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Community Health Needs AssessmentOctober 2016

2016 Ross County Community Health Needs Assessment

Introduction

The term “health” embodies a multi-faceted concept, particularly from a community perspective. An individual’s health is measured by the presence and/or severity of illness; whether or not they engage in behaviors that are a risk to their health, and if so, the length of time the behavior has occurred. It can also be measured by asking individuals to report their personal perception of their overall health. The health of an entire community is measured by collecting and compiling individual data. Commonly used measurements of population health status are morbidity (incidence and prevalence of disease) and mortality (death rates). Socioeconomic data is usually included, as it relates to the environment in which individuals live. A particular population’s level of health is usually determined by comparing it to other populations, or by looking at health-related trends over time. Everyone in a community has a stake in health. Poor health is costly to people trying to maintain employment, and employers pay for it via high rates of absenteeism and higher health insurance costs. Whole communities can suffer economic loss when groups of citizens are ill. As a result, everyone benefits from addressing social, environmental, economic, and behavioral determinants of health.

Health status is closely related to a number of socioeconomic characteristics. Individuals of various socioeconomic status show different levels of health and incidence of disease, while race and culture matter in complex ways. Social and economic variables that have been shown to impact health include: income, education, and employment; as well as literacy, language, and culture. Health literacy is a concept that links a person‘s ability to understand and act upon health information, and ultimately, to take control of their health. Individuals with poor health literacy are at risk for poor health outcomes when important health care information is communicated using medical jargon and unclear language that exceed their literacy skills. These individuals - who tend to be poorly educated, immigrants, elderly, or members of racial/ethnic minority groups - can have issues reading and comprehending materials such as prescription bottles, educational brochures, and nutrition labels. Thus, they are more likely to have higher rates of complications than people who are more literate.A comprehensive community health needs assessment (CHNA) can provide a better understanding of a population’s health needs. Provisions of the Patient Protection and

Affordable Care Act (ACA) requires all 501(c) (3) health systems, operating one or more hospitals, as well as federally-qualified health centers (FQHC’s) to complete a CHNA every three years. All public health districts are required to complete health needs assessments every five years. The purpose of the assessment is to provide the health continuum in a community. This serves as a foundation for community health planning and provides information to policymakers, provider groups, and community advocates for improvement efforts, including the best ways to direct health-related grants and appropriations. Obtaining information and views from community members is one of the most important aspects of the CHNA. This involves surveying a percentage of the community to determine which health problems are most prevalent, and to solicit their ideas concerning strategies to address these problems. It also explores the factors that impact the design of programs and services to effectively address the identified health problems on a broader scope.

Community Health and Needs Assessment


The U.S. Department of Health and Human Services established four overarching health goals for the year 2020: 1. Attain high-quality, longer lives free of preventable disease,

disability, injury, and premature death.2. Achieve health equity, eliminate disparities, and improve the

health of all groups.3. Create social and physical environments that promote good

health for all.4. Promote quality of life, healthy development, and healthy

behaviors across all life stages.To achieve these goals, a comprehensive set of objectives were established (Healthy People 2020). The objectives include 26 leading health indicators arranged into 12 topics used to set priorities and measure health over a 10-year period. These indicators, selected on the basis of their ability to motivate action, the availability of data to measure progress, and their importance as health issues for the public, influenced the development of Partners for a Healthier Ross County’s 2016 Community Health Needs Assessment.

Partners for a Healthier Ross County

Established in 1996, the Partners for a Healthier Ross County is a collaborative, community-based group whose efforts are aimed at improving the quality of life for the people of Ross County. For nearly 20 years, each participating agency conducted its own community health assessment and created subsequent, individual plans. In 2016, the group is working in partnership to complete Ross County’s first collaborative assessment and strategic plan. The coalition, organized with a memorandum of understanding (MOU), is structured with a steering committee and senior advisory council. Both have representation from the following agencies:Adena Health System; Chillicothe City Schools; Chillicothe Gazette; Hope Clinic of Ross County; Hopewell Health Center; Ohio Department of Job and Family Services; Ohio State University Extension; Ohio University – Chillcothe; PACCAR; Paint ValleyADAMH Board; Recovery Council; Ross

County Child Protection Center; Ross County Health District; Ross County YMCA; Scioto Paint Valley Mental Health Center; Union-Scioto School District; United Way of Ross County; Veterans Administration Hospital. For the 2016 assessment and strategic plan, Partners used the data-driven Mobilizing Action for Planning and Partnership (M.A.P.P.) process developed by the National Association of City and County Health Officials (NACCHO) and the Centers for Disease Control (CDC). This six-phase process includes a four- part community health needs assessment, as well as an in-depth analysis of current community trends, gaps, and resources. Information with which to comprehensively evaluate the current state of health in Ross County, and to prioritize key public health issues. This data was then used to develop the county’s first community health strategic plan.

Utilizing the values of commitment, engagement, communication, and respect, it is the vision of Partners for a Healthier Ross County that all people within the region are empowered and inspired to reach their fullest physical and mental potential, in a clean and safe environment through positive community collaborations. By working through strategic initiatives that improve the physical, mental, emotional, and socioeconomic well-being of Ross County residents, this will be achieved.


Process

Data AcquisitionThis 2016 Community Health Needs Assessment was completed through a comprehensive process of data collection and evaluation utilizing the M.A.P.P. process. The data for this report reflects only Ross County.

Both qualitative and quantitative data were collected from primary and secondary sources. Data was collected in a total of four categories (Figure 1): Community Themes and Strengths; Local Public Health System; Community Health Status; and Forces of Community Change.

This information was compiled and evaluated by the Partners Steering Team, focus groups, and the Partners Senior Advisory Council in order to finalize specific health-related priorities. The published assessment

completed as part of these efforts is intended to inform decision makers and funders about the challenges Ross County faces in improving community health, and the priority areas where support is most needed. The information is also intended to be useful as a planning tool for community organizations.Methods Quantitative and qualitative methods were used to collect information for

this assessment. Quantitative data collected includes demographic data for the county’s population, vital statistics such as birth and death rates, and disease prevalence for the county. Qualitative data for this report was collected to

provide greater insight into the issues experienced by the population. Data includes opinions expressed from a widely distributed community health survey - which received more than 1,000 responses - as well as community stakeholder interviews.Source Primary and secondary data sources were used as part of the needs assessment and came from both internal and external sources. Internal data came from within the health system/hospital (patient population data) and external from outside the health system/hospital (county and state). The primary data gathered includes new information that may be used to investigate and help solve a problem. An example of this would be the percentage of survey participants who ranked obesity as a top-10 health problem. Secondary data are the statistics and other data already published or reported to government agencies. An example of this would be rates of childhood obesity.


Secondary Data: Publicly-Available StatisticsExisting data were collected from all applicable local, state, and federal agency sources, including public health agencies (e.g., Ohio Department of Health, Ohio Department of Job and Family Services, U.S. Department of Labor, U.S. Census Bureau). These data

included demographics, economic and health status indicators, and service capacity/availability. While data at the national and state level are generally available for community health-related indicators, local data - from counties and cities - are less accessible and sometimes less

reliable. Some data from publicly-available sources also typically lags by at least two years because it takes time for reported data to be received, reviewed, approved, analyzed, and prepared for presentation.

Primary Data: Community InputPrimary methods used in the assessment process for collecting input from the community were a community survey and key stakeholder interviews. Community Questionnaire A questionnaire was developed for the general public, which queried respondents about the most important health needs, common barriers, and habits they used to maintain their own personal health (See Attachment 1). The survey was distributed in hard copy by member agencies and community partners to a variety of locations in Ross County where the groups of interest would best be reached. These included local food banks, social service providers, community health clinics, and Adena

Health System physician offices. In addition, the survey was made available online through Survey Monkey. Notices about the online version with its link were posted on member agency’s websites, social media pages, published via local media (Chillicothe Gazette, iHeart Radio), emailed to members of local business, government, civic groups, schools, and universities. All of the hard-copy survey data was entered into the electronic Survey Monkey by Adena Health System volunteers.Focus Group To inform the assessment, a focus group of social workers, community volunteers, and nurses (school, hospital, and clinic) was convened to discuss the most common barriers reported by

the population they and/or their agency are currently serving. The focus group provided an informed perspective from those working in the community, and provided an increased awareness about the agencies and the services that are provided. Most gave input about gaps and possible duplications in service, and offered ideas about possible solutions and partnership opportunities. The focus group also informed the needs assessment on particular issues of concern where individuals with specific expertise could confirm or dispute patterns in the data, and identify data and other studies of which the project team might not otherwise be aware.


EXECUTIVE SUMMARY

Indirect influences on the state of health in Ross County are well documented: the economy; per-capita and household incomes; overall poverty - especially children living in poverty; and educational attainment levels all continue to lag behind state and national levels. At the same time drug use and its negative impacts on crime, disease, morbidity, mortality, and overall health continue to increase and to devastate our community.

But not all of the news is bad: With difficulties comes opportunity. Improvements in community coalitions and partnerships are slowly occurring; access to new and existing resources is expanding; and the public health and healthcare systems are striving to become more dynamic. Hope is not lost: Most of our citizens who were surveyed agree that Ross County remains a good place to raise children; a good place to grow old; and that there is good healthcare

available to its citizens. What follows are the highlights of the 2016 Community Health Assessment (CHA) and the items identified as community health priorities by the core group after meetings and review of the overall CHA.

Health Outcomes and ConditionsBased on vital statistics data provided by the Ohio Department of Health and the Ross County Health District, the following were identified as the leading causes of death in Ross County.

The steering team reviewed 14 health outcomes and conditions and ranked their top five in order of importance.1. Addiction – Almost two-thirds of

the steering team ranked addictionas the number one conditiondetrimental to health/public healthin Ross County.

2. Depression and anxiety – Perhapssurprisingly, 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 steeringteam ranked obesity in the topfive, recognizing its prevalence inour community and its impact onother aspects of health, such asheart 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.

• Heart Disease

• Cancer (all forms)

• Unintentional Injury

• Pulmonary-Resporatory Disease

• Stroke


4. Lung Cancer – 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, whichis much higher than the rate for Ohio (57.1) and a startlingly 44% higherthan the U.S. rate (50.6). Part of this imbalance might be explained by thepercentage of smokers in Ross County (31.2%), which is again higher thanstate 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 slightlybelow 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 highin Ross County (27.3% compared to a state average of 16.9%); teen birthrates 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 lowbirth weights is higher than state and national numbers, as is the number ofmothers who received first trimester prenatal care.

Health Behaviors of ImportanceThe steering team reviewed and ranked the top five health behaviors of importance. 1. Substance use/abuse – In line with

addiction as the top concern inthe health outcome/condition,substance use/abuse was easilyranked as the top health behaviorof concern. Over half of thoseresponding to the communityhealth survey listed substance use/abuse as a behavior the communityneeded more information about.Last year drugs were directlyinvolved with about 40 deaths thatoccurred in Ross County, an all-timehigh number.

2. Mental health support – Some 85%of the core group ranked mentalhealth support in their top threehealth behaviors of importance.Likewise, 42% of those respondingto the community health surveyranked it as a health topic theywant to know more about, and 34%responded that children need moreinformation about mental healthissues. When asked about neededservices, counseling/mental health/support groups was named behindonly higher paying employment inthe community survey.

3. Tobacco use – As mentionedpreviously, smoking rates in RossCounty continue to be considerablyhigher than they are in the stateand the nation. Tobacco use haslong been a public health issuelocally, and smoking has negativeimpacts on cancer rates, heartdisease, blood pressure, and bothmorbidity and mortality. With theincrease in the use of other drugs,tobacco use is often overlooked

4. Nutrition – In the communityhealth survey, just over 22% ofrespondents mentioned eatingwell/nutrition as a health behaviorthe community needed moreinformation about, while nearly38% responded that children andthey themselves needed andwanted more information aboutnutrition. In the same survey, only22.7% said they eat three servingsa day or fruits and vegetables,32.5% said they eat two, and40.8% responded that they onlyconsume one serving of fruits andvegetables a day. Just over 4% saidthey do not eat fruits or vegetables.Proper nutrition can reduce therisk of overweight and obesity,cancer, heart disease, and improvemorbidity and mortality.

5. Primary care – Almost 90% of thosesurveyed go either to the doctor orto an urgent care for their medicalneeds, however, 8% respondedthat they do not go to the doctor.There are eight primary care serviceagencies listed in Ross County,but according to the communityhealth survey barriers to care doexist. Responders most often listedthe following: the inability to affordtheir share of the healthcare cost;the inability to get time off of workto go see a doctor; insurance thatdidn’t cover the needed service; theinability to get an appointment/wait time that was too long. Only8.4% of responders did not havehealth insurance.


Environmental Factors of Importance

Environmental factors do have a significant impact on individual health and public health in general, and they are wide ranging and diverse. The steering team ranked five in order of importance.1. Economics and poverty (jobs, pay,

educational attainment) – People of lower incomes or those living on government assistance seldom can afford healthier foods (i.e., fruits, vegetables, low-sugar drinks), which are more expensive than high calorie, low nutrition foods (i.e., soda pop, fast foods, junk foods). Those lacking in education can have difficulty comprehending public health messages intended to help

them establish healthy behaviors. In rural Ross County, Appalachian Ohio, and certain urban areas of Ohio, the poor and uneducated are traditionally unhealthier than their more affluent suburban neighbors of means, and likewise their quality and their length of life suffer in comparison. In 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.

2. Basic needs (housing, food, social services) – Directly related to the economy and existing poverty, basic needs such as affordable housing, access to affordable, healthy food, and the ability to access needed social services can negatively affect individual and public health. In the most recent County Health Rankings Ross County is in the middle of the pack in Ohio when it comes to housing issues, and in the lower one-third in the food environment index. However, 16.1% of residents are thought to suffer from food insecurity (Ohio – 17.2%, U.S. – 15.9%).

3. Safety (violence and crime) – According to Federal Bureau of Investigation reporting, Ross County (105 violent crimes per 100,000 population) is below both Ohio (284.9) and U.S. (365.5) rates. However, the 2016 County Health Rankings (data from 2010-2012), Ross County has the 13th worst rating for violent crimes (248 per 100,000). This is easily the worst among the rural counties of southeast Ohio, but still under state and national averages. (The County Health Rankings uses data from the National Archive of Criminal Justice Data.)4. Healthcare access – Per

the 2016 County Health Rankings, Ross County ranks a respectable 30th out of Ohio’s 88 counties in the Clinical Care measures, which are used to designate the overall ranking in Health Outcomes. About 10% of residents are estimated to be uninsured, which ranks favorably with Ohio (9.8%) and U.S. (12%) numbers. Among those responding in the Community Health Survey nearly half, 45.3%, agreed or strongly agreed with the statement

that “There is good healthcare in Ross County.” Among the barriers to care, those surveyed listed their deductible/copay as being the top barrier (28.6%). The second most commonly listed barrier to health care was the inability to leave work or to get time off (17.8%). However, 95.8% of those responding to the survey said they have either health insurance or a medical card; 83.3% said they have dental insurance; and 79.3% had vision insurance.

5. Air quality – As noted previously, lung cancer rates and deaths from lung cancer in Ross County are alarmingly high when compared to Ohio and the United States. Smoking rates may explain part of this, but without additional investigation into other possible environmental dangers (pollution, workplace air quality, air quality in homes, etc.) it might be impossible to determine why this disturbing imbalance exists. No air quality monitoring programs are in place currently, and it is unknown how environmental air quality is – or is not – affecting the lung cancer cases and associated deaths.


Community Health Survey HighlightsNearly 1,000 surveys were completed. Below are spotlighted responses from those surveyed, which reflect their perceptions about our community, as well as their opinions of healthcare and their own personal health.


Ross County is located in rural, south central Ohio (Figure 2) and is one of Ohio’s 32 Appalachian counties. The county covers 688.5 square miles, of which only about three percent is used for residential, commercial or industrial purposes (Ohio Development Services Agency 2014). Over 44% of the land is forested and more than 38% is farmland. The remaining 14% is pasture. The population of Ross County is 77,170 (U.S. Census Bureau 2015). Approximately 21,738 live in the county seat, Chillicothe. It is divided into two Congressional Districts (2nd and the 15th) and contains the population patterns and distinct economic conditions inherent of the Appalachian region of the U.S. These include challenges such as low educational attainment, limited economic diversification and growth.

Community Assets

ROSS COUNTY, OHIO

Seven total community capitals were assessed in a separate study con-ducted in the fall of 2015 as part of a Ross County Chamber of Commerce planning exercise and are provided for this report (Jones 2015). These in-clude natural, cultural, human, social, political, financial and built capital. In addition, governance of the region was also researched. The following provides a summary of each of these assessments.Natural CapitalThe Chillicothe and Ross County region is rich in natural capital. This is detailed in Chapter 3 in the description of the current state of the land, water, soil, climate, and wildlife. In addition, natural resources were also inventoried and assessed. Almost half of Ross County (400,000 acres) is covered in trees, with 10 total acres inside the city of Chillicothe alone. This makes the forested areas of the region one of the most important natural capital resources. The county also has an ample supply of high-quality water, has rich soil

that provides infrastructure to support more than 1,000 farms, and a temperate climate that allows a 140-170 day growing season. The diversity of the landscape of Chillicothe and Ross County supports a very diverse wildlife population. The numerous bodies of water and acres of forestry provide the habitat for many species of birds, mammals, fish, reptiles, amphibians, butterflies, and insects. In addition, numerous plant species are also abundant. These numerous resources make natural capital one of Chillicothe and Ross County’s greatest assets.Cultural CapitalThe Chillicothe and Ross County region has a rich history that dates to pre-historic times. The area has mounds, created by the ancient Hopewell culture, scattered across the county. These mounds were later used by the Native American tribes, who also inhabited the area, in sacred rituals. The Shawnee Tribe was very welcoming to European settlers,

including Thomas Worthington, who built an estate here. Worthington was Ohio’s sixth governor and helped to make Chillicothe Ohio’s first capital city. This history draws many tourists each year who can still tour the mounds and the Adena Mansion, the home of Worthington’s family. These tourist attractions are some of the most important cultural capital for the region.Chillicothe and Ross County are situated in the Appalachian region. The community culture is indicative of this part of the United States. More than a quarter of the population is affiliated with one of the 119 churches in the area, but still resonates the independent nature and clan culture that developed in the first settlers in the area. This often times limits the willingness of individuals and small groups to integrate and collaborate with others. There is also limited diversity among the population.


Human CapitalChillicothe and Ross County have numerous civic and philanthropic groups that work to increase the capacity of the residents. This includes a branch of Ohio University, the oldest college in the midwest. The rates of educational attainment are slowly increasing in the region, partially due to the career-ladder opportunities the college makes available to older students. There are also many civic and philanthropic groups that support education with scholarships and volunteer support. These resources are some of the most important human capital for the region.Although the population of the City of Chillicothe continues to decline, the population of the county as a whole continues to increase. A recent survey conducted by the Partners for a Healthier Ross County, found that more than 70% of the general public believe the quality of life in area is “good” or “excellent.” Overall, these capacity building resources make the human capital of the region strong.Social CapitalThe numerous groups, including churches in the community, engage much of the population which encourages interaction and collaboration. Currently there are 11.8 associations per 10,000 people, which has continued to increase over the years. There is also a developing community council which is looking at ways to increase this engagement. These are some of the most important social capital for Chillicothe and Ross County.Local media also helps to engage the public. The Chillicothe Gazette, the only newspaper for the area, has a wide circulation and is considered an important source of information. Social media utilization has been on the rise over the last 10 years. More than a quarter of the population is now using it and many organizations, including local government agencies, rely on it to inform the public on important issues and events. These

resources contribute to the social capital in Chillicothe and Ross County. Political CapitalChillicothe and Ross County have a number of organizations and agencies that advocate on the behalf of the population. These include political groups, socio-economic support agencies, disability support services, cancer and crime victim support. In addition, there are a number of civic groups that provide volunteer support for many local causes. These are some of the most important political capital for the area. About 25 individuals with economic and outside political capacity also work to influence the community. Most are local business owners interested in developing the region, particularly if it serves to develop their own resources. This, along with their political and economic connections outside the community, also increases their capacity to influence. All of these resources contribute to the political capital of Chillicothe and Ross County. Financial CapitalThe region has numerous financial resources both in the community and at the state level to pull from. These include more than $1 billion in taxable real estate and a number of banks in the region. In addition, the state development agency provides numerous bonds, grants, loans, and tax credit that are favorable to counties in the Appalachian region of the state. These are some of the most important financial capital for the area. In addition to these resources, Ross County has other economic engines. These include a number of employment opportunities in manufacturing, healthcare, and the service industry. There is also an Economic Development Alliance that works to continue attracting new employers to the area. All of these resources contribute to the financial capital of the area.

Built CapitalChillicothe and Ross County has a tremendous amount of built capital. This includes a state supported road, bridge, water, and communication infrastructure, as well as many historic buildings and sites such as the Hopewell Mounds. There is also a strong civic infrastructure. The local healthcare system provides 261 beds for care. There are also seven local school districts with almost 700 staff members. These are some of the most important built capital for the area.Housing stock is also ample and newer than in other parts of the state. The median housing value is about $111,000, making it affordable for a large segment of the population. There is also a limited amount of low-income housing within the City of Chillicothe and across the county. All of these resources contribute to the built capital of the area. GovernanceChillicothe and Ross County has a government structure that is supported by a number of committees and commissions. These include seven different city commissions dedicated to planning, development, and community improvement. The county is also supported by a three member board of commissioners that oversees ten different county offices supporting infrastructure, planning, development, and budget management. Community Capitals Asset MapAs outlined above, Chillicothe and Ross County have numerous resources that provide the infrastructure and capacity of the region. These resources make up the seven different community capitals. Many of these resources were found to be in multiple categories, making them high-value assets. Figure 3 below provides a summary of these assets. Attachment 3 provides a full summary of community assets and a “mapping.”


Figure 3: Community Capital Asset Map for Chillicothe and Ross County, Ohio 2015

COMMUNITY & ENVIRONMENT A profile of Ross County and its residents was formulated by collecting publicly available data such as vital statistics, economic, and education data. Research shows that sociological and economic factors affect health in complicated ways, so it is understood that this information must be re-viewed with public opinion data (provided in the next section) to develop a clear understanding of the state of health of a particular community.

Population Data The current total population of Ross County is estimated at 77,170. This is a more than 5% growth since 2000, even though current estimates indicate a population decrease since 2010. This is significantly less growth than what is currently seen in Ohio as a whole and across the U.S.


Approximately 64% of the population is between the ages of 18 and 64. About 14% of the population is over the age of 65. The majority of the population is white, with African Americans making up the majority of the region’s minority population. Table 2 provides demographic information reported by the U.S. Census Bureau’s American Community Survey from 2013 for Ross County.


Household InformationThe average household size in Ross County is slightly larger in comparison to households across Ohio but smaller than the U.S. average. This is also true for the percentage of households with children under the age of 18 years. More than half of the population (58.7%) of Ross County lives outside its one urban designated area, Chillicothe. This is a significantly larger portion of the population than in other parts of Ohio or the U.S., which is around 20%.

Socio-Economic DataThe Ross County region has many of the same socio-economic conditions prevalent in other part of the Appalachian region. Educational attainment is considerably lower than in other parts of Ohio and U.S., particularly for advanced education. Median individual and family income is also lower. The following provides a breakdown of education, employment, industry, occupations, income and poverty for Ross County and how it compares with the rest of Ohio and the U.S.Education Approximately 16% of the adults in Ross County have not graduated from high school. This percentage is higher than both Ohio (11.5%) and national (14%) averages. Fifteen percent of the population holds a Bachelor’s degree or higher, which is significantly lower than state and national averages.


Employment Status The unemployment rate in Ross County (5%) is currently comparable to the Ohio (5.2%) and U.S. (5.4%) average. However, more than 45% of the population is not in the workforce. This is higher than the state and national averages (36.5%).

Industry and Occupations The private sector provides more than 65% of the employment opportunities in Ross County with service providing organizations providing more than 45% of those opportunities. More than 20% of the population is employed by a local, state, or federal agency. Ross County has more than 45%of its workforce employed in trade, transportation, and utilities occupations (16.6%),


Income & Poverty The per capita, median, and mean household incomes in Ross County are lower than the state and U.S. averages. Poverty rates are also higher than state and national averages but lower than the rest of the region. Approximately 30% of children are living at or below 100% of the Federal Poverty Level (FPL).

Environmental DataInformation on environmental and community factors health - food, air, water, housing and crime - can provide insight into many of the underlying issues that impact the health of a community. Data on food and housing access and security, air and water quality, and safety was collected to inform on how residents of Ross County access basic needs. Food The food insecurity experienced by Ross County residents is slightly higher (16.1%) than the U.S. as a whole (15.9%), but lower than the rest of Ohio (17.2%). Nearly one-fifth of Ross County households (19.6%) receive SNAP benefits, which is slightly higher than the rest of Ohio (14.5%) and the U.S. (12.4%). There is also less access to grocery stores for Ross County residents.


Housing While Ross County has a larger percentage of home owners (71.1%) than the rest of Ohio (66.9%) and the U.S. (64.4%), there is a significantly lower rate of HUD housing available to the population. Median gross rent is lower than the state and national averages and there are fewer households burdened with the cost of housing (more than 30% of household income).

Crime The rate of both property crime and violent crime in Ross County is significantly less than the rest of Ohio and the U.S.

Air and Water Quality There is currently no ambient air quality monitoring conducted in Ross County, though there are monitoring stations within the southeast Ohio region. A hydrogen sulfide monitor was installed by Ohio EPA in February 2015 to begin monitoring emissions from local manufacturers (Witherspoon 2016). There currently is no other monitor of this kind operating in Ohio to provide comparison. No toxicity report has been compiled to determine if the readings from this monitor indicate harmful air emissions.In 2015, the City of Chillicothe and the Ross County Water Company completed EPA sampling for the aquifers that provide drinking water to the residents of Ross County. Sampling tests for bacteriological (coliform), radioactive contaminants (pCi/L), inorganic contaminants (lead, fluoride, copper, nitrate, barium), synthetic organic contaminants including pesticides and herbicides, volatile organic contaminants (trihalomethanes and haloacetic acids), and residual disinfectants (chlorine). Neither the City of Chillicothe (City of Chillicothe 2015) nor the Ross County Water Company (Ross County Water Company 2015) received violations as a result of the samplings.

Health Care AccessThe Ross County community has a regional medical center/hospital (Adena Regional Medical Center) serving the broader community, in addition to a regional medical center dedicated to serving veterans (Chillicothe VA Medical Center). Both of these facilities have emergency departments, as well as inpatient psychiatric units. The community also has three community health clinics and a free clinic. Health Care Service Access Ross County has a partial medically underserved area (MUA) designation, as well as a partial medically-underserved population (MUP). This is due to the limited number of providers who access Medicaid, and the geographic isolation experienced in deep rural areas of the county. The area is considered a health care provider shortage area (HPSA) due to limited access for some services.


Ross County has limited capacity to provide health care services. There are currently 1,560 patients for every primary care provider. There are 1,930 patients for every dentist in Ross County. The number of mental health providers has increased to improve access to mental and behavioral health services. There is now a provider for every 460 patients in Ross County. This ratio is better than Ohio (640:1) and nearing some of the top U.S. performers.

Health Care Access Among those with health insurance in Ross County, the majority have direct or employer-sponsored health insurance (49%). Similar to Ohio and the rest of the U.S., less than 6% of Ross County children under the age of eighteen lack health insurance. More than 44% of children in Ross County access healthcare services with Medicaid, which is 10% higher than state and national rates.

COMMUNITY THEMES AND PUBLIC SURVEY A community survey (Attachment 1) was distributed online and in hard copy in various community locations throughout Ross County in an attempt to gain a wider understanding of the health needs of those who live here. Examples of sites that hosted the questionnaire, which included placements intended to reach higher-risk populations, are local food banks, social service providers, senior center, community health clinics, and Adena and Ross County Health District clinics. Additionally the survey was made available online through Survey Monkey. Notices about the online version with its link were posted on the Adena Health System and partner websites, published in the Chillicothe Gazette, broadcast on local Clear Channel radio stations and emailed to all members of local business, government, civic groups, schools, and universities. In total, 983 surveys were attempted and 808 were completed. It should be noted that the first survey question asked the respondent if they were a resident of Ross County, Ohio. The online survey was automated to end the survey if the respondent answered “no” to this question. No paper copies were completed by respondents who were not residents of Ross County.

Respondent Data While there was an even distribution of respondents across different age and educational attainment categories, there were significantly more female respondents than male. More than half of respondents indicated there were two or less people in the home. Approximately 17% of respondents indicated they are currently caring for a member of their extended family (grandchild, sibling, niece, nephew, etc.)


Quality of LifeApproximately half of survey respondents agreed or strongly agreed that Ross County had good health care, and it was a good place to raise children and grow old. Approximately one third of respondents believe Ross County is a safe place to live, while another third do not. Half of respondents indicate they do not believe there is enough economic opportunity in the area. However, more than 40% indicated there is enough help in times of need.

Respondents were asked “In your opinion, what one issue most affects the quality of life in Ross County?” and asked to pick one issue from a list. More than 46% of respondents chose low income and poverty as the top issue. More than 10% felt that violent crime was a priority issue, followed by 9% choosing theft as a priority issue. Better and more high paying jobs was chosen as the biggest need in Ross County, followed by mental and behavioral health support, availability of employment and engagement of teens.

Figure 4: Priority Community Issue


Community ImprovementRespondents were also asked questions relating to what needs improvement in Ross County. When asked, “Which service needs the most improvement in your neighborhood or community?” more than 15% of respondents chose higher paying employment and over 9% chose availability of employment. More than 13% chose more counseling, mental and behavioral health services, with another 9% indicating more affordable health services were needed.

Figure 5: Needed Services in Ross County

When asked, “Which one health behavior do people in your community need more information about?” 46% of respondents chose substance abuse prevention. A total of 22% selected eating well and nutrition, with 14.7% choosing exercise and 14% selecting managing weight.

Figure 6: Health Behavior Needs


Personal Health Respondents were also asked questions relating to personal health. When asked, “What health topics or diseases would you like to learn more about?” more than 42% of respondents chose mental health. A total of 38% selected nutrition, with 37.6% choosing drug abuse.

Figure 7: Respondent Health Topic Interests

When asked “What health topics or diseases do you think your child needs more information about?” almost 70% of respondents chose drug abuse. A total of 37.7% selected nutrition, with 36.3% choosing both mental issues and safe sex.

Figure 8: Respondent Health Topic Interests for Children


When asked, about how they would rate their own health, 50% of respondents selected very good with another 8.7% selecting excellent. More than 36% rated their health as fair and 4.4% rated their health as poor.

Figure 9: Respondent Health Status

Respondents were then asked to provide information on health conditions and diseases they have been diagnosed with. Approximately 40% of respondents have been told they are overweight or obese by a medical provider. A total of 37.8% have been diagnosed with depression and 36.7% have been diagnosed with high blood pressure. A total of 11.7% of respondents have been diagnosed with diagnosed with diabetes.

Figure 10: Respondent Health Conditions


More than 12% of respondents have been diagnosed with cancer.

Figure 11: Respondents Diagnosed With Cancer

For those who indicated they have been diagnosed with cancer, respondents were asked to identify the cancer they have been diagnosed with. A total of 52.1% indicated their diagnosis was breast cancer, with more than 20% indicating a cervical cancer diagnosis. A total of 16.7% indicated they have received a colon cancer diagnosis.

Figure 12: Respondents Currently Receiving Cancer Treatment

Almost 52% of respondents have a family member who has been diagnosed with cancer.

Figure 13: Respondents Having a Family Member with Cancer


Health BehaviorsRespondents were asked questions relating to health behaviors. When asked “Have you had any of the following cancer screenings within the last year?” a total of 38% had a mammogram and 35.4% had a clinical breast exam. More than 42% also had a pap smear and almost 17% had a colonoscopy.

Figure 14: Cancer Screenings Completed By Respondents in the Last Year

Respondents were asked “During a normal week, other than in your regular job, do you engage in any physical activity or exercise that lasts at least a half an hour?” A total of 70.6% answered yes.

Figure 15: Respondents Getting Weekly Exercise


For respondents answering “yes” to exercising at least once per week, they were also asked “Where do you go to exercise or engage in physical activity?” More than 76% indicated they exercise at home, while almost 25% go to the park. About 34% use a private gym, YMCA or public recreation center.

Figure 16: Location for Exercise

For respondents who answered “no” to exercising at least once per week, they were asked “What the reasons you do not exercise for at least a half hour during a normal week?” A total of 43% responded they were too tired to exercise, while more than 27% responded they do not have enough time to exercise. A total of 23.8% responded they do not like to exercise.

Figure 17: Respondents Not Exercising

Respondents were then asked a series of questions related to their consumption habits. More than 22.7% responded they are eating three more servings of fruits and vegetables per day. About 41% indicated there eating only one serving per day, while 4% indicated they do not eat fruits and vegetables. More than 82% indicated they cook most of their own food purchased from a grocery store, while 12.5% indicate they use restaurants as their primary source of food. Almost 20% of respondents currently smoke or use tobacco. The majority use cigarettes with 11% using vapor or e-cigarettes and 5% using smokeless tobacco. More than 54% of respondents drink alcohol with nearly a third of those


who do drink, drinking at least one time per week and 50% consuming more 2-3 drinks per sitting. A total of 13% of respondents indicated they regularly utilize some kind of drug. A total of 8% indicated they use Marijuana and almost 6% indicated they use some form of opiate.

Those respondents who indicated they regularly consume some form of drug were also asked how often they use it. Of those utilizing Marijuana, almost 15% indicated they use it on a daily basis, with another 15% indicating they use it less than once per month. Of those using opiates, more than 18% indicated they use them on a daily basis and 14% using them less than once per month.


Access to Care/Family HealthRespondents were also asked a series of questions related to how they access medical care. Almost 77% indicated they mostly use a doctor’s office for their health care, while more than 12% indicated the use an Urgent Care. More than 8% responded they do not go to the doctor. When asked about the frequency of their medical visits, more than 82% responded they had seen their family doctor within the last year. More than 63% had visited the dentist and 56% had also visited an optometrist or

ophthalmologist. A total of 18% had also had an emergency room visit in the last year. More than 95% of respondents indicated they have insurance or a medical card with 83.3% also having dental insurance and 79.3% having vision insurance. When asked about the barriers they most often experience when trying to coordinate medical care, more than 28% of respondents indicated their share of the cost as their primary barrier. About 18% responded leaving work

or getting time off as their primary barrier.When asked about mental health, specifically where they would refer a friend or loved one in need of mental and behavioral health services, more than 34% indicated they would refer to a doctor. Another 29.5% indicated they would refer their friend or loved one to a mental health clinic and 8.6% said they would refer to a minister or religious official.


Community Recommendations for Improving HealthFinally, respondents were asked, “What would you like to see in Ross County to help the community with health?” A total of 377 respondents answered this question. A text analysis was completed to look for repeated words and themes. The themes that emerged from this analysis include:• Drug use and prevention• Healthcare access• Economic opportunity• Nutrition and fitness• Family

Figure 18: Respondent Feedback on Improving Community’s Health

Front Line Focus GroupAs part of collecting information on community themes and strengths, the steering committee coordinated a two-hour focus group comprises of “front-line service workers” in the Ross County community. This included social workers, social service case workers, school nurses, law enforcement, community health nurses, addiction specialists, and agency officials. The participants utilized a grid which started with the most prevalent causes of death. Participants then created lists of the most common barriers reported by those they served, as well as a correlating list of the most common underlying causes contributing to the barriers. Information obtained from this group was based solely on what participants believed they saw the most in community among the clients they served and among their own friends and family. Figure 19 outlines the results of this focus group.


COMMUNITY HEALTH STATUS

County Health RankingsThe economic and educational challenges experienced in Ross County and the surrounding region have been correlated to declining health. Many southern Ohio counties, including Ross County, are considered some of Ohio’s unhealthiest. A 2016 report published by the Robert Wood Johnson Foundation and the

University of Wisconsin Population Health Institute, County Health Rankings: Mobilizing Action Toward Community Health. In overall positive health outcomes, the State of Ohio ranked 37th nationally. All 88 counties in Ohio were then ranked both related to health outcomes and health factors.

Rates of death from heart disease, lung cancer, and pulmonary-respiratory disease are all above state and national averages. Ross County is currently ranked 74th out of 88 counties for health outcomes and 64th for health factors, which is an improvement over recent years.

Vital Statistics DataThe leading causes of death, illness, and injury are indicators to the primary health challenges facing a population in a particular region. They can also indicate what health risk factors are most prevalent among a population. The Ross County Health District compiled death certificates for 2014 and 2015 to provide the most up-to-date information on causes of death for this report. However, it must be noted that state and national data is not yet available to provide a comparison for these years so information from the Centers for Disease Control’s 2007-2011 report is provided as well. Mortality Rates The three leading causes of death in Ross County are heart disease, cancer and unintentional injuries. The rate of death for each of these conditions is significantly higher than state and national averages. More than 55% of unintentional deaths in 2014 and 2015 were due to a drug overdose.


While lung cancer deaths are much higher than state and national averages, deaths from prostate and breast cancer are lower. The crude 2014-2015 mortality rates provided by the Ross County Health District also indicate these are continuing to decline.

Suicide The rate of suicide in Ross County is currently higher than Ohio and the rest of the U.S.

Infant Mortality The infant mortality rate in Ross County has reduced to align with the U.S. average. The infant mortality rate for Ross County was reported by the Ohio Department of Health in 2008 to be 8.8.


Birth Rate The crude rate of birth in Ross County is lower (10.7) in comparison to Ohio.

Health Condition & Disease Prevalence Data The prevalence of certain health conditions as well as disease can provide insight to leading causes of death in a population in a particular region. They can also indicate what health behaviors are most prevalent among a population.Obesity and Related Issues More than 29% of Ross County’s residents are considered overweight, with almost 36% being obese. Obesity rates are considerably higher than state (30.1%) and national averages (27.1%). The percentage of the population with other health conditions – diabetes, high cholesterol, high blood pressure and heart disease – is also higher than state and national averages.

Respiratory Issues Pulmonary and respiratory issues are also prevalent in Ross County. More than 22% of the population experiences asthma, which is considerably higher than state (13.8%) and national (13.4%) averages.


Cancer Data Of all cases of cancer experienced in Ross County, breast cancer and prostate cancer are most often experienced. The rate of breast cancer occurrence in Ross County (110.5) is less than state (120) and national (122.7) averages. The same is true of prostate cancer occurrence. The occurrence of lung, cervical and colorectal cancer however is higher, with lung cancer occurrence being considerably higher (87.9) than state (72.4) and national (64.9) averages.

Sexually Transmitted Disease Data The overall rate of occurrence for sexually transmitted disease is considerably lower than state and national averages.

Maternal Health The rate of low and very low birth weights in Ross County is higher than state and national averages. The rate of maternal smoking is significantly higher (27.3%) than the rest of Ohio (16.9%). The number of women receiving prenatal care within their first trimester of pregnancy is considerably lower (38%) than the rest of Ohio (57.9%).


Child Health More than 800 children were screened for lead exposure in 2014 with none testing for elevated blood levels. However, the number of children between the ages of two and five who are overweight or obese is higher than the rest of Ohio.

Oral Health More than 27% of the population experiences poor dental health. This is significantly higher than state (18.7%) and national (15.7%) averages. Oral health problems for children in Ross County is also much higher than the rest of state. More than 33% of children have untreated cavities and 60% have a history of tooth decay.

Health BehaviorsThe prevalence of certain health behaviors can serve as early indicators for a number of health conditions and diseases, as well some causes of death. Nutrition, fitness, and other behaviors for Ross County were researched from public health information, as well as surveyed within the population. According to data from the Centers for Disease Control, more than 29% of Ross County residents are not engaging in enough physical activity or getting enough fruits and vegetables in their diet. Alcohol consumption is not as high as other parts of Ohio and the U.S. but smoking prevalence continues to be much higher.


PUBLIC HEALTH SYSTEM ASSESSMENT

An assessment of the local public health system should include measurement of the activities, competencies, and capacities of the healthcare delivery continuum within a community. This includes some services that impact individual health such as food security, material assistance (food, clothing, and shelter), transportation, and personal support.

Ross County Health ContinuumThe healthcare continuum in Ross County was inventoried for this report. The inventory provides a breakdown of the number of organizations providing a specific service within a category on the continuum. The continuum includes the categories of primary and specialty care, mental and behavioral health, pharmacy and medical equipment, vision services, oral health services, health and environmental protection, social services, and fitness. Clinical care for specialty services (cardiac, cancer, women’s health, etc.) is more prevalent in Ross County, as well as home health services.


Public Health System and the Health Continuum The location information for each of the agencies in the inventory was given to the Ross County Engineer’s office which used the information to complete a mapping of the continuum (Map 21). The mapping demonstrates the high concentration of services available within the City of Chillicothe, but not as accessible in the outlying county. There are also some gaps in services in some parts of the Chillicothe.


FORCES OF CHANGEAs part of the data collection, review and discussion process, the Partners for a Healthier Ross County have completed compiled information relating to what is currently occurring or emerging in the Ross County community that may impact the health of the community or the local public health system. This information was categorized and summarized by strengths, weaknesses, opportunities, and threats (SWOT) in Figure 18.


ROSS COUNTY COMMUNITY HEALTH PRIORITIES After the primary and secondary data was collected and summarized from each of the four assessment categories, the results were then analyzed to identify the opportunities to improve the health of Ross County. The top mortality causes, health behaviors, and related environmental factors that resulted from the prevalence data collected and summarized (Figure 20) are all listed in order of their rate of occurrence.

Figure 20: Community Health Priority Summary Based on Prevalence and Public Opinion

Health Data, Survey and Focus Group AnalysisThe relationship between these results was then analyzed to see if there was a clear priority based on the data collected. More discussion by the steering committee resulted in what the community may see as the health priorities, but that could differ due to one primary threat which surfaced during the SWOT analysis: drug addiction. As seen in the figure below, many of the current health factors are related to the region’s leading cause of death, which is heart disease. However, while heart disease is more prevalent in the community, the increase in overdose deaths and crime related to drugs made it the number one concern of the public opinion survey. In addition, the prevalence of mental health related issues were also of concern.

• Heart Disease• Cancer (all forms)• Unintentional Injury• Pulmonary-Resporatory 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


The group agreed to look at each of the top causes of death and how they align with the current, most prevalent health conditions, as well as environmental factors related to the conditions. Data on most commonly reported barriers, collected from the focus group, was also considered as part of the prioritization process. Table 33 outlines the work completed.

Prioritization Worksheet

Outcomes Conditions Behaviors Environment

Heart Disease Deaths

Cancer Deaths

Unintentional Injury Deaths

Pulmonary-RespiratoryDeaths

Other - Mental and Behavioral Health Issues

Other

Obesity Rate: 35.9%Survey Results: Health conditions-overweight/obese 39.7%Survey Results: Health conditions-high blood pressure 36.7%Survey Results: Health conditions-high cholesterol 25.4%

Nutrition: Fruit and vegetable consumption: 86.1%Survey results: 40.1% eating 1 serving of fruits and vegetables per daySurvey results: Health Topics-nutrition 38%Survey results: Eating well/nutrition 222.1%Survey results: 37.7% kids need nutrition infoSurvey results: Health topics-diabetes management 18%Survey results: Health topics kids-nutrition 37.7%

Fitness:Survey results: 26.2% not exercising at allSurvey results : Managing weight 14%Survey results: Exercising/fitness 14.7%Survey results: 43% I’m too tired to exerciseSurvey results: 43% too tired to exerciseSurvey results: 24% don’t like to exerciseSurvey results: 27% don’t have time to exerciseTobacco Use:Estimated smokers: 31.2%

Lung cancer prevalence: 87.9Cervical cancer prevalence: 10.8Colon and Rectal cancer prevalence: 50

Tobacco Use:Estimated smokers: 31.2%Maternal Smoking 27.3%Survey results: Kids need tobacco prevention info 27.8%

Survey results” 19.6% using tobaccoSurvey Results: Needed services-quitting smokingSurvey results: Health topics kids-tobacco use prevention 27.8%

Infant Mortality Rate: 8.1

Survey results: Health topics kids need reckless driving info 27.8%

Asthma 22.8% Tobacco Use:Estimated smokers: 31.2%Maternal Smoking 27.3%

Air quality:Survey results: Top issues- air pollutionNo ambient air quality monitoring

Suicide rate : 15.9

Survey Results: Health conditions-depression and anxiety 37.8%

Substance Use/Abuse:Survey results: Kids need substance abuse prevention 69.9%Survey results: Substance abuse prevention 54.6%Survey results: Health topics-drug abuse 37.6%Survey results: Health topics kids-drug abuse 69.9%Survey results: 8% using marijuanaSurvey results: health topics alcohol abuse for kids 31.9%

Mental Health Support:Survey Results: Needed services-counseling and mental healthSurvey Results: Needed services-positive teen activitiesSurvey Results: Health topics- mental health issues 42%Survey results: health topics Suicide prevention for kids 35.5%Survey results: health topics suicide prevention for general 17%Survey results: Health topics kids-mental health issues 36.3%

Poor dental health: 27.4%Teen Birth rate: 54.5Hepatitis C prevalence: 133Survey results: 17.3% need suicide prevention infoSurvey results: 42.2% need mental health infoSurvey results: 35.5% kids need suicide prevention info43% of seniors with disabilities

Maternal Health:First Trimester Prenatal visit: 38%

Primary Care:Survey results: 8% don’t go to the doctor

Safe Sex:Survey results: health topics kids need STD info 25%

Economic Environment: Survey results: There is plenty of economic opportunitySurvey results: Top issue-low income povertySurvey Results: Needed services- higher paying employmentSurvey Results: Needed services-employment opportunitiesOnly 15% with a Bachelor’s Degree29.3% of children below poverty level45% of the population are not in the workforceBasic Needs:306.1 Rate of HUD Housing access 16.1 % Food Insecure populationSurvey Results: There is plenty of help15.4 Rate of Grocery Store Access

Safety:Survey results: Ross County is safe place to liveSurvey results: Top issue-theftSurvey results: Top issue-violent crime105 Rate of violent crime

Healthcare Access:Survey Results: Needed services-more affordable healthcareLimited provider rate in Ross CountySurvey results: 28.6% my cost/copay too highSurvey results: 17.8% couldn’t leave work to go to doctorSurvey results: 11.6% insurance didn’t coverSurvey results: 10.6% Couldn’t get an appointmentSurvey results: 11.2% wait was too long58.7% of the population is rural


Health Priorities After considering the data from all four of the data categories, the steering committee set up a survey for members of the Partners for a Healthier Ross County so each could vote on what they believed to be the most emergent community health needs in Ross County. Figure 21 provides a summary of top issues.

Next Steps The Partners for a Healthier Ross County will ensure that the findings and recommendations from the current needs assessment are widely shared with the community - and tracked - so that awareness about the priorities and progress in implementing them is high. This will be done by first completing a strategic community health plan, with strategic questions built around each of the health priorities. Goals and objectives, with related metrics, will then be formulated around these strategic questions.The team believes projects based in the community have the best opportunity to make a real difference in the health of individuals and their families, and those providing care. Visions for future community support in all of the priority areas will require identifying suitable leadership, raising awareness among stakeholders, determining how to involve them, and agreeing in what areas and how each group will collaborate. Engagement to address the list of community health needs will be prioritized in order to ascertain greater outreach and long-term impact. In addition, different strategies will be used with each of these health needs depending on the capability of each participating agency to address the issue.

• Addiction• Obesity and Diabetes• Depression and Anxiety• Lung Cancer/respiratory issues (COPD, Asthma)• Infant Mortality

• Drug and alcohol use• Mental health management• Tobacco use• Poor nutrition• Limited primary use

• Economics and poverty• Basic needs access (housing, food and transportation)• Safety (crime and violence)• Healthcare access (preventative services and

education)• Air quality


REFERENCESCity of Chillicothe. 2015. “Drinking Water Consumer Confidence Report.” Retrieved March 27, 2016 (http://www.chillicothe.com/documents/2015DWConsumerConfidenceReport.pdf )

Federal Bureau of Investigation. 2015. National Crime Data, 2014. Retrieved July 5, 2016 (https://ucr.fbi.gov/crime-in-the-u.s/2014/crime-in-the-u.s.-2014/tables/table-10/table-10-pieces/Table_10_Offenses_Known_to_Law_Enforcement_Ohio_by_Metropolitan_and_Nonmetropolitan_Counties_2014.xls)

Jones, Susan K. 2015. Community Profile of Chillicothe and Ross County.

Ohio Department of Health. Oral Health Isn’t Optional: A Report on the Oral Health of Ohioans and Their Access To Dental Care, 2011. Retrieved March 20, 2016 (https://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/health%20resources/reports/oralhealthisntoptionalreport.pdf )

Office of Research. 2014. Ohio County Profiles: Ross County. Ohio Economic Development Services Agency. Retrieved July 1, 2016 (https://development.ohio.gov/files/research/C1072.pdf ).

Ross County Water Company. 2015. “Annual Drinking Water Quality Report.” Retrieved March 27, 2016 (http://rosscowater.org/docs/2015-Water-Quality-Report.pdf )

U.S. Census Bureau Retrieved. 2016. Quickfacts: Ross County Ohio. March 15, 2016 (http://www.census.gov/quickfacts/table/PST045215/39141

Lewis, Jamie M. and Rose M. Kreider. 2015. “Remarriage in the U.S.” American Community Survey Reports Retrieved March 26, 2016 (https://www.census.gov/content/dam/Census/library/publications/2015/acs/acs-30.pdf )

Interview with Melissa Witherspoon, Assistant Chief, Southeast District Office, Ohio EPA June 29, 2016 Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Additional data analysis by CARES. 2011-12. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2012.

APPENDIX 01

SPECIAL THANKSDevon Shoemaker, Ross County Engineer’s Office

Olivia McBee, Ross County community

Ohio University-Chillicothe Healthcare Administration program

Jennifer Caplinger, Adena Health System

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