2016 Cobb and Douglas Community Health Assessment EXECUTIVE SUMMARY

Transcription

1 2016 Cbb and Duglas Cmmunity Health Assessment EXECUTIVE SUMMARY

2 Table f Cntents Letter frm Leadership... 2 Intrductin... Errr! Bkmark nt defined. Cbb Cunty CHA... 5 Cunty Sci-demgraphics... 5 Leading Causes f Death... 7 Chrnic Diseases... Errr! Bkmark nt defined. Chrnic Disease Risk Factrs... Errr! Bkmark nt defined. Mental and Behaviral Health Maternal, Child, and Adlescent Health Infectius Diseases Envirnmental Health Duglas Cunty CHA Cunty Sci-demgraphics Leading Causes f Death Chrnic Diseases Chrnic Disease Risk Factrs Mental and Behaviral Health Maternal, Child, and Adlescent Health... Errr! Bkmark nt defined. Infectius Diseases Envirnmental Health Frces f Change Assessment Cbb Cunty Duglas Cunty Lcal Public Health System Assessment (LPHSA) Lcal Resurces in Cbb and Duglas Cunties References..23 1

3 Letter frm Leadership Dear Cmmunity Partner, On behalf f ur cmmunity partners, we are pleased t prvide yu with the 2016 Cmmunity Health Assessment Executive Summary fr Cbb and Duglas cunties. Cbb & Duglas Public Health (CDPH), alng with Kennesaw State University (KSU) and the steering teams f Cbb2020 A Partnership fr Health and Live Healthy Duglas (LHD), cnducted this thrugh Cmmunity Health Assessment between January 2016 and Octber 2016 t determine leading cmmunity health issues, resident pririties and cmmunity resurces. The partnership uses a natinally-recgnized health assessment and strategic planning mdel - Mbilizing fr Actin thrugh Planning and Partnerships (MAPP) - t identify public health issues in Cbb and Duglas unties, and t develp gals and strategies t address them. This reprt prvides: the mst current, reliable measures t evaluate the health f ur cmmunity trends in key health measures t allw readers t evaluate changes in lcal health status and cmpare these measures t natinal gals resurces fr pririty setting in preventing disease, prmting health and imprving access t care health infrmatin and websites fr mre detailed infrmatin abut the issues linkages t the Cbb2020 and LHD Cmmunity Health Imprvement Plans We gathered and analyzed data fr key cmmunity health indicatrs acrss a cmprehensive set f categries. Due t the cmpressed time and the vluntary nature f these effrts, sme data frm existing surces was utilized. Care was taken t btain data frm credible surces that will be reprducible in the future. Cbb and Duglas data were cmpared t reginal, state and natinal trends when available. The full Cbb and Duglas CHA Technical Reprt is available fr review at (CHA tech reprt weblink will be available in September) The 2016 Cbb and Duglas CHA is a crucial cmpnent f the cmmunity health strategic planning prcess. The 2016 CHA findings are being used t identify key strategic issues and pririties fr cmmunity actin and t develp a cmmunity health imprvement plan available at (CHIP hyperlink). Mre infrmatin abut the Cbb2020 and LHD Strategic Health Plans may be fund at r Please feel free t share and use this infrmatin as needed fr planning and decisin making. We hpe this reprt assists yu in yur effrts t address health-related cncerns in ur cmmunity. Sincerely, Dr. Jhn Kennedy Rebecca Shipley Carl Lindstrm District Directr Chair Chair Cbb & Duglas Public Health Cbb2020 A Partnership fr a Live Healthy Duglas Healthier Cbb Cunty 2

4 Intrductin The Rad t Health Engages Everyne While health is understd as a dynamic state f cmplete physical, mental, spiritual, and scial well-being and nt merely the absence f disease r infirmity, 1 public health is what we as a sciety d cllectively t assure the cnditins in which peple can be healthy. 2 This definitin f public health prvides a basis fr the missin t engage partners in the wrk f prmting and prtecting the health and safety f the residents f Cbb and Duglas cunties. These partners make up the lcal public health system, cmmnly defined as all public, private, and vluntary entities that cntribute t the delivery f essential public health services within a jurisdictin. Ideally, a public health system will include: Public health agencies at state and lcal levels Healthcare prviders Public safety agencies Human service and charity rganizatins Educatin and yuth develpment rganizatins Recreatin and arts-related rganizatins Ecnmic and philanthrpic rganizatins Envirnmental agencies and rganizatins Cbb & Duglas Public Health (CDPH) recgnizes that imprving the cunty s health is a cllabrative effrt with the lcal public health netwrks, scietal infrastructures, and cmmunity members. The Cmmunity Health Assessment (CHA) - A Partner-Driven Prcess The Cmmunity Health Assessment (CHA) is a data cllectin tl that prvides a cmprehensive picture f what is happening related t health in a cmmunity. Such an assessment is typically cnducted every three t five years. In 2011, CDPH engaged ver 60 partners in its first multi-phase CHA. These partners wrked in calitins Cbb 2020 A Partnership fr a Healthier Cbb Cunty and Live Healthy Duglas in Duglas Cunty and used the Mbilizing fr Actin thrugh Planning and Partnerships (MAPP) framewrk 3 t cmplete their CHA and priritize each cunty s public health issues. (The utcmes f the first MAPP prcess are dcumented in the 2012 Cmmunity Health Assessment and Imprvement Plan fr Cbb and Duglas cunties.) In 2016, bth calitins began wrk n the secnd iteratin f the MAPP cycle, starting again with assessment f the cmmunities strengths, needs, and desires. Fr mre infrmatin n these calitins, please visit and MAPP Academic Mdel 3

5 The 2016 CHA was Implemented as Fur Types f Assessments Fllwing the MAPP framewrk t cnduct the 2016 Cmmunity Health Assessment (CHA), CDPH, in partnership with Kennesaw State University (KSU), cnducted fur categries f assessments between January Octber Detailed infrmatin gathered frm these fur assessments is available in the CHA Technical Reprt (hyperlink will be available in September 2017). Cmmunity Health Status Assessment (CHSA) This assessment answers the questins, Hw healthy are ur residents? and What des the health status f ur cmmunity lk like? The results prvide an understanding f the cmmunity s health status and ensure that the cmmunity s pririties cnsider specific health status issues. Methds 1. Primary data cllectin Randm telephne survey f Cbb and Duglas residents with 2,111 calls made and 274 respndents Online survey t Greystne Pwer Crpratin and Cbb Electric Membership Crpratin (EMC) custmers in Cbb and Duglas cunties 291 respndents 2. Secndary data cllectin Lcal data frm numerus reliable surces, primarily Gergia Department f Public Health s OASIS ( and U.S. Census Bureau ( Cmmunity Themes & Strengths Assessment This assessment prvides a deep understanding f the issues residents feel are imprtant by answering the questins What is imprtant t ur cmmunity? Hw is quality f life perceived in ur cmmunity? and What assets d we have that can be used t imprve cmmunity health? 1. Primary data cllectin Same as CHSA Methds Cbb and Duglas Cunty fcus grups 6 cmmunity grups, strategized t give a vice t ptentially-disparate ppulatins 1 healthcare prvider grup 2. Secndary data cllectin Same as CHSA Secndary data shared by WellStar Health System s 2016 Cmmunity Health Needs Assessment (CHNA) Key Infrmant Survey and Hispanic ppulatin fcus grups Lcal Public Health System Assessment This assessment answers the questins, What are the cmpnents, activities, cmpetencies, and capacities f ur lcal public health systems? and Hw are the 10 Essential Public Health Services being prvided t ur cmmunity? Methds 1. Online survey t 65 lcal representatives (including healthcare, schls, emplyers, state and lcal public health, city gvernment) t rate the lcal public health system s perfrmance against Mdel Standards, the gld standard n Ten Essential Public Health Services (EPHS) 4 2. Fllwed by a 1.5-hur in-persn meeting t discuss survey results and identify strengths, weaknesses, and pprtunities Frces f Change Assessment This assessment answers the questins, What is ccurring r might ccur that affects the health f ur cmmunity r the lcal public health system? and What specific threats r pprtunities are generated by these ccurrences? Methds CHA Frces f Change findings ed t Cbb2020 and Live Healthy Duglas Steering Cmmittees fr review 2. Fllwed by a 1.5 hur in-persn meeting with bth Steering Cmmittees separately t discuss: - What has significantly changed in the cunty since 2012 and what is expected t change in the future? -What frces nw and in the future can reinfrce health equity in the cmmunity? -Hw can we take advantage f these frces? 4

6 Cbb Cunty CHA Cunty Sci-demgraphics Cbb Cunty's Ppulatin Cntinues t Increase, , , , , , , Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health, 2016 Cbb Cunty s ppulatin increased by 6.3% in a five-year span, frm 697,553 in 2011 t 741,334 in While Cbb Cunty s ppulatin remained predminately white (64% in 2015), the cunty saw larger increases in minrity ppulatins between 2011 and 2015: the African American ppulatin increased by 14.2%, frm 180,339 t 205,979; the Asian ppulatin increased by 20.2%, frm 32,657 t 39,258; the Multiracial ppulatin increased by 18.6%, frm 15,096 t 17,908; the Hispanic r Latin (any race) ppulatin increased by 8.4%, frm 87,477 t 94,853. Ppulatin by Race, Cbb Cunty, % 1% 0% 2% 28% 64% White Asian Native Hawaiian r Pacific Islander Black r African-American American Indian r Alaska Native Multiracial Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health,

7 Sci-demgraphic Snapsht f Cbb Cunty Language Age Incme Emplyment Pverty Cbb Cunty cntained 274,468 husehlds between , and 3.6% f Cbb Cunty husehlds had limited English-speaking ability. 5 The median age in Cbb Cunty was 36.3 years in 2015, an increase frm 35.6 years in Between 2011 and 2015, residents years ld cmpsed the largest age grup, at 41%. Hwever, the number f residents 65+ years ld increased by 28.5% during this time perid. 6 The median husehld incme (in inflatin-adjusted 2014 dllars) in Cbb Cunty was $64,657. This is higher than bth the US and Gergia median husehld incmes f $53,657 and $49,342, respectively. In the same time frame, the per capita incme in Cbb Cunty was higher than the state average, at $33,418 and $25,427, respectively. 7 The unemplyment rate in Cbb Cunty was 5.9% in 2015, dwn frm 11.1% unemplyment in In 2015, 70.4% f Cbb Cunty residents aged 16 and lder were in the civilian labr frce, with a civilian emplyed ppulatin f 383, Health Insurance Educatin Husing 12.4% f Cbb Cunty residents were belw pverty level between , cmpared t 18.4% f Gergia residents belw pverty level in the same time perid. Pverty levels disprprtinally affected sme residents f Cbb Cunty by race and ethnicity, age grup, educatinal attainment, and emplyment status between : 17.6% f African-Americans and 25.5% f Hispanics were belw the pverty level, cmpared t 7.3% f the white, nn-hispanic ppulatin belw the pverty level. 17.4% f children under the age f 18 were belw the pverty level, cmpared t 11.3% f adults aged 18-64, and 7.2% f adults 65 years and ver. 25.7% f residents with less than a high schl diplma were belw the pverty level, cmpared t 15.1% f high schl graduates (r equivalent) and 4.2% f thse with a Bachelr's degree r higher belw the pverty level. 5 Of the civilian nninstutinalized residents f Cbb Cunty, 13.3% had n health insurance cverage in 2015, a decrease frm 18.7% in Cbb Cunty high schl (Cbb and Marietta districts cmbined) graduatin rates increased 20.5% ver the timespan, frm 64.8% t 78.1%. Hwever, within Cbb Cunty, Hispanic (56.9%) and African-American (65.4%) students had lwer graduatin rates than their Asian (89.8%) and white (85.6%) cunterparts. Ecnmically-disadvantaged students (all races) als had lwer graduatin rates, at 70.2%. 9 The median value f Cbb Cunty s wner-ccupied husing units ( ) was $197,400, which is higher than the median value f $148,100 in Gergia during the same time perid. The median grss rent in Cbb Cunty ( ) was $1,006, als higher than the Gergia median grss rent f $

8 Leading Causes f Death in Cbb Cunty The dashbard belw represents the age-adjusted death rate fr the 10 mst cmmn causes f death in Cbb Cunty. The clrcded gauge represents percentiles frm the lwest rate (green) t the highest rate (red). The dashbard needle indicates Cbb Cunty s rate, the label GA indicates Gergia s statewide rate, and the number belw the cause f death is the number f deaths in that time perid. Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health, 2016 Premature death is defined as death befre age 75. The tp causes f premature deaths in Cbb Cunty belw are ranked by Years f Ptential Life Lst (YPLL), which is the number f years a persn died befre age 75. Leading Causes f Premature Death in Cbb Cunty, Accidental pisning and expsure t nxius 6. Malignant neplasms (Cancer) f the trachea, brnchus, and substances lung 2. Certain cnditins riginating in the perinatal perid 7. Assault (Hmicide) 3. Intentinal self-harm (Suicide) 8. Cngenital malfrmatins, defrmatins and chrmsmal abnrmalities 4. Ischemic heart and vascular disease 9. Cerebrvascular disease (Strke) 5. Mtr vehicle crashes 10. Malignant neplasm f the breast (Breast cancer) The #1 cause f premature death in Cbb Cunty between was due t accidental pisning by and expsure t nxius substances, defined by the Wrld Health Organizatin as accidental (specifically nt suicidal r hmicidal) verdses; the wrng drug being given r taken in errr; drugs taken inadvertently; drug-related accidents in medical and surgical prcedures; and accidental r nt-clearly-intentinal pisning. 10 It was previusly the #4 cause f premature death. The primary grup affected between was white males aged years ld, with 113 deaths in that five-year perid. 6 7

9 Chrnic Diseases in Cbb Cunty Cardivascular Disease Cardivascular disease is the #1 cause f death in bth men and wmen acrss the United States and in Cbb Cunty. It is respnsible fr 1 in every 4 deaths, and it kills abut 610,000 peple every year. Tw cmpnents f cardivascular disease were respnsible fr many deaths in Cbb Cunty between : 1. Ischemic heart & vascular disease the #1 cause f death 2. Cerebrvascular disease, better knwn as strke the #4 cause f death Death rates due t cardivascular diseases in Cbb Cunty between differed greatly by sex and racial grups: Males had a higher death rate frm cardivascular disease (165.0 per 100,000) than females (153.0). White males had the highest death rate (206.3 per 100,000), fllwed by white females (199.3). African-American males and females died frm cardivascular disease at nearly half thse rates, at and 90.1, respectively. 6 Results frm the Cbb Cunty CHA Survey revealed interesting findings regarding the prevalence f cardivascular disease in Cbb Cunty residents specifically abut their chlesterl levels and bld pressure levels. Cancer The vast majrity f survey participants (88.9%) had their chlesterl checked at least nce. Of thse peple, 40.6% said they had been tld by a medical prfessinal their chlesterl levels were high. Over a third (39.5%) f Cbb Cunty survey participants said they had been tld at sme pint by a medical prfessinal that they have high bld pressure, with an additinal 7.4% being tld their bld pressure was brderline r pre-hypertensive. Three types f cancer (Cancer f the Trachea, Brnchus, & Lungs; Cln, Rectum & Anus, and Breast) were in the tp 10 causes f death & premature death in Cbb Cunty between Bth Cbb Cunty s and Gergia s age-adjusted mrtality rate due t all types f cancer declined slightly ver that same time perid, but Cbb Cunty s average rate (147.1 per 100,000) was lwer than Gergia s statewide rate (164.9). Death rates due t cancer in Cbb Cunty differed greatly by sex, race, and age grups: Diabetes Males had a higher death rate frm cancer (130.5 per 100,000) than females (119.2). White males had the highest death rate (163.0 per 100,000), fllwed by white females (144.5). African-American males and females died frm cancer at abut half thse rates, at 73.6 and 88.2, respectively. 6 Diabetes was the #11 cause f death in Cbb Cunty during A 2014 Behaviral Risk Factr Surveillance System (BRFSS) survey f the Cbb & Duglas district revealed that 6.8% f the cunties adult residents had diabetes. 11 Asthma Males had a slightly higher rate f diabetes (7.6%) than females (5.9%). Whites and African-Americans had almst the same rates f diabetes, at 7.3% and 7.4%, respectively. Older residents had much higher rates f diabetes than yunger residents. 11 Asthma was the #1 cause f hspitalizatins in children aged 1-9 years and #9 cause f emergency department (ED) use in all ages in Cbb Cunty during There were 18,288 visits t the ED, a statistically significant increase frm , but lwer than Gergia s rate during that time perid. Between , asthma-related ED visit rates by Cbb Cunty children aged 0-17 years with Medicaid, PeachCare, r Self-Pay * were ver three times higher than visits by children with private insurance, at and per 100,000, respectively. 6 * Medicaid, based n Title XIX f the Scial Security Act, is a Federal-State matching entitlement prgram that pays fr medical assistance fr certain vulnerable and needy individuals and families with lw incmes and resurces; PeachCare fr Kids (Gergia's State Child Health Insurance Prgram (SCHIP)) is a prgram that prvides cmprehensive health care insurance fr children thrugh the age f 18 wh d nt qualify fr Medicaid and live in husehlds with incmes at r belw the federal pverty level; Self-Pay includes patients with n prf f insurance, patients filing their wn insurance claims, patients paying their wn bills, Hill-Burtn cases, charity cases, etc. 8

10 Chrnic Disease Risk Factrs in Cbb Cunty Overweight and Obesity In adults, besity increases the risk f develping chrnic diseases that are sme f the leading causes f death, including high bld pressure, Type 2 diabetes, crnary heart disease, strke, high chlesterl, gallbladder disease and sme types f cancers. In children, besity increases the risk fr chrnic health cnditins such as asthma, sleep apnea, bne and jint prblems, and Type 2 diabetes, and it may lead t adult besity. 12 Results frm the 2014 BRFSS survey fund that 37.9% f the Cbb & Duglas district s adult residents were verweight and 23.4% were bese. This was higher than Gergia s 2014 prevalence f verweight adults (35.2%) but lwer than the state s besity prevalence (30.5%). The BRFSS survey als fund that African-Americans (bth sexes) in the district had a higher rate f besity than white residents, and males (all races) in the district had higher besity rates than females. 11 Nutritin A nutritius diet can help prevent besity, cardivascular disease, steprsis and bne fractures, dental prblems (e.g., cavities, gum disease, tth lss), and certain types f cancer. Hwever, nearly half f Gergia adlescents eat fruits r vegetables less than 1 time daily. Nearly half f Gergia adults eat fruit less than 1 time daily, and nearly a quarter eat vegetables less than 1 time daily. 13 In the Cbb & Duglas CHA Fcus Grups, participants identified challenges they face in btaining healthy fd, such as: the small number f quick-service restaurants that serve healthy fd versus the many fast-fd utlets that serve unhealthy fd; the high cst f nutritius fds at quick-service restaurants versus thse same restaurants highly prcessed 99-cent specials; the scarcity f fresh, natural fds in the city; prblems grwing vegetables during the summer heat and in Cbb and Duglas cunties red clay sil. Physical Activity Physical activity is a vital part f a healthy lifestyle. The cmbinatin f exercise and making gd fd chices can help peple maintain a healthy weight, reduce their risk f chrnic diseases, and imprve their general physical and mental health. Results frm the 2014 BRFSS Survey fund that 17.4% f Cbb and Duglas adult residents reprted n leisure-time physical activities in the past mnth. The prevalence f physical inactivity was higher amng females (19.6%) than males (15.4%), and higher amng white residents (19.1%) than African-American residents (12.6%). 11 Participants in the Cbb Cunty CHA Survey were asked t rate the pprtunities fr physical activity in the areas in which they lived. Of the Cbb Cunty respndents, 81.4% rated them as Gd r Very Gd; 9.0% rated them as Fair; 6.4% rated them as Pr r Very Pr; 3.2% didn't knw r refused t answer. 9

11 Mental and Behaviral Health in Cbb Cunty Mental Illness Mental illnesses are health cnditins invlving changes in thinking, emtin r behavir (r a cmbinatin f these). Mental illnesses are assciated with distress and/r prblems functining in scial, wrk r family activities. 14 Unfrtunately, the current rates f mental illnesses amng Gergia and Cbb Cunty residents are unknwn. Hwever, in a 2016 reprt, the Cbb and Duglas Cmmunity Services Bards (CSB), which prvide citizens challenged by mental health, develpmental disabilities and/r addictive disease issues with apprpriate care and resurces, reprted serving apprximately 6,000 individuals in Cbb and Duglas cunties per year. Of thse patients seen at CSB, 50% were diagnsed with Md Disrders, 25% with Anxiety Disrders, and 25% with Psychtic Disrders. In the Cbb Cunty CHA Survey, 10.9% f survey participants reprted they are currently taking medicine r receiving treatment frm a dctr r ther health prfessinal fr any type f mental health cnditin r emtinal prblem. Substance Use Disrders Accrding t Substance Abuse and Mental Health Services Administratin (SAMHSA), Substance use disrders ccur when the recurrent use f alchl and/r drugs causes clinically and functinally significant impairment, such as health prblems, disability, and failure t meet majr respnsibilities at wrk, schl, r hme. The United States, including Gergia, is currently experiencing an piid epidemic. Opiids are a class f drugs used t reduce pain. Types include prescriptin drugs, fentanyl, and herin. In bth Gergia and Cbb Cunty, age-adjusted death rates frm verdses f all piids (including bth prescriptin piids and herin) increased between 2011 and The increase in Cbb Cunty was mst drastic, frm 12 deaths at a rate f 1.7 per 100,000 in 2011 t 88 deaths at a rate f 11.4 per 100,000 in Age-Adjusted Death Rates in Cbb Cunty and Gergia frm Opiids, Gergia Cbb Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health, 2016 Within Cbb Cunty, certain grups have been mst affected by the recent piid epidemic. Between , the white nn- Hispanic ppulatin had an age-adjusted death rate frm piid verdses nearly six times higher than the African-American ppulatin, at 8.7 versus 1.5 per 100,000, respectively. Males (all races) in Cbb Cunty saw an age-adjusted death rate f mre than duble that f females, at 7.1 versus 3.0 per 100,000, respectively. Of all the life stages, adults aged years ld in Cbb Cunty had the highest number and rate f deaths, with a ttal f 131 deaths, and a death rate f 10.1 per 100,

12 Maternal, Child, and Adlescent Health in Cbb Cunty Pregnancies and Births Cbb Cunty recrded 61,806 pregnancies, with an aggregate pregnancy rate * f 51.0 per 1,000, between 2011 and 2015, nearly equal t Gergia s pregnancy rate f 50.8 in the same time perid. Pregnancy rates decreased 6.2% in Cbb Cunty between 2011 and 2015, frm 53.1 t 49.8 per 1,000, respectively. Teenage pregnancies als decreased in this time frame, frm 36.9 t 23.3 per 1,000, mirrring the state s decline frm 50.0 in 2011 t 33.5 per 1,000 in In the same five years, Cbb Cunty recrded 47,162 live births, with an aggregate birth rate ** f 38.9 per 1,000. Birth rates remained relatively stable in Cbb Cunty. Hispanic females had the highest pregnancy rates in the cunty, in bth teenage and adults age grups. 6 Pr Birth Outcmes 1. Lw Birthweight babies weighing less than 5.5 punds r 2500 grams at birth: 8.4% f Cbb Cunty infants, a ttal f 3,956, were brn at a lw birthweight between Females aged years had the highest percentage f lw birthweight babies cmpared t ther age grups, fllwed by teenage mthers aged years. African-American females f all ages had the highest percentage f lw birthweight babies cmpared t ther racial/ethnic grups. 2. Infant Mrtality - the death f a baby befre his r her first birthday frm any cause: A ttal f 280 infants died in Cbb Cunty between 2011 and 2015, with an aggregate infant mrtality rate f 5.9 per 1,000. Hwever, there was a 30% increase frm 5.4 in 2011 t 7.0 per 1,000 in With 142 deaths, African-American infants had the highest rate f death, with a five-year aggregate infant mrtality rate f 10.8 and an increase frm 10.9 in 2011 t 11.8 per 1,000 in Adlescent Health Issues In 6 12 th grade students frm bth public-schl systems in Cbb Cunty, a ttal f 47,547 adlescents were surveyed: Physical Activity: 12.2% (5,822 students) reprted they were nt physically active fr at least 60 minutes n any day in the past 7 days. An additinal 8.6% (4,075 students) were physically active nly ne day in the past week; Alchl Use: 7.8% (3,727 students) reprted drinking alchl at least ne day ut f the last 30 days, with 144 f thse students reprting having at least ne drink f alchl every single day in the past 30 days; Electrnic Vapr Prducts: 3% (1,433 students) reprted smking an electrnic vapr n at least ne day ut f the last 30 days; Prescriptin Drug Use: Of the 7,740 students reprting using prescriptin drugs withut a dctr's prescriptin, 70.8% said they used it fr "medical reasns" and the remaining 29.2% (2,260 students) reprted using prescriptin drugs t either "feel mre alert", "relax r quiet my nerves", "enjy myself", r "get high ; Attempted Suicide: 9% (4,258 students) reprted they have seriusly cnsidered attempting suicide at least ne time in the past 12 mnths, with mre than ne-third f these students seriusly cnsidering it at least 3 times. 15 * Pregnancy rate is the ttal number f pregnancies (including live births, abrtins and fetal deaths) per 1,000 females ages years f age. ** Birth rate is the number f live births per 1,000 females ages years f age. 11

13 Infectius Diseases in Cbb Cunty Infectius diseases are caused by pathgenic micrrganisms such as bacteria, viruses, and parasites. These diseases spread frm persn t persn thrugh a variety f methds, and may lead t epidemics. A primary missin f CDPH is preventing epidemics and the spread f disease within ur cmmunity. Per the legal authrity f the Official Cde f Gergia (OCGA sectin ), diseases deemed ntifiable by the state must be reprted t Public Health by physicians, labratrians, and ther health care prviders. (CDPH Ntifiable Disease Pster) One f the ntifiable diseases, syphilis, remains a majr and increasing health prblem bth lcally and natinally. It is a bacterial infectin that may cause genital ulcers and ther, ptentially fatal effects. If syphilis is left untreated, it may cntribute t transmitting and acquiring HIV infectin. In 2015: Gergia reprted the secnd-highest rate f primary and secndary (P&S) syphilis in the US 14.0 per 100,000 which is nearly duble that year s natinal rate; Cbb Cunty reprted the 60th-highest number f primary and secndary syphilis cases in US cunties and independent cities (11.2 per 100,000); Males made up the vast majrity f primary and secndary syphilis, bth lcally and natinally; African-Americans (bth genders, all ages) had the highest rate f P&S syphilis in Cbb Cunty. 6 Envirnmental Health in Cbb Cunty Frm , the air quality in Cbb Cunty has generally imprved. The yearly percentage f Air Quality Index (AQI) scres in the best pssible range (Gd) has increased nearly every year, while the ttal number f days per year in which a AQI scre was measured has als generally increased ver time--frm 317 days in 2011 t 362 days in Frm , fine particulate matter (PM2.5) has been the main pllutant in Cbb Cunty fr several mre days per year than Ozne, with an average f 222 days versus 118 days, respectively Air Quality Index in Cbb Cunty, Gd Mderate Unhealthy fr Sensitive Grups Surce: Envirnmental Prtectin Agency, Air Quality Index Reprt,

14 Duglas Cunty CHA Cunty Sci-demgraphics 142, , , , , , ,000 Duglas Cunty's Ppulatin Cntinues t Increase, , Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health, 2016 Duglas Cunty s ppulatin increased by 5.5% in a five-year span, frm 133,355 in 2011 t 140,733 in While Duglas Cunty s White ppulatin decreased by 4%, the cunty saw larger increases in minrity ppulatins between 2011 and 2015: the African-American ppulatin increased by 12.9%, frm 55,538 t 62,688; the Multiracial ppulatin increased by 31.5%, frm 2,634 t 3,464; the Asian ppulatin increased by 11.1%, frm 2,196 t 2,440; the Hispanic ppulatin increased by 11.3%, frm 11,452 t 12,747. Ppulatin by Race, Duglas Cunty, % 0% 2% 2% 45% 51% White Asian Native Hawaiian r Pacific Islander Black r African-American American Indian r Alaska Native Multiracial Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health,

15 Sci-demgraphic Snapsht f Duglas Cunty Language Age Incme Emplyment Pverty Duglas Cunty cntained 48,493 husehlds between , and 1.9% f Duglas Cunty husehlds had limited English-speaking ability. 5 The median age in Duglas Cunty was 36.7 years in 2015, a slight increase frm 36.3 in Between 2011 and 2015, residents years ld cmpsed the largest age grup, at 41%. Hwever, the number f residents 65+ years ld increased by 25.1% during this time perid. 6 The median husehld incme (in inflatin-adjusted 2014 dllars) in Duglas Cunty was $52,997. This is higher than Gergia but lwer than the US median husehld incmes f $49,342 and $53,657, respectively. In the same time frame, the per capita incme in Duglas Cunty was lwer than the state average, at $23,356 and $25,427, respectively. 7 The unemplyment rate in Duglas Cunty was 8.8% in 2015, dwn frm 15.6% unemplyment in In 2015, 66.4% f Duglas Cunty residents aged 16 and lder were in the civilian labr frce, with a civilian emplyed ppulatin f 65, Health Insurance Educatin Husing 16.4% f Duglas Cunty residents were belw pverty level between , cmpared t 18.4% f Gergia residents belw pverty level. Pverty levels disprprtinally affected sme residents f Duglas Cunty by race and ethnicity, age grup, and educatinal attainment: 58.9% f American Indian/Alaskan Natives, 18.6% f African-Americans and 27.6% f Hispanics were belw the pverty level, cmpared t 12% f the White, nn-hispanic ppulatin. 22% f children under the age f 18 were belw the pverty level, cmpared t 15% f adults aged 18-64, and 9.9% f adults 65 years and ver. 29.7% f residents with less than a high schl diplma were belw the pverty level, cmpared t 13.8% f high schl graduates (r equivalent) and 6.5% f thse with a Bachelr's degree r higher. 5 Of the civilian nninstutinalized residents f Duglas Cunty, 14.5% had n health insurance cverage in 2015, a decrease frm 17.7% in Duglas Cunty high schl graduatin rates increased 22.5% ver the timespan, frm 72% t 88.2%. Hwever, within Duglas Cunty, Hispanic (67.5%) and African-American (74%) students had lwer graduatin rates than their Asian (86.6%) and white (79.1%) cunterparts. Ecnmically-disadvantaged students (all races) als had lwer graduatin rates, at 71.8%. 9 The median value f Duglas Cunty s wner-ccupied husing units ( ) was $121,300, which is lwer than the median value f $148,100 in Gergia during the same time perid. The median grss rent in Duglas Cunty ( ) was $949, which is higher than the Gergia median grss rent f $

16 Leading Causes f Death in Duglas Cunty The dashbard belw represents the age-adjusted death rate fr the 10 mst cmmn causes f death in Duglas Cunty. The clrcded gauge represents percentiles frm the lwest rate (green) t the highest rate (red). The dashbard needle indicates Duglas Cunty s rate, the label GA indicates Gergia s statewide rate, and the number belw the cause f death is the number f deaths in that time perid. Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health, 2016 Premature death is defined as death befre age 75. The tp causes f premature deaths in Duglas Cunty belw are ranked by Years f Ptential Life Lst (YPLL), which is the number f years a persn died befre age 75. Leading Causes f Premature Death in Duglas Cunty, Mtr vehicle crashes 6. Ischemic heart and vascular disease 2. Accidental pisning and expsure t nxius 7. Cngenital malfrmatins, defrmatins, and chrmsmal substances abnrmalities 3. Intentinal self-harm (Suicide) 8. Diabetes mellitus 4. Malignant neplasms (Cancer) f the trachea, 9. Cerebrvascular disease (Strke) brnchus, and lung 5. Certain cnditins riginating in the perinatal perid 10. Assault (Hmicide) The #1 cause f premature death in Duglas Cunty during was mtr vehicle crashes. Males made up a disprprtinate number f the deaths resulting frm mtr vehicle crashes in Duglas Cunty, cmprising 73% (69) f the 95 ttal deaths. The death rate amng males (21.3) was nearly 3 times the death rate in females (7.6) acrss all races and age grups. In particular, white males made up 41%, and African-American males made up 31.5% f all deaths in Duglas Cunty that resulted frm mtr vehicle crashes. 6 15

17 Chrnic Diseases in Duglas Cunty Cancer Malignant neplasms (cancer) f the trachea, brnchus, and lung was the #1 cause f death and the #4 cause f premature death in Duglas Cunty between 2011 and Additinally, cancer f the cln, rectum, and anus was the #10 cause f death in the cunty in this time perid. Bth Duglas Cunty s and Gergia s age-adjusted mrtality rate due t cancer declined slightly between 2011 and 2015, but Duglas Cunty s average rate (170.4 per 100,000) was higher than Gergia s statewide rate (164.9). Death rates due t cancer in Duglas Cunty differed greatly by sex and racial grups: Males had a higher death rate frm cancer (154.3 per 100,000) than females (135.9). White males had the highest death rate (213.2), fllwed by white females (191.7). African-American males and females died frm cancer at far lwer rates, at 84.6 and 82.6, respectively. 6 Cardivascular Disease Cardivascular disease is the #1 cause f death in bth men and wmen acrss the United States. It is respnsible fr 1 in every 4 deaths, and it kills abut 610,000 peple every year. Tw cmpnents f cardivascular disease were respnsible fr many deaths in Duglas Cunty between : 1. Ischemic heart & vascular disease - the #3 cause f death; 2. Cerebrvascular disease, better knwn as strke the #5 cause f death. Death rates due t cardivascular diseases in Duglas Cunty between differed greatly by sex and racial grups: Males had a higher rate f death frm majr cardivascular disease (223.9 per 100,000) than females (175.2). White males had the highest death rate (320.6), fllwed by white females (258.9). African-American males and females died frm cardivascular disease at less than half thse rates, at and 100.5, respectively. 6 Results frm the Duglas Cunty CHA Survey revealed interesting findings regarding the prevalence f cardivascular disease in Duglas Cunty residents specifically abut their chlesterl levels and bld pressure levels. Diabetes The vast majrity f Duglas Cunty survey participants (90.4%) had their chlesterl checked at least nce. Of thse peple, 47.9% said they had been tld by a medical prfessinal their chlesterl levels were high. Well ver a third (42.6%) f Duglas Cunty survey participants said they had been tld at sme pint by a medical prfessinal that they have high bld pressure. Of the ther participants, 8.0% were tld their bld pressure was brderline r pre-hypertensive. Diabetes was the #6 cause f death in Duglas Cunty during A 2014 Behaviral Risk Factr Surveillance System (BRFSS) survey f the Cbb & Duglas district revealed that 6.8% f the cunties adult residents had diabetes. Asthma Males had a slightly higher rate f diabetes (7.6%) than females (5.9%). Whites and African-Americans had almst the same rates f diabetes, at 7.3% and 7.4%, respectively. Older residents had much higher rates f diabetes than yunger residents. 11 Asthma was the #1 cause f hspitalizatins in children aged 1-9 years and #9 cause f emergency department (ED) use in all ages in Duglas Cunty during There were 5,407 visits t emergency rms in that time perid, with a higher rate than Gergia and statistically significant increase frm Between , asthma-related ED visit rates by Duglas Cunty children aged 0-17 years with Medicaid, PeachCare, r Self-Pay were ver three times higher than visits by children with private insurance, at 1,120.6 and per 100,000, respectively. 6 16

18 Chrnic Disease Risk Factrs in Duglas Cunty Overweight and Obesity In adults, besity increases the risk f develping chrnic diseases that are sme f the leading causes f death, including high bld pressure, Type 2 diabetes, crnary heart disease, strke, high chlesterl, gallbladder disease and sme types f cancers. In children, besity increases the risk fr chrnic health cnditins such as asthma, sleep apnea, bne and jint prblems, and Type 2 diabetes, and it may lead t adult besity. 12 Results frm the 2014 BRFSS survey fund that 37.9% f the Cbb & Duglas district s adult residents were verweight and 23.4% were bese. This was higher than Gergia s 2014 prevalence f verweight adults (35.2%) but lwer than the state s besity prevalence (30.5%). The BRFSS survey als fund that African-Americans (bth sexes) in the district had a higher rate f besity than white residents, and males (all races) in the district had higher besity rates than females. 11 Nutritin A nutritius diet can help prevent besity, cardivascular disease, steprsis and bne fractures, dental prblems (e.g., cavities, gum disease, tth lss), and certain types f cancer. Hwever, nearly half f Gergia adlescents eat fruits r vegetables less than 1 time daily. Nearly half f Gergia adults eat fruit less than 1 time daily, and nearly a quarter eat vegetables less than 1 time daily. 13 In the Cbb & Duglas CHA Fcus Grups, participants identified challenges they face in btaining healthy fd, such as: the small number f quick-service restaurants that serve healthy fd versus the many fast-fd utlets that serve unhealthy fd; the high cst f nutritius fds at quick-service restaurants versus thse same restaurants highly prcessed 99-cent specials; the scarcity f fresh, natural fds in the city; prblems grwing vegetables during the summer heat and in Cbb and Duglas cunties red clay sil. Physical Activity Physical activity is a vital part f a healthy lifestyle. The cmbinatin f exercise and making gd fd chices can help peple maintain a healthy weight, reduce their risk f chrnic diseases, and imprve their general physical and mental health. Results frm the 2014 BRFSS Survey fund that 17.4% f Cbb and Duglas adult residents reprted n leisure-time physical activities in the past mnth. The prevalence f physical inactivity was higher amng females (19.6%) than males (15.4%) and white residents (19.1%) than African-American residents (12.6%). Participants in the Duglas Cunty CHA Survey were asked t rate the pprtunities fr physical activity in the areas in which they lived. Of the respndents, 76.6% rated them as Gd r Very Gd; 11.7% rated them as Fair; 5.9% rated them as Pr r Very Pr; 5.9% didn't knw r refused t answer. 17

19 Mental and Behaviral Health in Duglas Cunty Mental Illness Mental illnesses are health cnditins invlving changes in thinking, emtin r behavir (r a cmbinatin f these). Mental illnesses are assciated with distress and/r prblems functining in scial, wrk r family activities. 14 Unfrtunately, the current rates f mental illnesses amng Gergia and Duglas Cunty residents are unknwn. Hwever, in a 2016 reprt, the Cbb and Duglas Cmmunity Services Bards (CSB), which prvide citizens challenged by mental health, develpmental disabilities and/r addictive disease issues with apprpriate care and resurces reprted serving apprximately 6,000 individuals in Cbb and Duglas cunties per year. Of thse patients seen at CSB, 50% were diagnsed with Md Disrders, 25% with Anxiety Disrders, and 25% with Psychtic Disrders. In the Duglas Cunty CHA Survey, 15% f survey participants reprted they are currently taking medicine r receiving treatment frm a dctr r ther health prfessinal fr any type f mental health cnditin r emtinal prblem. Substance Use Disrders Accrding t Substance Abuse and Mental Health Services Administratin (SAMHSA), Substance use disrders ccur when the recurrent use f alchl and/r drugs causes clinically and functinally significant impairment, such as health prblems, disability, and failure t meet majr respnsibilities at wrk, schl, r hme. The United States, including Gergia, is currently experiencing an piid epidemic. Opiids are a class f drugs used t reduce pain. Types include prescriptin drugs, fentanyl, and herin. In bth Gergia and Duglas Cunty, age-adjusted death rates frm verdses f all piids (including bth prescriptin piids and herin) increased between 2011 and 2015, with a mre dramatic increase in Duglas Cunty frm 5.2 in 2011 t 11.4 per 100,000 in A ttal f 55 Duglas Cunty residents lst their lives t piid verdses, with 38 f thse frm misuse f prescriptin piid pain relievers alne, between 2011 and Age-Adjusted Death Rates frm Opiids in Duglas Cunty and Gergia, Gergia Duglas Surce: Online Analytical Statistical Infrmatin System, Office f Health Indicatrs fr Planning, Gergia Department f Public Health, 2016 Within Duglas Cunty, certain grups have been mst affected by the recent piid epidemic. The white nn-hispanic ppulatin had an age-adjusted death rate frm piid verdses ver six times higher than the African-American ppulatin, at 16.2 versus 2.6 per 100,000, respectively, between 2011 and Males (all races) in Duglas Cunty saw an age-adjusted death rate f mre than duble that f females, at 11.2 versus 5.3 per 100,000, respectively, between 2011 and Of all the life stages, adults aged years ld in Duglas Cunty had the highest number and rate f deaths, with a ttal f 38, and a death rate f 16.2 per 100,

20 Maternal, Child, and Adlescent Health in Duglas Cunty Pregnancies and Births Duglas Cunty recrded 11,406 pregnancies, with an aggregate pregnancy rate * f 48.8, between 2011 and 2015, lwer than Gergia s pregnancy rate f 50.8 in the same time perid. Pregnancy rates remained relatively stable in Duglas Cunty between 2011 and 2015, with nly a 1.8% decrease frm 50.8 t 49.9 per 1,000, respectively. Teenage pregnancies als decreased during this time, frm 46.9 in 2011 t 33.8 per 1,000 in In the same five years, Duglas Cunty recrded 8,806 live births, with an aggregate birth rate ** f 37.6, lwer than Gergia s birth rate f 40.4 in the same time perid. Birth rates remained relatively stable in Duglas Cunty. Multiracial females had the highest adult pregnancy rates in the cunty; hwever, Hispanic females had the highest teen pregnancy rate. 6 Pr Birth Outcmes 1. Lw Birthweight babies weighing less than 5.5 punds r 2500 grams at birth: 9.5% f Duglas Cunty infants, a ttal f 836, were brn at a lw birthweight between Females aged years had the highest percentage f lw birthweight babies cmpared t ther age grups, fllwed by teenage mthers aged years. African-American females f all ages had the highest percentage f lw birthweight babies cmpared t ther racial/ethnic grups. 2. Infant Mrtality - the death f a baby befre his r her first birthday frm any cause: A ttal f 64 infants died in Duglas Cunty between , with an aggregate infant mrtality rate f 7.3 per 1,000. Hwever, a 45% increase frm 6.7 in 2011 t 9.7 per 1,000 in With 34 deaths, African-American infants had the highest rate f death f all infants, with a five-year aggregate infant mrtality rate f 9.1 and an increase frm 9.8 in 2011 t 11.8 per 1,000 in Adlescent Health Issues In 6th 12 th grade students frm the Duglas Cunty Schl System, a ttal f 10,682 adlescents were surveyed: Physical Activity: 13.6% (1,453 students) reprted they were nt physically active fr at least 60 minutes n any day in the past 7 days. An additinal 7.9% (841 students) were physically active nly ne day in the past week; Alchl Use: 6.5% (698 students) reprted drinking alchl at least ne day ut f the last 30 days, with 18 f thse students reprting having at least ne drink f alchl every single day in the past 30 days; Electrnic Vapr Prducts: 4.4% (469 students) reprted smking an electrnic vapr n at least ne day ut f the last 30 days; Prescriptin Drug Use: Of the 1,916 students reprting using prescriptin drugs withut a dctr's prescriptin, 77.7% said they used it fr "medical reasns" and the remaining 22.3% (427 students) reprted using prescriptin drugs t either "feel mre alert", "relax r quiet my nerves", "enjy myself", r "get high ; Attempted Suicide: 8.8% (941 students) reprted they have seriusly cnsidered attempting suicide at least ne time in the past 12 mnths, with mre than ne-third f these students seriusly cnsidering it at least 3 times. 15 * Pregnancy rate is the ttal number f pregnancies (including live births, abrtins and fetal deaths) per 1,000 females ages years f age. ** Birth rate is the number f live births per 1,000 females ages years f age. 19

21 Infectius Diseases in Duglas Cunty Infectius diseases are caused by pathgenic micrrganisms such as bacteria, viruses, and parasites. These diseases spread frm persn t persn thrugh a variety f methds, and may lead t epidemics. A primary missin f CDPH is preventing epidemics and the spread f disease within ur cmmunity. Per the legal authrity f the Official Cde f Gergia (OCGA sectin ), diseases deemed ntifiable by the state must be reprted t Public Health by physicians, labratrians, and ther health care prviders. (CDPH Ntifiable Disease Pster) One f the ntifiable diseases, syphilis, remains a majr and increasing health prblem bth lcally and natinally. It is a bacterial infectin that may cause genital ulcers and ther, ptentially fatal effects. If syphilis is left untreated, it may cntribute t transmitting and acquiring HIV infectin. In 2015: Gergia reprted the secnd-highest rate f primary and secndary (P&S) syphilis in the US 14.0 per 100,000 which is nearly duble that year s natinal rate; Duglas Cunty reprted an increase f 108.6% frm 2014 t 2015 in P&S syphilis rates, frm 5.8 t 12.1 per 100,000. Males made up the vast majrity f primary and secndary syphilis, bth lcally and natinally; African-Americans (bth genders, all ages) had the highest rate f P&S syphilis in Duglas Cunty. 6 Envirnmental Health in Duglas Cunty The air quality in Duglas Cunty has imprved frm 2011 t Althugh the annual number f days in which an Air Quality Index (AQI) was measured has remained fairly cnsistent, the percentage f AQI scres in the best pssible range (Gd) has increased while the percentage f AQIs in the Mderate and Unhealthy fr Sensitive Grups ranges has decreased. Frm , Ozne was identified as the main pllutant in Duglas Cunty; hwever, fine particulate matter (PM2.5) was nt measured in this time perid. 250 Air Quality Index in Duglas Cunty, Gd Mderate Unhealthy fr Sensitive Grups Surce: Envirnmental Prtectin Agency, Air Quality Index Reprt,

22 Frces f Change Assessment Cbb Cunty A ttal f ten frces representing the greatest pprtunities and threats fr Cbb Cunty were identified during the Frces f Change assessment. Access t healthcare* Behaviral health* Cmmunity health* Public transprtatin Onset f prfessinal sprts Educatinal changes Technlgy advances Increasing aging ppulatin Ecnmy Increase in racial/ethnic diversity *These frces emerged as the largest cntributing factrs t the physical and mental health f Cbb Cunty residents. Duglas Cunty A ttal f seven frces representing the greatest pprtunities and threats fr Duglas Cunty were identified at the Frces f Change assessment. Pst-recessin upswing* Cmmunity health* Behaviral health* Public transprtatin Access t healthcare Disaster preparedness Technlgy Advances *These frces emerged as the largest cntributing factrs t the physical and mental health f Duglas Cunty residents. Lcal Public Health System Assessment (LPHSA) Summary f Strengths and Weaknesses Identified in the Cbb and Duglas Public Health System Strengths Gaps / Opprtunities fr Imprvement ES 2: Diagnsing & investigating diseases ES 5: Develping health plicies/plans ES 6: Enfrcing laws related t the public s health ES 7: Linkage t Health Services ES 1: Mnitring cmmunity health status ES 4: Mbilizing partnerships ES 8: Assuring a strng wrkfrce ES 10: Research/Innvatins The results f the LPHSA helped t identify strengths and weaknesses, determine pprtunities fr immediate imprvements, and establish pririties fr lng term investments fr imprving the public health system. The infrmatin btained frm this assessment will be used t imprve and better crdinate public health activities by cmmunity partners in Cbb and Duglas cunties. 21

23 Lcal Resurces in Cbb and Duglas Cunties Medical and Behaviral Health Safety Net Prgrams Services Lcatins Served Website WellStar Cmmunity Clinics at Cbb Hspital Cbb Cunty WellStar Cmmunity Clinics at Kennestne Hspital Cbb Cunty Gd Samaritan Health Center f Cbb Als Dental Clinic & Prescriptin Assistance Prgram The Family Health Centers f Gergia (previusly knwn as West End Medical Center) Als Prescriptin Assistance Prgram Cbb & Duglas Public Health (CDPH) Als Dental Clinic & Prescriptin Assistance Prgram Cbb and Duglas Cmmunity Services Bard (CSB): Child/Adlescent Services Develpmental Disabilities Mental Health Outpatient Services Substance Abuse (Addictive Disease) Residential Services Prescriptin Assistance Prgram Cbb Cunty Cbb Cunty Cbb & Duglas Cunties Cbb & Duglas Cunties The CarePlace f Duglas Cunty Als Prescriptin Assistance Prgram Schl-Based Health Clinic: The Family Health Center at Duglas Cunty Schls Burnett/Eastside Schl-Based Health Center Duglas Cunty Duglas Cunty Online Prescriptin Assistance Prgrams Needy Meds Partnership fr Prescriptin Assistance RxAssist RxHpe RxOutreach 22

24 References 1 Wrld Health Organizatin. Review f the Cnstitutin f the Wrld Health Organizatin: Reprt f the Executive Bard special grup, Accessed January Institute f Medicine. The future f public health. Washingtn, DC: Natinal Academy Press; Accessed January Natinal Assciatin f Cunty & City Health Officials. Mbilizing fr Actin thrugh Planning and Partnerships (MAPP). Accessed Nvember Natinal Assciatin f Cunty & City Health Officials. Phase 3: The fur assessments. Accessed Nvember US Census American Cmmunity Survey. Accessed Nvember Gergia Department f Public Health OASIS. Accessed Nvember US Census American Cmmunity Survey. Accessed Nvember US Census 2015 American Cmmunity Survey. Accessed May Gergia Gvernr s Office f Student Achievement. Help/Graduatin Drput_Rate.htm. Accessed Nvember Wrld Health Organizatin. Chapter XX: External causes f mrbidity and mrtality (W00-X59). Accessed Nvember Behaviral Risk Factr Surveillance System (BRFSS) survey. Accessed Nvember Centers fr Disease Cntrl and Preventin. Overweight & besity. Accessed Nvember Centers fr Disease Cntrl and Preventin, Natinal Center fr Chrnic Disease Preventin and Health Prmtin. Nutritin, physical activity, and besity: Data, trends and maps. Accessed Nvember American Psychiatric Assciatin: Accessed July Gergia Student Health Survey Instructin/GSHS-II/Pages/Gergia-Student-Health-Survey-II.aspx. Accessed Nvember

25 BACK COVER Cbb & Duglas Public Health 1650 Cunty Services Parkway Marietta, Gergia cbbandduglaspublichealth.rg (P) Kennesaw State University 1000 Chastain Rad Kennesaw, GA kennesaw.edu (P) Cbb2020 A Partnership fr a Healthier Cunty! 1650 Cunty Services Parkway Marietta, Gergia cbb2020.cm Live Healthy Duglas 1650 Cunty Services Parkway Marietta, Gergia healthyduglas.rg 24