29 per 1,000 adults aged years) are the leading causes of ED visits. [5] Asthma is the leading ambulatory care sensitive condition for hospitalizations among children (0.96 per 1,000 children), while for adults age years, it is bacterial pneumoniae (1.09 per 1,000 adults). [5] For Medicare beneficiaries, chronic obstructive pulmonary disease is the leading cause of hospital admission (12.3 per 1,000 Medicare beneficiaries) and 30-day readmission (2.5 per 1,000 Medicare beneficiaries). [5] HEALTH OUTCOMES Mortality Hunterdon County s age-adjusted mortality rate is 613 per 100,000 population. [5] This is significantly lower than the state s rate of 723 per 100,000. [5] Average Years of Potential Life Lost is also substantially lower than state and national averages as seen in Figure 30. These are key figures that led to Hunterdon being ranked as the healthiest county in NJ by the County Health Rankings. [20] FIGURE 30: Premature Death: Years of Potential Life Lost based on 3-Year Averages Source: County Health Rankings, 2012 Note: Premature death is represented by the years of potential life lost before age 75 (YPLL-75). Every death occurring before the age of 75 contributes to the total number of years of potential life lost. Leading Causes of Death In 2007, the top 3 reported causes of death in Hunterdon County were cancer, heart disease and stroke. The mortality rates due to these diseases were notably lower than New Jersey s 2013 Hunterdon County Community Health Needs Assessment

46 rates. Among the 7 leading causes of death in the county, only the mortality rate due to influenza and pneumonia was higher than the state rate. FIGURE 31: Leading Causes of Death per 100,000 Population (2007) Cancer Diseases of the heart Stroke Chronic respiratory disease Unitentional injuries Influenza & Pneumonia Alzheimer's disease Hunterdon County New Jersey Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 Cancer Incidence rates for all cancer sites combined are significantly higher in Hunterdon compared to NJ. This is especially true for breast cancer (among females only) and melanomas of the skin. FIGURE 32: Cancer Incidence per 100,000 Population by Site (2008) Breast (female only) Prostate (male only) Melanomas of the skin Lung & Bronchus Colon & Rectum Hunterdon County New Jeresey Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County Hunterdon County Community Health Needs Assessment

47 Overall, Hunterdon County mortality rates for all cancer sites combined are lower than the NJ as a whole with the exception of deaths due to prostate and colorectal cancers. FIGURE 33: Cancer Mortality per 100,000 Population by Site (2007) All Sites Lung & Bronchus Prostate (male only) Colon & Rectum Breast (female only) Hunterdon County New Jersey Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 Morbidity The County Health Rankings project looks at 4 factors in determining morbidity: Reported poor or fair health, poor physical health days, poor mental health days and low birth weight. In all 4 categories, Hunterdon is either the number 1 ranked in the county or tied for first place. Again, this is one of the reasons Hunterdon was ranked the healthiest county in NJ for health outcomes. Maternal and Child Health The birth rate in Hunterdon County is significantly lower than the state rate, with a slightly higher percentage of C-sections, particularly repeat C-sections. Percentage of multiple births is also higher in Hunterdon County as is the percentage of births to women who are over the age of 34. On the other hand, percentage of teen pregnancy is significantly lower in the county compared to the state Hunterdon County Community Health Needs Assessment

48 TABLE 5: Maternal and Child Health (2010) Hunterdon County New Jersey Birth Rate 7.4 per 1,000 population 12.6 per 1,000 population Multiple Births 7.5% 3.7% Births to Mothers < 15 years 0.0% 0.1% Births to Mothers years 2.0% 5.6% Births to Mothers > 34 years 34.6% 20.7% Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 FIGURE 34: Method of Delivery (2010) Vaginal Primary C-section Repeat C-section New Jersey 60.6% 12.0% 27.4% Hunterdon County 58.8% 10.1% 31.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 The percentage of pregnant women who receive prenatal care in the first trimester is significantly higher than the state average and actually exceeds the Healthy People 2020 target. However, racial/ethnic disparity exists, primarily among Hispanic and Black, non-hispanic pregnant women. Only 57.3% Hispanic and 66.7% Black, non-hispanic pregnant women received prenatal care in the first trimester compared to 90.3% White, non-hispanic pregnant women Hunterdon County Community Health Needs Assessment

49 FIGURE 35: Percentage with Prenatal Care in the 1 st Trimester, by Mother s Race/Ethnicity (2009) 100.0% 80.0% 60.0% 90.3% 87.8% 66.7% Healthy People 2020 Target (77.9%) 65.3% 70.3% 57.3% 86.0% 87.8% 86.1% 76.9% 40.0% 20.0% 0.0% White, non- Hispanic Black, non- Hispanic Hispanic, any race Asian/Pacific Islander, non- Hispanic All Race (Total) Hunterdon County NJ Source: NJ Department of Health, Center for Health Statistics, State Health Assessment Data Web site, 2013; U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020 Percentage of Hunterdon babies born with low birth weight is increasing and is actually higher than the statewide average. However on a positive note, the percentage of infants exclusively breastfeeding at hospital discharge is considerably higher than the state average, 48 % and 36%, respectively. [5] FIGURE 36: Percentage of Babies Born with Low Birth Weight, <2,500g (2009) 10.0% 8.0% 6.0% 6.6% Healthy People 2020 Target (7.8%) 6.9% 7.8% 8.2% 4.0% 2.0% 0.0% Hunterdon County 2006 Hunterdon County 2008 Hunterdon County 2010 New Jersey 2010 Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012; U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People Hunterdon County Community Health Needs Assessment

50 Mental Health As shown by the increasing rates of hospital utilization due to mental/behavioral health conditions, mental health is an issue among county residents. Substance abuse and the success-driven culture of the county are believed to contribute to this growing problem. Stress and anxiety, due to the pressure to succeed academically and athletically among youths and professionally and financially among adults, were mentioned in the focus group sessions to be contributing to the mental health problem. A focus group participant said that there seems to be a competition to excel to make more money or to do better. Another stated that kids have limited time to relax between their schoolwork, sports and other extra-curricular activities. According to the 2012 Youth Risk Behavior Survey (YRBS), 13% Hunterdon high school students seriously considered suicide, while 9% made a plan about how they would attempt suicide and 4% actually attempted suicide. Although percentages for these 3 indicators are lower than state and national average, it still serves as a reminder that this is a severe problem with serious consequences and should not be ignored. FIGURE 37: Depression and Suicide Among Youth 30.0% 28.5% 26.1% 25.0% 20.8% 20.0% 15.8% 15.0% 12.5% 12.9% 10.0% 5.0% 12.8% 10.9% 9.3% 4.4% 6.0% 7.8% 0.0% Felt sad or hopeless Ever seriously considered almost every day for 2 attempting suicide weeks or more in a row that they stopped doing some usual activities Made a plan about how they would attempt suicide 2012 Hunterdon County 2011 New Jersey 2011 US Actually attempted suicide Source: Hunterdon County Youth Risk Behavior Survey, 2012 Depression and mental health issues also affect adults. In the 2010 BRFSS, 33% of adults reported feeling sad, blue or depressed at least once in the past 30 days. Even more concerning is that among those who felt sad, blue or depressed, only 21% sought help to address concerns they had regarding their feelings. [22] And among those who sought help, 17% were unable to get the help they were looking for. [22] The most common reason cited was that they did not know where to go (57%). [22] Focus group participants mentioned the challenges facing Hunterdon residents in accessing mental healthcare services and identified the importance of increasing capacity and awareness of how and where to access these services Hunterdon County Community Health Needs Assessment

51 Cardiovascular Disease Cardiovascular diseases are the 2 nd and 3 rd leading causes of mortality in Hunterdon, just behind death due to cancer of all sites combined [see Figure 33]. A picture of Hunterdon s cardiovascular health is presented in Figure 38. With the exception of the percentage of individuals ever been told they had high blood cholesterol, a lower proportion of Hunterdon residents reported having cardiovascular health problems compared to the state average. However, the rate of ED visits due to unspecified chest pain (6.42 vs per 1,000 population) and heart disease (5.4 vs. 5.3 per 1,000 population) in 2010 were higher in Hunterdon compared to the state average for both conditions. [5] FIGURE 38: Percentage of Adults with Cardiovascular Health Issues 40.0% 30.0% 20.0% 26.9% 28.1% 38.0% 37.0% 10.0% 0.0% Ever had high blood pressure Ever had high blood cholesterol 1.8% 3.6% 2.0% 3.7% 1.6% 2.0% Ever had heart attack or myocardial infarction Ever had angina or coronary heart disease Ever had Stroke Hunterdon County New Jersey Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010 Other Chronic Disease In the 2010 BRFSS, 23% survey respondents replied yes when asked if they have been diagnosed as having a chronic condition. Ashtma was the chronic condition reported to be the most prevalent, followed by diabetes. FIGURE 39: Percentage of Adults with Asthma and Diabetes 20.0% 15.0% 10.0% 5.0% 14.6% 12.6% 5.7% 8.8% 0.0% Ever had asthma Have diabetes Hunterdon County 2010 New Jersey 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, Hunterdon County Community Health Needs Assessment

52 Diabetes is closely associated with obesity and being overweight. And this is further evident when a crosstabulation analysis showed that 17% of obese individuals are diagnosed with diabetes compared to only 4% of individuals who were neither overweight or obese based on their BMI. [22] HEALTH BEHAVIORS Obesity, Physical Activity and Nutrition Obesity, physical activity and nutrition have been in the national spotlight because of the rising prevalence of obesity across all age groups, among children in particular. This has an alarming impact on our health, the healthcare system and the economy. According to the F as in Fat Report (2012), if current trends continue, 44% of people in the US will be obese by 2030 and the incidence of obesity-related diseases such as type 2 diabetes, coronary heart disease and stroke, hypertension, arthritis and cancer will increase drastically. [30] In addition, obesity-related healthcare costs will increase by 10-20% nationwide. [30] Prevalence of obesity among adults in Hunterdon County is lower compared to the state according to the BRFSS study. However, just like the trend nationwide, it continues to rise. The electronic health records (EHR) maintained by Hunterdon Healthcare System were also analyzed. The aggregate BMI data of patients are based on actual measurement taken during physician office visits. It is interesting to note that these BMI data are significantly higher when compared to the self-reported BRFSS data. The BRFSS data indicated an obesity rate of 18.8% while the EHR data from approximately 75,000 adult patients living in Hunterdon County indicated an obesity rate of 31%. [31] Similarly, the BRFSS data suggested 60% were either overweight or obese, whereas the EHR data indicated 65% were either overweight or obese. [31] This shows the importance and value of the EHR as a health surveillance tool, allowing the hospital and other service providers in the county to better understand the scope and trends of important health indicators such as obesity. FIGURE 40: Percentage of Adults Who are Obese (BMI 30) 30.0% 28.2% 25.0% 23.9% 27.4% 20.0% 18.8% 15.0% 10.0% 5.0% 0.0% Hunterdon County 2010 Hunterdon Latino 2011 New Jersey 2009 US 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, Hunterdon County Community Health Needs Assessment

53 Once again, poorer health outcomes are observed among the Hunterdon Hispanic community compared to the general Hunterdon County population with 28.2% considered obese and 70.8% either obese or overweight. FIGURE 41: Percentage of Adults Who are Obese or Overweight (BMI 25) 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 55.3% 70.8% 61.9% 63.7% 0.0% Hunterdon County 2010 Hunterdon Latino 2011 New Jersey 2009 US 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011 County residents generally demonstrate healthier behavior when it comes to physical activity and nutrtion when compared to their counterparts nationally according to the BRFSS and YRBS. They consume more fruits and vegetables and a larger proportion engage in at least 10 minutes of moderate physical activity. [22, 32] Hunterdon youths also tend to eat breakfast on a daily basis while consuming less soda. [32] In addition, they participate in sports teams and are physically active for longer periods of time while not spending as much time playing video games or watching TV. [32] Substance Use and Abuse Alcohol, Tobacco and Drugs Alcohol continues to be the drug of choice in Hunterdon. The prevalence of binge drinking among Hunterdon County adults (29.3%) is higher than the state s average (25.5%), and is expected to continue to rise. Percentage of adult heavy drinkers in Hunterdon is 6.2% compared to NJ s average of 4.3%. [5] According to the CDC, adults are considered heavy drinkers when they consume an average of more than 2 drinks per day for men and more than 1 drink per day for women. [33] This data is not surprising as studies have shown that individuals [34, 35] with higher incomes tend to consume alcohol more frequently Hunterdon County Community Health Needs Assessment

54 FIGURE 42: Percentage of Adults Who Engage in Binge Drinking 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 29.3% Healthy People 2020 Target (24.3%) 25.5% 29.6% 0.0% Hunterdon County 2010 New Jersey 2009 US 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020 Note: Binge drinking males having 5 or more drinks on a single occasion or women having 4 or more drinks on a single occasion, generally within about 2 hours [33] Alcohol is also the substance used most often by high school students with 33.1% reporting to have had at least one alcoholic drink in the past 30 days. [Figure 43] The majority of high school students had their first alcoholic drink when they were between years old. [32] On average, binge drinking among high school students is below state and national average. However, when analyzed by grade level and gender, it shows that 12 th grade Hunterdon male and female students engage in binge drinking more often than the national average [Table 6]. FIGURE 43: Alcohol Consumption, Binge Drinking and Marijuana Use Among High School Students, Past 30 Days 50.0% 40.0% 33.1% 42.9% 38.7% 30.0% 20.0% 19.6% 23.7% 21.9% 23.1% 21.1% 13.6% 10.0% 0.0% Drank Alcohol Engaged in Binge Drinking Used Marijuana Hunterdon County 2012 New Jersey 2011 US 2011 Source: Hunterdon County Youth Risk Behavior Survey, Hunterdon County Community Health Needs Assessment

55 TABLE 6: Binge Drinking of 12 th Graders, by Gender Hunterdon County 2012 US 2011 Males 40.3% 35.7% Females 32.1% 27.0% Source: Hunterdon County Youth Risk Behavior Survey, 2012 After alcohol, marijuana is the 2 nd most prevalently used substance among high school students. There seems to be a growing perception that smoking marijuana is socially acceptable and pose very little risk. When students were asked How much do you think people risk harming themselves physically or in other ways when they smoke marijuana once or twice a week, 19.6% responded no risk. Even more concerning is when asked How wrong do your parents and friends feel it would be for you to smoke marijuana, 2.9% felt that their parents find it not at all wrong, while 22.9% believe that their friends find it acceptable. Similar questions were asked regarding use of other substances. Having alcohol drinks 1 to 2 times daily is the 2 nd behavior perceived by students to not meet parental disapproval. TABLE 7: Student Perception that Substance/Drug Use is Not Harmful (2012) Substances % of Students Who Thinks There s No Risk of Harming Themselves Drink 1 or 2 alcoholic drinks nearly every day 5.8% Smoke 1 or more packs of cigarettes per day 3.3% Smoke marijuana once or twice a week 19.6% Use heroin 2.2% Use Rx drugs not prescribed to you 2.3% FIGURE 44: Perception of Parental and Peer Disapproval of Substance/Drug Use (2012) 25.0% 20.0% 22.9% 15.0% 10.0% 5.0% 0.0% 10.5% 2.1% 1.9% Have 1-2 alcoholic drinks daily 12.6% 2.9% 5.0% 2.3% 1.0% 1.3% Smoke tobacco Smoke marijuana Use heroin Use prescription drugs not prescribed to you Parents Peers Source: Hunterdon County Youth Risk Behavior Survey, Hunterdon County Community Health Needs Assessment

56 Although at a much lower prevalence than alcohol and marijuana, other drugs such as cocaine, heroin, and prescription drugs are also being used, misused or abused by Hunterdon high school students. [32] According to the 2012 YRBS, 3.9% of high school students in Hunterdon took prescription drugs without a prescription within the past 30 days. [32] Meanwhile 1.9% and 1.2% used cocaine and heroin, respectively, within the past 30 days. [32] Figure 45 shows percentage of high school students who have tried various drugs at least once in their lifetime. The percentage of high school students in Hunterdon who have ever tried any drug is generally lower compared to state and national average. FIGURE 45: Percentage of High School Students Lifetime Use of Drugs 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Alcohol Marijuana Cocaine Heroin Meth Ecstasy Rx Drugs w/o Prescription Hunterdon County 2012 New Jersey 2011 US 2011 Source: Hunterdon County Youth Risk Behavior Survey, 2012 Note: Cocaine includes powder, crack or freebase forms Heroin also called smack, junk or China White Meth short-term for Methamphetamine, also called speed, crystal, crank and ice Ecstasy also called MMDA Rx Drugs examples include OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin and Xanax However, the reverse is true for some of the drugs when looking at frequency of use. According to the 2012 YRBS, 1.2% of Hunterdon high school students have used heroin 40 or more times in their lifetime compared to just 0.5% in NJ and 0.8% in the US [Table 8]. Heroin use, especially among youth was mentioned to be an increasing problem in Hunterdon County. Heroin is no longer limited to urban areas. Dealing and using heroin is now moving into more suburban and affluent communities, according to a participant in the FOCA Hunterdon County Community Health Needs Assessment

57

58 Although prevalence of smoking cigarettes among Hunterdon adults dropped considerably from 14.1% in 2001 to 8.7% in 2010, [22] the fact remains that tobacco use is still the single largest preventable cause of death and disease in the United States. [37] FIGURE 47: Percentage of Adults Who Currently Smoke Cigarettes 50.0% 40.0% 38.3% 42.0% 30.0% 20.0% Healthy People 2020 Target (12%) 10.0% 8.7% 0.0% Hunterdon County 2010 New Jersey 2009 US 2009 Source: Hunterdon County Behavioral Risk Factor Surveillance System, 2010; U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020 Note: Current smokers are those who currently smoke every day or most days and has smoked at least 100 cigarettes in their lifetime A smaller percentage of Hunterdon high school students smoked cigarettes in the past 30 days compared to state and national data. It is notable that both Hunterdon County s adult and youth current cigarette smoking rates meet and actually exceed the Health People 2020 Target. FIGURE 48: Percentage of High School Students Who Smoke, Past 30 Days 20.0% 15.0% Healthy People 2020 Target (16%) 16.1% 18.1% 10.0% 10.3% 5.0% 0.0% Hunterdon County 2012 New Jersey 2011 US 2011 Source: Hunterdon County Youth Risk Behavior Survey, 2012; U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People Hunterdon County Community Health Needs Assessment

59 According to data gathered data from the YRBS, a larger percentage Hunterdon County high school seniors under the age of 18 years, were able to purchase cigarettes from a store or gas station compared to the national average, especially among male students. TABLE 9: Percentage of High School Seniors (Under 18 years) Who Reported Purchasing Cigarettes from Convenience Store or Gas Station, by Gender Males Females Hunterdon County % 30.0% United States % 15.5% Substance Abuse Treatment According to the 2009 NJ Household Survey on Drug Use & Health, 10.2% of Hunterdon County Residents met the criteria for substance abuse or dependence compared to 9.4% of Adult residents in the whole state. Among Hunterdon residents across all age groups admitted for substance abuse treatment in 2011, 48.5% were for alcohol, followed by 26% for heroin and opiates, 18.7% for marijuana and 6.8% for cocaine and other drugs. FIGURE 49: Distribution of Substance Abuse Treatment Admissions by Primary Drug, Hunterdon County Residents Across All Age Groups (2011) Other Drugs, 3.5% Marijuana, 18.7% Heroin & Opiates, 26.0% Alcohol, 48.5% Source: NJ Drug and Alcohol Abuse Treatment, Hunterdon County Subtance Abuse Overview, 2011 Bullying Cocaine, 3.3% Bullying is another national concern that is also prevalent among Hunterdon County youth according to the recently completed Youth Risk Behavior Survey. A higher percentage of high 2013 Hunterdon County Community Health Needs Assessment

60 school students in Hunterdon County reported being bullied on school property in the past 12 months compared to state and national average. It is a problem that cuts across gender and grade level as seen in Table 10. Electronic bullying is also more prevalent among females. Females are twice as likely to have been electronically bullied compared to their male counterpart a pattern not unique to Hunterdon. FIGURE 50: Percentage of High School Students Bullied (2012) 25.0% 21.5% 20.0% 20.1% 20.0% 15.6% 14.4% 15.0% 16.2% 10.0% 5.0% 0.0% Bullied on School Property Bullied Electronically Hunterdon County 2012 New Jersey 2011 US 2011 Source: Hunterdon County Youth Risk Behavior Survey, 2012 TABLE 10: Percentage of High School Students Reported Having Ever Been Bullied in the Past 12 Months, by Gender Grade Level Bullied on School Property Bullied Electronically Males Females Males Females HC 2012 US 2011 HC 2012 US 2011 HC 2012 US 2011 HC 2012 US th 22.2% 21.5% 27.3% 27.1% 8.9% 8.9% 19.4% 22.6% 10 th 22.3% 20.4% 22.7% 24.6% 10.1% 12.6% 21.4% 24.2% 11 th 17.4% 16.7% 25.0% 17.5% 9.3% 12.4% 17.3% 19.8% 12 th 17.1% 13.4% 18.2% 17.2% 9.3% 8.8% 18.6% 21.5% Sexual Activity A significantly lower percentage of Hunterdon high school students reported ever having had sexual intercourse compared to the state average, 24.8% and 44.6%, respectively. And among those who are sexually active, more Hunterdon students reported using condoms during their 2013 Hunterdon County Community Health Needs Assessment

61 last sexual intercourse. The most frequently used method to prevent pregnancy among county youths is condoms (61.2%) followed by birth control pills (17%). [32] Only 7.1% reported not using any method to prevent pregnancy during their last intercourse, lower than the state s average of 14.4%. However, among those who had sexual intercourse in the past 3 months, a larger percentage of Hunterdon high school students drank alcohol or used drugs before their last sexual intercourse compared to the state and national average. FIGURE 51: Sexual Behaviors Among High School Students (2012) 50.0% 47.4% 44.6% 40.0% 34.2% 35.9% 30.0% 20.0% 24.8% 24.9% 21.1% 20.4% 29.3% 14.4% 12.6% 10.0% 7.1% 0.0% Ever had sexual intercourse Drank alcohol or used drugs before last sexual intercourse Did not use condom during last sexual intercourse Did not use any method to prevent pregnancy during last sexual intercourse Hunterdon County 2012 New Jersey 2011 US 2011 Source: Hunterdon County Youth Risk Behavior Survey, Hunterdon County Community Health Needs Assessment

62 COMMUNITY THEMES AND STRENGTHS ASSESSMENT INTRODUCTION The purpose of the Community Themes and Strengths Assessment (CTSA) is to gather input from community members to develop a more in-depth understanding of issues they feel are important, their concerns, and their perceptions about quality of life. Focus group was the approach used to engage the community, to generate ideas, and to prioritize issues perceived as having the greatest impact on the health of the community, and to obtain an in-depth view of their idea of a healthy community. Six focus groups were completed between November 2011 and January 2012 with a total of 49 participants -- an average of 8 participants per group. Participants were chosen from various sectors of Hunterdon County Leaders of the Faith Community, County Planning Board, Chamber of Commerce, Latino Healthcare Access Committee, School Nurses Association and Healthcare and Social Service Providers. These groups were targeted as they were considered to be in a position to know the community as a whole - its needs and concerns, as well as its assets - due to the nature of their work and the numerous and diverse county residents with whom they interact. The purposive sampling process used entailed reaching out to a key member of each of the previously-mentioned groups, informing them of the purpose of the focus group and the time commitment required. They were then asked to participate and to help in the recruitment of 6 to 8 other members. Afterwards, project staff contacted the possible participants to provide additional details and to confirm their involvement. METHODOLOGY A modified version of the Nominal Group Technique (NGT) was employed in conducting the focus groups. These steps included: 1. An Introduction of all participants, the facilitator and note taker, 2. A brief overview of the Robert Wood Johnson Foundation grant project, 3. An outline of the general rules to be observed during the session, and 4. A review of the three questions to be posed: a. What factors contribute to quality of life living in Hunterdon County? b. What factors reduce quality of life living in Hunterdon County? c. What recommendations do you have to improve quality of life in Hunterdon County? 5. A round-robin method was used by the facilitator who would call on each participant (in turn) to share an idea in response to the question posed. Each unique idea was written on a board or a flip chart poster in the exact words used by the participants. Each participant got two turns to respond to each question. Afterwards, the facilitator opened the floor and asked participants to share any additional ideas they had that were not yet listed on the board. 6. The ideas were then clarified and grouped. Participants were asked to look at the ideas listed on the board and to agree on a final listing. The voting then began. Each idea was read to the group by the facilitator, and the participants, by raising their 2013 Hunterdon County Community Health Needs Assessment

63 hands, cast two votes on the ideas they believed to be the most important. The votes were then tallied and recorded. The same steps were followed for all 3 questions. Data from all 6 focus groups were collected and analyzed independently and collectively. The analysis identified prevailing themes in each of the three questions and coded accordingly [see Appendix C for code book]. The group and date of the sessions are as follows: Group # of Participants Date Latino Healthcare Access Committee 8 Nov. 7, 2011 School Nurses 8 Nov. 14, 2011 County Planning Board 8 Dec. 1, 2011 Faith Leaders 7 Dec. 8, 2011 HRCH Staff and Social Service Providers 11 Jan. 3, 2012 Chamber of Commerce 7 Jan. 5, 2012 RESULTS Because participants of the focus groups were from varying background with varying life and work experiences, a broad range of responses was expected. However, in spite of their differences, common themes across all 6 focus groups were apparent in each of the 3 questions. Factors Contributing to Quality of Life For factors that contribute to quality of life in Hunterdon, common responses from participants were -- natural beauty of the county and the opportunity it provides residents to engage in outdoor physical activity, majority of residents have health insurance and have access to healthcare and social services, community is safe and people are willing to volunteer their time and other resources. Figure 52 highlights the most important factors contributing to the quality of life in Hunterdon, as voted by all focus group participants Hunterdon County Community Health Needs Assessment

64 FIGURE 52: Leading Factors that Contribute to Quality of Life in Hunterdon County Most Prioritized Contributing Factors to Quality of Life Rural character Accessibility and availability of healthcare and social services Safe neighborhood Excellent school system Strong civic support and engagement # of Priority Votes Rural Character When you re stuck at home, you can just look out and enjoy nature. The rural character of the county was mentioned numerous times in almost all of the 6 focus groups as being one of the leading factors that contribute to quality of life. Rural character includes the county s natural resources, parks, open space and the overall beauty of the county s physical environment. A clean and beautiful neighborhood has a profound impact on the physical and mental health and well-being of its residents. [38, 39] The availability and accessibility of open space encourage physical activity by providing opportunities to engage in various outdoor recreation activities. [39] Access to and Availability of Healthcare and Social Services The ratio of primary care physicians to residents and the focus on preventive care was mentioned as a major strength of the county. There are also many services available for the residents including targeted services for the more vulnerable groups -- children, seniors and the growing Latino population. Majority of residents have some type of health insurance, reducing barrier to accessing needed health services. Many of the participants believe this to be reflective of the county s affluence and higher than state-average employment rate Hunterdon County Community Health Needs Assessment

65 Community Safety I forget to lock my door sometimes and still feel safe. The low crime rate in the county is one of the main factors that enhance quality of life in Hunterdon and draw people to live and raise a family here. Many expressed that there is a general sense of being safe in the community. Excellent School System It s the reason why I moved here. Having access to the excellent public school system and quality educational opportunities is a key reason why a lot of families or couples thinking of raising a family choose to reside in Hunterdon County. Civic Support and Engagement People not only give money. But more importantly they volunteer their time, knowledge and expertise. Hunterdon is a geographically large area, yet there remains a sense of a small-town community. It was indicated by participants that the county is rich in human capital highly educated, caring and generous individuals who are invested in their community. Business owners also support, promote and fund various community programs. Factors Reducing Quality of Life For factors that reduce quality of life living in Hunterdon, a lot of the responses were related to the challenges of living in the county and the specific groups who are struggling. The most frequently mentioned responses were having a relatively low income in an expensive county making it challenging to meet basic needs and continue living in Hunterdon, having limited services and programs that cater to the growing Latino population and limited affordable transportation options which impacts a large Hunterdon population s ability to access needed services. Figure 53 depicts the factors voted by focus group participants to have a significantly negative impact on the quality of life living in Hunterdon Hunterdon County Community Health Needs Assessment

66 FIGURE 53: Leading Factors that Reduce Quality of Life in Hunterdon County Most Prioritized Factors that Reduce Quality of Life High cost of living 15 Limited services/programs for Latinos Mental health issues Limited affordable transportation options 10 Large number of low income residents 9 Commercialization High Cost of Living You can t retire here. High property taxes and relatively higher cost of services are detrimental to the community. It makes it difficult for many to make ends meet. This especially affects those with lower income and the young adult population. According to one participant, people who grew up in the county do not come back after graduating college because they cannot afford to live here. The high cost of living also affects the workforce, especially caregivers. A focus group participant said that there is a shortage in [caregiver] applicants because they do not get paid enough to be able to afford to live in the county. Limited Services and Programs for Latinos Although progress has been made with regards to expanding services and programs for members of the Latino community, it is still lacking. The needs and challenges of the Latino community -- language barriers, cultural differences, lack of advocacy services, literacy and health education programs -- remain inadequately addressed, negatively affecting their health and quality of life. Mental Health Issues Youth are at school during the day...play sport from late afternoon to early evening...then, they have homework to do when they get home. They have no time to relax. High level of stress and anxiety brought about by the pressure to excel both academically and athletically among children and young adults are on the rise. Many of the participants believe 2013 Hunterdon County Community Health Needs Assessment

67 that this pressure stems from the naturally competitive environment in Hunterdon County and the current bad economy. Parents want their kids to do better and excel in all areas in order to increase their chances of moving ahead and succeeding. In addition, parents and adults are stressed out themselves trying to maintain the lifestyle they and their family are accustomed to, at a time when budget is a little tighter. Limited Affordable Transportation Options Although improvements have been made, transportation continues to be a major challenge especially in the more rural areas of the county where places are not within walking distance or roads are not safe for pedestrians. This continues to be a key barrier to accessing healthcare and social services for a lot of people. Large Low Income Population Hidden poor The overarching theme that cuts across a lot of the factors cited by the participants is income. It affects access to care, proper nutrition and opportunities to participate and engage in physical activities, especially for school-aged children. Focus group participants used the term hidden poor to refer to those individuals who are unable or barely able to meet their daily living expenses. Many of these residents are not willing to or do not know who or how to ask for help. This makes it very challenging to identify those who are in need and provide them with needed assistance. In addition, the general affluence of the county gives the illusion that poverty is not an issue, understating the scope of the problem. Recommendations to Improve Quality of Life When participants were asked what recommendations they have to improve quality of life living in Hunterdon, it is not surprising that they mentioned changing the factors they mentioned to be detrimental to quality of life living in the county. Most frequently cited recommendations included improving coordination of, accessibility to and awareness of various healthcare and social services, investing in community education, especially parents as they play an important and influencing role in their child s well-being and expanding and making services for vulnerable county residents more affordable such as seniors and Latinos. Figure 54 illustrates the recommendations focus group participants voted to be of top priority Hunterdon County Community Health Needs Assessment

68 FIGURE 54: Leading Recommendations to Improve Quality of Life Living In Hunterdon County Most Prioritized Recommendations to Improve Quality of Life Management of health care and social services 21 Improve transportation Promote/Provide health & lifeskills education Decrease cost of living Increase/Improve services for Latinos Improve Management and Coordination of Healthcare and Social Services Affordability of healthcare is a key concern that needs to be addressed. Many decide to forego seeing a doctor or getting preventive services or needed treatment due to cost. The impact, if any, of the ongoing healthcare reform on residents, especially those who are uninsured, remains to be seen. Also, improvements in coordination, collaboration and provision of care and services are sorely needed. Although Hunterdon offers a lot of resources and services, many of its residents are not aware that that they exist. And if they do, they do not know how or where to go to avail of these services. Respondents suggested that providers be educated on the resources available so they can refer their clients appropriately and efficiently. Improve Transportation The county needs to offer more low-cost public transportation options besides the LINK to improve accessibility to many services. Promote and Provide Health and Life Skills Education Providing health literacy and other life management educational programs would be beneficial to the community. It would enable individuals to take charge of and be more proactive with their health and well-being. Respondents mentioned that investing in parenting education is of a particular importance, as parents play an important role in their child s development and overall well-being Hunterdon County Community Health Needs Assessment

69 Decrease cost of living Although understandably more difficult to do and beyond the control of most, many participants said that reducing taxes and the overall cost of living would improve the quality of life of residents living in Hunterdon. It will alleviate residents financial concerns, allow them to live more comfortably and encourage more people to move in or remain in the county. Increase/Improve services for Latinos The Latino population is rapidly growing in Hunterdon County and it is essential that their needs and challenges are addressed. Disparity in health status and access to care exists and they face additional barriers, such as language and cultural differences. Although progress has been made in expanding services and programs targeting the Latino community, more remains to be done. Focus group participants felt strongly that in order to reduce health disparity and improve quality of life of the Latino community, provision of culturally and linguistically appropriate care and services is imperative Hunterdon County Community Health Needs Assessment

70 FORCES OF CHANGE ASSESSMENT INTRODUCTION The purpose of the Forces of Change Assessment (FOCA) is to identify and analyze present and future external forces expected to have an impact, be it positive or negative, on the public health system and the community s health and well-being. Forces of change include: Trends patterns over time, such as migration in and out of the community or a growing disillusionment with government Factors discrete elements, such as a community s large ethnic population, an urban setting or the jurisdiction s proximity to a major waterway Events one-time occurrences, such as a hospital closure, a natural disaster or the passage of new legislation Categories of forces of change include: Social, Economic, Political, Technological, Environmental, Scientific, Legal and Ethical. METHODOLOGY A total of 14 key stakeholders and community leaders participated in the Forces of Change brainstorming session. Participants were chosen because of their knowledgeable of Hunterdon County and their informed perceptions regarding impending changes that will affect the community and its health. The Assessment was held on March 30, 2012 and the session was 2 hours long. Similar to the focus group, a modified version of the Nominal Group Technique was used. In round robin fashion, each participant identified a force of change. All responses were listed on the board by the facilitator. This process was repeated. Once every participant had the opportunity to share at least 2 responses, the facilitator asked if any of the forces written on the board can be combined (i.e. similar ideas). Next, participants were given a ballot which lists the final 21 discrete forces identified and grouped during the brainstorming session. They were then asked to select their Top 5 Forces and rank them in order of significance (with 1 being the most significant). The ballots were collected and rankings were assigned points. The force ranked #1 (i.e. the most important) received 5 points, #2 (i.e. 2 nd most important) with 4 points, and so on. Points were added and the 5 forces that have the highest point total were considered to be the most important forces for the whole group. RESULTS The following lists by category, all the individual Forces of Change identified by the FOCA participants: Social Aging population End-of-Life care challenges Need for home and community-based services 2013 Hunterdon County Community Health Needs Assessment

71 Better organized faith community Increasing incidence of mental illness and substance abuse Increasing gang activity Increasing immigrant population Rising incidence of domestic violence Adult and childhood obesity Decreasing volunteerism and commitment Increasing awareness of health behaviors Limited services available for the disabled Limited knowledge of and other access barriers to available community services Economic Healthcare affordability Growing uninsured population Changing economic landscape Widening philosophical gap between the haves and have nots Difficulty in adapting to economic reality Shift in funding focus from programs to policy and environmental change Political Changing government policies and priorities regarding health and human services Local government s denial of real issues Gap between the local, state and national health priorities Environmental Increasing environmental awareness Limited affordable transportation options Highland Act Lack of affordable housing Technological Expanding use of the Internet and social media Ethical Advancing medical technologies 2013 Hunterdon County Community Health Needs Assessment

72 Participants were asked to combine, if any, forces they believe to be similar. After much discussion, the group ultimately settled on a final list and ranked their Top 5 Forces of Change. The forces identified to be most significant are to some extent interrelated with each other and are also reflective of issues of concern on a national level. The 5 ranked to be the leading Forces of Change are as follows: 1. Changing economic landscape; Difficulty adapting to new economic reality; Widening gap between the haves and have nots The economic downturn was a major factor among the participants. It has affected and will continue to affect the health and well-being of the Hunterdon community and the delivery of services by the healthcare and local public health systems. In addition, these tough economic times not only affect residents finances, but also their health. The financial stress of figuring out a way to maintain the lifestyle they are used to may have a harmful effect on their mental health as well as their children. 2. Healthcare affordability; Growing uninsured population Although the impact of the healthcare reform on healthcare delivery, affordability and accessibility remains uncertain, participants believe that these are important issues that need to be addressed as they significantly influence the health of the community. 3. Aging population; End of life care challenges The changing demographic, the growing elderly population in particular, will contribute to an increase in demand for specific healthcare, social and supportive services, such as home care, and end-of-life and palliative care. Participants agreed that the public health system and the hospital will need to determine ways to fill the gaps and provide the needed care and services. Raising awareness of the available services and resources for seniors is a key step to this process. 4. Increasing incidence of mental illness and substance abuse; Increasing gang activity Participants cited that substance abuse and its high prevalence of comorbidity with mental illness continue to be a pervasive problem in Hunterdon. In addition, because of the high demand for and profitability of drugs, gang activity is increasing in Hunterdon. Increasing accessibility to treatment services for substance abuse and mental illness is imperative to meet the persistent need. Emphasis on prevention efforts is also critical to curb this problem. 5. Changing government policies and priorities regarding health and human services; Local government s denial of real issues; Gap between local, state and national government when it comes to health priorities The differing priorities of federal, state and local governments are creating confusion and affecting availability and accessibility of services and programs in the county. Focus on the federal level is prevention and public health. However, decreasing budget has led to shifting of priorities away from health and human services and decreasing funding and staffing of various public health services at the local level Hunterdon County Community Health Needs Assessment

73 The following are Forces of Change identified by the group, but not ranked in the Top 5, and their accompanying discussion points: Forces of Change Challenges/Threats Opportunities/Strategies Increasing prevalence of obesity across all ages Increasing immigration Increases cost burden to the healthcare system Increases incidence of chronic illnesses Reduces quality of life Unhealthy lifestyle is being passed on to the next generation Discrimination or fear of discrimination A lot of immigrants are uninsured or underinsured, underpaid and are not given any benefits, affecting their access to care and thus their overall health Increasing demand for healthcare, public health and social services Language barriers and acculturation challenges Advancing medical technology Ethical dilemma on how to appropriately use/apply technology on elderly patients and who makes that decision Promotes practice of defensive medicine increasing healthcare cost which burdens the healthcare system Expanding use of the internet and social media Increasing concern regarding protection of privacy, proliferation of child pornography, and encouragement of and support for negative behaviors Increase wellness programs and nutrition education at workplace Collaborate with schools, workplace to encourage physical activity Create more community and school gardens Increases diversity and cultural influence Immigrant population are a major contributor to the workforce Improve quality and prolong life Convenient means for service providers and community-based organizations to reach out and connect with the community - better understand and respond to their needs 2013 Hunterdon County Community Health Needs Assessment

74 Forces of Change Challenges/Threats Opportunities/Strategies Decreasing volunteerism There is a gap in the volunteer workforce Loss of expertise and inkind contribution Increasing awareness of healthy behaviors May translate to adopting healthier behaviors and lifestyle Limited public transportation Limits access to services in the community Barrier to getting and keeping jobs Rising incidence of domestic violence Hunterdon Interfaith Outreach Council Highlands Act Increasing environmental awareness Families are torn apart Increase in mental health issues Growth is restricted. If there are no new houses, there are no new people to share tax burden with Explore and promote sustainable transportation options and promote physical activity Promote awareness and create support groups Better organized faith community Avenue for communication and looking at the needs of the community as a whole group of faith leaders Able to have a bigger and better impact Avoids overdevelopment and preserve natural resources and beauty of the county Protects the quality of drinking water Improve physical environment Better quality local food production 2013 Hunterdon County Community Health Needs Assessment

75 LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT INTRODUCTION For the Local Public Health System Assessment a survey tool developed by the National Public Health Performance Standards Program (NPHPSP) was used. This survey is intended to help answer questions such as "What are the activities and capacities of our public health system?" and "How well are we providing the Essential Public Health Services in our jurisdiction?" The dialogue that occurs in answering these questions can help identify the relative strengths and weaknesses of the system and determine opportunities for improvement. The objective of this process is to improve the local public health system and ultimately the overall health of the community. The Ten Essential Public Health Services (EPHS), which defines public health and describes its scope in all states and communities, is the fundamental framework for the NPHPSP instrument. The Ten Essential Public Health Services 1. Monitor health status to identify community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate and empower people about health issues. 4. Mobilize community partnerships to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure a competent public health and personal health care workforce. 9. Evaluate effectiveness, accessibility and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems. Any organization or entity that contributes to the health or well-being of a community - such as existing community partnerships, hospitals, local health department, social service providers and the faith community, schools, - is considered part of the public health system Hunterdon County Community Health Needs Assessment

76 Organizations Included in the Local Public Health System METHODOLOGY During the December 2, 2012 Partnership for Health meeting, committee members were informed that the Local Public Health System Assessment will be conducted. They were also presented with a brief overview of the assessment and its purpose. It was decided that the assessment will be completed in 10 separate hour-long meetings (one for each Essential Public Health Service) in order to accommodate everyone s busy schedule. A sign-up sheet for each Essential Service was placed at the back of the meeting room and committee members were asked to voluntarily sign-up for the Essential Service they would like to assess. A total of 18 individuals from varying organizations participated in the LPHSA. The LPHSA meetings were conducted between January and February Dates of the assessment meetings were as follows: Essential Public Health Service Date of Assessment # of Participants 1 Monitor Health January Diagnose and Investigate January Inform, Educate and Empower January Mobilize Community Partnerships January Develop Policies January Enforce Laws January Link to/provide Care January Assure Competent Workforce February Evaluate January Research February Hunterdon County Community Health Needs Assessment

77 For each Essential Service, the model standards describe or correspond to the optimal performance level of the primary activities conducted at the local level. The number of model standards varies across the Essential Services; while some Essential Services include only two model standards, others include up to four. There are a total of 30 model standards in this instrument. Each model standard in each Essential Service has a series of stem questions that break down the standard into its component parts and sub-questions to detail stem question responses. Participants assess and respond to each EPHS, model standard, stem question and sub-question on the following scale: No Activity Minimal Activity Moderate Activity Significant Activity Optimal Activity 0% or absolutely no activity Greater than 0, but no more than 25% of the activity is met Greater than 25%, but no more than 50% of the activity is met Greater than 50%, but no more than 75% of the activity is met Greater than 75% of the activity is met Using the responses to all of the assessment questions, a scoring process generates scores for each stem question, model standard, Essential Service and one overall score. The scoring methodology is available from CDC or can be accessed online at Each meeting started with a brief orientation of the NPHPSP s LPHSA instrument format and response options. The model standard was first read and discussed by the group prior to the questions. Participants then discussed each question and collectively determined the response that best describes the current level of activity within the system. Further discussion occurred when there was a disparity in responses. The consensus response was then recorded. Upon conclusion of the assessment process, the recorded data was electronically entered to the NPHPSP data reporting page: NPHSP then analyzed the results, calculated the scores, and generated a report for Hunterdon County. RESULTS Each Essential Public Health Service (EPHS) score is a composite value determined by the scores assigned to the activities within each Essential Service. These scores range from a minimum value of 0% (no activity is performed according to the standards) to a maximum of 100% (all activities associated with the standards are performed at optimal levels).the range bars in Figure 55 show the minimum and maximum values of responses within the Essential Service. Overall, Hunterdon County s local public health system is operating at an optimal level, especially due to the Partnership for Health and the opportunity it provides its members to collaborate and maximize their efficiency and impact. However, due to recent and continuing changes occurring in the County Division of Health (formerly the Department of Health), 2013 Hunterdon County Community Health Needs Assessment

78 assessment participants are not certain how these changes would impact the county s public health infrastructure and if they will continue to perform at an optimal level. * Table 10 and Figure 55 provide an overview of the Local Public Health System s (LPHS) performance in each of the 10 EPHS TABLE 11: Summary of performance scores by Essential Public Health Service (EPHS) EPHS Score 1 Monitor health status to identify community health problems 76 2 Diagnose and investigate health problems and health hazards 90 3 Inform, educate and empower people about health issues 77 4 Mobilize community partnerships to identify and solve health problems 70 5 Develop policies and plans that support individual and statewide health efforts 67 6 Enforce laws and regulations that protect health and ensure safety 94 7 Link people to needed personal health services and assure the provision of 89 health care when otherwise unavailable 8 Assure a competent public and personal health care workforce 47 9 Evaluate effectiveness, accessibility and quality of personal and populationbased 77 health services 10 Research for new insights and innovative solutions to health problems 63 OVERALL PERFORMANCE SCORE 75 FIGURE 55: Rank ordered performance scores for each Essential Service, by level of activity (With range) No Activity Minimal Moderate Significant Optimal 2013 Hunterdon County Community Health Needs Assessment

79 Results by Essential Service: Scores and Discussion Themes Essential Service #1: Monitor Health Status to Identify Community Health Problems Overall Score = 76 (OPTIMAL) Overall Ranking: 6 th of 10 3 Model Standards, 32 Questions EPHS 1 service includes: Accurate, periodic assessment of the community s health status, including: o Identification of health risk, determinants of health and determination of health service needs; o Attention to the vital statistics and health status indicators of groups that are at higher risk than the total population; and o Identification of community assets that support the local public health system (LPHS) in promoting health and improving quality of life. Utilization of appropriate methods and technology, such as geographic information systems (GIS), to interpret and communicate data to diverse audiences. Collaboration among all LPHS components, including private providers and health benefit plans, to establish and use population health registries, such as disease or immunization registries Population-Based Community Health Profile (CHP) OPTIMAL Access to and Utilization of Current Technology to Manage, Display, MODERATE 46 Analyze and Communication Population Health Data 1.3 Maintenance of Population Health Registries OPTIMAL 100 Discussion: Data Collection The local public health system (LPHS) does well with data collection especially due to the administration of the county s Behavioral Risk Factor Surveillance System (BRFSS) survey every 5 years since Other data used is governmental data both national and state. Comparison of data with other representative areas or population is done to a certain extent by using the County Health Rankings (by the University of Wisconsin). However, this needs to improve as comparison is not done on all data sets. In addition, data is lacking for certain key health issues, such as asthma and communicable diseases. Data Availability The value and use of data is promoted and encouraged through radio promotions and by making it available in the library (hardcopy) and the Partnership for Health website (electronically). Technology Database technology is not state of the art. However, the hospital has shifted to using Electronic Health Records (EHR) which allows data to be broken down by zip codes and data collected through the Communicable Disease Reporting and Surveillance System (CDRSS) can be broken down by municipality. Geographic information system (GIS) is not used often; only when specific information is needed. Importance Everything is data-driven. You have to have data to get funded Hunterdon County Community Health Needs Assessment

80 Essential Service #2: Diagnose and Investigate Health Problems and Health Hazards Overall Score = 90 (OPTIMAL) Overall Ranking: 2 nd of 10 3 Model Standards, 41 Questions EPHS 2 service includes: Epidemiological investigations of disease outbreaks and patterns of infectious and chronic diseases and injuries, environmental hazards and other health threats. Active infectious disease epidemiology programs. Access to a public health laboratory capable of conducting rapid screening and high volume testing. 2.1 Identification and Surveillance of Health Threats OPTIMAL Investigation and Response to Public Health Threats and Emergencies OPTIMAL Laboratory Support for Investigation of Health Threats OPTIMAL 100 Discussion: Funding and Staffing Performance and capacity is highly dependent on funding. Responses to majority of the questions are based on 2011 funding and staffing levels. If we lose Homeland Security and Public Health Preparedness funding, cost may not be picked up by the local government and we will lose our service level. In addition, capacity is low which affects the LPHS s ability to manage case loads and submit reportable disease information in a timely manner. With the exception of the Hunterdon Healthcare System, there is usually a lag in reporting incidences of reportable diseases. Coordination There is coordination and communication among the different agencies. Participants also agreed that they do a decent job in communicating and reaching out to the community leaders (who were identified as the Freeholders, Mayors, Appointed Boards of Health and other political leaders). However, assessment participants agreed that they usually do not get a response from them. Therefore, participants had some difficulty rating coordination with local community leaders. Participants were unsure what the question meant by coordinate. Participants believe that communication is uni-directional, while coordination implies that both parties are working together. Due to the agreed upon distinct differences between communication and coordination, the group decided to rate coordination with community leaders as minimal Hunterdon County Community Health Needs Assessment

81 Essential Service #3: Inform, Educate and Empower People about Health Issues Overall Score = 77 (OPTIMAL) Overall Ranking: 5 th of 10 3 Model Standards, 38 Questions The instrument asks 38 questions to assess performance against three model standards. EPHS 3 service includes: Health information, health education and health promotion activities designed to reduce health risk and promote better health. Health education and health promotion program partnerships with schools, faith communities, work sites, personal care providers and others to implement and reinforce health promotion programs and messages that are accessible to all populations. Health communication plans and activities such as media advocacy and social marketing. Accessible health information and educational resources. Risk communication processes designed to inform and mobilize the community in time of crisis. 3.1 Health Education and Promotion OPTIMAL Health Communication SIGNIFICANT Risk Communication OPTIMAL 90 Discussion: Health Promotion and Education There are a lot of programs and services available but there is also lack of engagement from the community. A lot do not take advantage of these programs and services. The health department and other agencies try to filter out information to the public via the media, putting out fliers and brochures, hosting events and town hall meetings and posting information on the website. In addition, due to the funding cuts and reorganization of the local health department, there s uncertainty as to what will happen to programs that are currently offered. It was also pointed out that holding health promotion and education activities do not necessarily translate into behavior change. Collaboration Although efforts and activities are somewhat coordinated through the Partnership for Health, there is still a lot room for improvement as there are still others who are not willing to collaborate. Practices, Campaigns and Programs Use of evidence-based practices is preferred, especially since most grants require them. Some campaigns use messages and formats that are tailored for a specific group. However, it is still severely lacking especially for certain sub-groups such as the Latinos, the in-between age group and the LGBT population. Reason for this deficiency is not always due to lack of trying, but also due to certain populations/group not wanting to get engaged Hunterdon County Community Health Needs Assessment

82 Essential Service #4: Mobilize Community Partnerships to Identify and Solve Health Problems Overall Score = 70 (SIGNIFICANT) Overall Ranking: 7 th of 10 2 Model Standards, 32 Questions EPHS 4 service includes: Identifying potential stakeholders who contribute to or benefit from public health and increase their awareness of the value of public health. Building coalitions and working with existing coalitions to draw upon the full range of potential human and material resources to improve community health. Convening and facilitating partnerships and strategic alliances among groups and associations (including those not typically considered to be health-related) in undertaking defined health improvement activities, including preventive, screening, rehabilitation and support programs and establishing the social and economic conditions for long-term health. 4.1 Constituency Development SIGNIFICANT Community Partnerships SIGNIFICANT 68 Discussion: Collaboration and Partnership The Partnership for Health is one of the county s strength as it plays a huge role in constituency development. However, there is still a lot of work that needs to be done to strengthen, broaden and diversify its membership. Participants also agreed that the Robert Wood Johnson Foundation (RWJF) grant will contribute to constituency development and encourage active participation and collaboration in the county. Volunteers The LPHS support and provide opportunities for volunteers. There are over 100 volunteers in the Medical Reserve Corps who are trained to help the Department of Health during mass clinics and other public health preparedness activities. The United Way also spend hours on volunteer engagement. The problem is not recruitment of volunteers. The challenging aspect is training, retention and keeping them engaged. Evaluation Evaluation is weak and lacking. No formal evaluation has been done to assess the effectiveness of and satisfaction with the Partnership for Health. One of the deliverables of the RWJF grant is a pre and post network analyses which will measure the nature and strength of partnerships among the community agencies in the Partnership for Health. Recommendation to Improve Partnership There is a need to invite and encourage nonmembers to attend the quarterly Partnership for Health meetings and share information via e- mail. Possibly have an intern put together an updated list of organizations (a directory of sort) that comprise the LPHS to help identify potential partners Hunterdon County Community Health Needs Assessment

83 Essential Service #5: Develop Policies and Plans that Support Individual and Community Health Efforts Overall Score = 67 (SIGNIFICANT) Overall Ranking: 8 th of 10 4 Model Standards, 47 Questions EPHS 5 service includes: An effective governmental presence at the local level. Development of policy to protect the health of the public and to guide the practice of public health. Systematic community-level planning for health improvement and public health emergency response in all jurisdictions. Alignment of local public health system (LPHS) resources and strategies with a community health improvement plan. 5.1 Government Presence at the Local Level SIGNIFICANT Community Health Improvement Process SIGNIFICANT Plan for Public Health Emergencies OPTIMAL 99 Discussion: Funding and Personnel There have been a lot of changes in the local health department which has reduced its capacity to deliver some of the Essential Public Health Services. Some of the changes include re-classification of the health department to the division of health, not having a full-time licensed health officer and cutting the funding for public health nursing by 2/3 making them incapable of meeting all their mandates. Funding cuts have also caused needed, but not mandated programs to either be curtailed or completely removed, such as the dental and flu shot program. Politics The LPHS makes an effort to influence public health policy - whether it s successful or not is another matter. Partners have alerted the policymakers of what is going on and possible ramifications of their actions. However, they have not notified the public as much. Participants felt that the political atmosphere is poisonous making people afraid to speak up and If you re afraid to say your challenges, then you can t identify it Hunterdon County Community Health Needs Assessment

84 Essential Service #6: Enforce Laws and Regulations that Protect Health and Ensure Safety Overall Score = 94 (OPTIMAL) Overall Ranking: 1 st of 10 3 Model Standards, 27 Questions EPHS 6 service includes: The review, evaluation and revision of laws, regulations and ordinances designed to protect health and safety to assure that they reflect current scientific knowledge and best practices for achieving compliance. Education of persons and entities obligated to obey or to enforce laws, regulations and ordinances designed to protect health and safety in order to encourage compliance. Enforcement activities in areas of public health concern, including, but not limited to the protection of drinking water; enforcement of clean air standards; emergency response; regulation of care provided in health care facilities and programs; re-inspection of workplaces following safety violations review of new drug, biologic and medical device applications; enforcement of laws governing the sale of alcohol and tobacco to minors; seat belt and child safety seat usage; and childhood immunizations. 6.1 Review and Evaluate Laws, Regulations and Ordinances OPTIMAL Involvement in the Improvement of Laws, Regulations and Ordinances OPTIMAL Enforce Laws, Regulations and Ordinances OPTIMAL 96 Discussion: * This essential service was ranked as the highest scoring section of the assessment. Laws and Regulations There are officials who either do not know the laws and regulations or are willingly choosing not to know them. Laws and regulations are followed because they are mandated. Although ability to continue to do so remains to be seen due to the reduction in the workforce. In addition, activities that are not required by law, but are necessary to protect the public s health get cut. There are programs that have been done in the past and were successful, but are no longer being done right now, or at least not at the same level (for example, twice a year inspection of restaurants and lead inspection). Due to the changes going on in the local health department and the uncertainty of what is going to happen in the future, participants believe that this assessment may not capture the whole picture Hunterdon County Community Health Needs Assessment

85 Essential Service #7: Link People to Needed Personal Health Services and Assure the Provision of Health Care when Otherwise Unavailable Overall Score = 89 (OPTIMAL) Overall Ranking: 3 rd of 10 2 Model Standards, 14 Questions EPHS 7 includes the following services: Identifying populations with barriers to personal health services. Identifying personal health service needs of populations with limited access to a coordinated system of clinical care. Assuring the linkage of people to appropriate personal health services through coordination of provider services and development of interventions that address barriers to care (e.g. culturally and linguistically appropriate staff and materials, transportation services). 7.1 Identification of Populations with Barriers to Personal Health Services OPTIMAL Assuring the Linkage to People to Personal Health Services OPTIMAL 78 Discussion: Population Needs Various assessments are conducted to identify health needs in the community. An example of which is the Latino Health Behavior Risk Factor Study which specifically targets Latinos, a group who experiences numerous barriers to care. However, gaps do exist. The system does not address certain populations, such as individuals coming out of correctional institutions. LPHS Network There are a lot of services available for populations who may experience barriers to health services. However, people either do not know how to navigate the system or that such a service/assistance exists. There are also systems in place to help link or refer people to services. However, it is not always used efficiently. It s a matter of getting to the right link. Once you get that right link, it cascades down. There is a need to pool resources and strengths and improve care coordination to achieve better health for all Hunterdon County Community Health Needs Assessment

86 Essential Service #8: Assure a Competent Public and Personal Health Care Workforce Overall Score = 47 (MODERATE) Overall Ranking: 10 th of 10 4 Model Standards, 44 Questions EPHS 8 includes the following services: Assessment of all of the workers within the local public health system (LPHS) (including agency, public and private workers, volunteers and other lay community health workers) to meet needs for public and personal health services. Maintaining public health workforce standards, including efficient processes for licensure/credentialing of professionals and incorporation of core public health competencies needed to provide the Essential Public Health Services into personnel systems. Adoption of continuous quality improvement and life-long learning programs for all members of the public health workforce, including opportunities for formal and informal public health leadership development. 8.1 Workforce Assessment, Planning and Development MODERATE Public Health Workforce Standards OPTIMAL Life-Long Learning Through Continuing Education, Training and Mentoring MODERATE Public Health Leadership Development MODERATE 34 Discussion: * This essential service was ranked as the lowest scoring section of the assessment. Workforce Assessment There are internal workforce assessments that have been conducted, but not at an organized and collaborative level. In those internal assessments, gaps have been identified especially in terms of the health department, but nothing is being done to address those issues. Gaps include not having a full-time licensed health officer and a qualified supervisor of public health nursing. However, other organizations like Hunterdon Medical Center do have a formal process to evaluate the effectiveness of plans to address workforce gaps. Workforce Development HMC provides its employees plenty of opportunities to participate in educational and training experiences. However, most other agencies do not. The local health department for example is allowed to only take continuing education credits that are required in order to maintain their license/position but, not to learn something new or to develop. There is a lack of having the mindset to invest in your workforce. Mindset of most is, if you really want to develop, then you have to go get it yourself Hunterdon County Community Health Needs Assessment

87 Essential Service #9: Evaluate Effectiveness, Accessibility and Quality of Personal and Population-Based Health Services Overall Score = 77 (OPTIMAL) Overall Ranking: 4 th of 10 3 Model Standards, 35 Questions EPHS 9 includes the following services: Evaluating the accessibility and quality of services delivered and the effectiveness of personal and population-based programs provided. Providing information necessary for allocating resources and reshaping programs. 9.1 Evaluation of Population-based Health Services OPTIMAL Evaluation of Personal Health Care Services OPTIMAL Evaluation of the Local Public Health System (LPHS) MODERATE 49 Discussion: Evaluation Evaluation is lacking because for the most part it is easier to just keep on doing what we are doing. HMC does have a satisfaction survey that is given to random patients. Results of the surveys are considered in the hospital s strategic and operational planning Hunterdon County Community Health Needs Assessment

88 Essential Service #10: Research for New Insights and Innovative Solutions to Health Problems Overall Score = 63 (SIGNIFICANT) Overall Ranking: 9 th of 10 3 Model Standards, 16 Questions EPHS 10 includes the following services: A continuum of innovative solutions to health problems ranging from practical field-based efforts to foster change in public health practice, to more academic efforts to encourage new directions in scientific research. Linkages with institutions of higher learning and research. Capacity to undertake timely epidemiological and health policy analyses and conduct health systems research Fostering Innovation SIGNIFICANT Linkage with Institutions of Higher Learning and/or Research OPTIMAL Capacity to Initiate or Participate in Research SIGNIFICANT 64 Discussion: Research A lot of agencies receive funding to conduct programs and these grants are usually linked with higher institutions. The Hunterdon County Behavioral Risk Factors Surveillance System (BRFSS) survey is a great source of county-level data on a variety of health outcomes and health indicators. Partnership for Health members refer to it to help identify and prioritize problem areas and issues that need to be tackled. However, even if data is available, there is not enough staff to really begin a research using that data. Collaboration The Partnership for Health allows for strong collaboration. However, collaborating on programming is different than collaborating on research. Many believe that the RWJF grant will improve this area as it will bring about transparency, allowing each agency to learn about what the other is doing and encourage sharing of information Hunterdon County Community Health Needs Assessment

89 PRIORITIZATION On July 16, 2012, approximately 30 members of the Hunterdon County Partnership for Health gathered to review the results of the Community Health Assessment data. The meeting was convened by Hunterdon Regional Community Health (HRCH), acting as an agent of the Partnership. It was facilitated by Lisa McCracken from Holleran Consulting. The goal of the meeting was to discuss and prioritize key research findings and to lay the groundwork for an updated Community Health Improvement Plan (CHIP). The meeting began with introductions and a check-in with attendees regarding their expectations for the day. The participants shared the following expectations for the day and the planning process: To leave the day with key health initiatives identified To understand how the Partnership for Health can make a difference To maximize collaboration and define it in a concrete way To ensure the integration with InsightVision, a strategy-management software, for collaboration and communication To focus on goals and objectives that are measurable and reflect known best practices To have participants leave with a clear understanding of their roles and responsibilities To ensure inclusion of the Hispanic community in discussions To have discussion around marrying previous action teams with newly defined focus areas To ensure that the group does not marginalize a particular demographic group (e.g. by age, gender, ethnicity, race, etc.) Following a discussion of expectations, a research overview was presented by John Beckley, of Beckley Consulting, and Joanna Chua, of HRCH. The research overview provided a synthesis of the key data findings from a variety of data sources including the Behavioral Risk Factor Surveillance System (BRFSS) study, County Health Rankings, among others. The overview included primary and secondary data [see Appendix D and E for data summary]. Additionally, key themes from the other MAPP assessments were shared. This included an overview of key forces of change in Hunterdon County, a profile of the local public health system and key community themes and strengths from focus group sessions. It should be noted that the majority of the research findings had been communicated to the attendees in advance as well. Subsequent to the research overview, participants were asked to share openly what they perceived to be the leading health needs and areas of opportunity in the county. The intent was to develop a master list of potential health priorities for inclusion in the update CHIP. The following list was developed by the attendees along with relevant notes related to each priority issue Hunterdon County Community Health Needs Assessment

90 Master List of Community Priorities (in no particular order): 1. Obesity/Overweight Relationship with chronic diseases such as heart disease, diabetes, hypertension, etc. Role of nutrition and exercise 2. Integration of physical and mental health This is a system as an individual issue Recognizing the comorbidity with mental illness and health outcomes 3. Substance Abuse Specific concerns with underage users/abusers Increase in abuse of prescription drugs Limited funding in law enforcement to address the problem Relationship between drug use and gang activity 4. Gang Activity Closely related to drug use; responding to local demand for drugs Increased in recent years 5. Disparities with Hispanic/Latino population Poorer health outcomes 6. Prenatal Care 7. Dental Care Cost as a barrier No dental providers for uninsured in the county 8. Aging-related Issues Needs of caregivers are significant as well Assisted living access Aging-in-place services and support End of life issues A number of cross-cutting issues were identified as well. These issues were perceived as having broad impact across the spectrum of health issues. They included: Barriers to access to care Transportation Funding shortages Cultural competency Future Partnership work was encouraged to consider each of these cross-cutting issues when identifying potential interventions and community improvement activities. Once the master list was compiled, participants were then asked to rate each need based on 2 criteria - (1) seriousness of the issue, which included size and consequence, and (2) ability to impact or make a difference. Respondents were asked to rate each issue on a 1 (not at all serious; no ability to impact) through 5 (very serious; great ability to impact) scale. The ratings were gathered instantly and anonymously through an Option Finder, a wireless audience 2013 Hunterdon County Community Health Needs Assessment

91 response system. Each attendee received a keypad to register their vote. The following table and figure reveal the results of the voting. TABLE 12: Master List of Top Health Issues with Corresponding Seriousness and Ability to Impact Scores Master List Seriousness Ability to Impact (average rating) (average rating) Obesity/Overweight Integration of Physical and Mental Health Substance Abuse Disparities with Hispanic/Latino Population Gang Activity Prenatal Care Dental Care Aging-related Issues FIGURE 56: Top Health Issues with Corresponding Seriousness and Ability to Impact Scores 5 Impact Seriousness Obesity/Overweight Integration of Phys. & Mental Health Substance Abuse Latino Health Disparity Gang Activity Prenatal Care Dental Care Aging-Related Issues The Quadrant Map outlines the intersection of the seriousness and ability to impact ratings. The issues that are in the upper right of the map are those that have the highest ratings across the 2 criteria Hunterdon County Community Health Needs Assessment

92 During the meeting, the attendees expressed an interest in selecting a limited set of key issues that would foster collaboration and upon which they could have an impact. It was also reiterated that individual agencies or groups may elect to focus on particular areas related to their respective areas of expertise. Attendees reviewed the findings from the voting and discussed approaches to reducing the master list. There were several issues that were eliminated from consideration given their associated ratings or the fact that other groups in the area already begun addressing that health issue/need. The attendees reached consensus and identified the following to be the priority health issues of Hunterdon County and to be adopted for inclusion in the CHIP: 1. Obesity/Overweight 2. Substance Abuse 3. Latino Health Disparities 4. Aging-related Issues ASSETS AND RESOURCES IDENTIFIED Afterwards, attendees broke out into small groups to focus on each of the four priority areas. The small groups identified and discussed current community assets and resources for each of their respective priority areas. Obesity/Overweight o School Nurses o School Wellness Councils o School Parent Teachers Organizations o Pediatricians o Parish Nurses and Faith-Based Organizations o Rutgers Cooperative Extension o YMCA o Local Supermarkets o Hunterdon Medical Center o Center for Nutrition and Diabetes Management o Center for Advanced Weight Loss o Parks and Recreation o Registered Dieticians in Private Practices o Health Quest/HMC Wellness Centers o Food Pantries o Farmers Markets and Community Gardens o Local Industries/Corporations o Employee Health Programs o County Health Division o Chamber of Commerce o Senior Groups o Local Media e.g. WDVR, the Democrat 2013 Hunterdon County Community Health Needs Assessment

93 Substance Abuse o Safe Communities Coalition o Hunterdon Medical Center o Hunterdon Interfaith Outreach Council o Law Enforcement and the Prosecutor s Office o Grant Writers for Drug-Free Communities funding opportunities o Volunteers o Youth Coalition o Business partners o Hunterdon Prevention Resources o Hunterdon Behavioral Health o Residential Treatment Facilities Latino Health Disparities o Latino Healthcare Access Committee o Hunterdon Medical Center o Public Health Nursing o Latino Affinity Groups (Merck and Chubb) o Fisherman s Mark Aging-related Issues o Senior Health Services county and state agencies o Center for Healthy Aging o YMCA o Hunterdon Regional Community Health and Briteside o United Way o Meals on Wheels o Nursing Homes, Assisted Living and other Long-term Care facilities o Faith-Based Organizations and Hunterdon Interfaith Outreach Council o Municipal Clubs and Municipal Liaisons o ARC o Hunterdon Developmental Center o Seasoned Years newsletter CONCLUSION This Community Health Needs Assessment report includes both qualitative and quantitative data, and provides an overview of the health status and health needs of the Hunterdon community. In addition, it captures the perceived strengths and weaknesses of the public health system of county. Quantitative data were gathered from multiple sources, both primary and secondary, such as the BRFSS, YRBS, US Census Bureau, NJHA County Health Profile and others. Qualitative data were collected from focus groups with members of the Latino and business communities, faith leaders, healthcare and social service providers, school nurses, and 2013 Hunterdon County Community Health Needs Assessment

94 county planning board, as well as from the Forces of Change brainstorming session with key community stakeholders. Common and overarching themes became apparent after the review and analysis of all data: Growing Hispanic population and the aging population The Hispanic population and the elderly face considerable challenges in accessing care and navigating the complex healthcare and social service system. Examples of challenges they face include lack of transportation, lack of insurance or inadequate coverage, language barriers and cultural differences. Conversely, the changing demographic and their unique needs also pose a number of challenges for the social service and healthcare delivery system. They must ensure that they are adequately and efficiently addressing the needs of the population and providing linguistically and culturally appropriate services. Limited Affordable Transportation Options Limited transportation was one of the most frequently cited problems during the focus groups. Although certain municipalities are denser than others, Hunterdon as a whole is a low-density county with services, stores and other facilities and infrastructures far from one another, making most residents dependent on cars to get around. This makes it very challenging for those who do not own one and have to rely on walking, bicycling or on the limited public transportation available. The main mode public transportation in the county is the LINK. However, most focus group participants say the LINK buses are unreliable and services are not enough to support the high demand. This makes it very difficult for residents, particularly the seniors, the disabled and lower income, to schedule appointments, go to work, access other services and carry out their daily activities. Economic Downturn and Widening Socioeconomic Gap While Hunterdon County has been ranked as one of the richest counties in the US and have a lower unemployment rate compared to the rest of the state, there are many residents who are struggling to make ends meet or are living below the poverty line. They do not make enough money to meet basic needs such as food, shelter, clothing and healthcare. Focus group participants said that there are a lot of hidden poor in the county who have never needed any help or handout before, but have hit tough times and are now in need. However, they do not know where to go and ask for help or they are too embarrassed to do so, making it very challenging to get them the support and assistance they need. Shifting Government Priorities and Funding Cuts Due to the economic crisis, deep funding cuts were observed across the board. Many needed public health and social services, programs and supports were curtailed or completely lost. However, on a more positive note, budget cuts provide opportunities for agencies and organizations servicing Hunterdon to work together and collaborate to maximize their impact Hunterdon County Community Health Needs Assessment

95 Lack of Awareness and Coordination of Services There are plenty of services, programs and resources offered in Hunterdon. However, they are mostly being underutilized. Anecdotal reasons shared to explain underutilization were lack of awareness that such a service exists, transportation issues, and lack of coordination among service providers. Focus needs to be on collaboration and coordination among service providers, agencies and organizations in order to better meet the needs of the community and improve their overall health. Other Key Findings o Hunterdon is ranked the healthiest county in NJ o Majority of Hunterdon adults have some form of health insurance coverage o Significantly more Hispanics reported having problems accessing healthcare due to cost, lack of insurance, language barriers and cultural differences compared to the general Hunterdon population o Although lower than state and national average, prevalence of obesity among adults in Hunterdon is increasing o Leading causes of death were cancer, diseases of the heart and cerebrovascular diseases including stroke o Alcohol consumption among adults in Hunterdon are higher than state average o Alcohol and marijuana are the most frequently used substance among Hunterdon high school students Review and analysis of all data helped the members of the Partnership for Health to identify Obesity, Substance Abuse, Latino Health Disparities and Aging-related Issues as the priority health issues in the community. Action teams, comprised of individuals with the expertise, passion and knowledge of the 4 identified priority health issues, have been formed. Action team members are tasked to define attainable goals and objectives and develop clear strategies to address their respective health issues - All of which will be captured and documented in the 2013 CHIP. In addition, action team members will also discuss and identify broad measures to track and measure both short-term and long-term progress and success in addressing each of the identified issues Hunterdon County Community Health Needs Assessment

96 REFERENCES 1. US Census Bureau. (2010). Hunterdon County, New Jersey, DP Demographic profile [Data file] Census. Retrieved from: 2. Hunterdon County Planning Board. (2011). Population Density by County and Municipality: New Jersey, 2000 and Retrieved from: 3. Hunterdon Healthcare System. (n.d.). About Us. Retrieved on March 5, 2013 from: 4. Hunterdon County Planning Board. (2002). Hunterdon County 2010 and 2020 Projections. Retrieved from: 5. Health Research and Educational Trust (HRET) of New Jersey. (2012). County Health Profiles: Hunterdon County Princeton, NJ: HRET/New Jersey Hospital Association. 6. Cohn, D., & Taylor, P. (2010, December 20). Baby Boomers Approach 65 Glumly. Pew Research Social & Demographic Trends. Retrieved from: 7. NJ Department of Labor and Workforce Development. (2012). Projections of Population by Age and Sex: New Jersey, 2010 to 2030 [Data file]. Retrieved from: 8. US Census Bureau. (2012, December 12). US Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now. Retrieved from: 9. Turner, M.A., & Rawlings, L. (2009). Promoting Neighborhood Diversity: Benefits, Barriers, and Strategies. Report for the Urban Institute. Retrieved from: NJ Department of Education. (2012) Adjusted Cohort 4 Year Graduation Rates [Data file]. Retrieved from: Egerter, S., Braveman, P., Sadegh-Nobari, T., Grossman-Kahn, R., & Dekker, M. (2009, September). Education Matters for Health (Issue Brief 6: Education and Health). Retrieved from: 2cd65956f00e/Issue%20Brief%206%20Sept%2009%20-%20Education%20and%20Health.pdf 12. Morello, C., & Mellnik, T. (2012, September 19). Seven of nation s 10 most affluent counties are in Washington region. The Washington Post. Retrieved from: 2013 Hunterdon County Community Health Needs Assessment

97 13. US Census Bureau. ( ). Hunterdon County and Municipalities, New Jersey, DP03 Selected economic characteristics [Data file] American Community Survey 5-Year Estimates. Retrieved from Pearce, D.M. (2008). The real cost of living in 2008: The self-sufficiency standard for New Jersey. Prepared for the Legal Services of New Jersey Poverty Research Institute. Retrieved from: US Department of Health & Human Services. (n.d). Frequently asked questions related to the poverty guidelines and poverty. Retrieved from: US Census Bureau. (2003). New Jersey: 2000 Summary social, economic, and housing characteristics Census of population and housing. Retrieved from: Young, E., & Bass, F. (2011, December 15). NJ s richest county leads rise in food stamp recipients. Bloomberg. Retrieved from: US Conference of Mayors. (2011). Hunger and homelessness survey. Retrieved from: US Census Bureau. ( ). Hunterdon County, New Jersey, DP02 Selected social characteristics [Data file] American Community Survey 5-Year Estimates. Retrieved from University of Wisconsin Population Health Institute. (2012). County Health Rankings 2012, Hunterdon County, New Jersey. Retrieved from NJ Department of Law & Public Safety Division of State Police. (2010). Gangs in NJ: Municipal Law Enforcement Response to the 2010 NJ State Police Gang Survey. Retrieved from: Hunterdon County Partnership for Health. (2010). Hunterdon County Behavioral Risk Factor Surveillance System. Accessible at: Godin, S. (2011). United Way of Hunterdon County Latino Health Behavior Risk Factor Survey. Accessible at: Hunterdon County Community Health Needs Assessment

98 24. Yeo, S. (2004). Language barriers and access to care. Annual Review of Nursing Research, 22(1), Retrieved from: Flores, G., & Tomany-Korman, S.C. (2008). The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics, 121(6), doi: /peds Holahan, J., & Spillman, B. (2002, January). Health care access for uninsured adults: A strong safety net is not the same as insurance (Series B-42). Retrieved from: Gill, J.M., & Mainous, A.G. (1998). The role of provider continuity in preventing hospitalizations. Archives of Family Medicine, 7(4), PMID: US Department of Health and Human Services. (2000). Oral Health in America: A Report of the Surgeon General-- Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. Retrieved from: NRNODEGUID=%7b7A6ABF55-F4F9-4FF9-9FC4-3BF6A423CD4F%7d&NRORIGINALURL=%2fdatastatistics%2fsurgeongeneral%2freport%2fexecu tivesummary%2ehtm&nrcachehint=guest#foreword 29. NJ Council of Teaching Hospitals. (2008). New Jersey Physician Workforce Task Force Report. Retrieved from: d690dbcbb99f/final-nj-physician-workforce-report aspx 30. Trust for America s Health & Robert Wood Johnson Foundation. (2012). F as in Fat: How Obesity Threatens America s Future Accessible at: Hunterdon Healthcare Partners. (2012). Electronic Health Records [Data file]. 32. Hunterdon County Partnership for Health. (2012). Hunterdon County Youth Risk Behavior Survey. Accessible at: Centers for Disease Control and Prevention. (2012, November 7). Alcohol and Public Health Frequently Asked Questions. Retrieved May 7, 2013 from: Casswell, S., Pledger, M., & Hooper, R. (2003). Socioeconomic status and drinking patterns in young adults. Addiction, 98(5), PMID: Hunterdon County Community Health Needs Assessment

99 35. Newport, F. (2010, July 30). US drinking rate edges up slightly to 25-year high. Gallup Wellbeing. Retrieved from: Year-High.aspx 36. Bloustein Center for Survey Research, The Edward J. Bloustein School of Planning and Public Policy, & Rutgers, the State University of NJ. (2009). The 2009 NJ Household Survey on Drug Use and Health. Retrieved from: Centers for Disease Control and Prevention. (2012, November 9). Current Cigarette Smoking Among Adults United States, MMWR, 61(44), Retrieved from: Wells, N.M., & Evans, G.W. (2003). Nearby nature: A buffer of life stress among rural children. Environment and Behavior, 35, doi: / Cornell University College of Human Ecology. (n.d.) How natural and built environments impact human health. Retrieved from: Hunterdon County Community Health Needs Assessment

100 APPENDIX A: List of Partnership for Health Members Cancer Coalition of Hunterdon and Mercer Central Jersey Family Health Consortium Delaware Valley Family Health Center Flemington Jewish Community Center Francis Desmares Elementary School HART Commuter Information Services Hunterdon Care Center Hunterdon County Chamber of Commerce Hunterdon County Resident Hunterdon County Division of Health Hunterdon County Division of Senior, Disabilities and Veterans Services Hunterdon County Office of the Prosecutor Hunterdon County Public Health Nursing and Education Hunterdon County Superintendent of Schools Hunterdon County YMCA Hunterdon Drug Awareness Program Hunterdon Helpline Hunterdon HealthCare Partners Hunterdon Medical Center o Center for Healthy Aging o Center for Nutrition and Diabetes Management o Hunterdon Behavioral Health Hunterdon Pediatric Associates Hunterdon Regional Cancer Center Hunterdon Regional Community Health Hunterdon and Mercer County Regional Chronic Disease Coalition Hunterdon Prevention Resources Latino Healthcare Access Committee Phillips Barber Family Health Center Readington Township Board of Health Rutgers Cooperative Extension Services Safe Communities Coalition of Hunterdon and Somerset County United Way of Hunterdon County 2013 Hunterdon County Community Health Needs Assessment

101 APPENDIX B: County Health Rankings Model 2013 Hunterdon County Community Health Needs Assessment

102 APPENDIX C: Focus Group Code Book Factors that Contribute to Quality of Life: Access to fresh fruits and vegetables Access to healthcare and social services Civic support and engagement Employment opportunities Excellent school system Faith community Housing and community development Inter-agency collaboration Location of the county Programs and services for Latinos Recreation activities Rural character Safe community Socioeconomic status Transportation Factors that Reduce Quality of Life: Commercialization Elitism Gap in healthcare services High cost of living Inability to get resources or funding Lack of awareness of services Lack of privacy and control over personal property Limited affordable housing options Limited services and programs for Latinos Low income Mental health Obesity Overcrowded school Pollution Rural Substance Abuse Traffic Transportation Unemployment Recommendations to Improve Quality of Life: Advocacy Decrease cost of leaving Enhance government support Enhance services for Latinos Family values Health and life skills education Improve awareness of available services Improve planning Improve public infrastructure Improve management of healthcare services Improve safety Improve transportation Increase housing options Promote physical activity and healthy eating Support local economy 2013 Hunterdon County Community Health Needs Assessment

103 APPENDIX D: Data Summary by Health Issues Hunterdon County Data Review Health Indicators Organized by Health Issues Data Source Health Indicators Data is comparatively worse than NJ and/or US Alcohol Consumption 1 Adult Binge Drinking x, 2 Adult Heavy Drinking x, 2 Adult DUI arrests x 6 HS seniors alcohol consumption x 6 HS seniors drunk in the past 30 days x 2 Drinking during pregnancy x, 2 Alcohol treatment admissions x, 8 Adult substance (mostly alcohol) abuse/dependence x Drug Abuse 2 Marijuana treatment admissions x, 8 Adult illicit drug use in the past 30 days x, 8 Adult substance (mostly alcohol) abuse/dependence x Data not comparatively bad, but trending direction is cause for concern and/or presents challenges Sub population/group Disparity 5 Middle school students annual use of prescription drugs w/o prescription x, 5 Middle school students annual illicit drug use x 7 HS students annual marijuana use x 7 HS students use of prescription drug w/o prescription x Tobacco Use 7 HS students cigarette smoking in the past 30 days x Overweight/Obesity - Physical Activity & Nutrition 1 & 3 Adult Obesity Prevalence x x 1 & 3 Adult Overweight Prevalence x x 4 Access to healthy food x Diabetes 1 Ever been told they have pre-diabetes or borderline diabetes x 1 Ever been told they have diabetes x 2 ED visits due to diabetes x Access to Health Care 1 & 3 Uninsured x 1 & 3 Could not get healthcare due to cost x 3 Latinos who could not get healthcare due to language barrier x 1 & 3 Have a particular doctor they see when they need healthcare x 1 & 3 Never seen a doctor for routine checkup x 2013 Hunterdon County Community Health Needs Assessment

104 APPENDIX D: Data Summary by Health Issues Data Source Health Indicators Data is comparatively worse than NJ and/or US Data not comparatively bad, but trending direction is cause for concern and/or presents challenges Sub population/group Disparity 1 & 3 Women 40 years ever had a mammogram x 1 & 3 50 ever had a colonoscopy/sigmoidoscopy x 1 & 3 Never seen a dentist x 1 & 3 Never seen a dentist due to cost x Mental Health 2 Children ED visits for depression and other mood disorders x, 2 Children ED visits for Attention deficit and disruptive behavior x, 2 Adult ED visits for Mental/Behavioral Health Conditions x 1 Depression/Anxiety/Emotional Problems limited activities x Maternal and Child Health 2 Low birth weight babies x 2 Drinking during pregnancy x, 9 % of eligible children receiving free/reduced price school meal x Cancer 2 Incidence of Melanoma x 1 & 3 Never use sunscreen when outside on a sunny day for more than 1 hour x 1 Adults who have had a sunburn in the past 12 months x 2 Breast cancer incidence x, Cardiovascular Disease 1 Ever been told they have high blood pressure x 1 Ever been told they have high blood cholesterol x Asthma 1 Adults ever been told they had asthma (Lifetime asthma) x 4 # of days when ozone levels were unhealthy x Social and Economic 9 % of Households spending more than 30% of income on rent x, 2 # of Individuals using government assistance programs x 10 Presence of gang activity x Infectious Disease 2 Incidence of tick-borne diseases x Note: - Also trending in the nega ve direc on Data Sources: 1. Hunterdon County Behavioral Risk Factor Surveillance Survey, American Drug and Alcohol Survey, County Health Profiles, Hunterdon County, NJ High School Risk & Protective Factor Survey, Latino Health Behavior Risk Factor Survey, NJ Household Survey on Drug Use & Health, 2003 & County Health Rankings, NJ Kids Count County Rankings, NJ Middle School Risk and Protective Factor Survey, NJ State Police Gang Survey, Hunterdon County Community Health Needs Assessment

105 APPENDIX E: Data Summary by Health Factors/Health Outcomes Hunterdon County Data Review Areas of Concern Organized by Health Factors/Outcomes Health Factors/Outcomes Health Behaviors Health Care Delivery/ Utilization Social and Economic Factors Health Status Physical Environment Data Differential (Data comparatively worse than NJ/US) Adult binge drinking 1 Adult heavy drinking 2 Drinking during Pregnancy 2 Adult DUI arrests 2 Adult illicit drug use past 30 days 8 Adult substance(primarily alcohol) abuse/dependence 8 Middle school prescription drug use w/o prescription 5 HS Senior alcohol consumption 6 HS Senior drunk last 30 days 6 HS annual marijuana use 7 HS prescription drug use w/o prescription 7 HS cigarette smoking past 30 days 7 Alcohol treatment admissions 2 Marijuana treatment admissions 2 Children ED visits for depression and other mood disorders 2 Children ED visits for attention deficit and disruptive behavior 2 % of Houshold spending >30% of income on rent 9 % of eligible children receiving free/reduced price school meal 9 Prediabetes prevalence 1 Melanoma incidence 2 Breast cancer incidence 2 Adults ever had asthma 1 Incidence of tick-borne disease 2 # Ozone alert days/yr 4 Access to healthy foods 4 Trending Challenge (Data trending in the negative direction) Group Disparity Had sunburn in the past 12 months 1 Latinos never use sunscreen 3 ED visits due to diabetes 2 Adult ED visits for mental/behavioral health conditions 2 Depression/anxiety/emotional problems limited activities in the past 30 days 1 Latinos uninsured rate 3 Latinos never seen MD for routine checkup 3 Latinas never had a mammogram 3 Latinos ever had colonoscopy/sigmoidoscopy 3 Latinos who do not go to a particular doctor 3 Presence of gang activity 10 Latinos could not see MD due to cost 3 Use of government assistance programs 2 Latinos could not get healthcare due to language barrier 3 Low birth weight babies 2 Adult obesity 1 Adult overweight 1 Diabetes prevalence 1 High blood cholesterol 1 High blood pressure 1 Latinos never seen a dentist 3 Latinos did not see dentist in the past year due to cost 3 Overweight & obese Latinos 3 Transportation Cross-Cutting Issues Increasing healthcare costs Availability/accessability/awareness of services (particularly for Latinos) Financial instability/2008 Recession Changing governmental policies/priorities regarding program/service funding levels Changing demographics: Aging population & growing Latino population Sources: 1 Hunterdon County Behavioral Risk Factor Surveillance Survey, Hunterdon County Health Profiles, Hunterdon County Latino Health Behavior Risk Factor Survey 4 County Health Rankings, NJ Middle School Risk & Protective Factors Survey, American Drug & Alcohol Survey, NJ High School Risk & Protective Factors Survey, NJ Household survey on Drug Use & Health, 2003 & NJ Kids Count, NJ State Police Gang Survey, Hunterdon County Community Health Needs Assessment

106 2013 Hunterdon County Community Health Needs Assessment

107