COMMUNITY HEALTH ASSESSMENT Ho-Chunk...

COMMUNITY HEALTH ASSESSMENT

Ho-Chunk Nation December 2013

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Table of Contents

I. Acknowledgements.............................................................................................................. 3

II. List of Figures, Tables and Charts .......................................................................................... 4

III. Introduction ........................................................................................................................ 5

IV. Methodology ....................................................................................................................... 5

V. Demographics ...................................................................................................................... 7

VI. Indicators of Health ............................................................................................................. 9

Health Outcomes ........................................................................................................... 9

Maternal and Child Health (MCH) (NATALITY) ............................................................... 11

Immunization .............................................................................................................. 12

Diabetes ...................................................................................................................... 12

Health Status ............................................................................................................... 13

VII. County Health Rankings Model........................................................................................... 14

Physical Environment ................................................................................................... 15

Social and Economic Factors ......................................................................................... 16

Health Behaviors.......................................................................................................... 17

VIII. Summary of Data ............................................................................................................... 21

IX. Identified Health Needs ..................................................................................................... 22

X. Strengths and Challenges of Conducting a Community Health Assessment .......................... 23

XI. Next Steps ......................................................................................................................... 23

XII. Community Stakeholders and Resources ............................................................................ 24

XIII. APENDIX A: Additional Data ............................................................................................... 25

XIV. APENDEX B: Individual and Household Survey Results ........................................................ 27

XV. APENDIX C: PHAB Standards & Measures Comparison (Version 1.0) .................................... 27

XVI. References ......................................................................................................................... 28

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I. ACKNOWLEDGEMENTS The Ho-Chunk Nation Community Health Assessment Survey would not have been possible without the

assistance of several employees, community members, and partnering agencies. The Ho-Chunk

Nation Department of Health would like to thank the Community Health Assessment Team who worked

diligently in developing the Community Health Assessment Survey questionnaire. Team members

included: Ruth Puent, Community Health Representative Supervisor; Carol Rollins, Environmental

Health Director; Louise Voss, Community Health Educator; Marilyn Yellowbird, Community Health

Nursing Supervisor; Denise Dodson, Nutrition Supervisor; Karena Thundercloud, Diabetes Project

Coordinator; Kathleen Clemons, Exercise Physiologist; Tyler Doyle, Health Information Systems staff;

Christie Becker, Contract Health staff; Julie Abbott-Jones, Behavioral Health Director; and Nancy

Rybski, Quality Improvement Supervisor. Under the coordination of the Community Health

Representative Program and Environmental Health program, a number of Health Department staff also

contributed their time at community events to gather important data. The leadership of Alec

Thundercloud MD, Health Executive Director, guided the assessment process from start to finish.

We would also like to take the opportunity to thank Christine Hovell, Jackson County Public Health,

Samantha Lucas, Great Lakes Epidemiologist, Megan Porter, Great Lakes Epidemiologist, and Karen

Maddox RN, MSN, MPH, PNP, Associate Professor Emerita UWEC who facilitated the development of

the Community Health Assessment Survey, under the guidance of Kristin Hill, Director of Great Lakes

Epidemiology Center. The final efforts of Joan Greendeer-Lee, Health Information Systems Director

and Ruth Puent, Community Health Representative Supervisor should be applauded for compiling the

final survey results and organizing responses by area. A special thank you to Lindsay Menard, MPH,

who completed the final Community Health Assessment document.

SPECIAL ACKNOWLEDGEMENTS

The Ho-Chunk Health Department would also like to extend a special thank you to all of the community

members who provided wonderful insight and participated in each community event. It is their input

that will help shape the future programming of the Health Department. Pinigigi! Finally, we would like to

thank all Ho-Chunk Nation Health Department programs and associated staff for participating in each

Community Health Assessment Survey event. During these community gatherings staff provided food,

information on current programs, and assisted Tribal members with completing the assessment

surveys. The information gathered by the community health assessment survey will be vital to the

Health Department as it seeks to provide quality, relevant health care to Tribal members.

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II. LIST OF FIGURES, TABLES, AND CHARTS

Figure 1: Ho-Chunk Nation Legislative Districts ........................................................................................................... 5

Figure 2: County Health Rankings Model .................................................................................................................. 14

Table 1: Race Distribution ........................................................................................................................................... 7

Table 2: Age and Sex Distribution ............................................................................................................................... 8

Table 3: Death from Specific Causes ......................................................................................................................... 10

Table 4: Infant Birth Weights .................................................................................................................................... 11

Table 5: Prenatal Care Received by Women in the Ho-Chunk CHDSA ........................................................................ 11

Table 6: Women that Smoked During Pregnancy ...................................................................................................... 11

Chart 1: Age Distribution of Survey Respondents ....................................................................................................... 9

Chart 2: Respondents Diagnosed with Negative Health Outcomes ........................................................................... 10

Chart 3: Body Mass Index ......................................................................................................................................... 12

Chart 4: Blood Pressure ............................................................................................................................................ 13

Chart 5: Glycemic Control ......................................................................................................................................... 13

Chart 6: Distribution of Reported Health Status ........................................................................................................ 13

Chart 7: Health Risks Survey Respondents are Most Concerned About in Their Homes ............................................ 15

Chart 8: Annual Household Income of Survey Respondents ...................................................................................... 16

Chart 9: Percent of Survey Respondents that are High School Graduate or Have GED .............................................. 16

Chart 10: Distribution of Survey Respondents that are Current Smokers .................................................................. 17

Chart 11: Former Smokers-Time Since Quitting ........................................................................................................ 17

Chart 12: Current Smokers Interested in Cessation Classes ....................................................................................... 17

Chart 13: Days per Week Survey Respondents Exercise (Excludes Work Activities) .................................................. 18

Chart 14: Reasons for Not Being More Physically Active for all Respondents ............................................................ 18

Chart 15: Percent of Times Fast Food Was Consumed ............................................................................................... 19

Chart 16: Patient Visits for Mental Health Services ................................................................................................... 19

Chart 17: Clients Served by Mental Health Services .................................................................................................. 20

Chart 18: Clients Referred to In-Treatment Services ................................................................................................. 20

Chart 19: Health Insurance Distribution of Survey Respondents ............................................................................... 25

Chart 20: Locations Respondents Seek Care at When Sick ........................................................................................ 25

Chart 21: Frequency of Seat Belt Use While Riding in the Car ................................................................................... 26

Chart 22: Helmet Use of Respondents ...................................................................................................................... 26

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III. INTRODUCTION

Community health assessments (CHA) are a vital and important step in improving the health of

communities. Community health assessments identify the health needs of a community by

surveying residents to determine their perceived health status of the community as well as to seek

input on their own perceived health status. The purpose of this CHA is to:

1. Assess the needs of the community

2. Identify the top health needs of the community

3. Identify stakeholders and resources available to address the greatest health needs of

the community

IV. METHODOLOGY1

In 2011, the Ho-Chunk Health Department

created two surveys (individual surveys

and household surveys) with the support

of Great Lakes Inter-Tribal Epidemiology

Center (GLITEC) staff while the Ho-Chunk

Health Director oversaw the entire

process. It is important to note the survey

was approved by the Ho-Chunk

Institutional Review Board (IRB).

Approximately 625 individuals were

surveyed while 202 households were

surveyed. All individuals and households

surveyed lived in three defined geographic

areas or legislative districts (Figure 1).

Data is reported by overall responses and

then broken down by the Ho-Chunk

representative districts, known as Area 1,

Area 2, and Area 3.

This map shows four of the five Ho-Chunk Nation tribal voting

districts. The 5th district includes members who lives any place

in the world outside the State of Wisconsin.

Figure 11: Ho-Chunk Nation Legislative Districts

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It is important to note that data was not compiled from Areas 4 and 5 as these areas are not in Ho-

Chunk’s Contract Health Service Delivery Area (CHSDA). Respondents were asked several

different questions to determine how socioeconomic factors, the effectiveness and efficiency of the

healthcare system, health behaviors, and access to services all influenced the health of tribal

members. Also, survey respondents were asked to answer questions regarding the perceived

health needs of the community and potential programs/services to develop and implement in the

future to help improve the health of community members.

The sample was a convenience sample; Ho-Chunk adults over 18 years of age who answered the

survey and lived near one of the six tribal community buildings where health staff conducted the

surveys. Each survey was self-administered, using pen and paper. It was filled out at community

meetings where a meal was provided. All adults completed a survey about their individual health.

In addition, one adult from each household in which at least one minor resided was asked to fill out

a household survey. This adult answered questions about all minors living in the household. Ho-

Chunk employees staffing the events carefully distributed the household surveys so that each

household would only be represented once.

There were 827 surveys in the sample. The data was hand-entered into excel; every tenth entry

was compared to the original paper survey to check for accuracy. Data were analyzed using SAS

software.

These data have limitations. The survey utilized convenience methods; data were self-reported. In

some cases, the questions used non-standard wording and/or response options, limiting

comparability to other populations. For the household survey, data were reported by an adult in the

household, not the minor; no formal mechanism existed to ensure that each child was included

only once.

The results of the survey were collected, analyzed, and developed into a CHA. The CHA will then

be utilized by leaders of the Ho-Chunk Nation Health Department to develop a Community Health

Improvement Plan (CHIP) which will be used to move strategies and interventions forward to

reduce the health needs identified in this assessment.

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V. DEMOGRAPHICS

Understanding the demographics of a population begins to frame the health of the community.

Three important factors used to identify and analyze the health needs of a community are race,

age, and sex distribution.

Ho-Chunk Nation has tribal members spread throughout the state of Wisconsin. Ho-Chunk Nation

cannot be defined by one geographic location. As stated earlier, data for the CHA was gathered at

one of six tribal community buildings and at several community meetings during 2011. As National

and State data are not available for tribes at the reservation geographic level the data provided for

comparison of Areas 1, 2, and 3 in the demographics section includes the population of Ho-

Chunk’s CHSDA. Therefore race, age, and sex distribution data incorporate data from the

following counties2:

Area 1: Clark, Eau Claire, Jackson

Area 2: Columbia, Crawford, Dane, La Crosse, Monroe, Sauk, Vernon and Houston

County in Minnesota

Area 3: Adams, Juneau, Marathon, Shawano, and Wood

Table 13-19

: Race Distribution, Areas 1, 2, 3 and All Races in Wisconsin*, 2010

Race Area 1 Area 2 Area 3 Wisconsin

American Indian/Alaska Native 1,916 3,912 4,996 54,559

Asian/Pacific Islander 3,536 29,236 8,907 131,152

Black 1,354 29,049 2,567 359,249

White 143,542 737,902 275,234 4,920,637

Some other race 1,436 14,989 2,636 135,879

Two or more races 2,091 16,549 3,960 104,537

Total 153,875 831,637 298,300 5,706,013

*Including Houston County, MN Based on Ho-Chunk’s CHSDA, the most populous area is Area 2 which includes the counties of

Columbia, Crawford, Dane, La Crosse, Monroe, Sauk, Vernon, and Houston (Minnesota). Even

though Area 2 has the most residents, Area 3 has the highest number of American Indians/Alaska

Natives living within its counties. In Wisconsin the majority of citizens are white (86%) and this

trend is also found in areas 1, 2, and 3. Overall, less than .1% of residents living in all 16 counties

of the CHSDA are American Indian/Alaska Natives.3-19

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Age and sex distribution also provide valuable information on the health outcomes witnessed in

populations. For example, if the majority of the population consists of people over the age of 65

the health outcomes and health needs reported will more than likely be different than those

reported if the majority of the population was between the ages of 20 and 40. Ho-Chunk’s CHSDA

have approximately an even sex distribution; although, men tend to outnumber women in the

majority of age ranges. Furthermore, it can be concluded the majority of residents (~81%) in the 3

service areas are aged 1 to 59 which is similar to the state of Wisconsin.3-19

Table 23-19

: Age and Sex Distribution, Areas 1, 2, 3 and All Ages in Wisconsin*, 2010

Age

Area 1 Area 2 Area 3 Wisconsin

Male Female Male Female Male Female Male Female

20 to 24 9.8% 10.0% 8.6% 8.5% 5.3% 4.9% 7.0% 6.6%

25 to 29 7.3% 6.3% 8.0% 7.4% 6.0% 5.7% 6.7% 6.4%

30 to 34 6.2% 5.4% 7.0% 6.5% 5.8% 5.3% 6.3% 6.0%

35 to 39 5.6% 5.3% 6.4% 6.1% 6.1% 5.7% 6.2% 6.0%

40 to 44 6.1% 5.6% 6.7% 6.4% 6.9% 6.6% 6.8% 6.6%

45 to 49 6.9% 6.7% 7.3% 7.3% 8.2% 7.7% 7.7% 7.7%

50 to 54 6.9% 6.7% 7.3% 7.3% 8.0% 7.9% 7.7% 7.6%

55 to 59 6.3% 6.4% 6.7% 6.7% 7.2% 7.0% 6.8% 6.7%

60 to 64 5.4% 5.4% 5.4% 5.4% 5.9% 6.1% 5.5% 5.5%

65 to 69 3.9% 3.9% 3.6% 3.8% 4.7% 5.0% 3.9% 4.1%

70 to 74 2.7% 3.2% 2.5% 2.8% 3.6% 3.9% 2.9% 3.2%

75 to 79 2.3% 2.8% 1.9% 2.4% 2.7% 3.2% 2.2% 2.8%

80 to 84 1.7% 2.4% 1.4% 2.1% 2.0% 2.8% 1.7% 2.4%

>85 1.7% 3.0% 1.2% 2.6% 1.6% 3.3% 1.3% 2.8% *Including Houston County, MN

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Surveying

individuals at a

variety of ages

helps gauge the

health status and

health needs of a

community

rather than if the

population was

close in age as it

allows for more

diverse

responses.

Survey

respondents ranged in age from 18 to older than 85 years old. In Areas 1, 2, and 3 the majority of

individuals surveyed were between the ages of 25 and 64. Less than 5% of respondents were

over the age of 85.1

VI. INDICATORS OF HEALTH

HEALTH OUTCOMES The health of a population is often measured by mortality (length of life) and morbidity (quality of

life) rates. It is difficult to quantify and define health; therefore, these two indicators have long

been used as the primary instruments to determine the health of a community. Other leading

indicators used to define the health of a community are infant mortality and birth weights.

Furthermore, immunization data and diabetes data provide extra insight on other important health

measures impacting the health of Ho-Chunk Tribal members.

0

5

10

15

20

25

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18-24 25-34 35-44 45-54 55-64 64-75 75-85 >85

Pe

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of

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nd

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Age

Age Distribution of Survey Respondents

Area 1

Area 2

Area 3

All Respondents

Chart 11: Age Distribution of Survey Respondents

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Tribal members reported the top six negative health outcomes experienced in the population are

high blood pressure, diabetes type 2, alcohol/drug dependency, high cholesterol, arthritis, asthma,

and cancer. Additionally, data gathered from the Wisconsin Bureau of Health Information indicated

heart disease and

cancer were the main

causes of mortality

(Table 3).2 In 2009,

the leading cause of

American

Indian/Alaska Native

deaths nationwide

were heart disease,

cancer, and injuries

(unintentional

injuries).20 The trends

identified in the overall

population of

American

Indians/Alaska

Natives in the United

States coincide with

the results of the community health survey. The majority of these negative health outcomes are

chronic conditions; preventative programs and services can be used to reduce the number of

adverse health outcomes reported by Ho-Chunk Tribal members.

Chart 21: Respondents Diagnosed with Negative Health Outcomes

Table 32: Death from Specific Causes

0

50

100

150

200

250

Ast

hm

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Dia

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Respondents Diagnosed with Negtative Health Outcomes

All Respondents

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MATERNAL AND CHILD HEALTH (MCH) (NATALITY)

Infant birth rates and prenatal

care received by mothers during

pregnancy are two additional

indicators to use when

determining the health of a

community. If infants are born

with low birth weights they are

more susceptible to negative

health outcomes such as

respiratory illness, lung disease,

and vision and hearing problems.

Low birth weight is defined as a newborn weight of lower than 2,500 grams.21 Data from the

Wisconsin Bureau of Health Information indicated that from 2000-2009, 77.4% of American

Indians/Alaska Natives infants born in the Ho-Chunk CHDSA were born in the average birth weight

category compared to 82.4% of all races in Wisconsin.2 Furthermore, only 5.6% of American

Indian/Alaska Natives born in the Ho-Chunk service area were born with low birth weight.2 Over

70% of American Indian/Alaska Native women in the Ho-Chunk CHDSA sought prenatal care from

2000-2009 in their first trimester while 65.1% did not smoke during pregnancy.2 Although some

MCH data appears promising, it is important to note 77.4% of infants born with average birth rates

is an unexpected finding and does not reflect pregnant women seeking prenatal care in the third

trimester (5.6%) and the number of women still smoking during pregnancy (33.9%).2

Table 62: American Indian/Alaska Native

Women that Smoked During Pregnancy

Table 52: Prenatal Care Received by

Women in the Ho-Chunk CHDSA

Table 42: Infant Birth Weights

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IMMUNIZATION DATA

Ensuring populations are immunized is one of the best ways to prevent the transmission of

communicable diseases. Immunizing infants and children is a primary preventive measure a

community can take to assure the health of its residents. A goal of the Ho-Chunk Health

Department is to ensure approximately 80% of Ho-Chunk children residing in the Ho-Chunk tribal

jurisdiction area and are turning 24 months of age complete 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3

Hepatitis B, 1 Varicella, and 4 Pneumococcal Conjugate immunizations.22 In 2011, 77.6 % of Ho-

Chunk children received their required immunizations; in 2012, 77.1% of Ho-Chunk children were

immunized.22 Healthy People 2020 established a goal of immunizing 90% of children aged 19 to

35 months with effective vaccination coverage levels for universally recommended vaccinations.32

DIABETES

Diabetes is another leading

health indicator to use when

determining the health of a

population. Diabetes Type 2 is

a common negative health

outcome. Several factors

influence the onset and

diagnosis of diabetes including

but not limited to predisposition,

weight, blood pressure,

genetics, and activity levels.

The Ho-Chunk Diabetes audit indicated that from 2008-2011 approximately 70% of CHDSA

diabetic patients were obese; tribal diabetic patient’s body mass index (BMI) was also found to be

greater than 30.0.2 In order to better control and treat diabetes it is recommended that diabetic

patients have a normal BMI reading (less than 25.0).2 Additionally, it is recommended blood

pressure levels read <120/<70 for diabetic patients.2 Unfortunately, 25%-35% of diabetic patients

in the Ho-Chunk CHDSA had blood pressure levels greater than the recommended value (Chart

4).2 Managing blood-sugar levels is also important for tribal diabetic patients; approximately one-

third of diabetic patients had blood-sugar levels equal to or less than the recommended goal for

the HbA1c test (Chart 5).2 Target goals established in Healthy People 2020 for diabetic patients

whose blood pressure is under control and have a HbA1c value less than 7% are 57.0% and

58.9% respectively.32

Table 6: Smoking During Pregnancy

Chart 32: Body Mass Index (BMI)

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HEALTH STATUS

Survey respondents had the opportunity to report their health status as either being poor, fair,

good, very good, or excellent. Approximately 40% of people in all three service areas reported

having good health and over 25% of all respondents reported having very good health.1

Approximately 5%-18% of all respondents reported having fair or poor health1 compared to 13.6%

of Native Americans/Alaska Natives in the nation in 20111,23. In order to reduce negative health

outcomes and increase productivity and happiness in the community it is crucial to have healthy

residents. According to the data, the majority of residents believe they are in good health; a

successful finding for health department staff and policy makers alike.

0 10 20 30 40 50

Excellent

Very Good

Good

Fair

Poor

Percent of Respondents Self

Re

po

rte

d H

eal

th S

tatu

s

Distribution of Self Reported Health Status of Survey Respondents

All Respondents

Area 3

Area 2

Area 1

Chart 61: Distribution of Reported Health Status

Chart 42: Blood Pressure Chart 5

2: Glycemic Control

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VII. COUNTY HEALTH

RANKINGS MODEL

Healthcare and public health

professionals

have defined health by death

and disease rates for decades.

In recent years however, new

ways of defining and

categorizing health have been

adopted. The Wisconsin

Population Health Institute and

the Robert Wood Johnson

Foundation developed a new

model, The County Health

Rankings Model, to help define

what impacts individual health

and health outcomes.

According to the model, the

physical environment, social and

economic factors, clinical care,

and health behaviors all

influence health outcomes. The model indicates that 10% of health is determined by physical

environments, 40% is impacted by social and economic factors, 20% clinical care, and 30% health

behaviors.24 Therefore, it is important to assess how income levels, educational attainment, the

places people live, work, and socialize, and individual behavior all impact the health of Ho-Chunk

Tribal members. It is essential to note the methods of measurement used to calculate the County

Health Rankings do not incorporate Ho-Chunk Tribal members as Wisconsin Data Systems have

certain restrictions including but not limited to being able to identify Native Americans by tribe (C.

Rollins, personal communication, November 20, 2013).

Figure 224

: County Health Rankings Model

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PHYSICAL ENVIRONMENT

According to survey respondents, the three biggest health risks tribal members are concerned

about in their households are slips and falls, mold, and the quality of their drinking water.

Approximately 10% of all respondents are concerned about slips and falls and mold while 18% of

all respondents are concerned about the quality of their drinking. Across Areas 1, 2, and 3 there

are no significant differences noticed. Overwhelmingly, approximately 45% of respondents in

Areas 1, 2, and 3 have no environmental concerns.

0

10

20

30

40

50

60

Allerginsthat

triggerAsthma

Slips andFalls

CarbonMonoxide

Gas

Radon Gas TheQuality of

MyDrinkingWater

Mold None

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of

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Health Risks Survey Respondents are Most Concerned About in their Homes

Area 1

Area 2

Area 3

All Respondents

Chart 71: Health Risks Survey Respondents are Most Concerned About in their Homes

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05

101520253035

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of

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Annual Household Income

Annual Household Income of Survey Respondents

Area 1

Area 2

Area 3

All Respondents

SOCIAL AND ECONONMIC FACTORS

Income levels, educational background, employment rates, family and social support, and

community safety are all variables that significantly influence health outcomes. Survey

respondents across all three areas reported household incomes to be less than $10,000 and more

than $75,000 dollars.1 In Wisconsin, the average household income from 2007-2011 was

$66,693.25 Overall, approximately 83% of all survey respondents make less than the average

household income of Wisconsin residents.1 Ho-Chunk members earning less than the average

household income are at a greater risk of reporting negative health outcomes such as heart

disease, high blood pressure, diabetes, obesity, etc.

Education is also another leading indicator of the health of communities. According to Ho-Chunk

Tribal members taking the community health survey, 68% are high school graduates or have their

GED. Whereas in Wisconsin, 85.4% of residents 25 years

of age or older are high school graduates or have their

GED.26 With that, approximately half of all Wisconsin

residents have some form of post-secondary education

compared to only 22% of tribal members.1,26 This

difference influences the health outcomes reported by Ho-

Chunk Tribal members significantly. Research has shown

people with higher levels of education are more likely to be

healthier than those with less education. Healthy People

2020 set a goal of having 97.9% of 18 to 24 years

complete high school in the coming decade.32

73.45

62.69 67.94

68.07

Percent of Survey Respondents that are High School Graduates or have

their GED

Area 1

Area 2

Area 3

Chart 81: Annual Household Income of Survey Respondents

Chart 91: Percent of Survey Respondents that are

High School Graduates or have their GED

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HEALTH BEHAVIORS

Health behaviors, according

to the Robert Wood Johnson

Foundation and the

Wisconsin Population Health

Institute, account for 30% of

morbidity and mortality

rates.24 Many interventions,

programs, and services in

public health are currently

focused on changing

individual behavior.

Smoking, excess drinking, unhealthy eating, lack of exercise, and other human behaviors impact

the health outcomes of individuals and populations. For example, smoking is a known cause of

lung cancer and cardiovascular disease. The three figures on this page highlight the smoking

behaviors of survey respondents. In areas 1, 2, and 3 approximately 50% of tribal members

reported being a current smoker; whereas in 2011, approximately 21% of all Wisconsin adults

currently smoked cigarettes.1,27 The traditional use of tobacco is a common practice among tribal

members. In future assessments it will be important to be strategic when developing questions

regarding traditional use of tobacco products as

010203040506070

Pe

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of

Cu

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nt

Smo

kers

Distribution of Survey Respondents that are Current Smokers

Yes

No

Only for CeremonialPurposes

Healthy People 2020 Target , 12.0%32

0

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30

40

50

60

70

Pe

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Smo

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Former Smokers-Time Since Quitting

Less Than a Year

1 to <3 Years

3 to <5 Years

5 Years or Greater

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Current Smokers Interested in Cessation Classes

Yes

No

Chart 101: Distribution of Survey Respondents that are Current Smokers

Figure #: Facilities Respondents Seek Care at When Sick

Chart 111: Former Smokers: Time Since Quitting

Chart 121: Current Smokers Interested in Cessation

Classes

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survey results may help develop more effective prevention programs (P. Thunder, personal

communication, November 20, 2013). Although the percent of current smokers is high, 50% of former

smokers that have quit smoking have been non-smokers for over 5 years.1 Reducing smoking

rates has been a goal

of public health

advocates for

decades. A primary

intervention used to

reduce the number of

smokers is the use of

cessation programs.

Unfortunately,

smoking cessation

programs may not be

the most successful

intervention to

implement throughout

the community as

over 60% of current

smokers are not

interested in

cessation classes

(Chart 12).1

Another important

health behavior

impacting the health

of community

members is the

amount of time

residents spend

exercising. Exercise

is vital in maintaining

a healthy weight and dealing with stress. Therefore, it is important Ho-Chunk Tribal members get

41.5

36.96

20.16

17.19 52.37

14.03

20.16

6.32

15.42

10.08

13.24 17.79

Reasons for Not Being More Physically Active for All Respondents

Lack of Time Due to Work/School

Lack of Time Due to FamilyObligationsLack of Facilities or Programs

Lack of Support from Family/Friends

Lack of Self-Discipline or Willpower

Fear of Injury

Distance I Have to Travel to Exercise

No Safe Place to Exercise

Long-Term Illness

Injury or Disability

I Do Not Know How to Start aFitness ProgramCost

0

5

10

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25

30

35

40

45

50P

erc

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Days per Week

Days per Week Survey Respondents Excercised (excludes work activities)

Area 1

Area 2

Area 3

All Respondents

Healhty People 2020 Target, 47.9% of adults will meet Federal pysical activity guidelines of engaging in 75 minutes of activity twice a week32

Chart 141: Reasons for Not Being More Physically Active for All Respondents

Chart 131: Days per Week Survey Respondents Exercise (Excludes Work Activities)

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adequate exercise. It is recommended by the Centers for Disease Control and Prevention (CDC)

that adults spend about seventy-five minutes, two days a week exercising to improve their health.28

Based on the community health survey results, 35%-40% of tribal members in Areas 1, 2, and 3 do

not regularly exercise (Chart 14).1 Those that do exercise regularly, exercise 1-3 days a week.1

The biggest barriers stopping

survey respondents from

exercising are the lack of

self-discipline or willpower

(52.37%), lack of time due to

work/school (41.5%), and

lack of time due to family

obligations (36.96%).1 It is

important to note survey

respondents were allowed to

select multiple reasons for

not being more physically

active (Chart 14).

Additionally, the number of times eating at various fast food restaurants also contributes to the

health of tribal members. Over half (56.98%) of survey respondents indicated eating at fast food

restaurants 1 to 5 times in the previous month.1 Fast food restaurants tend to serve unhealthier

foods high in calories, cholesterol, and fat. Educational campaigns developed by the Ho-Chunk

Health Department should focus on teaching

and encouraging tribal members to select

healthier items such as wraps, salads, and

fruit.

Another variable impacting the health

outcomes of Ho-Chunk Tribal members are

behavioral health conditions such as

depression, anxiety, schizophrenia, post-

traumatic stress disorder, and alcohol and

other drug addictions. From 2010 through

2012 patient visits for mental health services

4.98

56.98 15.45

4.49

3.82 1

1.5

11.79

Percent of Times Fast Food was Consumed (Last 30 Days) of All

Respondents

0

1 to 5

6 to 10

11 to 15

16 to 20

21 to 25

26 to 30

Don't Know/Not Sure

Chart 1629

: Patient Visits for Mental Health Services

Chart 151: Percent of Times Fast Food was Consumed

400

500

600

700

800

900

2010 2011 2012

Nu

mb

er

of

Pat

ien

t V

isit

s

Year

Patient Visits for Mental Health Services

# ofPatientVisits

20 | P a g e

doubled; there were approximately 450 patient visits in 2010 compared to over 800 in 2012.29 With

an increase in patient visits there was also an increase in the number of patients served. In 2010

the Ho-Chunk Health Department served approximately 1200 clients in the Behavioral Health

Department while in 2012 about 2000 clients were served.29 The trend for both patient visits and

clients served increased over

the past three years

indicating the need for

behavioral health support is

growing. A trend worth noting

is the decrease in clients

referred to in-treatment

services. In 2010,

approximately 180 clients

were referred to in-treatment

services compared to 80 in

2012.29 It is important to note the Ho-Chunk Tribal data may represent duplicated clients (P.

Thunder, personal communication, December 4, 2013). In Wisconsin, among adults with serious

psychological distress it is reported approximately half (49%) received mental health treatment or

medication in 2007.30 Furthermore, frequent mental distress was more prevalent among American

Indians (14%) compared to whites (8%) in Wisconsin.30 Healthy People 2020 has a goal of

assuring 64.6% of adults aged 18 years and older with serious mental illness receive treatment by

2020.32

Chart 1829

: Clients Referred to In-Treatment Services

1000

1500

2000

2500

2009 2010 2011 2012Nu

mb

er

of

Clie

nts

Se

rve

d

Year

Clients Served for Mental Health Services

# of Clients Served

0

50

100

150

200

2010 2011 2012

Nu

mb

er

of

Pat

ien

ts R

efe

rre

d t

o In

-P

atie

nt

Tre

atm

en

t

Year

Clients Referred to In-Treatment Services

# of Clients Referred to In-Treatment Services

Chart 1729

: Clients Served for Mental Health Services

21 | P a g e

VIII. SUMMARY OF DATA

The responses collected for the Ho-Chunk community health assessment were vast (625 individual

surveys and 202 household surveys) and produced an abundant amount of data. The majority of

individuals surveyed were between the ages of 25 and 64 while less than 5% of respondents were over

the age of 85.1 Community Health Service Delivery Area (CHSDA) 3 (Adams, Juneau, Marathon,

Shawano, and Wood Counties) has the highest number of American Indians/Alaska Natives living

within its counties.3-19

Morbidity and mortality rates are two of the leading indicators used to define the health of a population.

From the data presented and analyzed, the two leading causes of death from 2000-2009 in the Ho-

Chunk Nation are heart disease and cancer.2 Furthermore, the survey results aided in the identification

of the top negative health outcomes (high blood pressure, diabetes type 2, alcohol/drug dependency,

high cholesterol, arthritis, and cancer) experienced by tribal members along with how low infant birth

weights and diabetes affect the health of community members.1,2,22

Even though high rates of disease

exist throughout the community, approximately 40% of people in all three service areas reported having

good health and over 25% of all respondents reported having very good health.1

In assessing the variables that determine the health of a person or a community it is important to

include social, economic, and physical environment factors. Health is determined by more than

individual health behaviors and clinical care. According to the County Health Rankings Model from the

Robert Wood Johnson Foundation and the Wisconsin Population Health Institute, 10% of health

outcomes can be attributed to the physical environment, 40% to social and economic factors, 30% to

individual health behaviors, and 20% to clinical care.24

Ho-Chunk Tribal members (10-18%) are most concerned about slips and falls, the quality of drinking

water, and mold adversely influencing their health in their homes.1 Overall, 83% of all survey

respondents make less than the average household income of Wisconsin residents. Education is also

another leading indicator of the health of communities.1,25

According to Ho-Chunk Tribal members

taking the community health survey, 68% are high school graduates or have their GED.1 When

compared to the state of Wisconsin, 85.4% of adults aged 25 or older are high school graduates or

have their GED.26

Individual health behaviors such as smoking, alcohol consumption, exercising, and

wearing seat belts also influence the health of communities. Approximately 50% of tribal members

reported being a current smoker and 40% stated not participating in regularly exercise.1

In addressing the greatest health needs of the community, it will be important for Ho-Chunk Health

Department staff, community residents, and stakeholders to consider how income and education levels

influence the health of tribal members.

22 | P a g e

IX. IDENTIFIED HEALTH NEEDS

A way of determining the health needs of Ho-Chunk Tribal members is to identify the most

diagnosed health outcomes. The survey results indicate Ho-Chunk Tribal members suffer from six

main health problems:

1) High Blood Pressure (210 respondents)

2) Diabetes Type 2 (143 respondents)

3) Alcohol/Drug Dependency (118 respondents)

4) High Cholesterol (114 respondents)

5) Arthritis (92 respondents)

6) Cancer (50 respondents)

The Public Health Accreditation Committee reviewed the community survey questions and results.

The areas selected as the top health needs seemed to be mostly represented in either question or

answer form. Selecting the health needs of tribal members in this manner was a tangible way for

the committee to organize such a large amount of information into a more useable form (P.

Thunder, personal communication, December 4, 2013).

It will be important for the Community Health Improvement Plan (CHIP) to identify and implement

interventions, policies, programs, and services aimed at reducing the health needs listed above.

When developing ways to reduce the negative health outcomes it will be crucial for community

members to incorporate interventions aimed at addressing the social determinants of health.

Social, economic, and physical environmental factors influence health outcomes as much, if not

more, than individual behaviors and clinical care.24

23 | P a g e

X. STRENGTHS AND CHALLENGES OF CONDUCTING A COMMUNITY HEALTH ASSESSMENT Conducting a community health needs survey and facilitating community meetings are complex

and complicated tasks. Organizing the data gathered, analyzing the data, and developing a

community health needs assessment are also very difficult activities. Throughout the entire

process many strengths and challenges were identified.

A strength of conducting this community health assessment was the opportunity to reach out to

community members and seek their feedback on health programs without any political undertones.

Community members appeared to enjoy participating in the community conversations and

appreciated the chance to provide input. Additionally, staff members were able to connect with

communities and have conversations about the health and needs of tribal members in the CHSDA

regions. Another strength of this process was the chance to foster relationships with existing

community partners and develop new relationships with key stakeholders not previously involved

in this process.

With the many strengths of the community health assessment process, challenges arose, too. It

was difficult to locate and find national and state-wide data to use for comparison with the results

of the Ho-Chunk community health survey. With that, it was also difficult to bring together local

data in a tangible and meaningful way. Additionally, it was difficult to reach more of the targeted

population as tribal members are spread across a wide geographic area. Furthermore, since the

time the assessment process began, a tribal community assessment tool has been developed and

it is believed this tool would have helped the process move forward in a more organized manner.

Moreover, a GLITEC epidemiologist helped formulate the survey questions; some of the questions

did not provide the information needed. In this respect, a dialogue with the community would have

been preferable. Finally, one of the hardest challenges was moving forward in the process after

the survey data was collected, gathered, and grouped (Rollins, C. & Thunder, P., personal

communications, November 20, 2013).

XI. NEXT STEPS In late 2013 and early 2014, the Public Health Accreditation Committee will develop a Community

Health Improvement Plan (CHIP) to address the biggest health needs facing Ho Chunk Tribal

members. Ho-Chunk staff will identify focus areas and then solicit feedback from community

members. The CHIP will be written and ready for implementation in early 2014.

24 | P a g e

XII. COMMUNITY STAKEHOLDERS AND RESOURCES

A. Ho-Chunk Nation Social Services including Youth Services and the Tribal Aging

Unit

B. Ho-Chunk Nation Housing

C. Ho-Chunk Nation Community Development Agency

D. Jackson County Health and Human Services

E. Black River Falls Memorial Hospital

F. Ho-Chunk Nation Emergency Management

G. Jackson County Emergency Management

H. WI Department of Health Services

I. Western Regional DHS Office

J. Indian Health Service

K. Institute for Wisconsin Health, Inc

L. Ho-Chunk Nation Education Department including Head Start

M. Jackson County Child Death Review Team

N. Ho-Chunk Nation Tribal Police

http://www.ho-chunknation.com/?PageId=31




http://www.co.jackson.wi.us/index.asp?Type=B_BASIC&SEC=%7B20DC3C77-2232-4A62-AC97-A5D3BA8B0702%7D

http://www.brmh.net/


http://www.co.jackson.wi.us/index.asp?Type=B_BASIC&SEC=%7B179D9B16-51ED-4F7F-84E9-63A5A49D7E1F%7D

http://www.dhs.wisconsin.gov/

http://www.dhs.wisconsin.gov/R_Counties/RegionalStaffListings/WR_DPH_staff.htm

http://www.ihs.gov/

http://www.instituteforwihealth.org/



25 | P a g e

XIII. APPENDIX A:

ADDITIONAL DATA

Ho-Chunk residents

completing the survey are

insured by two primary

providers: employers

(47.26%) and

IHS/Contract Health

Service (44.61%).1 In the

County Health Rankings

Model, clinical care only

accounts for 20% of

health outcomes24. The

majority of community

members surveyed are

covered by two reliable

sources; therefore, residents have access to more affordable healthcare than if they were

uninsured. The

clinical care tribal

members have

access to is

important in

preventing,

diagnosing, and

controlling the

diseases faced

by the

population. Less

than 10% of all

survey

respondents

reported having

01020304050607080

Ho-ChunkTribalHealthCenterClinic

OtherTribalHealth

Care Clinic

Non-TribalHealth

Care Clinic

UrgentCare

HospitalEmergency

Room

Never goto any

place whenI'm sick or

needhealthadvice

Pe

rce

nt

of

Re

spo

nd

en

ts

Location

Locations Respondents Seek Care at When Sick

Area 1

Area 2

Area 3

All Respondents

Chart 191: Health Insurance Distribution of Survey Respondents

Chart 201: Locations Respondents Seek Care At When Sick

05

101520253035404550

Pe

rcen

t o

f R

esp

on

den

ts

Type of Health Insurance

Health Insurance Distribution of Survey Respondents

Area 1

Area 2

Area 3

All Respondents

26 | P a g e

no health care coverage at all (Chart 19).1 It is also important to note the IHS/Contract Health

Service coverage is more of a last resort payer for Ho-Chunk Tribal members rather than a primary

insurance provider (P. Thunder, personal communication, December 4, 2013).

As noted in Chart 20, when Ho-Chunk Tribal members seek coverage 75% of respondents

receive care at the Ho-Chunk Tribal Health Care Center.1 The management of chronic diseases

among tribal members has been a focus area of the Ho- Chunk Nation Health Department (C.

Rollins, personal communication,

November 20, 2013). A primary

prevention measure is regular

preventive care. Most tribal

members (70%) had a routine

check-up within the past year.1

Routine physicals and seeking

care by primary physicians

allows residents to form trusting

relationships with their providers

while also accessing more

affordable services. Primary

care is significantly less

expensive than emergency

department care. Also,

routine check-ups allow

survey respondents

to manage their care more

effectively which ultimately

impacts their health in a

positive way.

Other behaviors potentially

impacting the health

outcomes of tribal members

are adverse childhood

effects, the prevalence of

binge drinking, using a seat belt in a car, riding in a vehicle with a drunk driver, wearing a helmet,

Chart 211: Frequency of Seat Belt Use While Riding in the Car

0

20

40

60

80

100

Pe

rce

nt

of

Re

spo

nd

en

ts

Frequency of Seat Belt Use While Riding in the Car

Survey Respondents Use of Seat Belts in Car

Area 1

Area 2

Area 3

All Respondents

Healthy People 2020, Target, 92% for drivers and right-front seat pasengers32

01020304050607080

Nu

mb

er

of

Re

spo

nd

en

ts

Area

Respondents Reporting Wearing a Helmet

Bicycle

All-Terrain Vehicle

Motorcycle

Snowmobile

Healthy People 2020, Target 74 % for motorcycle operators & passangers32

Chart 221: Helmet Use of Respondents

27 | P a g e

etc. Approximately 75% of survey respondents (Chart 21) stated they always wear a seat belt

while driving in the car and approximately 25% of respondents reported wearing a helmet while

biking, using an all-terrain vehicle, motorcycling, and snowmobiling (Chart 22)1. Participating in

healthy behaviors helps reduce the risk of injury and lowers the rate of preventable injuries in the

community.

XIV. APPENDIX B: Individual and Household Survey Results

The results of the Individual and Household Surveys are available by request from the Ho-Chunk

Nation Health Department.

XV. APENDIX C: PUBLIC HEALTH ACCREDITATION BOARD Standards & Measures Comparison (Version 1.0)31

The Public Health Accreditation Board (PHAB) developed domains, standards, and measures for

State, Local, and Tribal health departments to meet in order to obtain voluntary national

accreditation. Striving to meet the standards and measures set forth by PHAB helps ensure a

health department is providing effective, efficient, and quality services. Domain 1, standard 1, and

measure 2 requires tribal health departments to complete a health assessment. In order to be in

compliance with the standards and measures tribal health departments must complete a

community health assessment and include the majority of components outlined in the measure:

A. Data and information from various sources contributed to the community health

assessment and how the data were obtained

B. A description of the demographics of the population

C. A general description of health issues and specific descriptions of population groups

with particular health issues

D. A description of contributing causes of community health issues

E. A description of existing community or Tribal assets or resources to address health

issues

The preceding Ho-Chunk Nation community health assessment encompasses the majority of the

required components. Data collected did not necessarily focus on specific population groups with

particular health issues as tribal members can be considered a low-income and minority

population. Furthermore, existing community and Tribal assets or resources can be elaborated

upon in more detail in future assessments and in the Community Health Improvement Plan.

28 | P a g e

XVI. REFERENCES

1 Ho-Chunk Nation Department of Health. (2013). Executive Summary of the 2011 Community Health Assessment

Survey. 2

Great Lakes Inter-Tribal Epidemiology Center. (2012). Ho-Chunk Community Health Profile. Great Lakes Inter-Tribal

Council, Inc. 2012.

3 United States Census Bureau. (2010). Adams County WI 2010 Demographic Profile. Retrieved from

http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml

4 United States Census Bureau. (2010). Clark County WI 2010 Demographic Profile. Retrieved from


5 United States Census Bureau. (2010). Columbia County WI 2010 Demographic Profile. Retrieved from


6 United States Census Bureau. (2010). Crawford County WI 2010 Demographic Profile. Retrieved from


7 United States Census Bureau. (2010). Dane County WI 2010 Demographic Profile. Retrieved from


8 United States Census Bureau. (2010). Eau Claire County WI 2010 Demographic Profile. Retrieved from


9 United States Census Bureau. (2010). Houston County MN 2010 Demographic Profile. Retrieved from


10 United States Census Bureau. (2010). Jackson County WI 2010 Demographic Profile. Retrieved from


11 United States Census Bureau. (2010). Juneau County WI 2010 Demographic Profile. Retrieved from


12 United States Census Bureau. (2010). La Crosse County WI 2010 Demographic Profile. Retrieved from


13 United States Census Bureau. (2010). Marathon County WI 2010 Demographic Profile. Retrieved from


14 United States Census Bureau. (2010). Monroe County WI 2010 Demographic Profile. Retrieved from


15 United States Census Bureau. (2010). Sauk County WI 2010 Demographic Profile. Retrieved from


16 United States Census Bureau. (2010). Shawno County WI 2010 Demographic Profile. Retrieved from


17 United States Census Bureau. (2010). Vernon County WI 2010 Demographic Profile. Retrieved from


18 United States Census Bureau. (2010). Wisconsin 2010 Demographic Profile. Retrieved from


19 United States Census Bureau. (2010). Wood County 2010 Demographic Profile. Retrieved from


20 Heron, M. (2012, Oct 26). National Vital Statistics Reports Deaths: Leading Causes for 2009. Retrieved from

http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_07.pdf

29 | P a g e

21 World Health Organization. (2013). Health status statistics: Morbidity. Retrieved from

http://www.who.int/healthinfo/statistics/indlowbirthweight/en/

22 Ho-Chunk Nation Department of Health. (2013). Immunization Program Data.

23 Centers for Disease Control and Prevention National Center for Health Statistics. (2012). Summary Health Statistics

for the U.S. Population: National Health Interview Survey, 2011. Retrieved from

http://www.cdc.gov/nchs/data/series/sr_10/sr10_255.pdf

24 University of Wisconsin Population Health Institute, Robert Wood Johnson Foundation. (2013). County Health

Rankings. Retrieved from http://www.countyhealthrankings.org/our-approach

25 United States Census Bureau. (2012). Selected Economic Characteristics: 2007-2011 American Community Survey

5-Year Estimates. Retrieved from

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_11_5YR_DP03

26 United States Census Bureau. (2012). Selected Social Characteristics in the United States: 2007-2011 American

Community Survey 5-Year Estimates. Retrieved from

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_11_5YR_DP02

27 Wisconsin Department of Health Services Wisconsin Tobacco Prevention Control Program. (2012). Tobacco Fact

Sheet. Retrieved from http://www.dhs.wisconsin.gov/publications/p4/p43073.pdf

28 Centers for Disease Control and Prevention. (2011). How Much Physical Activity Do Adults Need? Retrieved from

http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

29 Ho-Chunk Nation Department of Health. (2013). Activity Report for Mental Health Program.

30 Wisconsin Department of Health Services. (2010). Mental Health (Focus Area Profile). Retrieved from

http://www.dhs.wisconsin.gov/hw2020/pdf/mentalhealth.pdf

31 Public Health Accreditation Board. (2011). Standards & Measures. Retrieved from http://www.phaboard.org/wp-

content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf

32 U.S. Department of Health and Human Services. (2013). Healthy People 2020: Topics and Objectives. Retrieved from

http://healthypeople.gov/2020/topicsobjectives2020/default.aspx

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