Executive Summary - Citrus County Health Department

EXECUTIVE SUMMARY

Introduction

The mission of the Citrus County Health Department is. . . to serve as the community's focal point to promote and protect the health and safety of all people in Citrus County.

In striving to achieve its mission through the assessment and improvement of health, the Health Department decided to conduct a community needs assessment. The assessment would help identify resources and gaps within the community, allowing the Health Department to improve access to health care and decrease health outcome disparities within the rural community. This needs assessment has been developed by the Health Department in order to better understand and meet the needs of the Citrus County community.

To develop this needs assessment, the Health Departments administrator and staff reviewed, over a several-month period, the demographic and health status information compiled by the North Central Florida Health Planning Council, Inc. (the Council). The Council worked closely with Health Department staff and a graduate student from the University of South Florida to develop the survey instrument, and to organize and facilitate focus groups, interviews and the community forums. The recommendations and action plan were developed largely by community members through participation in the community forums. After a review of the needs assessment, the Health Department administrator approved the report and recommendations, which will be used to focus the Health Departments energy on special health related issues identified in the process.

Documents below are dated from Dec 2003

The demographic and socio-economic profile examines the population characteristics of Citrus County. When data are available, a comparison is provided with Hernando County and the State of Florida.

Citrus County has a population of over 118,000. The population density is 202 people per square mile, lower than both Hernando County and the state. But the population of Citrus County is growing. Between 1980 and 2000, Citrus County experienced a population growth of 116 percent, increasing its population from 54,700 to over 118,000. Population growth is projected to slow to 24.9 percent between 2000 and 2010. The areas of greatest population growth since 1990 include the Beverly Hills (34465), Homosassa (34446) and Lecanto (34461) Zip Code Areas.

Population growth in Citrus County is predominately due to in-migration. There are more deaths than births in Citrus County due to the extraordinary age structure of the population. Citrus County has one of the oldest populations in the state, with 32.1 percent of the population over the age of 65. As a result of the large elderly population, children age 0-17 represent only17.2 percent of the population, which is the 63^rd lowest proportion of children out of 67 counties.

Citrus County's population is 52 percent female and 94.8 percent white. 2.9 percent of the population is Hispanic and 2.4 percent is Black.

Personal income, cost of living, employment rates, labor force, employees by types of industry, and poverty are standard measures of the economic status of a county. Citrus County has a larger percentage of population with household income under $25,000 (35.7 percent) than either Hernando County or the state. For Citrus County, the per capital income ($20,546) is slightly higher than Hernando County ($20,151) and lower than the state ($24,118). Within the county, per capita income ranges from $17,455 in Floral City (34436) to $26,052 in Crystal River (34429). Crystal River (34429) is the only Zip Code area with a per capita income exceeding both Hernando County and the state.

The Florida price level index is used to compare the relative cost of living within counties and is set at 100. If a county's price index is higher than 100, that county's cost of living exceeds Florida's average cost of living. Citrus County's price level index is 90.9, ranking 56 among the states 67 counties. Of the five indices used to determine the index, food is the highest and housing is the lowest.

Citrus County's unemployment is usually higher than either Hernando County or the state. Unemployment rates declined from 6.2 percent to 4.7 percent between 1996 and 2000. The number of nonagricultural wage and salaried jobs increased in Citrus County by 13.7 percent between 1996 and 2000. Of note, the labor force of Citrus County is primarily comprised of small businesses. These businesses generally are less likely to provide health insurance benefits to employees.

Citrus County has higher percentages of poverty for both all persons and families than Hernando County, though those percentages are lower than the state. The highest concentration of persons and families living in poverty in Citrus County are located in the Inverness (34453) and Floral City (34436) Zip Code Areas. Poverty and public assistance are reviewed in detail.

Communities are interested in the health status of their population because healthy people are an essential resource. Numerous factors have a significant impact on good health: lifestyle and behavior, human biology, and environmental and socio-economic conditions, as well as the individuals access to adequate and appropriate health care and medical services.

Heart disease continues to be the leading cause of death in the nation, the state, and Citrus County. Citrus County's 10 leading causes of death are the same as for the state, though respiratory disease ranks as the third leading cause of death in Citrus County, while it is fourth in the state. Significance testing using a Standard Mortality Ratio indicates that respiratory disease, unintentional injuries, motor vehicle crashes, suicide and liver disease are diseases which account for significantly higher mortality in Citrus County than they do in the state. A review of age adjusted mortality rates is provided. Age specific mortality rates for heart disease, cancer, respiratory disease, unintentional injuries and motor vehicle crashes are reviewed at the Zip Code level.

Although review and analysis of mortality rates are important measures of the county's health status, they may fail to identify temporal changes in mortality. Since most deaths occur among persons in older age groups, the underlying disease processes of older residents dominate mortality data. Calculating the years of potential life lost (YPLL) is a complementary measure of a community's health status. The primary causes of premature mortality in Citrus County are cancer and heart disease, accounting for 13,705 YPLL, or 52.2 percent of YPLL due to the leading causes of death. Deaths of individuals 55-64 account for the largest proportion of YPLL for an age group. Just under half of all YPLL due to unintentional injures are due to motor vehicle crashes.

Morbidity is another measure to determine the health status of a population. Hospitalization and reported infectious disease data can be used as indicators of morbidity. A full review of hospital discharge data by age group indicate variations: among children 0-17, births account for the greatest number of discharges, with bronchitis/asthma second; among residents 18-64, childbirth accounts for the greatest number of discharges, with psychoses following as second; among residents 65 and over, heart failure accounts for the greatest number of discharges, with major joint replacement second. Nine of 24 leading reasons for hospitalization among those over 65 (40 percent) are for disorders of the circulatory system.

The majority of Citrus County's population (63 percent) use Medicare as their primary payor. This is substantially higher than either Hernando County or the state.

Ambulatory Care Sensitive (ACS) conditions represent a group of specific diseases and disorders that reflect the effectiveness of access to the health care delivery system in a community. These diseases were selected because they have been shown to be avoidable in many cases if timely and appropriate ambulatory and primary care is available and utilized. In Citrus County a lower percentage of discharges are ACS conditions than in Hernando County or the state, indicating that the community appears to be utilizing primary care more effectively than the comparable areas. A review of discharge by age and payor is provided.

Behavior is another important component of health, as well as an indicator for health risk and potential improvement. 26.8 percent of individuals in Citrus County reported themselves as smokers. This is higher than Hernando County or the state. 16 percent self reported as heavy or binge drinkers, again higher than Hernando County or the state.

Maternal health issues are also discussed in this section. Of note, the moving three-year average rate for low birthweight babies in Citrus County increased from 1997-1999 through 1999-2001, while Hernando County and state rates either dropped or stayed the same. Nonwhite births are low birthweight and very low birthweight more often than white births, 26 percent and 139 percent more often, respectively.

Focus groups consisting of members of target populations is a technique employed to assess community perceptions of the county's health status and unmet needs. These focus groups are intended to ascertain opinions of individuals identified in target populations of risk and potential health promotion programs. Target populations for these focus groups, as identified through analysis of the demographic, socio-economic and health status report, were elderly, Hispanics, Blacks, residents aged 35-54 and residents aged 18-26. This technique does not provide a quantitative analysis of the individual's opinions, but reveals some of the factors affecting and sentiments about healthcare services. A summary of their discussions is reported without judging the veracity of their remarks.

Overall, participants perceived Citrus County as a relatively healthy place to live. Participants discussed multiple characteristics of healthy community, some of which were characteristic of Citrus County, others of which were not. Some of the attributes identified as part of a health community included an educated population, clean air and water, recreational spaces, a smoke-free environment, and residents who look out for one another. The most common criticisms of the overall health of Citrus County revolved around smoking and obesity. Obesity was discussed in connection with both nutrition and exercise as problem areas.

The most important health issues identified in Citrus County were cost and education. Participants discussed cost as a barrier to access to health care as well as health promotion activities, such as joining a gym or healthy eating. Education was discussed, namely, as it pertains to the acquisition of information. Awareness of existing services was identified as a dominant issue affecting the health of the county.

Participants indicated that communication was necessary to address the current health issues in the county. There was variation in opinion on who was responsible for taking action. Some participants felt the Health Department should be responsible, while others stated that parents or the schools should take responsibility.

Overall, participants agreed that it is possible to improve the overall health of the county. The barriers that they identified included cost, education and an overwhelming sense of individual choice existing within the county. Fragmentation of the community was also identified as a potential barrier.

Review of further discussion surrounding target populations and health promotion programs is provided along with a detailed review of opinions summarized here.

Additionally, interviews were conducted to obtain a voice from the Hispanic population, which staff was unsuccessful at recruiting to attend focus groups. The voice of the Hispanic population echoed that of the focus groups.

Community forums were conducted in order to create a set of recommendations and action plan based on the quantitative and qualitative data. Forums were made up of community leaders, including health care professionals. Through utilization of the Popular Empirical Assessment for Community Health (PEACH), participants prioritized health issues in Citrus County. Through further discussion, participants developed the results of the process into four strategies for improving the health of Citrus County residents. The four strategies identified through the forums are:

To develop and implement a 211 call line whereby county residents can obtain information on existing services within the county;

To conduct a welcome fair to inform new and long-time residents of Citrus County of the services and resources to promote health available within their community;
To develop and implement a family mental health promotion campaign; and
To develop and implement a community awareness campaign on respiratory disease.

One of the major goals of the Community Needs Assessment process is to identify the critical health issues in Citrus County and to prioritize these issues in a systematic fashion. Based in large part upon the strategies and action plans identified through the community forums, the recommended priority strategies are listed below. Further detail for the implementation of the action plan is provided.

Develop and implement a 211 call line whereby county residents can obtain information on existing services within the county

Collaborate with Shared Services Alliance to provide Citrus County with a social service information call line

2. Develop an internal Health Department Communications Team (HDCT) to coordinate the Health Departments services updates for the 211 call line

Conduct a welcome fair to inform new and longtime residents of Citrus County of the services and resources to promote health available within their community

Create or expand an internal Health Department Communications Team (HDCT)
Identify and collaborate with Service Fair partners
Participate in monthly meetings
Develop sponsoring partnerships
Schedule and market semi-annual events
Hold events in April and October

Develop and implement a family mental health promotion campaign

Establish a Mental Health Task Force (MHTF) and subcommittees therein
Seek appropriate funding for county mental health promotion campaign
Review best practices for models of social marketing of mental health programs
Develop a Mental Health Promotion Campaign

Develop and implement a community awareness campaign on respiratory disease

Develop a multi-media communications campaign
Develop a workplace Freedom from Smoking Campaign
Work with pharmacies and private physicians to encourage clients to mark emergency inhalants with a red sticker

Develop and improve the communication mechanisms between the Citrus County Health Department and the community