Community Health Assessment 2018 Data Update

Community Health Assessment 2018 Data Update

Table of Contents: Introduction 2 Health Equity Analysis: How Income and Poverty affect Health Outcomes in Ross County 5 Air Quality and Health Risk Updates 18 Life Expectancy Update 21 2017 Infant Mortality Update 22 2018 Domestic Violence Data Update 23 2018 Homeless Data Update 25 Mapping of Community Resources and Assets Update 26 Resources and Acknowledgements 27 Appendix A: Community Resources and Asset Maps 28 Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 1

Introduction: The 2016 Ross County Community Health Assessment (CHA), developed by the Partners for a Healthier Ross County, provided the foundation for the development of the Ross County Community Health Improvement Plan (CHIP) in November of 2016. Shortly after adoption of the CHA and CHIP in 2017, the Partners for a Healthier Ross County (Partners) began implementing the CHIP in 2017. The 6 major subcommittees of the partnership began to collaborate to promote healthier communities in Ross County to tackle the top health issues identified in the 2016 CHA. As part of the collaboration, the major subcommittees, consisting of Lung and Respiratory (Breathe Well and Air Quality), Infant Mortality, Mental Health, Substance Abuse, and Obesity (Live Well), began meeting and implementing strategies defined in the CHIP with goals to improve health outcomes for Ross County. In this 2018 report, we will provide updated data and data analysis on several projects being conducted by the Partners for a Healthier Ross County. Figure 1: Partners for a Healthier Ross County Background on the 5 Major Health Priorities from 2016 CHA/ CHIP: During the Strategic Planning Phase of the 2016 CHA and CHIP, the Partners for a Healthier Ross County Steering Committee reviewed the 14 major health outcomes and conditions from the assessment and ranked their top five in order of importance: 1. Addiction Almost two-thirds of the steering team ranked addiction as the number one condition detrimental to health/public health in Ross County. 2. Depression and anxiety Perhaps surprisingly, depression, anxiety, mental health issues, and suicide were all selected often by those who responded to the community health survey, and listed as important issues that needed addressed. 3. Obesity Almost all of the steering team ranked obesity in the top five, recognizing its prevalence in our community and its impact on other aspects of health, such as heart disease, high blood pressure, diabetes, high cholesterol, cancer, and more. Almost 30 percent of Ross County residents are considered overweight (a Body Mass Index of 25-29.9), and nearly 36 percent are obese (BMI of 30 or higher). Both of those percentages are well above state and national averages. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 2

4. Lung Cancer and Respiratory Disease Lung cancer rates in Ross County (87.9 cases per 100,000) are well above those of Ohio (72.4) and the United States (64.9). Alarmingly, in Ross County the rate of death for those with lung cancer is 72.7, which is much higher than the rate for Ohio (57.1) and a startlingly 44% higher than the U.S. rate (50.6). Part of this imbalance might be explained by the percentage of smokers in Ross County (31.2%), which is again higher than state and national percentages. However, other factors might be in play, including air quality, for which there is currently no testing done. 5. Infant mortality The rate of infant mortality in Ross County (6.6) is slightly below the state rate (7.7), and on par with the national rate (6.5). However, three relevant factors are of concern: maternal smoking rates are very high in Ross County (27.3% compared to a state average of 16.9%); teen birth rates locally are very high (54.5 per 100,000), compared to Ohio (36) and U.S. (36.6) rates; and the percentage of babies born locally with low or very low birth weights is higher than state and national numbers, as is the number of mothers who received first trimester prenatal care. Heart Disease Cancer (all forms) Unintentional Injury Pulmonary- Respiratory Disease Stroke Obesity Poor Mental Health Drug use/abuse Poor Nutrition Poor physical activity levels Poor dental health Economics and poverty Educational attainment Basic needs access (housing, food and transportation) Safety Healthcare access Air quality Figure 2: Areas Identified by the 2016 CHIP for Top Causes of Death, Top Health Behaviors and Conditions, and Top Environmental Factors that lead to poorer health outcomes. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 3

2018 Community Health Assessment Updates: In the 2018 CHA update, you will find the updates: 2018 Health Equity Analysis A summary of the top health issues and how income / poverty affect health outcomes from respondents of the 2016 CHA public survey completed by the Ross County Health District. Air Quality Health Risks data update: Data collected by the Partners for a healthier Ross County s Air Quality Subcommittee which includes mapping of cancer risk and respiratory risk of data provided by the U.S. EPA from a 2014 report. Life Exectancy Data: Data provided in late 2018 throught the Center for Disease Control and Prevention (CDC) with life expectancy rates for Ross County by census tract. 2017 Infant Mortality Data: Data reported by the Ohio Department of Health on infant mortality for 2017, and includes updated 5 year infant mortality rates for Ross County. 2018 Ross County Domestic Violence Data 2018 Ross County Homeless Data Community Resource Mapping of Ross County Mapping of various community resources provded by Susan K. Jones research project, 2018 University of Nebraska Lincoln Institute for Agriculture and Natural Resources, on Defining Appalachian Health Culture, 2018 Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 4

2018 Health Equity Analysis: The purpose of the 2018 Health Equity Analysis is to better understand how social determinants and indicators can influence the health of those who reside in Ross County. The 2016 CHA identifies the top issues or social determinants that lead to poorer health in our communities of Ross County, which are led by Poverty and Economic Status. In the 2018 Health Equity Analysis, income and poverty will be studied to see how income and poverty can affect health outcomes in our communities. Before we begin, we must first understand health equity, and how health equity can aid the Partners for a Healthier in achieving their vision of empowering all people within the region to reach their Figure 3: Top Ross County Community Issues from 2016 CHA fullest physical and mental health potential, in a clean and safe environment through positive community collaborations. Defining Health Equity? Health equity is achieving the highest level of health for all people. Health equity entails focused, societal efforts to address avoidable inequalities by equalizing the conditions for health for all groups, especially for those who have experienced socioeconomic disadvantage or historical injustices. 1 According to Healthy People 2020, health starts in our homes, schools, workplaces, neighborhoods, and communities. We know that taking care of ourselves by eating well and staying active, not smoking, getting the recommended immunizations and screening tests, and seeing a doctor when we are sick all influence our health 1. Our health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. 2 The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be. Healthy People 2020 highlights the importance of addressing the social determinants of health. 2 To achieve the highest level of health for all people, we must first identify the health disparities that exist among our population. In many cases, this can be achieved by identification of the indicators that lead to health disparities, such as housing, neighborhoods, income, access to healthy food or healthcare, and other indicators. 3 1 Secretary s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. 2 World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health equity through action on the social determinants of health. https://www.who.int/social_determinants/thecommission/finalreport/en/ 3 Healthy People 2020: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 5

Low Income and Poverty in Ross County The Partners for a Healthier Ross County s 2016 Community Health Assessment Public Survey identifies Income and Poverty as the top community issue in Ross County, and a possible indicator or social determinant to health disparities in our county. Of the public survey responses, 45% of people felt that income and poverty are the top community issue in Ross County, compared to Violent Crime 10.56% and theft coming in as the second issue at 9.08% According to 2010-2014 US Census Bureau findings, for Ross County, 19.2% of all individuals (Ohio 15.8%, U.S. 14.8%), and 29.3% of all children (Ohio - 22.8%, U.S. - 21.6%) live in poverty. 29.3% of Children live Figure 2 above: Poverty Rates for Ross County Vs. Ohio and the U.S. (Source U.S. Census Bureau, 2010-2014) in poverty in Ross County. Poverty is one of the major social determinants that may lead to poorer health outcomes in Ross County. Figure 4 above shows the poverty rates in Ross County by census tract (data from the US Census Bureau, 2006-2010 census data). Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 6

Health Equity Data Analysis Background: In this health equity report, we will examine how household income and poverty affect health outcomes reported by respondents to our 2016 Community Health Assessment s Public Survey. In 2016, 983 public surveys were attempted, and 790 Ross County residents responded to the survey and answered all the questions needed for this analysis (total household income, number of persons living in the household, and health behaviors and conditions questions). The primary quantitative and qualitative data collected in 2016 provided the Partners a picture of how our population views their health, key information about quality of life, income, education, and other socioeconomic information about our communities in Ross County as it relates to health. 2016 CHA Public Survey Response Statistics for Income and Poverty: Ross County residents were able to respond to the 2016 CHA Public Survey during the 2016 Community Health Assessment data collection phase. The data collected during the 2016 CHA Public Survey provided information about each respondent s overall household income, number of family members living in their household and information about health behaviors and medical conditions of the respondents. Using this data, health behaviors and conditions as reported by respondents were compared to total household income and economic status of the respondents (Table 1 below): Income Level Total # of Respondents % of Total Respondents Less than $14,999 77 9.77% $15,000 $24,999 67 8.48% $25,000 $34,999 81 10.25% $35,000 - $49,999 105 13.29% $50,000 - $74,999 150 18.99% $75,000- $99,999 115 14.56% $100,000 or Above 127 16.08% Did not report income 68 8.60% By the number of household members reported by the survey respondents, we were able to calculate and categorize the total number of respondents who live above the median household income / did not report income, those who live below the median household income for Ross County (which includes those living in poverty), and those who are living in poverty as defined by U.S. Federal Poverty Rate Guidelines. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 7

Table 2 below indicates the total number of respondents who fall within each economic category: 1) low income = living in poverty according to federal guidelines; 2) households who earn less than the median household income in Ross County ($43,450 in 2016); 3) households that live above the median household income in Ross County or did not report income level: Economic Status of Respondents Total # of Respondents Percentage of Total Respondents Above the Median Household Income or did not report income. 463 58.61% Below the Median Household Income 327 41.39% Living in Poverty according to federal poverty guidelines 109 13.78% Table 3 below, from the 2016 CHA, includes Income and Poverty Data for 2016 for Ross County compared to Ohio and U.S. Averages: Income Ross County Ohio U.S. Per capita Income 2 $21,536 $25,250 $28,555 Median Household Income 1 $43,450 $48,849 $53,582 Poverty Ross County Ohio U.S. Individuals below poverty status 2 19.2% 15.8% 14.8% Children below poverty status (FPL 100%) 2 29.3% 22.8% 21,6% Children eligible for free school lunch / Reduced 2 Source: U.S. Census Bureau, 2010-2014 1 Source U.S. National Center for Educational Statistics 2012-2013 2 44.2% 40.7% 51.7% Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 8

Tobacco Use vs. Household Income and Poverty: The 2016 CHA public survey response data indicates 17.86% of respondents use tobacco, and of those, 91.6% smoke cigarettes. Below includes respondent data showing the trends in income and poverty vs. tobacco use in our community. Figure 5 below indicates percentage of respondents who use tobacco vs. their income level. 70.00% 60.00% 2016 CHA Public Survey - Tobacco Use by Total Household Income 50.00% 40.00% 42.29% 30.00% 25.37% 20.00% 10.00% 17.28% 15.24% 18.00% 16.52% 7.09% 13.24% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Figure 6 below indicates percentage of respondents who use tobacco vs. those who are living in poverty (low income) and those who live under the median household income of Ross County. 2016 CHA Public Survey - Tobacco Use Rate by Low Income and Median Household Income 17.86% 24.46% 38.53% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Tobacco Use All Repondents Less than Median Household Income Tobacco Use Low Income Tobacco Use Analysis on Tobacco use and Income Level: Data from figure 5 and 4 indicate that income / poverty can be a social determinate / indicator that can lead to higher rates of tobacco use in Ross County. Those who are low income or below the medium household income level are more likely to use tobacco than those above the median household income level. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 9

Asthma vs. Household Income and Poverty: The 2016 CHA public survey response data indicates 16.84% of respondents experience asthma. According to 2011-2012 data from the Center for Disease Control and Prevention, 22.8% of Ross County residents experience Asthma, which is higher than Ohio averages of 13.8%, and U.S. averages of 13.4%. Below includes respondent data showing the trends in income and poverty vs. asthma in our community. Figure 7 below indicates percentage of respondents who experience Asthma vs. their income level: 70.00% 60.00% 50.00% 40.00% 2016 CHA Public Survey - Asthma Rates by Total Household Income 30.00% 20.00% 10.00% 24.68% 20.90% 13.58% 7.62% 11.33% 13.04% 14.17% 13.24% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Figure 8 above indicates percentage of respondents who experience asthma vs. those who are living in poverty (low income) and those who live under the median household income of Ross County 2016 CHA Public Survey - Asthma Rates for Low Income and Median Household Income 16.84% 15.90% 28.44% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Asthma All Respondents Less than Median Household Income Low Income Asthma Analysis on Asthma and Income Level / Poverty: Data from figure 7 and 8 indicate that income / poverty can be a social determinate / indicator that can lead to higher rates of asthma for those that live in Ross County. Further analysis on factors that can contribute to asthma need to be assessed, such as housing, air quality, and second-hand smoke during future community health assessments. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 10

Anxiety or Depression vs. Household Income and Poverty: The 2016 CHA public survey response data indicates 33.74% of respondents experience mental health issues such as anxiety or depression. Below includes respondent data showing the trends in income and poverty vs. depression and anxiety in our community. Figure 9 below indicates percentage of respondents who experience anxiety or depression vs. their income level: 70.00% 2016 CHA Public Survey - Mental Health Depression or Anxiety by Total Household Income 60.00% 50.00% 40.00% 30.00% 46.15% 40.30% 38.75% 28.85% 32.00% 29.66% 22.05% 32.35% 20.00% 10.00% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Figure 10 below indicates percentage of respondents who experience anxiety or depression and are living in poverty (low income) or live under the median household income of Ross County: Depression or Anxiety 33.74% 42.20% 60.55% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Depression or Anxiety All Respondents Low Income Depression or Anxiety Less than Median Household Income Depression or anxiety Analysis on Anxiety and Depression and Income Level: Data from figure 9 and 10 indicate that income / poverty can be a social determinate / indicator that can lead to higher rates of depression or anxiety for those that live in Ross County. Further assessment / analysis on indicators or factors that can contribute to depression or anxiety need to be assessed during future community health assessments. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 11

Obesity and Diabetes vs. Household Income and Poverty: The 2016 CHA public survey response data indicates 35.2% of respondents are obese or overweight. Below includes respondent data showing the trends in income and poverty vs. obesity in our community. Figure 11 below indicates percentage of respondents who are overweight or obese by. their income level: 70.00% 2016 CHA Public Survey - Obesity Rate by Total Household Income 60.00% 50.00% 40.00% 30.00% 31.17% 46.27% 35.80% 38.10% 36.00% 40.00% 29.92% 23.53% 20.00% 10.00% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Figure 12 below indicates percentage of respondents who are obese or overweight and are living in poverty (low income) or live under the median household income of Ross County: 2016 CHA Public Survey - Obesity by Low Income and Median Household Income 35.22% 39.45% 38.53% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Overwieght / Obesity All Repondents Low Income Overweight / Obesity Less than Median Household Income Overweight / Obesity Analysis on Obesity and Income Level: Data from figure 11 and 12 indicate that income / poverty is not a strong social determinate / indicator that can lead to higher rates of obesity in Ross County. Rates of Obesity only vary by about 4% between each income level or low income / poverty, those who live with less than median household income, compared to the overall average for the population. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 12

The 2016 CHA public survey response data indicates 35.2% of respondents are obese or overweight. Below includes respondent data showing the trends in income and poverty vs. diabetes in our community. Figure 13 below indicates percentage of respondents who reported having diabetes vs. their income level: 70.00% 60.00% 50.00% 40.00% 2016 CHA Public Survey - Diabetes Rates by Total Household Income Level 30.00% 20.00% 10.00% 10.39% 17.91% 8.64% 8.57% 10.67% 7.83% 8.66% 8.82% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Figure 14 below indicates percentage of respondents who reported having diabetes and are living in poverty (low income) or live under the median household income of Ross County: 2016 CHA Public Survey Respondents - Diabetes 10.34% 12.54% 15.60% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Diabetes All Repondents Less than Median Household Income Diabetes Low Income Diabetes Analysis on Diabetes and Income Level: Data from figure 13 and 14 indicate that income / poverty can be a social determinate / indicator that can lead to higher rates of Diabetes in Ross County but is not a strong indicator. Rates of Diabetes were higher for an income range of $15K to 25K /year and are steady for those who make less than $10k or more than $25K per year. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 13

Cancer vs. Household Income and Poverty: 2016 CHA reports that 12.1% of respondents to the Public Survey current have or previously have been diagnosed as having cancer. 2016 CHA also reports that Ross County has a higher rate of lung cancer, 87.9%, compared to Ohio, 72.4%, and the U.S., 64.9%. Below includes respondent data showing the trends in income and poverty vs. cancer in our community. Figure 16 below indicates percentage of respondents who reported having or had cancer vs. their income level: 2016 CHA Public Survey - Cancer rates by Total Household Income Level 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 9.09% Less than $14,999 13.43% 13.58% $15,000 to $24,999 $25,000 - $34,999 10.48% 10.00% 11.30% 12.60% $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more 7.35% Did not report income level Figure 17 below indicates percentage of respondents who are obese or overweight and are living in poverty (low income) or live under the median household income of Ross County: 2016 CHA Public Survey Respondents - Cancer rates by Low Income, Median Household Income Levels 11.08% 11.62% 9.17% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Diabetes All Repondents Less than Median Household Income Diabetes Low Income Cancer Analysis on Cancer and Income Level: Data from figure 16 and 17 indicate that income / poverty is not a major social determinate / indicator that can lead to higher rates of Cancer in Ross County. Rates of Cancer were comparable for different income levels, only ranging between 7.35% to 13.58% between the different income levels. Environmental factors or other determinants other than income could be factors for cancer occurrence and should be explored in future community health assessments. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 14

Heart and Cardiovascular Health: Table 4 below includes respondent data showing the trends in economic status vs. high blood pressure, high cholesterol, and angina/ heart disease in our community. Economic Status High blood pressure High Cholesterol Angina/ Heart Disease Low Income 33.03% 22.94% 11.01% Less than Median Household Income 32.72% 22.32% 7.34% All Respondents 33.29% 23.04% 5.82% Analysis on Heart and Cardiovascular Health: Data from table 4 indicate that income / poverty is not a social determinate / indicator that can lead to higher rates of high blood pressure or high cholesterol in Ross County, but income / economic status can be a contributing social determinant / indicator for heart disease in our community. Rates of Heart Disease were higher for those who fell into the low income / poverty status (11.01%) compared to the overall average of all respondents (5.82%). Substance Use including Alcohol, Marijuana, and Opiates: The three leading substances reported sued by the 2016 CHA Public Survey Respondents include Alcohol (54.01%), Marijuana (8.01%) and Prescription Opiates (5.7%). Table 5 below include statistics of those who reported alcohol consumption during the 2016 CHA Public Survey with responses to Do you Drink Alcohol, How often do you Drink Alcohol? and How much alcohol do you drink? : Percentage of Respondents who drink alcohol 54.01% Alcohol users who drink daily 4.1% Alcohol users who drink 1-2 times per week 18.3% Alcohol users who drink 3-5 times per week 9.7% Alcohol users who drink a few times a month 20.1% Alcohol users who drink once per month 12.2% Alcohol users who drink less than once per month 35.6% Alcohol users who drink 1 drink per sitting 39% Alcohol users who drink 2-3 drinks per sitting 52.4% Alcohol users who drink 4-6 drinks per sitting 6.9% Alcohol users who drink more than 6 drinks per sitting 2.8% Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 15

Figure 18 below indicates percentage of respondents who responded yes to Do you drink alcohol according to their reported income level: Alcohol Consumption by Income 70.00% 60.00% 50.00% 40.00% 36.36% 43.28% 48.15% 47.62% 52.00% 55.65% 63.78% 39.71% 30.00% 20.00% 10.00% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Substance Use: 2016 CHA reports the next two leading substances used by respondents other than alcohol are marijuana, where 8.01% of respondents reported use of marijuana, and Opiates (Codeine Oxycodone, Hydrocodone, Vicodin, OxyContin, Percocet, Morphine, etc.), where 5.7% of respondents reported use of opiates. Below are trends of use of Marijuana and Opiates by Income Level: Figure 19 below indicates percentage of respondents who responded yes to Have you ever used any of these substances according to their reported income level: 70.00% 60.00% 50.00% 40.00% 2016 CHA Public Survey - Marijuana Use by Income Level 30.00% 20.00% 10.00% 10.39% 14.93% 8.64% 5.71% 6.00% 2.61% 6.30% 2.94% 0.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 16

Figure 20 below indicates percentage of respondents who responded yes to Have you ever used any of these substances according to their reported income level: 70.00% 50.00% 2016 CHA Public Survey - Prescription Opiate Use by Income Level 30.00% 10.00% 7.79% 7.46% 7.41% 4.76% 2.67% 5.22% 3.15% 2.94% -10.00% Less than $14,999 $15,000 to $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more Did not report income level Analysis on Substance Use: Data from figure 18 indicate that income / poverty is a social determinate / indicator that can lead to higher rates of consumption of alcohol, with the higher the income, the more people responded to use of alcohol, while marijuana and prescription opiate use was the opposite, the lower the income, the higher the use of marijuana and opiates. The data collection for substance abuse indicates that there could be areas for additional collection and analysis of data about the use of substances and the social determinants and indicators that can lead to the use of these substances. 2018 Health Equity Analysis Conclusion: As we studied how income and economical status affects health outcomes in our community, we have a better understanding of how income and economic status can be an indicator that can lead to poorer health outcomes in Ross County and our communities. It was evident that low income and poverty has a strong impact on health outcomes and behaviors for tobacco use, depression and anxiety, and asthma for the respondents who completed our public survey. Low income and poverty does not have a significant impact for health outcomes and behaviors for obesity, diabetes, heart disease, high blood pressure, high cholesterol, and cancer according to the responses to the public survey. Income does have an impact on types of substances used by respondents of the survey, and this varied for alcohol use vs. marijuana and opiate use. As we prepare for the 2019 Community Health Assessment, we strive to better understand the social determinants and indicators that exist in our communities that can lead to health inequities. Through partnerships, community assessments, and public feedback, we can better understand the social determinants and indicators that can lead to poorer health outcomes and behaviors and begin to break the barries that lead to health disparities in our communities. Our ultimate goal as the Partners for a Healtheir Ross County is to improve the health outcomes of all persons in our communities and that all persons have an equal opportunity for better health. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 17

2018 Air Quality Data Analysis Update: During 2017, the Partners began implementation of the CHIP, which lead to the formation of the Air Quality Subcommittee, a committee established under the Lung / Respirator Subcommittee. During spring of 2018, the Air Quality Subcommittee began to review and analyze data from the United States Environmental Protection Agency (U.S. EPA) on cancer risk and health risk in Ross County associated with air quality. This data reviewed and analyzed were provided from three U.S. EPA air quality databases: The National Air Toxics Assessment (NATA) The National Emissions Inventory (NEI) The Toxics Release Inventory (TRI) Data from the above listed sources provided census tract level comparisons of cancer risks, respiratory risks, and air pollutants due to potential sources of air pollution in Ross County. The data was reviewed and summarized by health district staff in addition to the report provided by the Partners for a Healthier Ross County. Figure 21 shows the cancer risk by census tract in Ross County and indicates there are neighborhoods in our communities that have a higher risk due to potential sources of air pollution. Figure 22 and 23 show Census Tract maps with Total Cancer Risk per census tract for Ross County and City of Chillicothe and surrounding areas. Figure 22: Total Cancer Risk from 2014 National Air Toxics Assessment (NATA) Ross County by Census Tract Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 18

Figure 23: Total Cancer Risk from 2014 National Air Toxics Assessment (NATA) City of Chillicothe and Surrounding areas by Census Tract Figure 24 and 25 below show Census Tract maps for Total Respiratory Risk per census tract for Ross County and City of Chillicothe and surrounding areas. Figure 24: Total Respiratory Risk from The National Emissions Inventory (NEI) Ross County by Census Tract Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 19

Figure 25: Total Respiratory Risk from 2014 The National Emissions Inventory (NEI) City of Chillicothe and Surrounding Areas by Census Conclusions from Air Quality Data: As the Partners for a Healthier Ross County s Air Quality Subcommittee continue to explore and better understand potential health impacts air quality can have on our population, goals have been set to establish an air monitoring program in our community. By utilizing U.S. EPA s NEI Data, NATA Reports, and TRI reports, the subcommittee has selected target areas in our community to further explore and gather additional data about air quality, potential sources that lead to higher respiratory risks in specific census tracts. In 2019, the subcommittee will begin to collect preliminary air quality data for particulate matter 2.5 (PM2.5) to better understand trends in air quality that could lead to higher health risks as described in the EPA s estimations. According to the US EPA, PM 2.5 is fine inhalable particles, with diameters that are generally 2.5 micrometers and smaller, and can cause respiratory problems for some people and pose a greater higher risk for health. Moving forward, the subcommittee will continue to work with the Ohio EPA and local partners to explore options for additional monitoring and data collection for other air pollutants that could pose a risk to respiratory health in our community. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 20

Ross County Life Expectancy by Census Tract: During 2018, the Center for Disease Control (CDC) released the U.S. Small-area Life Expectancy Estimates Project (USALEEP) which is a partnership of the Robert Wood Johnson Foundation (RWJF), and the National Association for Public Health Statistics and Information Systems (NAPHSIS) to produce a new measure of health for where you live. The USALEEP project produced estimates of life expectancy at birth the average number of years a person can expect to live for most of the census tracts in the United States for the period 2010-2015. This report provides valuable comparisons of life expectancy at a local level, where we can utilize the data to compare and compile health data reports and health behaviors / outcomes in our communities at the census tract / neighborhood level. Sharing this important information can help the Partners for a Healthier Ross County better understand our communities. As indicated on the map below, Ross County life expectancy can vary by up to 10 years based upon where you live in our community. This can help our partnership better understand the social, economic, and environmental indicators that can lead to poorer health outcomes and shorter life expectancies in our communities and target health services, improve access to healthcare, healthy food, and safe environments that can improve health in our communities. Figure 26: Below includes Life Expectancy Rates by Census Tract in Ross County by census tract. Source: U.S. Small-area Life Expectancy Estimates Project (USALEEP), 2018, Center for Disease Control https://www.cdc.gov/nchs/nvss/usaleep/usaleep.html Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 21

2017 Infant Mortality Report: The Ohio Department of Health released the 2017 Infant Mortality Report in December of 2018. This report summarizes the State of Ohio s Infant Mortality Data for 2017 and includes Ross County data. According to Ohio Department of Health, Ross County has a 5 year (2013-2017) Infant Mortality Rate of 6.3 compared to Ohio s Overall Infant Mortality Rate of 7.2. According to the Ohio Department of Health s 2016 Infant Mortality Report, Ross County had a rate of 6.8. Ross County Infant Mortality is declining from 6.8 to 6.3 from the 2016 report to 2017 report. Figure 27 below includes 5 Year Ohio County Comparison of Infant Mortality Rates per 1,000 Live Births in Ohio s Counties. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 22

2018 Sexual Assault Data Update: The Sexual Assault Survivor Advocate Program of Adena Health System is dedicated to serve the needs of women, children and men who have experienced Interpersonal Violence such as Sexual and/or Domestic Violence, Child and/or Elder Abuse or those who may have been victims of Hate Crimes. The Survivor Advocacy Program serves victims of interpersonal violence, who are primarily intercepted through Adena s Emergency Department or other areas with-in the health system, while some clients are self-referred from the community. The program is funded through the Ohio Attorney General s office Victims of Crime Grant (VOCA) as part of the state from the Federal Department of Justice (DOJ). Each quarter data must reported to the DOJ to monitor and determine the states eligibility and continued funding each grant cycle. The DOJ required sub-grantees to report demographic, victimization, and special population information. In addition, the program independently tracks where victims are intercepted from, showing that 95% of our clients where seeking emergency medical care when seeking services around their victimization. Breakdown of Sexual Assault Data: 2018 Sexual Assault Survivor Advocate Program Served: 131 Ross County residents were victims of Interpersonal Violence. 95% of victims were intercepted when seeking emergency medical care 92% identifies as White or Caucasian /4.5% Africa American/Black 20% Age 17 or younger 31% identified as having mental Health Issues 25% Identified as having Substance Abuse Disorder 38% had experience prior victimization 13% of people disclosed they were homeless 22% of victims were at risk of being sex trafficked meaning they met 3 or more indicators such as homelessness, past/present involvement in the sex trade industry, and substance abuse disorder. Race White/Caucasian 121 African American/Black 6 Hispanic/Latino 0 Asian 2 Middle Eastern 0 Pacific Islander 0 Native American/Alaskan 0 Multiple 2 Other 0 Gender Female 111 Male 20 Age 0-12 18 13-17 8 18-35 63 36-59 33 60+ 8 Unknown 1 At Risk Human Trafficking: Sex 29 Human Trafficking: Labor 0 Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 23

Figure 28 below indicates types of crime associated with sexual assault in 2018: Type of Crime Stalking/Harassment 4 Kidnapping (non-custodial) 1 Human Trafficking: Sex 22 Elder Abuse 5 Domestic/Family Violence 57 Child Sexual Abuse/Assault 20 Child Physical Abuse or Neglect 5 Adult Sexually Abused/Assaulted as a Child 9 Adult Sexual Assault 42 Adult Physical Assault 19 0 20 40 60 Figure 29 below indicates the special classification of the population in reference to the sexual assault. Special Classification of Population Prior Victimization Inmate Substance Abuse Mental Health Limited English Proficiency Victims with Disabilities Veterans LGBTQ+ Immigrants/Refugees/Asylum Seekers Homeless 1 1 2 5 7 8 17 33 41 50 0 10 20 30 40 50 60 Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 24

2018 Homeless Data Update: There are two homeless shelters located in Ross County that solely serve to temporarily house the homeless with the goal of transition them into permanent housing upon leaving the shelter. Operated by Ross County Community Action, the Men s Shelter is located in the city of Chillicothe and provides overnight housing for men, 18 years or older, a place to sleep. Seeds of Hope, which opened in 2017 just outside of Chillicothe City limits, is a private faith-based shelter for women and familiesthat can house up to 16 women, children, and men who are part of a family unit. Both of these shelters report information in the Homeless Management Information System. HMIS is an information technology system used to collect client-level data and data on the provision of housing and services to homeless individuals and families and persons at risk of homelessness. Additionally, both shelters serve on the Ross County Continuum of Care (CoC). The CoC Program is designed to promote communitywide commitment to the goal of ending homelessness; provide funding for efforts by nonprofit providers, and State and local governments to quickly rehouse homeless individuals and families while minimizing the trauma and dislocation caused to homeless individuals, families, and communities by homelessness; promote access to and effect utilization of mainstream programs by homeless individuals and families; and optimize self-sufficiency among individuals and families experiencing homelessness. All information collected and reported to HMIS is overseen by the Federal Department of Housing and Urban Development (HUD). Primary information reported is number of clients served, the number of bed nights reported for each shelter, and data collected during the annual Point-in-Time count of the homeless. A bed night refers to a unit of service where a client is residing overnight in a lodging project. The Point-in-Time (PIT) count is a count of sheltered and unsheltered homeless persons on a single night in January. HUD requires that Continuums of Care (CoCs) conduct an annual count of homeless persons who are living on the street or in a shelter that is not consider inhabitable for humans. Two Homeless Shelters in Ross County: Total Bed Nights - 6863 Ross County Community Action s Men s Homeless Shelter Served: Men Served 112 Total Bed Nights - 2314 Seeds of Hope Women s and Family Shelter Total Bed Nights - 4,549 * Bed night refers to a unit of service where a client is residing overnight in a lodging project Point in Time Count January 2018 11 January 2019-57 *The Point-in-Time (PIT) count is a count of sheltered and unsheltered homeless persons on a single night in January. HUD requires that Continuums of Care (CoCs) conduct an annual count of homeless persons who are living on the street or in a shelter that is not consider inhabitable for humans. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 25

Community Resource Mapping: In 2018, Community Resource Mapping was provided by Susan K. Jones through her research project conducted for the University of Nebraska Lincoln Institute for Agriculture and Natural Resources, on Defining Appalachian Health Culture in 2018 includes community resources mapping for Ross County. The GIS mapping, conducted by Jones with help from Ross County Soil and Water, is an inventory of Ross County resources and provides a picture of geographical locations of community resources ranging from health care facilities, food sources, and recreational areas. The maps can be a valueble asset for our Partnership and community assessments to better understand the disparities that occur in our communities that can lead to poorer health outcomes when certain populuations or neigborhoods lack easy access to healthcare, healthy food, transportation or community resources that can promote and improve health. The maps are located in Appendix A and include the following maps: Compiled Resource Map Map containing multiple resources on one map and includes: recreational areas, fitness locations, food access and types of food operations, emergency and urgent care facilities and operations, health and well being resources, and transportation resources such as bus stops. Emergency EMT s and Urgent Care Facilities Fitness Resources Food Security Health and Well Being Healthcare facilities and offices Stores Locations where food can be purchased, and identifies locations with fresh foods vs. prepackaged foods. Transportation Map of locations for bus stops in the county. Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 26

Special Thanks: Susan K. Jones, Adena Health System Brooke White, Mid-Ohio Regional Planning Commission Greg Rouse, Ross County Soil and Water Conservation District Ross County Health District Ohio Department of Health Resources: Partners for a Healthier Ross County, 2016 Community Health Assessment Secretary s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health equity through action on the social determinants of health. https://www.who.int/social_determinants/thecommission/finalreport/en Healthy People 2020: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-ofhealth Ohio Department of Health: 2016 and 2017 Infant Mortality Report https://odh.ohio.gov/wps/portal/gov/odh/media-center/odh-news-releases/2017-ohio-infant-mortality-report U.S. Environmental Protection Agency, National Air Toxics Assessment (NATA), National Emissions Inventory (NEI), Toxics Release Inventory (TRI) United States Census Bureau 2006-2010 Census Data, 2010-2014 Census Data U.S. National Center for Educational Statistics 2012-2013 Partners for a Healthier Ross County Community Health Assessment - 2018 Update Page 27

Appendix A Community Resource Maps *** Due to the file size of the Community Resource Maps, the maps will be located in a separate document titled: Partners for a Healthier Ross County 2018 CHA Data Update - Appendix A