Audrain County Health Department Audrain County Health Department 1130 S. Elmwood Drive Mexico, MO 65265 2015 Community Health Needs Assessment Table of Contents EXECUTIVE SUMMARY…… ...................................................................................................................................... ………………… 3 INTRODUCTION AND OBJECTIVES ................................................................................................................................................ 4 ABOUT AUDRAIN COUNTY HEALTH DEPARTMENT (ACHD) ......................................................................................................... 5 AUTHOR AND CONTRIBUTING MEMBERS .................................................................................................................................... 6 ACKNOWLEDGEMENTS ................................................................................................................................................................ 7 METHODOLOGY ........................................................................................................................................................................... 8 DESIGN OVERVIEW OF THE CHNA……………………………………………………………………………………………………………………………………..……9 DEMOGRAPHICS ......................................................................................................................................................................... 10 DEMOGRAPHIC & ACHD CHNA SURVEY FINDINGS .................................................................................................................... 13 ACHD SURVEY RESULTS .............................................................................................................................................................. 15 SURVEY RESPONDENT INFORMATION ....................................................................................................................................... 17 SECONDARY DATA ANALYSIS - CHSI OVERVIEW; CDC ................................................................................................................ 18 I. PHYSICAL ENVIRONMENT ................................................................................................................................................... 19 II. SOCIAL FACTORS….. ............................................................................................................................................................ 20 III. HEALTH CARE ACCESS & QUALITY ...................................................................................................................................... 24 IV. HEALTH BEHAVIORS ............................................................................................................................................................ 26 V. MORBIDITY ......................................................................................................................................................................... 29 VI. MORTALITY ......................................................................................................................................................................... 34 SECONDARY DATA ANALYSIS –OVERVIEW; UW/PHI & ROBERT WOODS JOHNSON FDN...………………………………..………………..38 I. STATE & CONTIGUOUS MULTI-COUNTY COMPARATIVE ANALYSIS ................................................................................ 40 SECONDARY DATA ANALYSIS –MISSOURI INFORMATION FOR COMMUNITY ASSESSMENT (MICA) …………..…………….……….42 SECONDARY DATA ANALYSIS –MISSOURI DEPARTMENT OF MENTAL HEALTH……………………………..………………..……………….….46 MEXICO POVERTY: CHILD ELIGIBILITY; FREE MEALS………………………………………………………………………………………………………………47 COMBINED SECONDARY ANALYSES – FINDINGS……………………………………….…………………………………………………………………………..48 FORCES OF CHANGE………………………………………………………………………………………………………………………………………………………………49 REFERENCES………………………………………………………………………………………………………………………………………………………………………….51 APPENDICES………………………………………………………………………………………………………………………………………………………………….…55-71 APPENDIX A: SURVEY RESPONDENT LETTER .............................................................................................................................. 55 APPENDIX B: ACHD CHNA SURVEY ............................................................................................................................................. 56 APPENDIX C: AUDRAIN COUNTY U.S. CENSUS TRACT ............................................................................................................... 60 APPENDIX D: CDC – CHSI AT-A-GLANCE SUMMARY; AUDRAIN COUNTY ................................................................................... 61 APPENDIX E: AMERICAN COMMUNITY SURVEY (ACS); 2009- 2013 ......................................................................................... 62 EXECUTIVE SUMMARY 2015 Community Health Needs Assessment Sandra M. Hewlett, MS, APRN, AOCN, FACHE Administrator, Audrain County Health Department To the Residents of Audrain County, In 2014, the Audrain County Board of Health commissioned the Audrain County Health Department (ACHD) to conduct a Community Health Needs Assessment (CHNA) for Audrain County. The assessment was designed to identify the most important health issues in the county using scientifically valid health indicators and comparative information. The assessment also identifies priority health issues where better integration of public health and healthcare can improve access, quality, and cost-effectiveness of services to residents of Audrain County. This project represents ACHD’s efforts to share information that may lead to improved health status and quality of care available to Audrain County residents while building upon and strengthening existing infrastructure of services and providers. We are confident that local organizations and providers will find the results of our CHNA to be helpful in planning how to improve the health of our community. The CHNA will serve as a guide in expanding and developing services to respond to the emerging health needs of our community, in partnership with other local providers and agencies. With the challenges facing today’s healthcare landscape, it is becoming increasingly important to intervene and educate the public to: Prevent. Promote. Protect. The primary goals of ACHD & public health. Warm Regards, Sandra M. Hewlett, MS, APRN, AOCN, FACHE Administrator, Audrain County Health Department Introduction Accountability & Transparency The Audrain County Health Department promotes practices, policies, procedures, and strategic document development that helps bring positive changes towards healthcare transparency and accountability - important aspects of patient-centered care1. Figure 1 We strongly support public reporting because it aids transparency, promotes more informed patient choice, helps improve quality, lowers the cost of care, and increases provider accountability1. Public reporting also provides a strong motivation for county public health departments, providers, healthcare institutions, first responder organizations, and local agencies to collaboratively work together to improve services within a community2. To that end, a copy of the ACHD 2015 Community Health Needs Assessment is available for the community at: www.audraincountyhealth.org . A community health needs assessment is one tool for stakeholders to evaluate the health needs of our community and advocate for and create better health care delivery, coverage and outcomes for all members in our community. The community health needs assessment process includes significant input from numerous individuals and data repository sources. This range of “voices” ensures that health in our community is viewed broadly and all encompassing. Beyond traditional health indicators, the assessment looks at a myriad of other issues that can affect health, such as transportation, poverty, education and the economy. Objectives The objectives for the 2015 Audrain County Health Department’s Community Health Needs Assessment are as follows: I. II. Develop a comprehensive baseline epidemiological profile of the population of Audrain County, including specific sub-county regional (i.e., cities, towns) issues3; Identify health factors, health outcomes, disparities, and service needs of Audrain County based on the community health profiles and related information; III. Identify to the extent the data permits how health disparities and service needs differ among sub-groups of the population (age and gender groups, racial, and ethnic minorities); IV. Identify barriers in the health system and the community that, if addressed, would improve population health, especially those identified as priority health issues; V. Begin to formulate recommendations on how to improve county priority service needs. VI. Integrate those recommendations in the follow-up ACHD strategic document entitled, “Audrain County Health Department: 2015 Community Health Improvement Plan”. The ACHD… Audrain County Health Department (hereinafter referred to as ACHD) is a not-for-profit (501c-3) public health department based in Mexico, Missouri. The ACHD proudly and diligently serves the residents of Audrain County and remains committed to addressing their public health needs. As a government-based public health department, the ACHD exists under RSMO §205.010-115, County Health and Welfare Programs, providing numerous, multi-faceted public health programs for the Audrain County community. ACHD Mission Statement: To protect and promote the public health and community well-being of the residents of Audrain County. ACHD Vision Statement: That each individual, every family, and the community as a whole, attains the highest degree of health achievable. ACHD Values Statement: The ACHD is committed to C.L.E.A.R. values: Communication, Leadership, Excellence, Accountability, and Respect. Public Health in Audrain County has a long and important history. In April 1961, the citizens of Audrain County formed the Audrain City-County Health Unit (ACCHU). ACCHU existed as a result of a cooperative agreement consisting of support provided by the Audrain County Commission, Audrain Medical Center, the City of Mexico, and the City of Vandalia under § 70.210 to of the Revised Statutes of the State of Missouri (RSMO). The Compact Agreement allowed for the establishment of the City-County Health Unit of Audrain County (dba) the Audrain City-County Health Unit. ACCHU began operations in April 1961 with a public health nurse, environmental sanitarian, and a part-time clerk typist. A local book, “The Friend of Audrain – A History of Medicine in Audrain County” (Hodge, 1985), has interesting information about mid-1800’s public health in Audrain County5. In November 2011, Audrain County voted and passed a ballot measure establishing a new form of governance for Public Health. This measure allowed for the formation of the Audrain County Health Center (dba) the ACHD under §§ 205.010 to 205.115 of the Revised Statute, State of Missouri (RSMO). The ACHD officially began operations January 1, 2013 and exists under an elected Board of Health. ACHD constantly assesses the health status, outcomes, resources, and unmet health needs of county residents. In addition to basic public health services and environmental public health programs related to food safety and sanitation, lodging, daycare inspections, and on-site sewage system permitting, numerous ACHD services are offered under the following programs: Maternal Child Health Immunizations Environmental Public Health Emergency Preparedness Communicable Disease Blood Pressure & STD Testing Foot Clinic Breastfeeding Support Women, Infants, & Children (WIC) Car Seat Program Safe Crib Program Chronic Disease Education & Support Thank you for reading the history of our health department. For more information or a copy of this report, we welcome you to visit us at www.audraincountyhealth.org. Author & Contributing Members The 2015 Community Health Needs Assessment was researched and written by: Sandra M. Hewlett, MS, APRN, AOCN, FACHE Administrator, Audrain County Health Department Contributing CHNA efforts included the following individuals: Katie Swaim, RN, BSN, CPN ACHD Communicable Disease Program Leader Becky Wieberg, RN ACHD Clinic & WIC Services Coordinator Brandi Meyers, LPN ACHD Immunization Program Leader Kerry Patton, LPN ACHD Maternal Child Health Program Leader Linda Spurling ACHD Accounting & Human Resources Manager Carol Stuart ACHD Clinical & Marketing Support Staff Member Kay Knipp ACHD WIC Support Staff Emily Stotler ACHD Webmaster & Social Media Sarah Palmer ACHD EPHS Support Staff Dorothy Schafer ACHD Reception Support Staff Becca Mickels MO-DHSS MICA Data Specialist, CHIR Requested by: Audrain County Board of Health: Faye Fairchild, RN, MSN, CNE AC BoH Chairperson Andrea Willer, FNP-BC AC BoH Secretary Sharon Stowers, RN (Retired) AC BoH Treasurer Clark Andelin, M.D. AC BoH Member Kathleen Weaver, M.D. AC BoH Member Copyright © 2015 by Sandra M. Hewlett, Administrator, Audrain County Health Department. All rights reserved. Reproduction or translation of any part of this work beyond that permitted by § 107 &/or § 108 of the 1976 U.S. Copyright Act without the permission of the copyright owner is unlawful. Requests for permission or further information should be addressed to the Audrain County Department of Health. Acknowledgements We wish to recognize other agencies and resources that were used in completing the CHNA, including: Central Missouri Community Action Needs Assessment: 2014 Central Missouri Community Action Community Health Status Indicators (CHSI), Centers for Disease Control & Prevention (CDC) U.S. Department of Health & Senior Services Community Toolbox – Needs Assessment, Work Group for Community Health & Development University of Kansas Data MICA; Missouri Information for Community Assessment, Community Health Improvement Resources (CHIR) Missouri Department of Health & Senior Services (MO DHSS) Community Profiles; MO DHSS Community Health Improvement Resources (CHIR) Missouri Department of Health & Senior Services (MO DHSS) Data; Kids Count! Annie E. Casey Foundation University of Wisconsin, Institute of Public Health Robert Wood Johnson Foundation Priorities MICA; MO DHSS Community Health Improvement Resources (CHIR) Missouri Department of Health & Senior Services (MO DHSS) 2010 Dicennial Census; U.S. Census Bureau 2015 Estimated Census; U.S. Census Bureau U.S. Department of Commerce Methodology The ACHD acknowledges the influence of social, cultural and environmental factors on health and recognizes that such influences may have particularly deleterious effects when they occur during critical periods over one’s life. In 2014, the Audrain County Board of Health commissioned a comprehensive community health needs assessment. This report summarizes the health status of our community and identifies priorities to address in partnership with others. Audrain County Community Health Needs Assessment Survey (ACCHNAS) The purpose of the ACCHNAS is to assess the health status of residents. Primary goals were to (a) gather specific data on behavioral and lifestyle habits of the adult population; (b) gather data on the prevalence of risk factors and disease conditions existing within the adult population; (c) compare, where appropriate, health data of residents to previous health studies; and (d) compare, where appropriate and available, health data of residents to state and national measurements. The ACHD randomly selected approximately 1,208 individuals from various areas within Audrain County to receive a 2015 CHNA Survey. The response rate from the survey was 264, or 21.9%. The surveys were completed in paper format and could be returned in the mail to the ACHD, or could be dropped off at four different and widely recognized Audrain County locations, including (see Appendix A): 1. 2. 3. 4. Drop-Off Site C & R Market ACHD Martinsburg Bank & Trust Vandalia City Hall Location Centralia, Missouri Mexico, Missouri Martinsburg, Missouri Vandalia, Missouri Secondary Data Analysis This assessment used several nationally recognized and validated health databases to provide a holistic picture of health in Audrain County (see Acknowledgements on preceding page) as well as high-quality data and trends analyses. The Secondary Data Analysis is an objective, rigorous adjunct to the primary data collection conducted in the Audrain County Community Health Needs Assessment Survey. The report summarizes the distribution of health indicators and outcomes among socioeconomic groups within Audrain County. These state and national data repositories provide free data on more than 1,000 health indicators at the state, national and county level. Data compiled from a variety of public, private, and government sources allows users to map, rank, trend, or download information. Finally, in addition to conducting a census decennially, the U.S. Census Bureau collects and disseminates data across a variety of topics. Sources for this information include the Population and Housing Census, National Health Interview Survey, Economic Census, The American Community Survey, 2010 Current Population Survey, and the 2015 Population Estimates. Design Overview of the CHNA Two theoretical frames for public health planning guided the CHNA activities: Mobilizing for Action through Planning and Partnership (MAPP) PRECEDE- PROCEED Model. MAPP was developed through a cooperative agreement between the National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). The MAPP framework is a community-wide strategic planning tool for improving community health and helping communities prioritize public health issues and identify resources to address them. MAPP is not an agency-focused assessment tool; rather, it is an interactive process that can improve the efficiency, effectiveness, and ultimately, the performance of local public health systems. Four assessments form the foundation of the MAPP process: 1. Community Themes and Strengths 2. Local Public Health System 3. Community Health Status 4. Forces of Change Figure 2. Figure 3. Process is illustrated in Figure 2. Collectively, the four MAPP Assessments have several purposes (MAPP, 2011): • Reveals gaps between current circumstances and a community's vision; • Provides information to identify the strategic issues to address to achieve the vision; and • Serves as source of information from which strategic issues, strategies, and goals are built. The PRECEDE-PROCEED Model is a comprehensive framework for planning population-based health programs. It was developed by Lawrence Green and Marshall Kreuter in 1980, adapted in 1999 & 2004. The PRECEDE-PROCEED frame uses an ecological and educational approach that respects context. The assessment team followed the MAPP steps and elements of the PRECEDE-PROCEED model that focus on Social Assessment, Situational Analysis and Epidemiological- Behavioral-Environmental assessments as illustrated in Figure 3. Demographics Population data for Audrain County is based on the 2010 Decennial Census and 2014 Population Estimates4 (U.S. Census Bureau, 2015a). Note that an asterisk (*) indicates a disparity or variance. Population Audrain County Missouri United States Population Estimates, July 1, 2014 25,887 6,063,589 318,857,056 Population, Census, April 1, 2010 25,529 5,988,927 308,745,538 Age & Sex Persons under 5 years, Census 6.8% 6.5% 6.5% Persons under 18 years, Census 24.9% 23.8% 24.0% Persons 65 and over, Census *16.0% 14.0% 13.0% Female persons, %, Census 53.8% 51.0% 50.8% Male persons, %, Census 46.2% 49.0% 49.2% *89.8% 82.8% 72.4% Black or African American, %, Census 6.4% 11.6% 12.6% American Indian and Alaska Native, %, Census 0.4% 0.5% 0.9% Asian alone, %, Census 0.5% 1.6% 4.8% 0% 0.1% 0.2% Two or More Races, %, Census 1.7% 2.1% 2.9% Hispanic or Latino, %, Census 2.6% 3.5% 16.3% Population Characteristics Veterans, 2009 – 2013 1,954 479,828 21,263,779 Foreign born persons, %, 2009 – 2013 1.5% 3.9% 12.9% Housing Housing Units, Census 10,852 2,712,729 131,704,730 Owner-Occupied Rate, 2009 – 2013 74.2% 68.4% 64.9% $90,500 $137,000 $176,700 Median Monthly Owner Costs; with Mortgage $992 $1,227 $1,540 Median Monthly Owner Costs; without Mortgage $346 $388 $452 Median Gross Rent, 2009 – 2013 $619 $727 $904 9,327 2,360,131 115,610,216 2.54 2.47 2.63 Living in Same House 1 Year Ago, %, 2009 – 2013 83.5% 83.8% 84.9% Language Other than English Spoken in Home *4.9% 6.1% 20.7% Education High School Graduate or Higher 84.3% 87.6% 86.0% *13.1% 26.2% 28.8% Race and Hispanic Origin White alone, %, Census Native Hawaiian & Pacific Islander, %, Census Median Value, Owner-Occupied Housing, 20092013 Families & Living Arrangements Households, 2009 – 2013 # of Persons per Household, 2009 – 2013 Bachelor’s Degree or Higher Demographics continued… Health & Economy With a Disability, <65 years, %, 2009 – 2013 Audrain County *11.8% Missouri 10.1% United States 8.4% Persons Without Health Insurance, <65 Years, % *16.8% 15.2% 15.3% Percent of Population 16 Years+ in Labor Force *57.9% 63.9% 63.8% Income & Poverty Median Household Income, 2009 - 2013 $43,013 $47,380 $53,046 Per Capita Income in Past 12 Months, 2009 – 2013 $19,687 $25,649 $28,155 Persons in Poverty, % *19.7% 15.9% 14.5% Mean Travel Time to Work, Minutes, Age 16+ 21.1 23.1 25.5 Total Employer Establishments, 2013 553 150,290 7,488,353 6,778 2,355,336 118,266,253 Total Employment % Change, 2012 – 2013 *-0.1% 1.5% 2.0% Total Non-Employer Establishments, 2012 1,393 394,685 22,735,915 Geography Population Per Square Mile, 2010 *36.9 87.1 87.4 Land Area in Square Miles, 2010 692.24 68,741.52 3,351,905.43 Businesses & Transportation Total Employment, 2013 Audrain County is bordered by: Monroe County (North) and Ralls County (Northeast) Boone County (Southwest) and Callaway County (South) Montgomery County (Southeast) and Pike County (East) Randolph County (Northwest) Audrain County is located in Central Missouri; Mexico is the county seat. Per the 2010 U.S. Census Tracts Reference Map, Audrain County Tracts (sub-county areas) include Tracts 9501through 9507. These tracts encompass the cities, villages, unincorporated communities, and townships listed below: Cities Centralia (Predominantly in Boone County) Farber Laddonia Mexico Vandalia Villages Benton City Martinsburg Rush Hill Vandiver Unincorporated Communities Rowena Thompson Townships Audrain County is divided into eight townships: Cuivre Linn Loutre Prairie Saling Salt River South Fork Wilson Multi-County Comparative Analysis Randolph County Population Population Estimates, July, 2014 Population, Census, April, 2010 Percent Change Age and Sex Persons < 5 years, %, July, 2013 Persons < 5 years, %, April, 2010 Persons <18 years, %, July, 2013 Persons <18 years, %, April, 2010 Persons 65 years+, %, July, 2013 Persons 65 years+, %, April, 2010 Females, %, July, 2013 Females, %, April, 2010 Housing Building permits, 2013 Education HS grad or higher, % age 25+, 2009-13 Bachelor's or higher, % age 25+, 2009-13 Health With a disability, < 65 years, %, 2009-13 Persons with no health insurance, < 65, % Income and Poverty Persons in poverty, % Total employer establishments, 2013 Total employment, % change, 2012-2013 Geography Population per square mile, 2010 Monroe County Callaway County Cole County Boone County Audrain County 25072 25414 -0.99 8707 8840 -0.98 44750 44332 0.99 76557 75990 1.01 172717 162642 1.06 25887 25529 1.04 5.9 6.3 22.5 23.1 15.1 14.2 47.9 47.7 5.2 6.1 22.6 23.3 20.2 18.6 49.7 50.0 5.7 5.9 21.8 22.6 13.8 12.3 48.9 48.6 6.2 6.6 23.1 23.6 13.6 12.3 49.5 49.5 6.0 6.2 20.6 21.1 10.1 9.3 51.6 51.5 6.3 6.8 23.4 24.9 16.5 16.0 54.6 53.8 14 24 46 224 1230 15 84.6 13.6 87.6 13.1 86.0 21.1 90.4 30.8 93.0 47.3 84.3 13.1 12.2 15.9 11.0 19.7 10.8 13.9 10.8 12.5 7.6 13.1 11.8 16.8 22.4 555 -6.8 15.7 197 3.8 13.8 745 5.7 13.7 2267 -1.8 19.8 4447 2.1 19.7 553 -0.1 52.7 13.6 53.1 193.0 237.3 36.9 (U.S. Census Bureau, 2015b) County Services There are an adequate number of public and private schools in Audrain County. Similarly, the fire, law enforcement and emergency medical services in Audrain County meet the needs of its population. Demographic Findings The Audrain County Health Department, SSM-Audrain Medical Center, and the Arthur Center, a federally qualified health center (FQHC) provide the main healthcare services in Audrain County. However, Audrain County, like most Missouri counties, lacks an appropriate number of mental health and dental care resources. In both instances, barriers to care exist, primarily of a financial, uninsured, educational, and/or cultural nature. It should be noted that many Audrain County Hispanic and African American residents have a delayed access or resistance to seek care. Audrain County has the following notable disparities or variances (either positive or negative) as compared to the six counties in the multi-county analysis listed above (U.S. Census Bureau, 2015): Second highest number of seniors in Census & 2013 estimates (16.5%); Monroe (20.2%). Second highest positive percent change in population (1.04%). Highest number of children under five years in Census & 2013 estimates (6.3%). Highest number of person <18 years in Census & 2013 estimates (23.4%). Highest percentage of females in Census & 2013 estimates (54.6%). Significantly higher percentage of residents living in poverty (19.7%). Lowest percentage of high school graduates, age 25+ (84.3%). Ties with Monroe County for lowest percentage of four-year college graduates (13.1%). Second highest percentage of residents <65 years who are disabled (11.8%) Second highest percentage of residents without health insurance (16.8%); Monroe (19.7%). Second lowest number of housing (building) permits issued, 2013 (15). Second lowest number of employers, 2013 (553). Third lowest percent, employment change (-0.1%), whereas three area counties have had significant job growth: Callaway (5.7%), Monroe (3.8%), and Boone (2.1%). Audrain County has the second lowest population density per square mile (36.9); farm-driven. Audrain County CHNA Survey Demographic Questions What is your age group? 2015 Community Assessment 6.50% 1.90% 12.60% Under 20 13.60% 20-29 13.10% 8.40% 30-39 40-49 50-59 60-69 12.10% 70-79 80 and above 17.30% No Response 14.50% Have you used any Audrain County Health Department services in the past two years? 2015 Community Assessment 8.90% 2.30% 44.40% Yes No Not Sure No Response 44.40% Over the last year was there someone in your household, who wanted to see a physician, dentist, the local public health agency (LPHA), or other health care provider but for some reason did not go? 12.00% 10.00% 8.00% 6.00% 4.00% Physician 2.00% Dentist 0.00% LPHA Other Not Specified Eye Doctor CHNA Survey Results IV. Community Health Assessment Comparative Health Analysis The following charts show the change of importance from the previous community health assessment surveys. 1. Children (Ages 1-9) Weight and obesity Lack of physical activities Lack of social activities Child abuse and neglect Availability of childcare, babysitters, daycare Car restraint use 1997 12% 31% 21% 24% Chronic childhood illness (asthma, ear infections, allergies) 22% Immunizations 28% Access to a supplemental food program such as WIC Availability of local allergy injections Other (not specified) 2. Adolescents/Young Adults (Ages 10-20) 1997 Drug use/abuse 39% Lack of parental supervision Alcohol use/abuse 39% Early or inappropriate sexual activity Weight, obesity 17% Behavioral or emotional problems(anger management, bullying) 31% Lack of youth activities Unintended pregnancy 39% Tobacco use 28% High school drop out rates 27% Weight, anorexia/bulimia Sexually transmitted diseases 32% Suicide 28% Car seat belt use 24% Motor vehicle accidents Immunizations Availability of local allergy injections Other (not specified) 3. Adults (Ages 21 and older) 1997 Drug use/abuse including synthetic and prescription Weight, obesity 45% Alcohol use/abuse Tobacco use Availabiltiy of family focused activities Behavioral or emotional problems 21% Stress 47% Diabetes 38% Availability of adult day care 18% Vision or hearing loss 32% Weight, anorexia, bulimia Bone or joint disease 37% Lung disease 39% Heart disease, heart attack 58% Cancer 57% High blood pressure 52% Stroke 52% Availability of activities for senior citizens Access to foot care Availability of local allergy injections Immunizations Other (not specified) - 2004 39% 55% 32% 41% 31% 44% 2004 68% 65% 59% 32% 52% 49% 49% 46% 32% 22% 50% 37% 30% 53% 2004 37% 46% 34% 31% 30% 48% 34% 19% 27% 14% 30% 29% 51% 51% 47% 43% - 2007 44% 34% 29% 28% 25% 20% 7% 4% 2007 46% 46% 43% 41% 40% 39% 38% 36% 35% 25% 24% 23% 23% 19% 16% 6% 2007 40% 37% 37% 29% 29% 27% 25% 20% 19% 17% 17% 15% 14% 11% 10% 9% 8% - 2015 (birth-9) 27% 25% 21% 18% 13% 10% 8% 9% 5% 9% 1% 2015 31% 29% 28% 34% 29% 53% 29% 32% 27% 28% 23% 24% 28% 21% 14% 14% 9% 3% 2015 29% 26% 22% 20% 23% 23% 23% 15% 13% 25% 10% 15% 11% 10% 14% 15% 21% 9% 8% 6% 1% Community Health Assessment Comparative Health Analysis - Continued 4. Pregnancy Unintended Pregnancy Transportation Language Barriers Access to postpartum support Tobacco use during pregnancy Availability of prenatal medical care Drug use during pregnancy Alcohol use during pregnancy Access to nutrition education Access to supplemental food program such as WIC Availability of prenatal vitamins and/or folic acid Access to breastfeeding support Access to adequate diaper supply 5. General Concerns Drug use and abuse Alcohol use and abuse Domestic violence Prescriptions causing financial burdens Family Relationship problems Dental care Parenting issues Tobacco use Transportation Nutrition Unemployment Language barriers Occupational accidents(including farming) Motor vehicle accidents Murder and violent acts Infectious diseases(pneumonia, TB, hep A,B,C, STDs, AIDS) Developmental and physical diabilities Vision or hearing loss Homelessness and sheltering Availability of residential assistance during extreme weather 6. Environmental Health Indoor air quality(mold, secondhand smoke, radon) Disaster preparedness, bioterrorism, homeland security Air pollution Restaurant food Animal vector control(vaccinations, rabies, stray animals) Public motels/hotels Rural sewage disposal West nile virus/Mosquito control Avian flu Water supply Lead exposure Trash/waste/sharps/medication disposal Influenza Other (not specified) 1997 14% 14% 14% 15% 15% 1997 28% 28% 28% 22% 28% 23% 28% 34% 28% 36% 36% 38% 25% 32% 1997 33% 31% 30% 37% 29% - 2004 49% 49% 45% 55% 50% 2004 49% 41% 44% 34% 29% 38% 36% 39% 23% 38% 30% 40% 29% 25% 2004 36% 22% 34% 21% 19% 38% 14% 19% - 2007 31% 25% 24% 23% 21% 21% 19% 17% 16% 2007 43% 41% 37% 37% 33% 33% 32% 32% 25% 24% 24% 22% 21% 21% 20% 13% 12% 12% 2007 34% 37% 26% 22% 22% 20% 19% 18% 18% 17% 17% 17% - 2015 15% 14% 13% 12% 19% 10% 17% 15% 9% 6% 7% 6% 7% 2015 28% 26% 30% 29% 24% 23% 22% 28% 23% 16% 25% 19% 14% 13% 21% 15% 19% 12% 23% 17% 2015 21% 15% 13% 7% 13% 7% 14% 11% 6% 9% 9% 7% 3% Survey Respondent Time Requirement The A u d r a i n County Community Health Needs Assessment Survey required respondents to provide a great deal of information about themselves on a broad range of health topics. The ACHD goal was to obtain accurate information about household members while limiting the time commitment required of the respondent. The surveys were designed to be user-friendly, requiring check boxes for responses and a readability level that met resident comprehension needs (see Appendix B). On average, the surveys required approximately 20.2 minutes to complete. Survey Respondent Bias It must be acknowledged that the ACHD staff had an inordinately high number of respondent “walk-ins” completing surveys at the ACHD. As a result, the 2015 Community Health Assessment Survey of Audrain County identified the following Top Three concerns based upon the perceived needs of community respondents. 1. Behavioral or emotional problems (anger management, bullying, etc.)* 2. Early or inappropriate sexual activity 3. Unintended pregnancy These are the remaining concerns to distinguish the Top Ten concerns identified during the 2015 assessment. They are listed in no particular order. The secondary data analysis will be critical in validating some of the top ten concerns. Drug use/abuse including synthetic and prescription* Domestic violence (child and /or adult)* Prescriptions causing financial burdens* Tobacco use Weight, obesity Lack of physical activities Weight, anorexia, bulimia* The heavy data collection on a similar characteristic-based subject group (ACHD clients) did skew some of the survey top priority results. This inadvertently occurred as most ACHD clients tend to be female, younger, healthier, and with issues in mind that reflect their age and those of their children. Asterisks (*) noted above acknowledge findings that were identified by a preponderance of walk-in ACHD clients and does not reflect findings in the three secondary analysis repositories, nor the Audrain County population at large. Secondary Data Analysis I. CDC: Community Health Status Indicators (CHSI) The Centers for Disease Control’s (2015) Community Health Status Indicators Summary (CHSI) Comparison Report (see Appendix D) provides an “at a glance” summary of how Audrain County compares with peer counties on the full set of primary indicators. Indicators are presented as Better, Moderate, or Worse in comparison with peer counties. Peer county values for each indicator were ranked and then divided into quartiles. CHSI 2015 was designed to complement other existing indicator applications including the Health Rankings and Roadmaps. For example, CHSI 2015 includes indicator values for each county benchmarked against similar “peer counties”, all U.S. counties, and Healthy People 2020 targets. The Rankings resource of “What Works for Health”, includes research that has been reviewed and rated on the effectiveness for a broad variety of strategies addressing health associated factors including behaviors, clinical care, social and economic factors, and the physical environment. Together, the Rankings and CHSI 2015 provide useful information for community health assessment and improvement including: A set of frequently recommended mortality, morbidity, and health determinant indicators compared to a wide range of benchmarks. Indicator values for subpopulations and census tract maps to assist with identification of vulnerable populations and potential health disparities Health status information integrated with info on health factors that influence health status. Rated strategies for addressing priority focus areas. CHSI 2015 Indicators and Definitions Indicators in the Better category (green circle) fall into the most favorable quartile compared to peers. Indicators in the Moderate category (yellow diamond) fall into the middle two quartiles. Indicators in the Worse category (red square) fall into the most unfavorable quartile. Distribution Display: Bar charts allowing users to visually compare indicators for the selected county to those of its peer counties. The display also shows median values for all U.S. counties and Healthy People 2020 targets, where applicable. Show Peer Counties Feature (bottom of the Distribution display): Allows users to examine maps of the geographic distributions of each group of peer county categorized indicators. Indicator Downloads: Indicator values for each group of peer counties can be downloaded for further examination and analysis. For indicators that are based on estimated values, this feature also allows users to examine the estimate and the associated margin of error (confidence interval). Indicator Description: Each CHSI 2015 indicator is accompanied by information describing the significance (importance) of the indicator, source and years of the data, methodology for creating the indicator, and important limitations, where applicable. Populations: Allows users to compare an indicator value for the entire population of a county with sub-populations defined by sex, age groups, and race/ethnicity. This feature can be used to assist with identifying potential health disparities that may warrant further attention. Census Tract Maps: Help identify vulnerable populations and potential health disparities by examining the geographic distribution of select social factor indicators within a county (by census tract), where data are available. Associated Indicators (AI): Indicators that are related to a primary indicator and may provide additional valuable information. For example, the primary indicator for educational attainment is on-time high school graduation rate. AIs include percent of adults without a high school diploma and percent of adults with an associate level college degree or higher. CHSI 2015 Topic and Indicator Selection Process CHSI 2015 topic areas (e.g., leading causes of death, poverty), and final set of indicators (e.g., stroke mortality rates, percent of the population whose income fall below the federal poverty level) were selected through a deliberative process. The process for identifying health outcomes and potential determinant topic areas consisted of a CDC staff review of the original CHSI and the CDC monograph, Community Health Assessment for Population Health Improvement: Most Frequently Recommended Health Metrics which identified topic areas to understand and improve community health. Next, a qualitative review of the scientific literature was performed to better understand the potential relationships between candidate health topic areas and population health outcomes. Finally, a systematic review similar indicator initiative and available data sources was conducted. The indicator initiatives reviewed included, but were not limited to: The County Health Rankings and Roadmaps (www.countyhealthrankings.org) United Health Foundation’s America’s Health Rankings (www.americashealthrankings.org) State of the USA Health Indicators (www.stateoftheusa.org) The Health Indicator’s Warehouse (www.healthindicators.gov) Canadian Index of Wellness (www.atkinsonfoundation.ca/ciw) Healthy People 2020 (www.healthypeople.gov) National Prevention strategy (www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf) Annie E. Casey Foundation’s KIDS COUNT (datacenter.kidscount.org) The results of these reviews were used to develop a set of CHSI indicators. Consistent with previous versions of CHSI, the final set of indicators were required to meet the following criteria: the indicators were considered important to public health, were actionable, were regularly reported, and were available for at least two-thirds of U.S. counties. Additionally, all health factor indicators included in CHSI 2015 were required to be supported by a body of scientific literature establishing their association with population health outcomes and identifying plausible mechanisms and pathways for those associations. Final indicator selection was based on the synthesized scientific evidence; input from external advisors and CDC subject matter experts; and consistency with similar indicator initiatives. CHSI 2015 Health Indicators Physical Environment 2. Annual average PM2.5 concentration (micrograms per cubic meter) Annual average concentration of PM2.5 in Audrain County, MO is9: 10.9 (µg/m3) Significance Poor air quality is linked to premature death, cancer, and long-term damage to respiratory and cardiovascular systems. Progress has been made to reduce unhealthy air emissions, but approximately 127 million people still live in U.S. counties that exceed national air quality standards8. Methodology This measure represents the average daily amount of fine particulate matter in micrograms per cubic meter (PM2.5) in a county. The monitoring data comes from the U.S. Environmental Protection Agency (EPA) Air Quality System (AQS)9. When AQS data are available from multiple monitors for a given county and day, the highest 8-h maximum (daily) ozone concentration among all the monitors is selected for purposes of creating daily county level data. 3. Unhealthy PM2.5 days (days) – AI of # 1 above. Number of days the air was rated unhealthy for PM2.5 in Audrain County, MO is9: 0.0 days Significance Acceptable PM2.5 results for Audrain County, Missouri; 2010 – 2012.. 4. Unhealthy ozone days (days) – AI of # 1 above. Number of days the air was rated unhealthy for ozone in Audrain County, MO is9: 0.0 days Significance Absence of unhealthy ozone days in Audrain County, Missouri; 2010 – 2012. CHSI 2015 Health Indicators Physical Environment (continued) 5. Living near highways (percent) Percent of population living near a highway in Audrain County, MO is11: 2.1 % Significance Numerous studies have documented that concentrations of traffic-related pollutants are highest in the near-road environment. A recent review determined that there is sufficient evidence of a causal association between exposure to traffic-related air pollution and asthma exacerbation and suggestive evidence of a causal association for onset of childhood asthma, non-asthma respiratory symptoms, impaired lung function, all-cause mortality, cardiovascular mortality, and cardiovascular morbidity10. Methodology Percent of population living within 150 meters of a highway. 6. Schools located near highways (percent) – AI of #4 above. Percent of schools located near a highway in Audrain County, MO is11: 42.9 % Significance As above. In Audrain County, chronic lower respiratory disease deaths are in the “Worse” category. Methodology This measure represents the percent of schools located within 150 meter of a highway. It was created by the CDC using data from the National Center for Education Statistics (NCES) and road network data from 2010, from NAVTEQ, a commercial company11. CHSI 2015 Health Indicators Social Factors 1. Children in single-parent households (percent) Percent of children in single-parent households for Audrain County, MO is12: 28.1 % Significance Children living in nuclear families, or families consisting of two married adults who are the biological or adoptive parents of all children in the family—were generally healthier, more likely to have access to health care, and less likely to have definite or severe emotional or behavioral difficulties than children living in nonnuclear families13. Methodology Percentage of all children in family households that live in households headed by a single parent (male or female head of household with no spouse present). 2. Single-parent families (percent) – AI of # 1 above. Percent of families with a single head of household for Audrain County, MO is12: 8.2 % 3. High housing costs (percent) Percent of individuals with high housing costs in Audrain County, MO is12: 22.1 % Significance Affordability of housing is linked to the health and well-being of individuals and families14. When a market lacks a sufficient supply of affordable housing, lower-income families are often forced to limit expenditures for food, medical care, and other necessities in order to pay rent14. Audrain County does well in providing affordable housing. Methodology This measure represents the percent of people that live in renter-occupied housing units or owneroccupied housing units with a mortgage and pay 30 percent or more of their household income on housing costs. Monthly owner costs come from ACS data on mortgage, second mortgage and/or home equity loans, real estate taxes, homeowners insurance, condo fee (if applicable), mobile home cost (if applicable), utilities (electricity, gas, water and sewer, and other utilities). Monthly gross rent costs come from ACS data on contract rent and utilities (electricity, gas, water and sewer, and other utilities). CHSI 2015 Health Indicators Social Factors (continued) 4. Inadequate social support (percent) Percent of adults reporting inadequate social support in Audrain County, MO is15: 17.0 % Significance Social relationships are fundamental to emotional fulfillment, behavioral adjustment, and cognitive function. Social isolation predicts morbidity & mortality from cancer, heart disease, and other causes16. Methodology Percent of adults 18 years & over who report not receiving sufficient social-emotional support; 2006 2012. Based on the BRFSS question "How often do you get the social & emotional support you need?" 5. On time high school graduation (percent) The on time high school graduation rate for Audrain County, MO is17: 90.1 % Significance Education, employment, and health are linked. Without a good education, prospects for a stable and rewarding job with good earnings decrease. Education is associated with living longer, experiencing better health, and practicing health-promoting behaviors such as exercising regularly. 6. Associates level degree or higher (percent) – AI of # 5 above. Percent of adults with an associate degree or higher in Audrain County, MO is 17: 19.1 % 7. No high school diploma (percent) – AI of # 5 above. Percent of adults without a high school diploma in Audrain County, MO is17: 15.8 % Significance Audrain County has a poor post-high school education rate. CHSI 2015 Health Indicators Social Factors (continued) 8. Poverty (percent) Percent of individuals living in poverty in Audrain County, MO is19: 20.3 % Significance Low-income and minority neighborhoods are less likely to have access to recreational facilities and fullservice grocery stores and more likely to have higher concentrations of retail outlets for tobacco, alcohol, and fast foods18. Adolescents who grow up in neighborhoods characterized by concentrated poverty are more likely to be a victim of violence; use tobacco, alcohol, and other substances; become obese; and engage in risky sexual behavior18. Methodology Percent of individuals living in households with income below the Federal Poverty Level (FPL); 2012. At the county level, SAIPE provides estimates on children ages 5-17 in families in poverty, children under age 18 in poverty, all people in poverty, and median household income19. 9. Children in poverty (percent) – AI of # 8 above. Percent of children living in poverty in Audrain County, MO is19: 29.4 % Methodology The percent of children under age 18 living in households with income below the Federal Poverty Line (FPL); 2008 - 201219. 10. Older adults in poverty (percent) – AI of # 8 above. Percent of older adults living in poverty in Audrain County, MO is: 12.2 % Methodology Percent of population aged 65 and older living below the Federal Poverty Line; 2008 – 201219. CHSI 2015 Health Indicators Social Factors (continued) 11. Unemployment (percent) The unemployment rate for Audrain County, MO is20: 5.4 % Significance The association between unemployment and poor physical and mental health is well established. Unemployed persons tend to have higher annual illness rates, lack health insurance and access to health care, and have an increased risk for death21. Methodology Percent of the civilian labor force, age 16 and older, that is unemployed, but seeking work through May, 201520. 12. Violent crime (rate per 100,000 persons) The rate of violent crime for Audrain County, MO is22: 181.1 (per 100,000) Significance Witnessing or being a victim of violence (e.g., child maltreatment, youth violence, intimate partner and sexual violence, bullying, elder abuse) are linked to lifelong negative physical, emotional, and social consequences18. Methodology Annual rate of violent crimes including homicide, forcible rape, robbery, and aggravated assault, per 100,000 population; 2010 – 2012. The violent crime rate is calculated as the sum of murder, forcible rape, robbery, and aggravated assaults over the three-year period divided by the aggregate population of areas covered by agencies reporting crimes, and then multiply 100,00022. CHSI 2015 Health Indicators Healthcare Access and Quality 1. Cost barrier to care (percent) Percent of adults who did not see a doctor due to cost in Audrain County, MO is15: 23.0 % Significance Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. Access to health services means the timely use of personal health services to achieve the best health outcomes and encompasses four components8: coverage, services, timeliness, and workforce. Barriers to services include: 1) Lack of availability, 2) High cost, and 3) Lack of insurance coverage. These barriers to accessing health services diminish quality of care and lead to delays in receiving appropriate care, the inability to get preventive services, and hospitalizations that could have been prevented8. Methodology Percent of adults 18+ who needed to see a doctor but could not because of cost; 2006 – 201215. Based on the BRFSS question: "Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?" 2. Older adult preventable hospitalizations (rate per 1,000 Medicare enrollees age 65 years or older) Older adult preventable hospitalizations rate for Audrain County, MO is7: 92.2 (per 1,000) Significance Preventable hospitalizations are admissions to a hospital for certain acute illnesses (e.g., diabetes) that might not have required hospitalization had these conditions been managed successfully by primary care providers in outpatient settings23. Hospitalization for diagnoses treatable in outpatient services suggests that the quality of care provided in the outpatient setting was less than ideal23. U.S. median: 71.3. Methodology Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees7. Ambulatory care-sensitive conditions include: convulsions, chronic obstructive pulmonary disease, bacterial pneumonia, asthma, congestive heart failure, hypertension, angina, cellulitis, diabetes, gastroenteritis, kidney/urinary Infection, and dehydration7. Rates are adjusted for age, sex and race using the indirect method, using the U.S. Medicare population as the standard7. CHSI 2015 Health Indicators Healthcare Access and Quality (continued) 3. Primary care provider access (rate per 100,000 persons) The primary care provider rate for Audrain County, MO is15: 78.2 (per 100,000) Significance Having a primary care provider (PCP) for routine care is very important. PCPs develop meaningful and sustained relationships with patients and provide integrated services while practicing in the context of family & community8. Having a PCP is associated with greater patient trust in the provider, good patient-provider communication, and increased likelihood that patients will receive appropriate care8. Methodology Rate of Primary Care Providers per 100,000 The Health Resources and Services Administration compile physician data from the American Medical Association Master File and from the Census Population Estimates program to report primary care provider data at the county level15. Primary care physicians are those who identify as practicing general practice, internal medicine, obstetrics and gynecology, or pediatrics15. 4. Dentists access (rate per 100,000 persons) – AI of # 3 above. The dentist provider rate for Audrain County, MO is7: 23.5 (per 100,000) Significance Lack of access to dental care for all ages remains a public health challenge7. The poverty rate in Audrain County makes this a significant outlier and resident concern. 5. Uninsured (percent) Percent of the population without health insurance in Audrain County, MO is7: 18.4 % Significance Persons aged 18–64 years with no health insurance during the preceding year were seven times as likely as those continuously insured to forgo needed health care because of cost. U.S. median is 17.7%7. CHSI 2015 Health Indicators Health Behaviors 1. Adult binge drinking (percent) Percent of adults who report binge drinking in Audrain County, MO is7: 14.2 % Significance Excessive alcohol use, including underage drinking and binge drinking (drinking 5 or more drinks on an occasion for men or 4 or more drinks on an occasion for women), can lead to increased risk of health problems such as injuries, violence, liver diseases, and cancer. Approximately 80,000 deaths are attributed annually to excessive drinking. Excessive drinking is the third leading lifestyle-related cause of death in the United States. The U.S. median is 16.37. Methodology Percent of adults 18 years and over that report binge drinking. Based on the BRFSS question: "Considering all types of alcoholic beverages, how many times during the past 30 days did you have [5 for men, 4 for women] or more drinks on an occasion?"7. 2. Adult female routine pap tests (percent) Percent of women who report having routine pap tests in Audrain County, MO is7: 68.7 % Significance Less than half of older adults are up-to-date on a core set of clinical preventive services (e.g., cancer screening and immunizations). U.S. median is 77.3%7. Methodology Percent of women age 18+ that report Pap test in the last 3 years. Based on the BRFSS questions: "A Pap test is a test for cancer of the cervix. Have you ever had a Pap test? and " How long has it been since you had your last Pap test?"7. 3. Adult physical inactivity (percent) Percent of adults who report no leisure time physical activity in Audrain County, MO is 7: 27.8 % Significance More than 80 percent of adults do not meet the guidelines for both aerobic and muscle-strengthening activities7. Regular physical activity can improve the health and quality of life of Americans of all ages, regardless of the presence of a chronic disease or disability. Methodology Adults that report no leisure-time exercise in past month. Based on the BRFSS question: "During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?"7. The U.S. median is 25.9% and the Healthy People 2020 target is 32.6%7. 4. Adult smoking (percent) Percent of adults who report smoking cigarettes in Audrain County, MO is7: 31.3 % Significance Tobacco use is the single most preventable cause of death and disease in the United States. Each year, approximately 443,000 Americans die from tobacco-related illnesses. For every person who dies from tobacco use, 20 more people suffer with at least 1 serious tobacco-related illness. In addition, tobacco use costs the U.S. $193 billion annually in direct medical expenses and lost productivity7. The U.S. median is 21.7% and the Healthy People 2020 target is 12. Audrain County is one of the few remaining counties that do not have a non-smoking ordinance in public venues and is well behind Missouri, national, and HP 2020 goals. Methodology Percent of adults 18 years and over that report currently smoking cigarettes. Based on the BRFSS question: "Do you now smoke cigarettes every day, some days, or not at all?" Persons are considered smokers if they reported smoking every day or some days7. 5. Teen Births (rate per 1,000 females age 15-19 years) The teen birth rate for Audrain County, MO is7: 49.6 (per 1,000) Significance Teen pregnancy and childbearing bring substantial social and economic costs through immediate and long-term impacts on teen parents and their children. In 2011, teen pregnancy and childbirth accounted for at least $9.4 billion in costs to U.S. taxpayers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers. Pregnancy and birth are significant contributors to high school drop-out rates among girls. Only about 50% of teen mothers receive a high school diploma by 22 years of age, versus approximately 90% of women who had not given birth during adolescence. The children of teenage mothers are more likely to have lower school achievement and drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult. These effects remain for the teen mother and her child even after adjusting for those factors that increased the teenager’s risk for pregnancy, such as growing up in poverty, having parents with low levels of education, growing up in a single-parent family, and having poor performance in school. The U.S. median is 42.1% and the HP 2020 target is 36.2%7. Audrain County’s teen pregnancy rate is higher than most Missouri counties, the nation, and the HP goal. By Age7 Aged 15-17 years Aged 18-19 years Audrain 23.0 96.3 Peer Median 18.7 77.2 Methodology Rate per 1,000 of births to females 15-19 years of age7. US Median 20.3 84.0 CHSI 2015 Health Indicators Morbidity 1. Adult diabetes (percent) Percent of adults living with diagnosed diabetes for Audrain County, MO is7: 11.2 % Significance Diabetes affects an estimated 23.6 million people in the United States and is the 7th leading cause of death. Diabetes lowers life expectancy by up to 15 years and increases the risk of heart disease by 2 to 4 times. Diabetes is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness. In addition to these human costs, the estimated total financial cost of diabetes in the U.S. in 2007 was $174 billion, which includes the costs of medical care, disability, and premature death. The U.S. median is 8.1%7. Methodology Percent of adults that report having been diagnosed as having diabetes. The prevalence of diagnosed diabetes was estimated for adults age 20 and over, using data from CDC's Behavioral Risk Factor Surveillance System (BRFSS), and data from the U.S. Census Bureau’s Population Estimates Program. Respondents were considered to have diabetes if they responded "yes" to the question, "Has a doctor ever told you that you have diabetes?"7. 2. Adult obesity (percent) Percentage of adult obesity for Audrain County, MO is7: 32.0 % Significance Obesity is common, serious and costly. In 2009-2010, more than one-third of U.S. adults (35.7%) were obese. The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight7. Methodology Percent of adults 20 years and over that report BMI >= 30, using the Behavioral Risk Factor Surveillance System (BRFSS)7. CHSI 2015 Health Indicators Morbidity (continued) 3. Adult overall health status (percent) Percent of adults reporting fair or poor health in Audrain County, MO is7: 21.6 % Significance Health-related quality of life (HRQOL) measures of perceived physical and mental health and function have become an important component of health surveillance and are generally considered valid indicators of service needs and intervention outcomes. Self-assessed health status also proved to be more powerful predictor of mortality and morbidity than many objective measures of health7. The U.S. median is 16.5%7. Methodology Percent of adults that report fair or poor health. Based on the BRFSS question : "Would you say that in general your health is— Excellent, Very good, Good, Fair, Or Poor?"7. 4. Adult mentally unhealthy days (per person) Average number of reported mentally unhealthy days per month among adults in Audrain County, MO is7: 4.8 (per person) Significance Health-related quality of life (HRQOL) measures of perceived physical and mental health and function have become an important component of health surveillance and are generally considered valid indicators of service needs and intervention outcomes. Self-assessed health status also proved to be more powerful predictor of mortality and morbidity than many objective measures of health7. Methodology Average number of reported mentally unhealthy days per month among adults 18 years and over. Based on the BRFSS question "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?"7. 5. Adult physically unhealthy days (per person) Average number of reported physically unhealthy days per month among adults in Audrain County, MO is7: 5.1 (per person) Methodology Average number of reported physically unhealthy days per month among adults 18 years+7. Based on the BRFSS question: "Now thinking about your physical health, which includes physical illness & injury, for how many days during the past 30 days was your physical health not good?"7. 6. Alzheimer's diseases/dementia (percent) Percent of older adults living with Alzheimer's/dementia for Audrain County, MO is7: 10.7 % Significance Dementia is an umbrella term for a group of cognitive disorders typically characterized by memory impairment, as well as marked difficulty in the domains of language, motor activity, object recognition, and disturbance of executive function – the ability to plan, organize, and abstract. Most often, dementia is an illness of older adults, which suggests that as successive cohorts of our population live longer, the urgency to better address dementia increases. The likelihood of developing Alzheimer’s doubles about every five years after age 65. Methodology Prevalence of Alzheimer's Disease and Dementia among Medicare fee-for-service Beneficiaries7. 7. Cancer (rate per 100,000 persons) Age-adjusted cancer incidence rate for Audrain County, MO is7: 514.5 (per 100,000) Significance Advances in cancer research, detection, and treatment have resulted in a decline in both incidence and death rates for all cancers. Among people who develop cancer, more than half will be alive in 5 years. Yet, cancer remains a leading cause of death in the United States, second only to heart disease7. The U.S. median is 457.6. Methodology Incidence rates of all cancer sites, all races, all ages. State Cancer Registry and the CDC's National Program of Cancer Registries Cancer Surveillance System (NPCR-CSS). Retrieved from: National Cancer Institute. State Cancer Profiles24. Rate Icon Description Peer Median HP 2020 Target US Median 51.3 Colon & rectum cancer 51.5 38.6 46.8 147.4 Female breast cancer 115.5 41.0 115.6 93.2 Lung & bronchus cancer 78.0 NA 71.7 148.6 Male prostate cancer 134.3 NA 137.9 CHSI 2015 Health Indicators Morbidity (continued) 8. Gonorrhea (rate per 100,000 persons) The gonorrhea rate for Audrain County, MO is7: 129.1 (per 100,000) Significance The CDC estimates that there are approximately 19 million new sexually transmitted disease (STD) infections each year—almost half of them among young people ages 15 to 24. The cost of STDs to the U.S. health care system is estimated to about $15.9 billion annually. Untreated STDs can lead to serious long-term health consequences, especially for adolescent girls and young women. CDC estimates that undiagnosed and untreated STDs cause at least 24,000 women in the U.S. each year to become infertile7. Audrain County has the highest gonorrhea rate in Missouri7. The U.S. median is only 30.5 cases per 100,0007. Audrain’s rate is greater than four times the national rate. Methodology Nationally notifiable STD surveillance data are collected and compiled from reports sent by the STD control programs and health departments in all 50 states, the District of Columbia, selected cities, and U.S. dependencies. Rates per 100,000 population were calculated for each STD7. 9. Chlamydia (rate per 100,000 persons) – AI of # 8 above. The chlamydia rate for Audrain County, MO is7: 512.4 (per 100,000) 10. HIV (rate per 100,000 persons) Rate of persons living with diagnosed HIV for Audrain County, MO is7: 154.4 (per 100,000) Significance Audrain County’s HIV rate is higher than the U.S. median of 105.5 cases/100,0007. 11. Syphilis (rate per 100,000 persons) The syphilis rate for Audrain County, MO is7: 0.0 (per 100,000) CHSI 2015 Health Indicators Morbidity (continued) 12. Older adult asthma (percent) Percent of older adults living with asthma for Audrain County, MO is25: 3.99 % Significance Currently, more than 23 million people have asthma in the U.S. The burden of respiratory diseases affects individuals, families, schools, workplaces, neighborhoods, cities, and states. Annual health care expenditures for asthma are estimated at $20.7 billion7. 13. Older adult depression (percent) Percent of older adults living with depression for Audrain County, MO is25: 12.7 % Significance Depression is characterized by depressed or sad mood, diminished interest in activities which used to be pleasurable, weight gain or loss, psychomotor agitation or retardation, fatigue, inappropriate guilt, difficulties concentrating, as well as recurrent thoughts of death. But depression is more than a “bad day”. APA criteria dictate that five or more of the above symptoms must be present for a period of at least2 weeks. Depression falls within the spectrum of affective disorders & is an issue for many seniors. 14. Preterm births (percent) Percentage of preterm births for Audrain County, MO is7: 12.1 % Significance In 2012, preterm birth affected more than 450,000 babies—1 of every 9 infants born in the U.S. Preterm birth occurs before 37 weeks of pregnancy. Preterm-related causes of death accounts for 35% of all infant deaths, more than any other single cause. Preterm birth is also a leading cause of long-term neurological disabilities in children. U.S. Median is 12.1, HP 2020 Target: 11.4. 15. Low birth weight (percent) Percentage of low birth weight deliveries for Audrain County, MO is7: 7.6 % CHSI 2015 Health Indicators Mortality 1. Alzheimer's disease deaths (rate per 100,000 persons) The age adjusted Alzheimer's disease death rate for Audrain County, MO is7: 24.5 (per 100,000) Significance Alzheimer’s disease is the 6th leading cause of death among adults aged 18 years and older7. Estimates vary, but experts suggest that up to 5.1 million Americans aged 65 years and older have Alzheimer’s disease. These numbers are predicted to more than double by 2050. Methodology Alzheimer’s death rates are calculated as the number of deaths assigned to ICD-10 code G30 per 100,000 population, age adjusted to the 2000 standard population7. 2. Cancer deaths (rate per 100,000 persons) The age adjusted cancer death rate for Audrain County, MO is7: 211.7 (per 100,000) Significance Cancer continues to be the second leading cause of death in the United States, accounting for more than 20% of all deaths in 2010. Advances in research, detection, and treatment have resulted in a decline in incidence and death rates for all cancers. In people with cancer, half are expected to be alive in 5 years. Methodology Death rates are calculated as the number of deaths assigned to ICD-10 codes C00-C97 per 100,000 population, age adjusted to the 2000 standard population7. 3. Chronic kidney disease deaths (rate per 100,000 persons) Age adjusted chronic kidney disease death rate for Audrain County, MO is: 19.9 (per 100,000) Significance Chronic kidney disease (CKD): 8th leading cause of death in the U.S. in 2010. More than 20 million, aged 20 years or older in the U.S. have CKD. CKD is an important risk factor for cardiovascular disease, including heart attacks, heart failure, heart rhythm disturbances, and strokes. CKD and end stage renal disease (ESRD) are very costly to treat. Nearly 25% of the Medicare budget is used to treat people with CKD and ESRD. CHSI 2015 Health Indicators Mortality (continued) 4. Chronic lower respiratory disease (CLRD) deaths (per 100,000 persons) Age-adjusted chronic lower respiratory disease (CLRD) death rate for Audrain County, MO is7: 71.8 (per 100,000) Significance Chronic lower respiratory diseases (CLRD) is the 3rd leading cause of death in the United States in 2010. Many of these adults have been diagnosed with chronic obstructive pulmonary disease (COPD the primary component of CLRD mortality). The burden of respiratory diseases affects individuals and their families, schools, workplaces, neighborhoods, cities, and states. U.S. median is 49.6. Methodology CLRD death rates are calculated as the number of deaths assigned to ICD-10 codes J40-J47 per 100,000 population, age adjusted to the 2000 standard population. 5. Coronary heart disease deaths (rate per 100,000 persons) Age adjusted coronary heart disease death rate for Audrain County, MO is7: 101.7 (per 100,000) Significance Together, heart disease and stroke are among the most widespread and costly health problems facing the Nation today, accounting for more than $500 billion in health care expenditures and related expenses in 2010 alone. Audrain County’s rate is excellent as the U.S. median is 126.7 & HP 2020 Target is 103.4. 6. Diabetes deaths (rate per 100,000 persons) The age adjusted diabetes death rate for Audrain County, MO is7: 30.4 (per 100,000) Significance Diabetes affects an estimated 23.6 million people in the U.S. and is the 7th leading cause of death. Diabetes lowers life expectancy by up to 15 years and increases the risk of heart disease by 2 to 4 times. Diabetes is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness. The estimated total financial cost of diabetes in the U.S. in 2007 was $174 billion, which includes the costs of medical care, disability, and premature death. CHSI 2015 Health Indicators Mortality (continued) 7. Female life expectancy (years) Female Life Expectancy for Audrain County, MO is7: 79.2 years Significance Between 2000 and 2007, life expectancies in more than 80% of United States counties fell in standing against the average of the 10 nations with the best life expectancies in the world27. 8. Male life expectancy (years) Male Life Expectancy for Audrain County, MO is7: 73.8 years Significance Similar to the national experience, Audrain County females live 5.4 years longer than males28. Methodology Life expectancy estimates were calculated using a mixed-effects Poisson statistical model with time, geospatial, and covariate components and Gaussian Process Regression to estimate annual life expectancy for U.S. counties28. 9. Motor vehicle deaths (rate per 100,000 persons) Age adjusted motor vehicle traffic-related death rate for Audrain County, MO is7: 17.4 (per 100,000) Significance Motor vehicle crash-related injuries are the leading cause of death among younger people aged 5 to 34 years. Motor vehicle crash fatality rates are especially high in rural areas and for residents of tribal lands, in part because of poor road maintenance, higher rates of alcohol impaired driving, lower rates of seat belt and child safety seat use, and less access to emergency response and trauma care. Methodology Number of vehicle related deaths [ICD-10 codes V02-V04 (.1, .9), V09.2, V12-V14 (.3-.9), V19 (.4-.6), V20-V28 (.3-.9), V29-V79 (.4-.9), V80 (.3-.5), V81.1, V82.1, V83-V86 (.0-.3), V87 (.0-.8), V89.2]7. CHSI 2015 Health Indicators Mortality (continued) 10. Unintentional injury (including motor vehicle) (rate per 100,000 persons) Age adjusted unintentional injury (including motor vehicle) death rate for Audrain County, MO is7: 47.1 (per 100,000) Significance Unintentional injuries were the 5th leading cause of death in the United States in 2010. Unintentional injuries are the leading cause of death for Americans ages 1 to 44, as well as a leading cause of disability for all ages, regardless of sex, race/ethnicity, or socioeconomic status. For children, motor vehicle and bicycle accidents are leading causes of injury and death. In June, 2015, ACHD added car seat and safe crib programs. A bicycle helmet program is in development. 11. Unintentional injury (excluding motor vehicle) (rate per 100,000 persons) Age adjusted unintentional injury (excluding motor vehicle) death rate for Audrain County, MO is7: 29.1 (per 100,000) Significance By gender, 28.1% of injuries involve females and 71.9% of injuries occur in males. 12. Stroke deaths (rate per 100,000 persons) The age adjusted stroke death rate for Audrain County, MO is7: 48.7 (per 100,000) Significance Heart disease and stroke are among the most widespread and costly health problems facing the nation today, accounting for more than $500 billion in health care expenditures and related expenses in 20107. Audrain County’s stroke death rate is higher than the U.S. median is 46.0 and the HP 2020 target of 34.8. Methodology Stroke death rates are calculated as the number of deaths assigned to ICD-10 codes I60-I69 per 100,000 population, age adjusted to the 2000 standard population7. II. UW/PHI & RWJF: County Health Rankings The Rankings are based on a model of population health that emphasizes the many factors that, if improved, can help make communities healthier places to live, learn, work and play. Building on the work of America's Health Rankings, the University of Wisconsin Population Health Institute, sponsored by the Robert Woods Johnson Foundation, has used this model to rank the health of Wisconsin counties every year since 200326. The County Health Rankings measure the health of nearly all counties in the nation and rank them within states. The Rankings are compiled using county-level measures from a variety of national and state data sources. These measures are standardized and combined using scientifically-informed weights26. The following elements comprise the Rankings model: Health Outcomes Health outcomes in the County Health Rankings represent the health of a county. Two types of health outcomes are measured: 1. How long people live (length of life); and H 2. How healthy people feel while alive (quality of life). Length of Life (Mortality) The Rankings examine mortality (or death) data to find out how long people live. More specifically, the Rankings measure what are known as premature deaths (deaths before age 75). Quality of Life (Morbidity) Quality of life refers to how healthy people feel while alive. Specifically, the Rankings report on the measures of their health-related quality of life (their overall health, physical health, and mental health) and it also looks at birth outcomes. Health Factors Health factors in the County Health Rankings represent what influences the health of a county. Four types of health factors are measured: health behaviors, clinical care, social and economic, and physical environment factors. In turn, each of these factors is based on several measures. A fifth set of factors that influence health (genetics and biology) is not included in the Rankings. Health Behaviors Alcohol & Drug Use Diet & Exercise Sexual Activity Tobacco Use Clinical Care Access to Care Quality of Care Social and Economic Factors Community Safety Education Employment Family & Social Support Income Physical Environment Air & Water Quality Housing & Transit A multi-county analysis that compares Audrain County to its seven contiguous neighboring counties and the State of Missouri metrics follows. Monroe Montgomery Pike (MR) (MY) (PI) Ralls (RS) Randolph Audrain Callaway Boone (RO) (AU) (CW) (BO) Health Outcomes 28 30 49 75 65 48 67 7 Length of Life 5 20 26 78 41 23 35 6 5,538 6,844 7,094 9,072 7,709 6,984 7,440 5,591 89 60 86 61 83 87 93 20 19% 15% 21% 22% 17% 11% 3.9 3.4 5.2 5.1 3.7 2.7 5.1 4.8 3.9 4.0 Missouri Premature death 7,714 Quality of Life Poor or fair health 16% 21% Poor physical health days 3.7 4.4 Poor mental health days 3.8 3.1 Low birthweight 8.0% 9.4% 7.2% 8.5% 7.9% 7.1% 7.6% 9.9% 7.4% Health Factors 52 68 84 20 56 57 46 3 Health Behaviors 48 82 87 30 59 66 78 1 3.8 4.8 Adult smoking 23% 26% 28% 27% 21% 27% 29% 30% 18% Adult obesity 31% 32% 33% 34% 35% 32% 31% 34% 24% Food environment index 7.0 7.7 7.3 6.8 8.2 6.8 7.1 7.8 6.3 Physical inactivity 26% 29% 28% 29% 28% 28% 29% 30% 21% Access to exercise opportunities 77% 45% 41% 50% 32% 61% 75% 65% 74% Excessive drinking 17% 21% 21% 18% 17% 15% 18% 15% Alcoholimpaired driving deaths 35% 45% 35% 29% 15% 19% 26% 38% 49% STDs 462 92 242 307 282 399 511 262 659 Teen births 40 30 50 44 33 50 50 30 20 49 75 87 71 46 36 24 2 18% 19% 16% 17% 18% 15% 15% Clinical Care Uninsured 16% 20% Primary care physicians 1,439:1 2,901:1 3,999:1 3,713:1 5,139:1 1,689:1 1,423:1 2,606:1 986:1 Dentists 1,920:1 4,387:1 5,983:1 3,734:1 10,192:1 2,771:1 3,666:1 4,929:1 1,691:1 Mental health providers 632:1 8,774:1 2,393:1 2,667:1 3,397:1 597:1 344:1 1,313:1 562:1 Missouri Monroe Montgomery Pike (MR) (MY) (PI) Ralls (RS) Randolph Audrain Callaway Boone (RO) (AU) (CW) (BO) Preventable hospital stays 65 55 72 87 76 77 82 66 45 Diabetic monitoring 86% 87% 84% 84% 85% 85% 85% 87% 86% Mammography screening 62.2% 63.0% 53.1% 58.2% 54.5% 55.6% 65.6% 61.4% 71.4% 62 57 75 14 64 67 49 10 Social & Economic Factors High school graduation 86% 93% 92% 84% 88% 90% 83% 82% 86% Some college 63.8% 45.0% 49.8% 36.3% 50.8% 48.9% 48.7% 54.6% 78.6% Unemployment 6.5% 7.3% 7.0% 5.9% 5.0% 6.5% 5.8% 5.8% 4.5% Children in poverty 22% 27% 23% 27% 17% 29% 33% 20% 17% Income inequality 4.6 3.5 4.4 4.7 3.1 4.6 3.7 4.1 5.4 Children in single-parent households 34% 25% 35% 35% 27% 40% 33% 29% 30% Social associations 11.9 17.2 16.7 19.4 7.8 15.8 13.7 11.1 11.7 Violent crime 452 257 136 179 88 151 181 266 408 Injury deaths 74 92 89 72 65 66 72 79 51 27 51 95 21 49 34 55 64 Physical Environment Air pollution particulate matter 10.2 10.3 10.8 11.0 10.6 10.0 10.4 10.4 10.2 Drinking water violations 4% 0% 2% 27% 0% 0% 7% 0% 0% Severe housing problems 14% 9% 10% 13% 9% 13% 10% 12% 18% Driving alone to work 81% 79% 79% 79% 78% 83% 79% 82% 78% Long commute 30% driving alone 41% 39% 27% 28% 23% 23% 26% 17% (University of Wisconsin, Public Health Institute & Robert Wood Johnson Foundation, 2015). III. MICA Child Health Update, Ages 1 – 14: Injury, ER Visits29 (MO DHSS, MICA, 2014). Child Health Update, Ages 15 – 19: Death, Suicide30 (MO DHSS, MICA, 2014). Leading Cause of Death Profile: Lung Cancer31 (MO DHSS, MICA, 2015). Leading Cause of Death Profile: Chronic Lower Respiratory Disease32 (MO DHSS, MICA, 2015). Leading Cause of Death Profile: Diabetes Mellitus33 (MO DHSS, MICA, 2015). Leading Cause of Death Profile: Smoking34 (MO DHSS, MICA, 2015). Leading Cause of Death Profile: COPD35 (MO DHSS, MICA, 2014). Women’s Health Profile: Cervical Cancer36 (MO DHSS, MICA, 2014). Mental Health, Substance Abuse, & Crime39 (MO Department of Mental Health, 2015). Mexico – Child Eligibility for Free Meals40 PUBLIC RELEASE Mexico School District announced its revised free and reduced price policy for school children unable to pay the full price of meals served in schools under the National School Lunch Program and the School Breakfast Program. Local education officials have adopted the following family-size income criteria for determining eligibility: Household Size 1 2 3 4 5 6 7 8 Each add’l member Maximum Household Income Eligible for Free Meals Annually Monthly Weekly $15,301 $1,276 $295 20,709 1,726 399 26,117 2,177 503 31,525 2,628 607 36,933 3,078 711 42,341 3,529 815 47,749 3,980 919 53,157 4,430 1,023 + 5,408 + 451 + 104 Maximum Household Income Eligible for Reduced Price Meals Annually Monthly Weekly $21,775 $1,815 $419 29,471 2,456 567 37,167 3,098 715 44,863 3,739 863 52,559 4,380 1,011 60,255 5,022 1,159 67,951 5,663 1,307 75,647 6,304 1,455 + 7,696 + 642 + 148 Children from families whose current income is at or below those shown are eligible for free or reduced price meals. Applications are available at the school office. To apply, fill out a Free and Reduced Price School Meals Family Application and return it to the school. The information provided on the application is confidential and will be used only for the purpose of determining eligibility. Applications may be submitted any time during the school year. A complete application is required as a condition of eligibility. A complete application includes: (1) household income from all sources or Food Stamp/TANF case number, (2) names of all household members, and (3) the signature and last four digits of social security number or indication of no social security number of adult household member signing the application. School officials may verify current income at any time during the school year. Foster children may be eligible regardless of the income of the household with whom they reside. If a family member becomes unemployed or if family size changes, the family should contact the school to file a new application. Such changes may make the children of the family eligible for these benefits. Households will be notified of their children’s eligibility status for free or reduced price meals. If any children were not listed on the eligibility notice for families receiving SNAP, TANF or FDPIR, the household should contact the school to have free meal benefits extended to those children. If any child(ren) was not listed on the eligibility notice, the household should contact the LEA or school to have free meal benefits extended to that child(ren). Under the provisions of the policy, the Food Service Director will review the applications and determine eligibility. If a parent is dissatisfied with the ruling of the determining official, they may wish to discuss the decision with the hearing official on an informal basis or he/she may make a request either orally or in writing to the Superintendent of Schools, Mr. Kevin Freeman. Hearing procedures are outlined in the policy. A complete copy of the policy is on file in each school and in the central office where any interested party may review it. Non-discrimination Statement: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (PDF), found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected] Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 8456136 (Spanish). USDA is an equal opportunity provider and employer. Combined Data Repository Findings: CHSI, the Rankings, & MICA A broad range of personal, social, economic, and environmental factors that influence health status are known as determinants of health. These factors are interrelated and determine both population and individual health outcomes. The county obesity rate is higher than the State average. Similarly, the county’s smoking rate (31.3%) is higher than the U.S (21.2%) & state (23%) rates. Consequently, the incidence of diabetes, heart disease, stroke, lung and oral cancers, and chronic upper respiratory diseases is higher than the norm. STDs are also one of the most critical health challenges facing Audrain County today. Audrain’s HIV prevalence rate (154.5 per 100,000 persons) is significantly higher than the U.S. rate (105.5 per 100,000 persons). Audrain’s Gonorrhea rate is significantly higher than the U.S. median (30.5/100,000 persons). The Audrain County Chlamydia rate (512.4 cases per 100,000 persons) is also significantly higher than both Missouri and U.S. rates. Top Five Causes of Morbidity38 Top Five Causes of Mortality38 1. Cancer 1. Heart Disease 2. Heart Disease 2. Cancer 3. COPD 3. COPD; Chronic Lower Respiratory Diseases 4. Stroke 4. Stroke 5. Diabetes Mellitus 5. Unintentional Injuries Top Five Causes of Inpatient Hospitalizations38 Top Five Causes of Emergency Room Visits38 1. Heart & Circulation 1. Injury & Poisoning 2. Heart Disease 2. Respiratory, Throat & Lung 3. Reproduction: Pregnancy; Birth 3. Symptoms & Ill-Defined Conditions 4. Respiratory, Throat & Lung 4. Respiratory Infections 5. Digestive System 5. Brain/Spinal Cord/Eyes/Ears Audrain County: Ranking Against 115 Counties in the State of Missouri: Health Outcomes Ranking: 48th Health Factors Ranking: 57th Preventable Hospital Stays: 88th overall and 2nd highest compared to the other 6 contiguous counties. Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of life for everyone. There are four components of access to care: coverage, services, timeliness, and workforce (Healthy People 2020–Access to Health Services). Rising health care costs cause policy makers to be concerned about emergency room (ER) visits, which are often more expensive than primary provider treatment. Preventable hospitalizations are hospitalizations that better primary care could have prevented.41 The preventable hospitalization rate is significantly higher than most of the 115 Missouri counties; ranking 88th. Combined Data Repository Findings: CHSI, the Rankings, & MICA Mental health is a critical component of overall health and quality of life and should be addressed with the priority that is given to physical health. Mental illness has been associated with the development and outcomes of several physical ailments and is regularly associated with health risk behaviors such as substance abuse, tobacco use, and physical inactivity. Moreover, depression has been found to be a risk factor for multiple chronic diseases–hypertension, cardiovascular disease, and diabetes–and can negatively impact these conditions. Audrain County findings include 4.8 mentally unhealthy days/month – higher than the State and U.S. norm. Bullying is a form of violence that occurs among children and youth. Bullying can lead to social and emotional distress, injuries and even death. Persons who are victims of bullying have escalated risks for mental health issues such as anxiety and depression. Although ACHD respondents identified bullying as an area of concern, all regions of the state have approximately the same rate of victims of bullying, with no statistical differences between the regions. The ACHD CHNA offers a comprehensive review of all of the organizations and entities that contribute to the public’s health. The assessment answers questions related to the activities, competencies and capacities of the system and how essential public health services are performed in the state. The public health system consists of not just the health department, but other government and non- government entities as illustrated below. Forces of Change Impact • The economic downturn and budget cuts in both the state and the U.S. adversely affect services to the most vulnerable populations and undermine past achievements. • Some lawmakers do not understand or appreciate the value of public health and some policies in the state confound and perpetuate growing economic gaps, leading to “haves and have-nots”. • Organizations are engaged in competition for limited resources to meet their respective missions, and such an environment inhibits collaborative partnerships. • The impact of the Affordable Care Act continues to unfold. • The lack of Medicaid expansion in Missouri has created a gap in service for some. • Many Audrain County residents are uninsured. The Kaiser Family Foundation has identified several key facts related to the uninsured in the U.S.: • More than half of people under the age of 65 receive health coverage as an employment benefit, consequently the loss of a job leads to the loss of insurance. • Most people without health coverage are in working families and have low incomes through low paying and part-time jobs. • Adults make up a disproportionate share of the uninsured population because they are less likely than children to be eligible for Medicaid. • While the majority of uninsured people are White non-Hispanic, racial/ethnic minorities are at especially high risk of being uninsured. • Health insurance is a deciding factor in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. • For many uninsured people, the costs of health insurance and medical care compete with other essential needs. The Patient Protection and Affordable Care Act of 2010 has the potential to decrease the number of uninsured in several ways: • Expanding the Medicaid program (states must agree & approve; MO has not). • Building on employer-based coverage using requirements and incentives • Providing premium subsidies & health exchanges to make private insurance affordable. Missouri Forces of Change That May Missouri Current Assets that May Impact Strategies to Respond to the Uninsured Issue Facilitate the Strategies to Respond to the Uninsured Issue Antigovernment sentiments Innovative initiatives from national Fewer factories and jobs with benefits and state foundations Recession Implementation of the Affordable Care Increasing disparities in wealth and economic opportunities Act of 2010 Government regulations that restrict business advocacy Aging population Increased push for living wages State and federal legislative State Medicaid Program Federally Qualified Health Centers Hospitals and the MHA References 1. O’Malley, P.O., Rainford, J., & Thompson, A. (2009). Transparency during public health emergencies: From rhetoric to reality. Bulletin of the World Health Organization, 87, p. 614-618. doi: 10.2471/BLT.08.056689 2. Washington Advocates for patient Safety. (2015). Transparency and accountability. Retrieved from http://www.washingtonadvocatesforpatientsafety.org/transparency-andaccountability/. 3. Central MO Community Action. (2014). Central MO Community Action: 2014 community assessment. Retrieved from http://www.showmeaction.org/public/csbg/2014na.pdf. 4. U.S. Census Bureau, U.S. Department of Commerce (2015a). 2010 Decennial census data. Retrieved from http://www.census.gov/quickfacts/table/PST045214/29007,29,00. 5. Hodge, L. (1985). The Friend of Audrain – A History of Medicine in Audrain County. Mexico, MO: Audrain Medical Center. 6. U.S. Census Bureau. (2010). 2010 Census Tracts: Audrain County. Retrieved from http://www2.census.gov/geo/maps/dc10map/tract/st29_mo/c29007_audrain/DC10CT _C29007_001.pdf 6. U.S. Census Bureau, U.S. Department of Commerce (2015b). Multi-county comparative analysis data. Retrieved from http://www.census.gov/quickfacts. 7. Centers for Disease Control & Prevention, U.S. Department of Health & Human Services. (2015). Community health status indicators: Audrain County. Retrieved from http://wwwn.cdc.gov/CommunityHealth/profile/currentprofile/MO/Audrain/ 8. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Retrieved from http://www.healthypeople.gov. 9. Centers for Disease Control and Prevention (2015). National Environmental Public Health Tracking Network. Retrieved from www.cdc.gov/ephtracking. 10. Boehmer, T., et al. (2013). Residential proximity to major highways - United States, 2010. MMWR. Surveillance summaries, 62, Suppl. 3: p. 46-50. 11. Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry (CDC/ATSDR). Geospatial Research, Analysis and Services Program (GRASP); 2010-2012. 12. American Community Survey (2015). Retrieved from www.census.gov/acs/www/. 13. Blackwell D.L. (2010). Family structure and children’s health in the United States: Findings from the National Health Interview Survey, 2001–2007. National Center for Health Statistics. References (continued) Vital Health Stat. 10(246). Retrieved from http://www.cdc.gov.nchs/data/series/sr_10 /sr10_246.pdf. 14. Freeman, L. (2002). America’s affordable housing crisis: A contract unfulfilled. American Journal of Public Health, 92, p. 709–712. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles /PMC1447149/. 15. Behavioral Risk Factor Surveillance System (BRFSS). (2015). Retrieved from Centers for Disease Control and Prevention, National Center for Health Statistics. Health Indicators Warehouse. 16. Hawkley, L. , & Cacioppo, J. (2003). Loneliness and pathways to disease. Brain, Behavior, and Immunity, 17 Suppl 1: S98-105. 17. U.S. Department of Education (EDFacts) (2015). On time high school graduation rate: Audrain County. Retrieved from https://explore.data.gov/Education/Adjusted-Cohort-Graduation-Rates -at-the-LEA-level-/gnfw-qmug. 18. National Prevention Council, National Prevention Strategy, U.S. Department of Health and Human Services, Office of the Surgeon General. (2011). Retrieved from http://www.surgeongeneral. gov/initiatives/prevention/strategy/report.pdf. 19. U.S. Census Bureau (2012). Small Area Income and Poverty Estimates (SAIPE). Retrieved from http://www.census.gov/. 20. Bureau of Labor Statistics. (2015). Local area unemployment statistics. Retrieved from http://data.bls.gov/map/MapToolServlet. 21. Centers for Disease Control and Prevention. (2013). Unemployment: U.S. 2006 & 2010. MMWR, 3(62), (Suppl 3): p. 27-31. Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6203.pdf. 22. United States Department of Justice, Federal Bureau of Investigation. (2014). Uniform crime reporting program data: County-level detailed arrest and offense data, 2012. ICPSR35019-v1. Ann Arbor, MI: Inter-University Consortium for Political and Social Research, 2014-06-12. http://doi.org/10.3886/ICPSR35019.v1. 23. Centers for Disease Control and Prevention. (2013). Potentially preventable hospitalizations: U.S. MMWR, 62(Sup 3), p.139-143. Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6203.pdf. 24. National Cancer Institute, Missouri Cancer Registry. (2015). State Cancer Profiles and the CDC National Program of Cancer Registries Cancer Surveillance System (NPCR-CSS). 25. Centers for Medicare and Medicaid Services. (2015). Medicare Chronic Conditions Dashboard: County Level. Retrieved from http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends- and-Reports/Dashboard/Chronic-Conditions-County/CC _County_Dashboard.html. References (continued) 26. University of Wisconsin, Public Health Institute & Robert Wood Johnson Foundation. (2015). County health ranking. Retrieved fromhttp://www.countyhealthrankings.org/app/missouri/2015/ compare/snapshot?counties=137%2B139%2B163%2B173%2B175%2B007%2B027%2B019. 27. Kulkarni, S., et al. (2011). "Falling behind: Life expectancy in U.S. counties from 2000- 2007 in an international context.". Population Health Metrics, 9(1), p. 16-16. Retrieved from http://www.pophealthmetrics.com/content/11/1/8. 28. Wang. H., Schumacher, A. E., Levitz, C. E., Mokdad, A. H., & Murray, C. J. L. (2013). Left behind: Widening disparities for males and females in U.S. county life expectancy, 1985-2010. Population Health Metrics, 11, p. 8. 29. Missouri Department of Health & Senior Services. (2014). Data MICA: ER Visits, Injury, Ages 1 – 14. Retrieved from http://health.mo.gov/data/mica/ASPsChildHealth/trend.php?county=007&code=051135. 30. Missouri Department of Health & Senior Services. (2014). Data MICA: Death, Suicide, Ages 15 – 19. Retrieved from http://health.mo.gov/data/mica/ASPsChildHealth/displaybar.php?typ=C&county=007&caus%5B %5D=081132&colrbw=0. 31. Missouri Department of Health & Senior Services. (2015). Lung Cancer. Retrieved from http://health.mo.gov/data/mica/ASPsDeath/displaybar.php?typ=R&code=011014&cnty%5B%5 D=007&colrbw=0. 32. Missouri Department of Health & Senior Services. (2015). CLRD. Retrieved from http://health.mo.gov/data/mica/ASPsDeath/displaybar.php?typ=R&code=011040&cnty%5B%5 D=007&colrbw=0. 33. Missouri Department of Health & Senior Services. (2015). Diabetes Mellitus. Retrieved from http://health.mo.gov/data/mica/ASPsDeath/displaybar.php?typ=R&code=011052&cnty%5B%5 D=007&colrbw=0. 34. Missouri Department of Health & Senior Services. (2015). Smoking. Retrieved from http://health.mo.gov/data/mica/ASPsDeath/displaybar.php?typ=R&code=011156&cnty%5B%5 D=007&colrbw=0. 35. Missouri Department of Health & Senior Services. (2014). Chronic disease comparisons: COPD. Retrieved from http://health.mo.gov/data/mica/ASPsChronicDisease/displaybar.php?typ=R&code=031211&cnty %5B%5D=007&colrbw=0. 36. Missouri Department of Health & Senior Services. (2014). Cervical cancer: Retrieved from References (continued) http://health.mo.gov/data/mica/ASPsWomensHealth/displaybar.php?typ=R&code=042302&cnty %5B%5D=007&colrbw=0. 37. Missouri Census Data Center. (2015). ACS Profiles [dataset application]. Retrieved from http://census.missouri.edu/acs/profiles/. 38. Missouri Department of Health & Senior Services. (2014). Community Data Profiles; MICA. Retrieved from http://health.mo.gov/data/CommunityDataProfiles/. 39. Missouri Department of Mental Health. (2015). Audrain County: Mental health, substance abuse, and crime. Retrieved from http://dmh.mo.gov/ada/countylinks/docs/indicator-audrain.pdf. 40. Mexico School District. (2015). Public Release: National School Lunch Program & the School Breakfast Program. Emailed to Administrator from MSD. 41. Moy, E., Barrett, M., & Ho, K. (2011). Potentially Preventable Hospitalizations-United States, 2004-2007. Morbidity and Mortality Weekly, (60)01, p.80-83. Appendix A. Audrain County CHNA Respondent Letter Appendix B. Audrain County CHNA Survey Audrain County Health Department Community Health Assessment 2015 PLEASE ANSWER ALL THE QUESTIONS ON THIS QUESTIONNAIRE 1. Are the following health concerns for children birth to Check one choice for each topic 9 being addressed to your satisfaction? YES NO UNKNOWN Access to a supplemental food program such as WIC □ □ □ Availability of childcare, babysitters, daycare □ □ □ Child abuse/neglect □ □ □ Car restraint use □ □ □ Immunizations □ □ □ Chronic childhood illness (asthma, ear infections, □ □ □ allergies) Weight, obesity □ □ □ Lack of physical activities □ □ □ Lack of social activities □ □ □ Availability of local allergy injections □ □ □ Other________________________________________ □ □ □ 2. Are the following health concerns for children ages 10 Check one choice for each topic to 20 being addressed to your satisfaction? YES NO UNKNOWN Alcohol use/ abuse □ □ □ Drug use/ abuse □ □ □ Unintended pregnancy □ □ □ Early or inappropriate sexual activity □ □ □ Behavioral or emotional problems (anger management, □ □ □ bullying, etc.) □ □ □ Sexually transmitted diseases □ □ □ Tobacco Use □ □ □ Motor vehicle accidents □ □ □ Suicide □ □ □ High school drop out rates □ □ □ Vehicle seat belt use □ □ □ Weight, obesity □ □ □ Weight, anorexia, bulimia □ □ □ Lack of youth activities □ □ □ Lack of parental supervision □ □ □ Immunizations □ □ □ Availability of local allergy injections □ □ □ Other________________________________________ □ □ □ 3. Are the following health concerns for ages 21 and older Check one choice for each topic being addressed to your satisfaction? YES NO UNKNOWN Cancer □ □ □ Alcohol use/ abuse □ □ □ Drug use/ abuse including synthetic and prescription □ □ □ Diabetes Tobacco Use Lung disease Heart disease, heart attack Stroke High blood pressure Weight, obesity Weight, anorexia, bulimia Stress Behavioral or emotional problems Vision or hearing loss Bone or joint disease Availability of activities for senior citizens Availability of family focused activities Access to foot care Availability of local allergy injections Immunizations Other________________________________________ 4. Are the following concerns before during and after pregnancy being addressed to your satisfaction? Alcohol use during pregnancy Drug use during pregnancy Tobacco use during pregnancy Availability of prenatal medical care Unintended pregnancy Language barriers Transportation Access to post-partum support Access to nutrition education Access to a supplemental food program such as WIC Availability of prenatal vitamins and/or folic acid Access to breastfeeding support Access to adequate diaper supply 5. Are the following general concerns being addressed to your satisfaction? Motor vehicle accidents Occupational accidents (including farming) Domestic violence (child and/or adult) Murder and or other violent acts Infectious diseases (pneumonia, TB, hepatitis A,B, C, sexually transmitted, AIDS, etc.) Nutrition Alcohol use/abuse Drug use/abuse Tobacco use Dental Care Developmental and physical disabilities □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Check one choice for each topic YES NO UNKNOWN □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Check one choice for each topic YES NO UNKNOWN □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Vision or hearing loss Family relationship problems Parenting issues to include parenting classes Language barriers Transportation Prescriptions causing financial burdens Unemployment Homelessness and sheltering Availability of residential assistance during extreme weather 6. Are the following environmental health concerns being addressed to your satisfaction? Air pollution Indoor air quality (mold, secondhand smoke, radon, etc.) □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Check one choice for each topic YES NO UNKNOWN □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Rural sewage disposal Lead exposure West Nile Virus/ Mosquito control Trash/waste/sharps/medication disposal Food establishment safety and sanitation Water supply Disaster preparedness, bioterrorism, homeland security Animal vector control (vaccinations, rabies, stray animals) Influenza Public motels/hotels (lodging) Other________________________________________ 7. Please answer the following nutrition and exercise related Check one choice for each topic where applicable questions. YES NO UNKNOWN If employed, does your work place have incentives for exercising? □ □ □ Do you read nutrition labels to help you decide what to eat or drink? □ □ □ How many times per week do you get take out or fast food? □ Never □ 1-2 ti mes □ 3-4 ti mes □ 5-6 times □ 7 or more How often do you exercise per week? □ Never □ 1-2 times □ 3-4 times □ 5-6 times □ 7 or more How do you perceive your weight? What kind of physical activities do you do on most days? □Swimming□ Cleaning □Yardwork □ Gym □ Bike Riding Which beverage do you consume the most of daily? □ Water □ Soda □ Juice □ Tea □ Coffee On a scale of 1-5, how willing are you to make changes in your lifestyle to live healthier? □ Normal □ Underweight □ Overweight □ None □ Walking □ Playing with children □ Alcohol □1 □4 □2 □5 □ Running □ Other □3 8. Over the last year was there someone in your household who wanted to see a physician, dentist, the local public health agency (LPHA), or other health care provider but for some reason did not go? Check all that apply. Location Cost No insurance Physician Dentist LPHA OTHER □ □ □ □ □ □ □ □ □ □ □ □ If other specify Transportation □ □ □ □ Inconvenient hours □ □ □ □ Insurance would not □ □ □ □ cover the service Language barriers □ □ □ □ Other_______________ □ □ □ □ 9. Have you used any Audrain County Health Department services in the past two years? Yes No Not Sure □ □ □ Information About You 1. Your sex Male Female 2. Race White Black or African-American Asian American Indian or Alaskan Native 3. What is your zip code? □ □ □ □ □ □ Native Hawaiian or Pacific Islander Two or more races Hispanic or Latino □ □ □ ___________ 4. Please identify your age group. □ Under 20 □ 20-29 □ 30-39 □ 40-49 □ □ □ □ 50-59 60-69 70-79 80 and above Dear Public Health Patrons, This information will help direct Public Health in Audrain County and will assist in allowing the Audrain County Health Department to continue to provide the high quality of care and customer service you have have been used to for over 50 years. Public Health in Audrain County is everyone's business. However, very few of us take the time to really think about it. For example, have you ever eaten at a local restaurant? If you have, then you have used Public Health services. Public Health is in the business of preventative medicine…that's why you usually hear very little from us. It doesn’t mean that we're not doing our job; it's just the nature of the business. If you do hear from us, it's usually a major issue, such as an outbreak of Pertussis (whooping cough) or a foodborne illness. Public Health provides many essential programs in the community and supports many more critical programs. Besides partnering with local, state, national, and global organizations; Public Health is involved with a multitude of issues from Communicable Disease Surveillance, Birth and Death Certificates, and Women, Infant, Children (WIC) programs to Disaster Preparedness, Immunization services, Blood Pressure Screenings, Flu Clinics, and Environmental Public Health Services. We appreciate your support, because Public Health is here for you…to Prevent, Promote and Protect. THANK YOU! Appendix C: 2010 U. S. Census Tracts: Audrain County, Missouri (U.S. Census Bureau, U.S. Department of Commerce, 2010). Appendix D: CDC CHSI, 2015. APPENDIX E: American Community Survey, 2015. ACS Profile Report37: 2009-2013 - Audrain County, Missouri (05000US29007) Demographic - D1. AGE Variable Universe: Total population Audrain County, Missouri Number Total population Percent 25,584 Under 5 years 1,705 6.7 5 to 9 years 1,696 6.6 10 to 14 years 1,715 6.7 15 to 19 years 1,678 6.6 20 to 24 years 1,482 5.8 25 to 34 years 3,370 13.2 35 to 44 years 3,103 12.1 45 to 54 years 3,541 13.8 55 to 59 years 1,684 6.6 60 to 64 years 1,473 5.8 65 to 74 years 2,121 8.3 75 to 84 years 1,386 5.4 85 years and over 630 2.5 Median age in years 38.8 5 years and over 23,879 93.3 15 years and over 20,468 80.0 6,227 24.3 18 years and over 19,357 75.7 21 years and over 18,408 72.0 25 years and over 17,308 67.7 62 years and over 4,963 19.4 65 years and over 4,137 16.2 Number Percent Under 18 years D2. AGE AND SEX Universe: Total population Variable Audrain County, Missouri Total population 25,584 Male 11,803 46.1 Males 18 years and over 8,409 71.2 Males 65 years and over 1,700 14.4 Female 13,781 53.9 Females 18 years and over 10,948 79.4 Females 65 years and over 2,437 17.7 Number Percent D3. RACE Universe: Total population Variable Audrain County, Missouri Total population 25,584 One race 24,923 97.4 White alone 22,962 89.8 1,534 6.0 American Indian and Alaska Native 51 0.2 Asian 80 0.3 Black or African American Native Hawaiian and Other Pacific Islander - Some other race 296 Two or more races 661 1.2 2.6 White (alone or in combination) 23,583 92.2 Black (alone or in combination) 1,987 7.8 American Indian (alone or in combination) 177 0.7 Asian (alone or in combination) 179 0.7 Native Hawaiian (alone or in combination) - Some other race (alone or in combination) 319 1.2 D4. HISPANIC OR LATINO (ANY RACE) Universe: Total population Variable Audrain County, Missouri Number Total population Percent 25,584 Hispanic or Latino of any race 681 2.7 Not Hispanic or Latino 24,903 97.3 White alone 22,611 88.4 1,533 6.0 American Indian and Alaska Native alone 34 0.1 Asian alone 80 0.3 Black or African American alone Native Hawaiian and Other Pacific Islander alone - ECONOMIC E1. HOUSEHOLD INCOME AND BENEFITS Universe: Total households Variable Audrain County, Missouri Number Total households Percent 9,327 Less than $10,000 577 $10,000 to $14,999 654 7.0 $15,000 to $24,999 1,336 14.3 $25,000 to $34,999 1,179 12.6 $35,000 to $49,999 1,512 16.2 $50,000 to $74,999 2,107 22.6 $75,000 to $99,999 1,195 12.8 $100,000 to $149,999 568 6.1 $150,000 to $199,999 97 1.0 102 1.1 $200,000 or more Median household income $43,013 Mean household income $52,396 With earnings 6,883 Mean household earnings 6.2 73.8 $52,081 With social security 3,467 Mean household social security income 37.2 $17,235 With retirement income 1,802 Mean household retirement income 19.3 $15,227 With supplemental security income 513 Mean household supplemental security income 5.5 $8,819 With cash public assistance income 246 2.6 Mean household cash public assistance income $4,147 With food stamp benefits in the past 12 months 1,247 13.4 E2. FAMILY INCOME AN D BENEFITS Universe: Family households Variable Audrain County, Missouri Number Percent Family households 6,430 68.9 Less than $10,000 338 5.3 $10,000 to $14,999 246 3.8 $15,000 to $24,999 690 10.7 $25,000 to $34,999 614 9.5 $35,000 to $49,999 1,036 16.1 $50,000 to $74,999 1,743 27.1 $75,000 to $99,999 1,071 16.7 $100,000 to $149,999 522 8.1 $150,000 to $199,999 84 1.3 $200,000 or more 86 1.3 Median family income $53,564 Mean family income $60,370 E3. OTHER INCOME MEASURES Universe: Various Variable Audrain County, Missouri Number Per-capita income Percent $19,687 Nonfamily households 2,897 Median nonfamily income $25,979 Mean nonfamily income $32,141 31.1 All full-time workers 8,028 All male full-time workers 4,424 55.1 All female full-time workers 3,604 44.9 Median earnings for workers $25,828 Median earnings for male full-time, year-round workers $39,809 Median earnings for female full-time, year-round workers $29,433 E4. POVERTY STATUS OVER THE LAST 12 MONTHS Universe: Persons for whom poverty status is determined Variable Audrain County, Missouri Number Persons for whom poverty status is determined Percent 23,823 Persons below poverty 4,049 Persons under 18 for whom poverty status is determined 6,126 Persons under 18 in poverty 1,576 Persons aged 18 to 64 for whom poverty status is determined 17.0 25.7 13,770 Persons aged 18 to 64 in poverty 2,069 Persons over 65 for whom poverty status is determined 3,927 Persons over 65 in poverty Persons in families for whom poverty status is determined 15.0 404 10.3 19,652 82.5 Unrelated individuals for whom poverty status is determined 4,171 Persons in families in poverty 2,782 14.2 Unrelated persons in poverty 15 years and over 1,267 30.4 Poverty ratio under 0.5 1,797 7.5 Poverty ratio in 0.5 to 0.99 2,252 9.5 Poverty ratio in 1 to 2 4,915 20.6 14,859 62.4 Number Percent Poverty ratio in 2 and over E5. EMPLOYMENT STATU S Universe: Population 16 years and over Variable Audrain County, Missouri Population 16 years and over 20,185 In labor force 11,698 58.0 Civilian labor force 11,690 57.9 Employed civilians 10,774 92.2 916 7.8 Unemployed civilians In military 8 Not in labor force 8,487 42.0 11,284 55.9 Females in labor force 5,738 28.4 Females in civilian labor force 5,738 28.4 Employed females 5,304 92.4 Number Percent Females 16 years and over E6. CHILDREN WITH ALL PARENTS WORKING Universe: Own children under 18 years in families and subfamilies Variable Audrain County, Missouri (Own) children under 6 1,944 All parents working 1,471 (Own) children aged 6 to 17 3,872 All parents working 2,867 75.7 74.0 E7. COMMUTING TO WOR K Universe: Workers 16 years and over Variable Audrain County, Missouri Number Workers 16 years and over 10,684 Workers 16+ who commute to work Percent 10,228 95.7 Car, truck, or van; drove alone 8,486 79.4 Car, truck, or van; carpooled 1,131 10.6 63 0.6 Walked to work 243 2.3 Other means of commuting 305 2.9 Worked at home 456 4.3 Mean travel time to work in minutes 21.1 Public transportation (excluding taxicab) E8. WORKERS BY OCCUP ATION Universe: Civilian employed population 16 years and over Variable Audrain County, Missouri Number Civilian employed population 16 years and over Percent 10,774 Management, professional, and related occupations 2,753 25.6 Service occupations 2,137 19.8 Number 2,510 Percent 23.3 Variable Audrain County, Missouri Sales and office occupations Farming, fishing, and forestry occupations 105 1.0 Construction, extraction, maintenance and repair occupations 1,033 9.6 Production, transportation, and material moving occupations 2,236 20.8 Number Percent E9. WORKERS BY INDUS TRY Universe: Civilian employed population 16 years and over Variable Audrain County, Missouri Civilian employed population 16 years and over 10,774 Agriculture, forestry, fishing and hunting, and mining 456 Construction 546 5.1 1,811 16.8 Manufacturing Wholesale trade 4.2 248 2.3 1,711 15.9 Transportation and warehousing, and utilities 657 6.1 Information 157 1.5 Finance and insurance, and real estate and rental and leasing 386 3.6 Retail trade Professional, scientific, management, and administrative 393 3.6 2,647 24.6 Arts, entertainment, and recreation, and accommodation, and food services 638 5.9 Other services, except public administration 546 5.1 Public administration 578 5.4 Number Percent Educational services, and health care, and social assistance E10. CLASS OF WORKER Universe: Civilian employed population 16 years and over Variable Civilian employed population 16 years and over Audrain County, Missouri 10,774 Private wage and salary workers 8,259 76.7 Government workers 1,727 16.0 759 7.0 29 0.3 Self-employed workers in own not incorporated business Unpaid family workers SOCIAL S1. HOUSEHOLDS BY TYPE Universe: Total households Variable Audrain County, Missouri Number Percent Total households 9,327 Family households 6,430 68.9 With own children under 18 years 2,623 28.1 Married-couple families 5,049 54.1 With own children under 18 years 1,707 18.3 Male householder, no wife present 394 4.2 With own children under 18 years 293 3.1 Female householder, no husband present 987 10.6 With own children under 18 years 623 6.7 Nonfamily households 2,897 31.1 Householder living alone 2,480 26.6 65 years and over living alone 1,161 12.4 Households with one or more people under 18 years 2,940 31.5 Households with one or more people 65 years and over 2,796 30.0 Average household size 2.54 Average family size 3.06 S2. PERSONS BY HOUSEHOLD TYPE / GROUP QUARTER S Universe: Total population Variable Audrain County, Missouri Number Percent Total population 25,584 Household population 23,698 92.6 Living in family households 20,272 85.5 Living in nonfamily households 3,426 14.5 Living alone 2,480 26.6 Living in group quarters 1,886 7.4 Number Percent 23,698 92.6 Householder 9,327 39.4 Spouse 5,052 21.3 Child 7,085 29.9 Other relatives 1,085 4.6 Nonrelatives 1,149 4.8 599 2.5 S3. RELATIONSHIP Universe: Household population Variable Audrain County, Missouri Household population Unmarried partner Unmarried-partner HHs per 1000 64 S4. MARITAL STATUS Universe: Population 15 years and over Variable Audrain County, Missouri Number Persons 15 years and over Never married Now married, except separated Separated Percent 20,468 5,231 25.6 10,768 52.6 461 2.3 Widowed 1,462 7.1 Divorced, and not currently married 2,546 12.4 S5. FERTILITY Universe: Women 15 to 50 years old who gave birth in the past 12 months Variable Audrain County, Missouri Number Percent Women 35 to 50 years 25 6.7 Per 1,000 unmarried women 32 Per 1,000 women 15 to 50 years 57 Per 1,000 women 15 to 19 years 3 Per 1,000 women 20 to 34 years 117 Per 1,000 women 35 to 50 years 9 S6. GRANDPARENTS AS CAREGIVERS Universe: Population 30 years and over Variable Audrain County, Missouri Number Grandparents living with own grandchildren under 18 years 405 Responsible for grandchildren Percent 210 51.9 Less than 1 year 33 15.7 1 or 2 years 97 46.2 3 or 4 years 48 22.9 5 or more years 32 15.2 Number Percent S7. SCHOOL ENROLLMEN T Universe: Population 3 years and over Variable Audrain County, Missouri Population 3 years and over 24,541 Population 3 years and over enrolled in school 5,706 23.3 In nursery school, preschool 386 6.8 In kindergarten 341 6.0 In elementary school, grades 1-8 2,745 48.1 In high school, grades 9-12 1,581 27.7 653 11.4 Number Percent In college or graduate school S8. EDUCATIONAL ATTAINMENT Universe: Population 25 years and over Variable Audrain County, Missouri Population 25 years and over 17,308 Less than 9th grade 877 5.1 9th to 12th grade, no diploma 1,836 10.6 High school graduate (includes equivalency) 7,920 45.8 Some college, no degree 3,316 19.2 Associates degree 1,094 6.3 Bachelors degree 1,405 8.1 Graduate or professional degree High school graduate or higher Bachelor degree or higher 860 5.0 14,595 84.3 2,265 13.1 Number Percent 19,349 100.0 1,954 10.1 S9. VETERAN STATUS Universe: Civilian population 18 years and over Variable Civilian population 18 years and over Civilian veterans Audrain County, Missouri S10A. DISABLED BY AGE Universe: Civilian noninstitutionalized population Variable Audrain County, Missouri Number Civilian noninstitutionalized persons Percent 23,914 With a disability 3,702 15.5 Under 18 6,213 26.0 With a disability 186 3.0 13,774 57.6 With a disability 2,173 15.8 65 years and over 3,927 16.4 With a disability 1,343 34.2 Number Percent 18 to 64 years S11. RESIDENCE 1 YEA R AGO Universe: Population 1 year and over Variable Audrain County, Missouri Population 1 year and over 25,312 Same house 21,133 83.5 Different house in the U.S. 4,170 16.5 Same county, different house 1,773 7.0 Different county 2,397 9.5 Different county, same state 1,897 7.5 500 2.0 Different state Lived abroad 1 year ago 9 S12. PLACE OF BIRTH AND CITIZENSHIP STAT US Universe: Total population Variable Audrain County, Missouri Number Percent Total population 25,584 U.S. native 25,198 98.5 Born in United States 25,099 98.1 Born in state of current residence 20,062 78.4 5,037 19.7 99 0.4 Born in different state than current residence Born in Puerto Rico, U.S. Island areas, or born abroad to American parents Foreign born 386 1.5 Naturalized U.S. citizen 155 40.2 Not a U.S. citizen 231 59.8 Number Percent S13. YEAR OF ENTRY Universe: Population born outside the United States Variable Audrain County, Missouri Population born outside the United States Native, born outside U.S. 485 1.9 99 20.4 Entered U.S. 2000 or later 5 5.1 Entered U.S. before 2000 94 94.9 Foreign born 386 1.5 Entered U.S. 2000 or later 140 36.3 Entered U.S. before 2000 246 63.7 S14. WORLD REGION OF BIRTH OF FOREIGN BORN Universe: Foreign-born population, excluding population born at sea Variable Audrain County, Missouri Number Percent 386 1.5 Europe 71 18.4 Asia 80 20.7 Africa 14 3.6 Foreign-born population, excluding population born at sea Oceania - Latin and Central America (includes Mexico) 221 Northern America 57.3 - S15. LANGUAGE SPOKEN AT HOME Universe: Population 5 years and over Variable Audrain County, Missouri Number Percent Population 5 years and over 23,879 93.3 English only 22,701 95.1 1,178 4.9 Speaks English less than "very well" 490 2.1 Speak Spanish 675 2.8 Speaks English less than "very well" 247 1.0 Number Percent Language other than English HOUSING H1. HOUSING OCCUPANCY AND TENURE Universe: Housing units Variable Audrain County, Missouri Total housing units 10,822 Occupied housing units 9,327 86.2 Owner-occupied 6,917 74.2 Renter-occupied 2,410 25.8 Average household size of owner-occupied unit 2.60 Average household size of renter-occupied unit 2.37 Vacant housing units 1,495 13.8 For sale 142 9.5 For rent 318 21.3 83 5.6 For seasonal, recreational, or occasional use Total owner units 7,059 Homeowner vacancy rate 2.0 Total rental units 2,728 Rental vacancy rate 11.7 People living in owned homes 17,985 70.3 People living in rental homes 5,713 22.3 Number Percent H2. UNITS IN STRUCTURE Universe: Housing units Variable Audrain County, Missouri Total housing units 10,822 Single-family units 8,908 82.3 Single unit, detached 8,779 81.1 Single unit, attached 129 1.2 Duplexes 370 3.4 3 or 4 units 359 3.3 5 to 9 units 240 2.2 10 to 19 units 61 0.6 20 or more units 71 0.7 813 7.5 Mobile home Boat, RV, van, etc. - Mobile homes per 1000 HUs 75 H3. YEAR STRUCTURE B UILT Universe: Housing units Variable Audrain County, Missouri Number Total housing units Percent 10,822 Built 2010 or later 9 Built 2000 to 2009 950 8.8 Built 1990 to 1999 1,420 13.1 Built 1980 to 1989 1,003 9.3 Built 1970 to 1979 1,678 15.5 Built 1960 to 1969 1,626 15.0 Built 1950 to 1959 1,620 15.0 Built 1940 to 1949 697 6.4 1,819 16.8 Number Percent Built 1939 or earlier 0.1 H4. YEAR HOUSEHOLDER MOVED INTO UNIT Universe: Occupied housing units Variable Audrain County, Missouri Occupied housing units 9,327 Moved in 2010 or later 1,442 15.5 Moved in 2000 to 2009 4,007 43.0 Moved in 1990 to 1999 1,661 17.8 Moved in 1980 to 1989 877 9.4 Moved in 1970 to 1979 746 8.0 Moved in 1969 or earlier 594 6.4 Number Percent H5. VEHICLES AVAILABLE Universe: Occupied housing units Variable Audrain County, Missouri Occupied housing units 9,327 No vehicles available 596 6.4 1 vehicle available 2,653 28.4 2 vehicles available 3,916 42.0 3 or more vehicles available 2,162 23.2 Number Percent H6. HOUSE HEATING FUEL Universe: Occupied housing units Variable Audrain County, Missouri Occupied housing units 9,327 Utility gas 4,200 45.0 Bottled, tank, or LP gas 1,058 11.3 Electricity 3,515 37.7 Fuel oil, kerosene, etc. Coal or coke Wood 493 5.3 8 0.1 Other fuel 20 0.2 No fuel used 33 0.4 Solar energy H7. SELECTED CHARACTERISTICS Universe: Occupied housing units Variable Audrain County, Missouri Number Occupied housing units Percent 9,327 Lacking complete plumbing facilities 111 1.2 Lacking complete kitchen facilities 163 1.7 No telephone service available 378 4.1 Number Percent H8. OCCUPANTS PER ROOM Universe: Occupied housing units Variable Audrain County, Missouri Occupied housing units 9,327 1.00 or less 9,240 99.1 1.01 to 1.50 55 0.6 1.51 or more 32 0.3 Number Percent H9. HOME VALUES Universe: Owner-occupied units Variable Audrain County, Missouri Owner-occupied units 6,917 Less than $50,000 1,323 19.1 $50,000 to $99,999 2,597 37.5 $100,000 to $149,999 1,367 19.8 $150,000 to $199,999 716 10.4 $200,000 to $299,999 543 7.9 $300,000 to $499,999 234 3.4 $500,000 to $999,999 102 1.5 $1,000,000 or more 35 0.5 Median home value $90,500 Average home value $118,639 H10. SELECTED MONTHL Y OWNER COSTS Universe: Owner-occupied units Variable Audrain County, Missouri Number Percent Owner-occupied units 6,917 Housing units with a mortgage 3,787 54.7 891 23.5 Owner costs 30% or more of HH income Median owner costs $992 Housing units without a mortgage 3,130 45.3 383 12.2 Nonmortgage owner costs 30% or more of HH income Median owner costs $346 H11. GROSS RENT Universe: Renter-occupied units Variable Audrain County, Missouri Number Percent Renter-occupied units 2,410 Paying cash rent 2,142 88.9 268 11.1 Paying no cash rent Median rent Average gross rent $619 - Gross rent 30% or more of HH income 820 34.0 Gross rent of $750 or more 594 24.6 Generated: Sun, 05 Jul 2015 21:48:50 -0500 by Sandra Hewlett, Administrator, ACHD.
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