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2014

Michaela Brtnikova

Erin Bomberger

Mary Newell

Chris Tyszka

Michael Wallingford

Understanding Population Health in

Aurora

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1. Executive Summary

The aim of this report was to identify health issues related to Aurora so as to aid Aurora

Health Access (AHA) in determining priorities and evaluating strategic directions.

An abbreviated community health assessment was conducted by students of the

Colorado School of Public Health (CSPH) and presented to the executive members of

AHA and community leaders in order to facilitate a brainstorming of strengths, assets

and resources of Aurora and a prioritization of health concerns. Results from this

process will inform AHA in determining future priorities and directions.

Background & Partnership

AHA is community coalition comprised of community members, healthcare providers,

and multiple agencies committed to improving health inequities in Aurora, Colorado.

AHA representatives included:

• Rich McLean – Board Chair

• Denise Denton – Executive Director

Led by the CSPH faculty member, Dr. Holly Wolf and teaching assistant, Talia Brown,

MPH students, Michaela Brtnikova, Erin Bomberger, Mary Newell, Michael Wallingford

and Chris Tyszka partnered with the AHA team to develop and clarify the scope of work.

The CSPH team held one in-person meeting to present the modified health assessment

and provide background for the AHA members to prioritize health concerns in Aurora.

Methods

Collection and Analysis of Secondary Data

Secondary data from Arapahoe, Adams and Douglas counties were used to calculate

weighted proportions of selected variables based on Aurora’s population size within

each county. Mortality, morbidity and Years of Potential Life Lost (YPLL) were selected

as the driving health outcomes for the health assessment. Based on the Health Equity

Model framework, eleven health indicators were selected based on significant

differences between Aurora and the state of Colorado and a literature review of risk

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factors associated with all three health outcome measures. As a result, ten health

concerns were formulated and later presented to the AHA members.

Ranking to identify top health concerns in Aurora

A Modified Hanlon Method was used to prioritize the ten Aurora health concerns based

on the assessment of magnitude, severity and feasibility. Magnitude scores were

determined by the percent of Aurora’s population affected. Severity scores were

determined by the frequency with which the health concern was associated with a

health outcome involving mortality, morbidity, and YPLL. Magnitude and severity

scores were predetermined by the student group and verified during the community

engagement event. The method utilized to determine the feasibility scores and

prioritization are discussed in the Community Engagement section, as these steps of

the modified Hanlon Method of prioritization were conducted with the participants of this

event.

Community Engagement

A presentation of the modified community assessment was followed by a brainstorming

exercise and a feasibility assessment. The brainstorming exercise enabled the

participants to identify Aurora’s strengths and assets based on community capacity by

answering the question,

“In thinking about the top 10 health concerns, what resources, strengths, and assets

does the city of Aurora have that can be used to impact these concerns?”

A list was generated and used as a contextual basis for determining feasibility.

A feasibility exercise enabled participants to score the feasibility of each health concern.

After discussing the magnitude and severity scores of each health concern, each

participant was asked to score the ten health concerns individually based on the

following components of feasibility: political climate, will to change, intervention

effectiveness, economic viability, and capacity to do work.

An aggregate score was calculated based on magnitude, severity, and feasibility. Health

concerns were then prioritized in order of the highest ranking score.

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Findings

Aurora’s Demographics

Aurora has a younger, reportedly growing, and a more diverse population living in areas

with high poverty when compared to Colorado. This combination has implications for

future healthcare systems functioning as well as population health. Diseases are often

associated with population characteristics. If the population composition of Aurora

continues to increase in age and diversity, with little or no change in poverty levels,

healthcare infrastructure will have to accommodate and prepare for this changing

population.

Modified Health Assessment

In the initial phase of the modified health assessment for the city of Aurora, three health

outcomes were examined: mortality, morbidity, and YPLL.

Ten Leading Causes of Mortality, Morbidity, and YPLL in Aurora

Rank Mortality Morbidity YPLL 1 Cancer Stroke Unintentional Injury 2 Heart Disease Heart Disease Cancer 3 Chronic Lower Respiratory

Disease Acute Myocardial Infarction Suicide

4 Unintentional Injuries Heart Failure Heart Disease 5 Alzheimer's Disease Adult Diabetes Perinatal Period Conditions 6 Cerebrovascular Disease Motor vehicle Accidents

Hospitalization Homicide/Legal Intervention

7 Suicide Invasive Cancer Chronic Liver Disease/Cirrhosis 8

Diabetes Congenital anomalies Congenital Malformations, Deformations, and Chromosomal Abnormalities

9 Chronic Liver Disease Breast cancer Cerebrovascular Diseases 10 Influenza Prostate cancer Diabetes Mellitus

Health indicators were used to describe the health of adults in Aurora, and two

indicators were used to describe the child population. These indicators were compared

to Colorado data and Healthy People 2020 (HP 2020) target goals, when applicable.

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The health indicators represent the overall health status of Aurora’s residents. Poverty,

tobacco use, and mental health affect less of the population in Aurora than Colorado,

but remain significant to health outcomes. Lower high school completion rates, fewer

adults and children with health insurance, greater percentages of adult and childhood

obesity and a larger proportion of the population who are physically inactive

disproportionately affect Aurora, highlighting disparities and unmet needs.

The top ten health concerns based on a literature review and indicators associated with

the health outcomes of mortality, morbidity, and YPLL were: Regular Healthcare

Provider, Educational Attainment, Healthcare Coverage, Obesity, Tobacco Use,

Poverty, Physical Inactivity, Mental Health, Cancer, and Heart Disease.

Based on the health indicators and health outcomes, the top ten health concerns were

identified for Aurora and compared to the Northwest Aurora (NWA) report from 2013.

This comparison showed that health care and educational attainment were top ranking

health concerns for both Aurora and NWA; poverty and mental health were also

important concerns for both.

Prioritization

A final prioritization based on the Hanlon Method ranked the top 10 health concerns.

The following table shows prioritization based on the aggregate score in the far right

column.

Rank Health Concern Aggregate Score 1. Regular Healthcare Provider 13

2. Educational Attainment 13 3. Healthcare Coverage 13 4. Obesity 12 5. Tobacco Use 10 6. Poverty 10 7. Physical Inactivity 9 8. Mental Health 9 9. Cancer 8 10. Heart Disease 7

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Regular healthcare provider together with healthcare coverage, and education were

rated the highest for Aurora. The comparison to NWA produced similar findings with

access to health care and education previously prioritized as top health concerns

affecting NWA. This is important for AHA to consider when deciding to expand their

efforts to the entire population of Aurora.

Brainstorming City of Aurora’s Resources, Strengths, and Assets

A brainstorming session identified Aurora’s strengths, assets, and resources related to

the health concerns. A list of 45 items was brainstormed and categorized as health-

related agencies and organizations, community and organizations, government

organizations and representatives, and the built environment.

Recommendations

It is recommended that AHA move forward on these health concerns focusing on the

entire City of Aurora.

Expand Target Population of AHA to the City of Aurora

• Consider a citywide approach to addressing identified health concerns

Access to Healthcare: Healthcare coverage/Having regular healthcare providers

• Explore dissemination of healthcare information methods such as mobile health

apps, social media, and texting.

• Create collaboration between health departments, community health

organization, and community organizations that are health assets in Aurora.

• Develop a health resource directory for all of Aurora.

• Monitor the impact the ACA has on health insurance coverage in Aurora.

Educational attainment

• Promote protective factors, such as school and family connectedness, as an

effective means of improving school retention rates.

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• Incorporate health educators into schools to reduce dropout rates.

• Reframe low educational attainment as a health problem.

Obesity

• Develop a resource guide for free or low-cost physical activity opportunities and

nutritional education in and around Aurora.

• Advocate breastfeeding and partner with breastfeeding friendly businesses,

childcare centers, and hospitals that protect, promote, and support breastfeeding.

• Support and collaborate with Healthy Eating and Active Living (HEAL) programs

that are being implemented in the community and schools.

• Emphasize existing fitness infrastructure throughout Aurora.

Additional Recommendations

• Qualitative data collection for a more comprehensive community health

assessment.

• Healthy People 2020 benchmarks can be used to track changes in Aurora’s

health status

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Table of Contents 1. Executive Summary …………………………………………………… 2

2. Acronyms………………………………………………………………… 8

3. Introduction……………………………………………………………. 9

A Background……………………………………………………... 9

B Partnership and Community Information……………………. 9

C Project Description……………………………………………. 10

4. Methods………………………………………………………………… 11

A Collection and analysis of secondary data…………………. 11

B Ranking to identify top health concerns in Aurora………… 14

C Community engagement and prioritization………………… 15

5. Findings………………………………………………………………… 18

A Aurora’s Demographics………………………………………. 18

B Modified Health Assessment…………………………………… 24

C Prioritization…………………………………………………………. 32

D Brainstorming Aurora’s Strengths and Assets……………… 34

6. Conclusions……………………………………………………………… 36

7. Limitations……………………………………………………………… 36

8. Recommendations……………………………………………………… 37

9. References……………………………………………………………… 41

10. Appendices…………………………………………………………….. 45

A Aurora Health Indicator matrix………………………………… 45

B AHA Informational Handout…………………………………… 46

C Top Health Concerns for Aurora……………………………… 48

D Magnitude and Severity Assessment………………………… 49

E Scope of work…………………………………………………… 50

F Presentation Slides……………………………………………… 56

G Selected Health Indicators for Aurora Health Assessment… 79

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2. Acronyms

ACA = Affordable Care Act

AHA = Aurora Health Access

BMI = Body Mass Index

BRFSS = Behavioral Risk Factor Surveillance System

CDC = Centers for Disease Control and Prevention

CDPHE = Colorado Department of Public Health and Environment

CHA = Community Health Assessment

CHI = Colorado Health Institute

CSPH = Colorado School of Public Health

HEAL = Healthy Eating Active Living

HP 2020 = Healthy People 2020

NACCHO = The National Association of County and City Health Officials

NGT = Nominal Group Technique

NWA = Northwest Aurora

YPLL = Years of potential life lost

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3. Introduction

A. Background

Aurora Health Aceess (AHA) has had several past partnerships with Colorado School of

Public Health (CSPH), Community Health Assessment class in order to make informed

decisions throughout their planning process. Previous student groups working with

AHA carried out assessments focusing on Northwest Aurora (NWA). This current

project widened the scope to focus on the City of Aurora and consisted of two major

components, a modified community health assessment and a community engagement

event. The modified health assessment aided in identifying health concerns in Aurora,

which the student group compared with previously identified NWA health concerns. The

community engagement consisted of three parts, presenting a summary of the modified

health assessment and comparison, brainstorming Aurora’s strengths and assets, and a

prioritization of Aurora’s health concerns. This information can be used to provide an

informed foundation on which to base future strategic directions of AHA.

B. Partnership and Community Information

CSPH

The Fall 2014 student group that partnered with AHA consisted of MPH students Erin

Bomberger, Mary Newell, Misha (Michaela) Brtnikova, Chris Tyszka, and Michael

Wallingford. The Community Health Assessment faculty, Holly Wolf, and teaching

assistant, Talia Brown, supported the student group throughout this partnership. Rich

McLean, AHA’s board chair, was the primary contact with AHA and Denise Denton,

AHA’s executive director, was secondary contact. This partnership worked

collaboratively to develop a scope of work, identify appropriate secondary data, and

facilitate a community engagement event.

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Aurora Health Access

Aurora Health Access is a community coalition comprised of community members,

healthcare providers, and multiple agencies committed to improving health inequities in

Aurora, CO. AHA has identified the current healthcare system in Aurora is not meeting

the needs of all its residents. AHA is dedicated to solving this urgent problem while

continuing to strengthen community partnerships. AHA is also committed to partnering

with the community in order to address the health equity issues and overall health

concerns facing the City of Aurora.

Northwest Aurora

Northwest Aurora is an urban neighborhood located within the Aurora city limits (see

Figure 1). NWA has been the focus of AHA priorities due to the high rates of poverty,

health inequity, and uninsured/underinsured experienced by the residents. Significant

demographic changes over the past 15 years, combined with depressing economic and

environmental conditions, have contributed to these high rates.

The City of Aurora

Aurora is Colorado’s third largest city and is primarily urban. As the focus of this

project, a thorough description of Aurora’s boundaries, population changes and current

composition, sociodemographic profile, and the health status of the city are detailed in

the Findings section of this report.

C. Project Description

The goal of this project was to identify key health concerns facing the City of Aurora and

create a foundation on which AHA can base future directional planning. The project

consisted of two major components, a modified community health assessment and a

community engagement event.

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A modified community health assessment (CHA) defined the community,

sociodemographics, and produced a list of the leading causes of mortality, morbidity,

and years of potential life lost (YPLL) for Aurora based on county level data. This data,

in combination with relevant health indicators, were used to identify the top health

concerns of the City of Aurora. The CHA results were then used to compare the health

concerns of the City of Aurora to the health concerns facing NWA as determined by

previous student groups.

A second component of this project entailed hosting a community engagement event

with members from AHA and interested community organizations. This meeting

consisted of presenting findings of the CHA and comparison to NWA, a Nominal Group

Technique (NGT) for brainstorming Aurora’s strengths, assets, and resources, and a

feasibility exercise aiding in the prioritization of health concerns.

4. Methods

For the purpose of this report, secondary data were used to assess health concerns in

Aurora. Results were compared to NWA and health concerns were later prioritized

during a community engagement event.

A. Collection and analysis of secondary data

The goal of the data collection and analyses was to identify key health concerns for the

City of Aurora. Secondary data were collected from multiple sources including the

Colorado Department of Public Health and Environment (CDPHE), Colorado Health

Information Datasets: Colorado Behavioral Risk Factor Surveillance System (BRFSS),

American Community Survey, Small Area Income and Poverty Estimates, Colorado

Department of Education; Colorado Health Institute (CHI), and the U.S. Census Bureau.

Since the City of Aurora is located in 3 different counties: Arapahoe County, Adams

County and Douglas County, and the majority of secondary data available was at the

county level, the percentages of the Aurora population within each county, 87.95% in

Arapahoe, 12% in Adams, and .05% in Douglas, were identified and used to create

weighted proportions for the City of Aurora (City of Aurora, 2014).

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Three major health outcomes were selected as the basis of the health assessment:

mortality, morbidity and YPLL. Top ten causes of each health outcome were calculated

based on weighted proportions from each county and used to identify associated health

indicators. All health outcomes were assessed specifically for the city of Aurora based

on three-year aggregate data from 2010-2012 (CDPHE, 2014).

The Health Equity Model, shown in Figure 1, was used as a framework to select health

indicators from social determinants of health and health factors. This framework was

selected because it conceptualizes the social determinants of health as life-enhancing

resources (such as food supply, housing, economic and social relationships,

transportation, education and healthcare), whose distribution across populations over

the life span, effectively determines length and quality of life.

Figure 1: Health Equity Model

Colorado Department of Public Health and Environment, Health Equity Model. (2014).

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Each health indicator was selected based on the following criteria:

● Literature review of main risk factors associated with ten leading causes of

mortality, morbidity, and YPLL, specifically in Aurora

● Statistically significant difference of the indicator between Colorado and

Aurora (assessed based on Arapahoe County measures)

Statistical significance was determined by utilizing confidence intervals, when available,

for the health indicators. All three counties were analyzed for comparison to the state of

Colorado as a whole, but Arapahoe County was chosen for closer evaluation due to the

greatest proportion of Aurora residing in this county. When significant differences were

found for an indicator, the value for each county was input in a spreadsheet and a

weighted calculation (Appendix A) was used for assigning the City of Aurora a value.

Due to the lack of available data at the municipal level, confidence intervals were only

compared between county and state data.

As each indicator was calculated based on weighted proportions from county data, an

example of the process of weighting proportions for the indicator of adult obesity is

shown below.

Example of weighted proportion calculation:

Arapahoe county * Adams County * Douglas County = Aurora

87.95% * 12% * 0.05% = Aurora

Example: Obesity, Percent of Adults 18+ who are Obese

Arapahoe Adams Douglas

21.4% * 87.95% + 24.8% * 12% + 16.1% * 0.05% = 21.8% Obesity in Aurora

Each weighted health indicator was then compared to similar measures for Colorado

and national Healthy People 2020 targets when applicable. The purpose of these

comparisons is to better understand the burden of each indicator in the City of Aurora

related to relevant populations.

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B. Scoring to identify top health concerns in Aurora

All selected health indicators were converted into health concerns and narrowed down

to ten based on severity and magnitude score. A description of the criteria for

determining severity and magnitude scores follows.

Severity

All selected health concerns were used to identify an association with the following

health outcomes:

● Leading ten causes of death (mortality data)

● Leading ten causes of illness (morbidity data)

● Leading ten causes of YPLL

The full matrix of all health concerns and associations with health outcomes is in

Appendix A.

Severity was scored between 1 and 5 and was based on the seriousness of the health

concern identified by the frequency the health concern was associated with the above

selected health outcomes (Appendix A).

1= Not Serious (the health problem was associated with less than 3 health events from

all, top ten causes of mortality in Aurora, top ten causes of morbidity in Aurora and top

10 causes of YPLL in Aurora)

2= Relatively Not Serious (association with 3-9 health events)

3= Moderately Serious (association with 10-16 health events)

4= Relatively Serious (association with 17-23 health events)

5= Very Serious (association with more than 23 events)

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Magnitude

Magnitude was scored based on the selected health indicators and the percent of the

population in Aurora affected. Magnitude scoring ranged between 1 and 5 as follows:

1= 0% of the population affected

2= up to 9% of the population affected

3 = 10%-20% of the population affected

4= 21%-50% of the population affected

5= Over 50% of the population affected

Magnitude scores, as well as severity scores, were both revisited during the community

engagement event and verified or adjusted based on the majority of votes from the

meeting attendees.

Severity and magnitude scores served two purposes: 1) narrow down lengthy list of

health indicators to top10 health concerns to present during the community engagement

event 2) as part of the composite score that also included feasibility to rank health

concerns for prioritization (methods explained in next section).

C. Community engagement and prioritization

In order to prioritize the top health concerns in Aurora, community leaders from various

organizations were invited to participate. First, a summary of the findings from the

modified community health assessment was presented to describe the health status of

the City of Aurora and illustrate a comparison to the health status of NWA to the

participants (Appendix F). Next, the resources, strengths and assets of the city of the

City of Aurora were brainstormed to help identify the feasibility of addressing each

health concern using the NGT. Finally, a prioritization process using a modified Hanlon

Method was facilitated to rank Aurora’s top ten health concerns. Informational handouts

were provided to participants detailing the top ten causes of mortality, morbidity, and

YPLL; the ten health concerns for Aurora; and a guide to the scoring methods of

magnitude, severity, and feasibility (Appendix B).

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Brainstorming City of Aurora’s Resources, Strengths, and Assets

The community leaders who attended the community engagement were asked to

participate in a brainstorming exercise. Brainstorming is a CDC recommended

technique for generating information and ideas in a group setting in which all members

are able to contribute and share their perspectives (Communities for Public Health,

n.d.). This CDC guide for brainstorming highlights 5 basic steps:

1. Define the topic

2. Ask group members to generate ideas

3. Record the answers

4. Combine similar or redundant ideas

5. Document the session

The purpose of the exercise was to create a comprehensive list of the resources,

strengths and assets in the City of Aurora. The question posed to the attendees was:

“In thinking about the top 10 health concerns, what resources, strengths, and assets

does the City of Aurora have that can be used to impact these concerns?”

Using the NGT as an effective means of generating many ideas in a limited amount of

time (National Association of County and City Health Officials [NACCHO], n.d.), the

participants were then asked to take a moment to silently and individually write down

the resources, strengths and assets they were familiar with to assist AHA in assessing

their role. To ensure that each person has the ability to contribute equally to the

development of a comprehensive list, NGT employs a round robin-style of

brainstorming. Starting at the front of the table, each participant was asked to state one

item from their list with the intent of going around the table in this fashion, for several

rounds. One student group member defined the topic and asked the members to

generate ideas while acting as moderator. One student was responsible for recording

the generated ideas; another student documented the brainstorming session.

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Modified Hanlon Method

A modified Hanlon Method for Prioritizing Health Problems was used to rank the

selected ten health concerns. The Hanlon Method for Prioritizing Health Problems is a

complex technique, which was modified for the purposes of this project to a more

simplified process still taking into account defined criteria and feasibility factors

(NACCHO, n.d.). The Hanlon Method follows 4 steps:

1. Rate against specified criteria

2. Apply the ‘PEARL’ test

3. Calculate priority scores

4. Rank the Health Problems

The first step, rating of magnitude and severity scoring was defined previously in this

report. The following sections describe how the 3 remaining steps of the modified

Hanlon Technique were utilized for the purposes of this project.

Feasibility assessment

AHA board members and Aurora community organizational leaders at the meeting

assessed feasibility. Each health concern was presented separately with the

predetermined severity and magnitude scores assigned by the student group. The

student moderator presented the given scores, and asked for agreement or

disagreement. When there was disagreement of the assigned score, a quick vote was

taken to determine if the score should be modified. When consensus was reached for

severity and magnitude, each attendee was then asked to score each of the ten health

concerns individually based on the following components of a modified ‘PEARL’ test of

feasibility:

● Political climate

● Will to change

● Intervention effectiveness

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● Economic viability

● Capacity to do work

Each participant wrote down a score of 1 to 5 based on AHA's ability to influence each

health concern as follows:

1= 1 of the 5 components applies for Aurora

2= 2 of the 5 components apply for Aurora

3= 3 of the 5 components apply for Aurora

4= 4 of the 5 components apply for Aurora

5= 5 of the 5 components apply for Aurora

Final prioritization

Once all ten health concerns were assigned a feasibility score, an average group

feasibility score was calculated and added to the severity and magnitude score to

calculate the final (aggregate) score for each health concern for a highest possible total

of 15. The highest final score was ranked first and the lowest final score was ranked

last resulting in a ranking of health priorities.

5. Findings

A. Aurora’s Demographics

Aurora’s geographic boundaries lie within Adams, Arapahoe, and Douglas counties as

shown in Figure 2. The city extends to the north as far as 70th Avenue, into Adams

County, south to County Line Road, where it slightly crosses into Douglas County, and

West to East from Yosemite Street to Schumacher Road, which is predominantly

Arapahoe County. Arapahoe and Adams counties contain the majority of Aurora

geographically and in population density.

Figure 2: Map of Aurora

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Google Maps (2014)

The City of Aurora is primarily an urban city. The U.S. Census Bureau estimates the

2013 population to be approximately 345,800, making it the third largest city in Colorado

and the fifty-fifth largest in the country. Aurora is roughly the size of New Orleans and

Tampa (City of Aurora, 2014). According to 2010 Census data (see Figure 3), the age

distribution of persons in the City of Aurora is as follows: children under the age of 5

represent 8.4%, persons, under the age of 19 represents 29.8% of the population,

persons 65 and older total 8.9% of the population, this means over 60% of Aurora’s

population is between the ages of 20 and 64 (U.S. Census Bureau, 2014). This means

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the City of Aurora has a relatively young population, with only 8.9% of the population

being 65 or older compared to Colorado’s proportion of 10.9%. Having a younger

population means that the top 10 leading causes of morbidity may have an impact on

the City of Aurora's healthcare system for extended years.

Figure 3: Population Age Distribution of Aurora and Colorado

Based on data from United States Census, 2010.

The City of Aurora has seen dramatic population increase over the last 20 years (see

Figure 4). The population in Aurora has increased by almost 50% since 1990, which is

represented by the red line in Figure 4. This increase is substantially more than what is

seen in Denver, represented by the blue line in the figure below, which is a 28%

increase. Since 1990, Aurora's population has grown significantly higher than Denver's

increase and even higher than the nearest towns of Thornton, Lakewood, and Arvada

(Figure 4). Therefore, the City of Aurora's healthcare system has to accommodate the

increasing population size.

Figure 4: Population Growth, 1990-2010

0% 2% 4% 6% 8%

10% 12% 14% 16% 18%

Under 5 years

5-9 years

10-14 years

15-19 years

20-24 years

25-34 years

35-44 years

45-54 years

55-59 years

60-64 years

65-74 years

75-84 years

85 years plus

Aurora Colorado

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City of Aurora, Planning & Development Services Department. (2012)

Census data for 2010 also report the racial demographics of the City of Aurora as

61.1% white, 15.7% African American or Black, 1.0% American Indian and Alaska

Native, 4.9% Asian, 0.3% Native Hawaiian or Other Pacific Islander, 11.7% were some

other race, and 5.7% were two or more races; approximately 29% self-report identifying

as Hispanic or Latino ethnicity (City of Aurora, 2012) as shown in Figure 5. When

considering the overall health status of the City of Aurora residents, it is important to

keep in mind that these sociodemographics play a key role in contributing to a

population’s health outcomes. The percentage for Hispanics is much larger in Aurora

than the 19% in Colorado over all. Additionally, Colorado has an African American

population of 4.4% (US Census Bureau, 2010), which is almost a quarter of that of the

City of Aurora. The diversity seen in the City of Aurora is important when thinking about

health outcomes because both Hispanics and African Americans are at a greater risk for

certain adverse health conditions (CDC, 2014).

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

1990 2000 2010

Aurora Denver Arvada Lakewood Thornton

46% change since 1990

28% change since 1990

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Figure 5: Racial Composition in Aurora

City of Aurora, Planning & Development Services Department. (2012).

Aurora has many areas where greater than 15% of the population is living below the

federal poverty level (see Figure 6). A higher proportion of people are living below

poverty on the western side of the city, and a concentrated area of poverty in NWA and

surrounding area (City of Aurora, 2012).

White, 61%

Black or African

American, 16%

American Indian or Alaska

Native, 1%

Asian, 5%

Native Hawaiian or other Pacific Islander, 0%

Some other Race, 12%

Two or more Races, 6%

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Figure 6: Percentage of the Population Living Below Poverty

City of Aurora, Planning & Development Services Department. (2012).

Aurora has a younger, reportedly growing, and a more diverse population living in areas

with high poverty when compared to Colorado. This combination has implications for

future healthcare systems functioning as well as population health. Diseases are often

associated with population characteristics. With regard to age, nationally, obesity is

higher among middle age adults 40-59 years old (39.5%), than among younger adults

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age 20-39 (30.3%), or adults over 60 or above (35.4%) (CDC, 2014). And in the U.S.,

Hispanic and African American populations specifically are at particularly high risk of

diabetes, heart disease, high blood pressure, renal disease and stroke (CDC, 2014).

Poverty is also inextricably linked to illness and poor health outcomes; indeed to such a

degree that childhood poverty affects and influences adult health even if the adult is no

longer living in poverty (Economou and Theodossiou, 2011). If the population

composition of the City of Aurora continues to increase in age and diversity, with little or

no change in poverty levels, healthcare infrastructure will have to accommodate and

prepare for this changing population.

B. Modified Health Assessment

In the initial phase of the modified health assessment for the city of Aurora, three health

outcomes were examined: mortality, morbidity, and YPLL at a municipal level. Table 1

presents the top 10 leading causes of all 3 health outcomes.

Table 1: Ten Leading Causes of Mortality, Morbidity, and YPLL in Aurora

Rank Mortality Morbidity YPLL 1 Cancer Stroke Unintentional Injury 2 Heart Disease Heart Disease Cancer 3 Chronic Lower

Respiratory Disease Acute Myocardial Infarction Suicide

4 Unintentional Injuries Heart Failure Heart Disease 5 Alzheimer's Disease Adult Diabetes Perinatal Period Conditions 6 Cerebrovascular

Disease Motor vehicle Accidents Hospitalization Homicide/Legal Intervention

7 Suicide Invasive Cancer Chronic Liver

Disease/Cirrhosis 8

Diabetes Congenital anomalies Congenital Malformations, Deformations, and Chromosomal Abnormalities

9 Chronic Liver Disease Breast cancer Cerebrovascular Diseases 10 Influenza Prostate cancer Diabetes Mellitus Data based on aggregate 3-year data from 2010-2012, CDPHE

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12% 14%

0% 2% 4% 6% 8%

10% 12% 14% 16% 18% 20%

Aurora Colorado

Additionally, nine health indicators were selected based on criteria described in the

Methods section to assess health of the adult population in the City of Aurora, which is

more than 70% of the entire population. Two more health indicators were added to

describe the child population to complete the list for the final analysis. All selected

indicators are described below and compared to Colorado state data and HP2020 when

available. A description of each indicator as it relates to Aurora is below.

1. Percent of population living below poverty level (Figure 7)

This indicator represents the total percent of the population living below the federal

poverty level, data from 2012 (CDPHE, 2012). The city of Aurora has less people living

below the poverty level when compared to Colorado.

Figure 7: Proportion of People Living Below Poverty Level

Small Area Income and Poverty Estimates, 2012.

2. High school completion rates (Figure 8)

The high school completion indicator is used as a measure of educational attainment. It

is defined as the four-year on time completion rate for students who graduate from high

school four years after entering ninth grade. This includes students who graduate with a

high school diploma, receive a certificate or designation of completion, or a G.E.D.

(CDPHE, 2012). The percentage is lower in Aurora compared to CO, and both Aurora

and CO are below the goal for HP2020.

19

73% 78% 82%

0%

20%

40%

60%

80%

100%

Aurora Colorado HP2020

21% 14%

0% 0%

10%

20%

30%

40%

50%

Aurora Colorado HP2020*

Figure 8: Proportion of High School Completion

Colorado Department of Education, 2012

3. Percent of adults 18-64 years without health insurance coverage (Figure 9)

This indicator represents the percentages of adults without health insurance coverage in

2013, which is prior to health reform. Health insurance coverage is defined as any type

of coverage during the year or past year (CDPHE, 2012). As of 2013, Aurora had 50%

more of the population that were uninsured compared to CO. These are the most

recent estimates for county and state level data; the next estimates are due to come out

in the summer of 2015, and will reflect the impact of health reform.

Figure 9: Proportion of Adults without Health Insurance

US Census Bureau, American Community Survey 1-yr Estimates, 2013

20

9% 8%

0% 0%

5%

10%

15%

Aurora Colorado HP2020*

77% 77% 84%

0%

20%

40%

60%

80%

100%

Aurora Colorado HP2020

4. Percent of population under 18 years without health insurance (Figure 10)

The percent of the population, less than 18 years old, without health insurance is

defined as having no type of healthcare coverage (CDPHE, 2012). The percentage of

uninsured children is slightly higher in Aurora than in Colorado, which are both higher

than the national goal for HP 2020.

Figure 10: Proportion of Children without Health Insurance

US Census Bureau, American Community Survey 1-yr Estimates, 2013.

5. Percent of adults 18+ reporting having one or more regular healthcare providers (Figure 11)

This indicator is defined as the percent of adults, 18 years and older, who reported

thinking of one person as their personal doctor or healthcare provider (CDPHE, 2012).

Aurora and CO have an equal proportion of adults with a regular HCP, which is below

the national goal.

Figure 11: Adults with a Regular Healthcare Provider

21

22% 20%

31%

0% 5%

10% 15% 20% 25% 30% 35%

Aurora Colorado HP2020

Colorado Behavioral Risk Factor Surveillance System 2011-2012

6. Percent of adults 18+ who are obese (Figure 12)

This indicator describes the percent of adults 18 years of age and older that have a

body mass index (BMI) greater than, or equal to 30 (CDPHE, 2012). The data are from

the years 2011-2012. Adult obesity is slightly higher in the City of Aurora than in CO,

and even though these proportions are lower than the national goal, obesity is on an

upward trend, and has the potential to continue increasing in the coming years.

Additionally, obesity is linked with several causes of morbidity and mortality.

Figure 12: Proportion of Adult Obesity

Colorado Behavioral Risk Factor Surveillance System 2010-2012

7. Percent of children 2-14 years who are obese (Figure 13)

The percent of children aged 2-14 who are obese is defined here as children with a BMI

greater than or equal to the 95th percentile (CDPHE, 2012). In contrast to adult obesity,

childhood obesity in the City of Aurora is slightly higher than in Colorado and the

national goal. This is important when thinking about the younger population in the City

of Aurora, and it suggests childhood obesity is already a major concern and the severity

is likely to increase.

22

16% 15% 15%

0%

5%

10%

15%

20%

Aurora Colorado HP2020

19% 17%

33%

0%

10%

20%

30%

40%

Aurora Colorado HP2020*

Figure 13: Proportion of Childhood Obesity, 2-14 years

Colorado Behavioral Risk Factor Surveillance System 2010-2012

8. Percent of adults 18+ who are physically inactive (Figure 14)

This indicator is defined as the percent of adults, 18 years and older who reported no

leisure time physical activity (CDPHE, 2012). This means, other than one’s regular job,

they do no participate in any physical activity or exercise. The City of Aurora has a

slightly higher proportion of the population who are physically inactive, compared to

Colorado.

Figure 14: Proportion of Adults that are Physically Inactive

Colorado Behavioral Risk Factor Surveillance System 2011-2012 9. Percent of adults 18+ who currently smoke cigarettes (Figure 15)

This indicator represents the percentage of adults, 18 years and older, who are current

smokers, the data is from 2011-2012 (CDPHE, 2012). Both the City of Aurora and CO

are above the HP2020 goal for this indicator.

23

17% 18% 12%

0% 5%

10% 15% 20%

Aurora Colorado HP2020

12% 14%

0%

5%

10%

15%

20%

Aurora Colorado

Figure 15: Proportion of Tobacco Use

Colorado Behavioral Risk Factor Surveillance System 2011-2012

10. Percent of the population that reported poor mental health in the past 30 days (Figure 16)

This indicator is used to represent the mental health status of a population. Poor mental

health is defined as reporting 8 or more days of feeling stressed, depression or

emotional problems in the past 30 days (CHI, 2013). Twelve percent of Aurora

residents reported poor mental health, compared to 14% in Colorado.

Figure 16: Proportion of People with Poor Mental Health

Colorado Health Institute, 2013.

11. Adult suicide rates (Figure 17)

This indicator measures the rate of suicides per 100,000 population. A similar trend to

the poor mental health indicator is seen in adult suicide rates in Aurora and CO, where

Aurora is slightly less than CO. There is also a national goal for comparison.

24

18 19

10

0

5

10

15

20

Aurora Colorado HP2020

Figure 17: Adult Suicide Rates

Colorado Health Information Dataset, 2013.

These health indicators are an illustration of the social determinants of health combined

with health factors, representing the overall health status of the City of Aurora’s

residents. Specific areas such as poverty, tobacco use and mental health are currently

affecting less of the population in Aurora when compared to Colorado, but remain

significant in the overall health status of a community. In contrast, Aurora is

disproportionately affected by lower high school completion rates, fewer adults and

children with health insurance, greater percentages of adult and childhood obesity and a

larger proportion of the population who are physically inactive, when compared to

Colorado. This highlights the disparities of this community and emphasizes their unmet

needs. Additionally, the population health of Aurora could continue to experience

poorer health outcomes if social determinants of health, like poverty and education, are

not directly addressed.

The data collected and analyzed for the indicators, as well as literature reviews of risk

factors for leading causes of mortality, morbidity, and YPLL, led to the development of

ten health concerns in Aurora. The concerns are as follows: Regular Healthcare

Provider, Educational Attainment, Healthcare Coverage, Obesity, Tobacco Use,

Poverty, Physical Inactivity, Mental Health, Cancer, and Heart Disease.

These concerns represent broader themes than what specific indicators measure since

the themes are areas that affect multiple aspects of population health.

25

C. Prioritization

As was described in the Methods section, the student group determined magnitude and

severity scores based on set criteria. The detailed assessment of magnitude score and

severity score are in Appendix D. After explaining how each magnitude and severity

score metric was calculated, the group had the opportunity to change any of the scores.

The only major discussion was centered around the magnitude of Educational

Attainment. The group decided to change this from a 3 to a 3.5 (rounded to 4) because

children are also impacted by the educational attainment of the community, which was

not included in the health indicator.

In order to conduct final prioritization, feasibility scores were determined by community

leaders. Feasibility scores were based on AHA’s capacity, skills and resources, and

ability to influence each concern. Final prioritization based on a modified Hanlon

Method ranked the top 10 health concerns for Aurora (Table 2) from the highest to the

lowest priority. This report shows that having a regular healthcare provider together

with healthcare coverage and education were ranked the highest.

Table 2: Prioritization Results, Ranked Health Concerns for Aurora

Rank Health Concern Magnitude Severity Feasibility Aggregate Score

1. Regular Healthcare Provider 4 5 4 13

2. Educational Attainment 4 5 4 13

3. Healthcare Coverage 4 5 4 13 4. Obesity 4 4 4 12 5. Tobacco Use 3 4 3 10

6. Poverty 3 4 3 10

7. Physical Inactivity 3 3 3 9 8. Mental Health 3 2 4 9 9. Cancer 3 2 3 8

10. Heart Disease 3 2 2 7

26

Based on the health indicators and health outcomes, ten health concerns were

prioritized for the City of Aurora based on severity, magnitude and feasibility ranking

and compared to the top ten health concerns identified in a NWA health assessment

from 2013 (Table 3). Highlighted in Table 4 are health concerns that overlapped in both

NWA and the city of Aurora. Both healthcare coverage and educational attainment

were ranked high as one of the top concerns in both studied regions. Poverty was an

important health concern in both regions that directly impacts healthcare coverage as

well as educational attainment. It has been previously studied that people living below

poverty level have lower education attainment than individuals above the poverty level

(BLS, 2013). Additionally, people living below poverty have less access to healthcare

services than other populations (Swartz, 2009). Mental health was identified in both

regions as an important health concern. While obesity was not mentioned in the NWA

report, it directly relates to access to healthy food and both concerns are related to

health outcomes associated with obesity.

Table 3: Comparison of Top Ten Health Concerns for Aurora and NWA

Aurora NWA

1. Regular Healthcare Provider 1. Access to Healthcare

2. Educational Attainment 2. At-Risk Births (Teen Pregnancy)

3. Healthcare Coverage 3. Educational Opportunity

4. Obesity 4. Access to Healthy Foods

5. Tobacco Use 5. Housing

6. Poverty 6. Mental Health

7. Physical Inactivity 7. Poverty

8. Mental Health 8. Recreation Space

9. Cancer 9. Security

10. Heart Disease 10. At-Risk Births (Maternal Mortality)

27

Even though some health concerns are not identical, many are related and influence

each other. For example, physical inactivity was ranked 7th for the City of Aurora while

recreational space was ranked 8th for NWA. Having recreational space availability

enhances physical activity and therefore, both health concerns are correlated (Heath,

2006). Similarly, both obesity and access to healthy foods were ranked 4th in either

report while the correlation of both health concerns has been previously confirmed

(Larson, Story, & Nelson, 2009).

The comparison of the City of Aurora and NWA produced similar findings when ranking

health concerns, which is important for AHA to consider when deciding to expand their

efforts to the entire population of Aurora.

D. Brainstorming City of Aurora’s Resources, Strengths, and Assets

In order to assess a feasibility score, the strengths, assets, and resources related to the

health concerns were identified using a brainstorming technique. A list of 45 community

features were brainstormed and categorized as shown in Table 4.

Table 4: Strengths, Assets and Resources in Aurora

Health-related agencies/organizations

Community and organizations

Government organizations/reps Built environment

Community clinics – physical and behavioral health

ACAN (Aurora coverage assistance network)

AHA (Aurora Health Access)

MCPN (Metro Community Provider Network)

Aurora Mental Health

Dawn Clinic

Tri-County Public Health

Colorado School of Public Health – Community Health Assessment

Kaiser

University Hospital

Ethnic and cultural diversity

Aurora use options.

cooking clinics (Cooking Matters)

2040 Partnership Outreach

Lowry Family Center

Social services organizations

Community campus partnership

Community members

Churches

Asian Pacific development center

Refugee Center

Fields Foundation

Medical school and training programs.

City Council

State representatives

Community colleges

Library

Police

Fire Department

primary and secondary schools businesses

Public transit

Good weather

Bike trails

Parks

28

Children's Hospital

The Medical Center of Aurora

SMHA (South Metro Health Alliance)

Resiliency Center

Denver Foundation

Community awareness – health and social determinants

Medical Students

Foundation community

be well Northwest Aurora

neighborhood associations

6. Conclusions

Aurora Health Access is currently considering an expanded mission to address health

needs of the greater City of Aurora and not just NWA. In this process of a modified

health assessment and prioritization process we found consistent results of top health

concerns in both NWA and the greater Aurora Community. Access to healthcare

measured by insurance coverage, having a primary care physician or any other health

indicator seem to be the most prioritized health concern. Also related, education

attainment has been identified within the top three health concerns. While education

level has been closely related to the health status (Adler et al., 1994), it is important to

focus public health organizations’ efforts to increase knowledge about health

maintenance, preventive care and access to health.

7. Limitations

There are several limitations regarding the methodology of this project. First, the

modified community health assessment reflects only quantitative, secondary data and

does not include corroborative qualitative data. Second, using a weighted proportion to

calculate health indicators based on the population of Adams, Arapahoe, and Douglas

counties requires several assumptions be made about the health of the City of Aurora.

For example, the health of the urban populations of each county will have a stronger

influence on the health indicator since the majority of the county population resides in

the more urban. However, when considering various approaches in order to study the

health concerns of the City of Aurora, which does not specifically collect health data

29

within city limits, weighted proportions was considered the most direct and

straightforward method. A third limitation is that previous student groups defining health

concerns for NWA were working with secondary data not available for the City of

Aurora. This results in the problematic reality that there is no scientific means of

comparing available NWA data to City of Aurora data. Finally, the most recent data for

health insurance rates are from the American Community Survey and Colorado Health

Institute, both in 2013, which is not reflective of health reform under the ACA. The

rollout of the health insurance exchange, the expansion of Medicaid in Colorado, and

the federal mandate requiring individuals to have health insurance may all affect the

rates of insured individuals. The next set of data on health insurance rates is due to

come out in the Summer of 2015, and will be a more accurate representation of these

changes.

8. Recommendations

Based on a modified health assessment and prioritization of the City of Aurora’s health

concerns, four health concerns considered top priorities for Aurora were selected to

provide possible strategies for AHA to consider in addressing population health. As

both having healthcare coverage and having a regular healthcare provider are aspects

of access to health care concerns, these health concerns have been grouped together

into the one for recommendations. When comparing the City of Aurora to NWA, the

highest top prioritized health concerns are the same, access to healthcare (healthcare

coverage and regular healthcare provider). Education is among the highest priorities for

both. Additionally, mental health and poverty were areas of concern for both

communities. These important health determinants are problematic in NWA, however,

these health concerns are not limited to NWA and affect the whole city, and therefore, it

is recommended that AHA move forward, especially in these areas, focusing on the

entire City of Aurora.

Expand Target Population of AHA to the City of Aurora

Many of the top health concerns identified in a health assessment focused on NWA and

the City of Aurora were similar including access to healthcare, educational attainment,

30

mental health, and poverty. AHA has been successful at leveraging community assets

to address community needs in healthcare. By expanding this mission to a larger

population, AHA can use this effective approach to impact a larger community in need

using similar resources and community assets.

Access to Healthcare: Healthcare coverage/Having regular healthcare providers

Having healthcare coverage and a regular healthcare provider are instrumental in

positive health outcomes as these factors impact utilization of preventive care, decrease

unnecessary emergency room care and costs, and improve disease treatment and

coordinated care (New York Department of Mental Health and Hygiene, 2007).

1. Explore new methods of information dissemination about healthcare coverage topics

and choosing/establishing a relationship with a regular healthcare provider. Mobile

health apps and other uses of technology and social media can play an important role in

connecting people to health information as Latinos, African Americans, and those

between the ages of 18 and 49 who are cell phone owners are more likely than others

to look for health information on their phones (Pew Research center, 2012).

2. The brainstorming exercise revealed health departments, community health

organization, and community organizations as assets in Aurora. Baron et al. (2014)

recommend collaboration between all of these entities as each can uniquely provide

effective methods for delivering health protection and health promotion programs,

especially to low-income earners (2014). AHA can begin the collaborative dialogue

among these entities to offer more comprehensive programs that promote healthcare

coverage and having a regular healthcare provider.

3. AHA provides a health resource directory for Northwest Aurora. Develop a directory

of resources that incorporates all of Aurora’s health resources to provide more residents

access to a more extensive, comprehensive directory.

31

4. Monitor the impact the ACA has on health insurance coverage in Aurora. These

changes may impact AHA’s future directions.

Educational attainment

Education inequalities are linked to poor or fair health, poor physical health days, and

poor mental health days, (Asada, 2014). Education level is a risk factor for multiple

health conditions including heart disease, certain cancers, obesity, Alzheimer's disease,

and depression (Adler et al., 1994). Inversely, higher education rates are correlated

with better health outcomes (CDC, 2014).

1. The CDC (2014) recognizes promoting protective factors, such as school and family

connectedness, as an effective means of improving school retention rates.

Freudenberg and Ruglis (2007) also report that feeling connected to school and a

caring adult reduces dropout rates. Several school and family related organizations

were identified as strengths and assets through the brainstorming process. These

strengths and assets can be partnered with to foster these protective factors and build

partnerships with organizations that promote school connectedness, build partnerships

with organizations promote family connectedness and positive parenting techniques.

Post a link on the AHA website to the CDC’s Handbooks as a resource for these

partners: School Connectedness: Strategies for Increasing Protective Factors Among

Youth and Parent Engagement: Strategies for Involving Parents in School

2. Freudenberg and Ruglis (2007) advocate that incorporating health coordinators or

educators into schools is an effective method of reducing dropout rates. These

professionals fill a gap between services in the community and student and family

health and can work to connect families and students to the sevices they need.

Additionally, they can effectively address sex education, substance abuse, violence

prevention, and mental health (Freudenberg and Ruglis, 2007).

3. Reframe educational attainment as a health problem (Freudenberg and Ruglis,

2007). Inform the public that health and education are linked in such a way that

improving high school completion rates can reduce socioeconomic and racial/ethnic

32

health disparities, health care cost over the life span, and risky health behaviors

(Freudenberg and Ruglis, 2007). Call on policy makers and community leaders to view

education in the greater health context as education level is a determinant of health.

Obesity

The CDC recognizes low levels of physical activity and poor nutrition as the leading

contributors to obesity (2014). Increasing physical activity and healthy eating is

considered to be an effective approach to obesity prevention (Tran, 2014, CDC, 2014).

1. Develop a resource guide for free or low-cost physical activity opportunities as well

as organizations that offer free or low-cost nutritional education trainings and counseling

in and around Aurora.

2. Advocate breastfeeding. Breastfeeding is an evidence-based strategy to prevent

overweight and obesity (CDC, 2014). Partner with and advocate for breastfeeding

friendly businesses, childcare centers, and hospitals that protect, promote, and support

breastfeeding.

3. Healthy Eating and Active Living (HEAL) programs are being implemented in many

communities and schools, they are feasible, and evidence-based approaches to obesity

and overweight prevention (Tran, 2014). AHA is currently connected to partners

advocating HEAL initiatives. Support these partners in promoting HEAL.

4. Emphasize existing infrastructure throughout Aurora by organizing community

activities and meetings in different locations to expand the number of people introduced

to Aurora’s infrastructure for various physical activities.

Additional Recommendations

Lack of qualitative data sources are noted as a project limitation as quantitative data

does not capture the complete picture of health in Aurora. Key informant interviews, in-

depth, structured interviews with relevant community partners, as well as focus groups

with the health community would aid AHA in developing a more comprehensive

understanding of the City of Aurora including NWA. The CDPHE recommends using

33

both types of data to inform community health assessments as a means of validating

finding (CDPHE, 2011).

This project highlighted Healthy People 2020 targets as a benchmark column in our

analysis. Healthy People is a nationwide, government-funded program that sets and

monitors ten-year objectives for improving the health of Americans and could be useful

for identifying areas where the City of Aurora is falling behind national targets. Using

this benchmark in future health assessments would serve as a useful tool in tracking

changes in Aurora’s health status.

0

9. References Adler, N., Boyce, T., Chesney, M., Cohen, S., Folkman, S., Kahn, R., Syme, S. (1994). Socioeconomic status and health: The Challenge of the Gradient. American Psychologist, Vol 49(1), Jan 1994, 15-24. DOI:org/10.1037/0003-066X.49.1.15

Asada, Y., Whipp, A., Kindig, D., Billard, B. Rudolph, B. (2014). Inequalities in Multiple Health Outcomes by Education, Sex, and Race in 93 U.S. Counties: Why we should measure them all. International Journal for Equity in Health, 13 (47). DOI: 10.1186/1475-9276-13-47

Aurora Health Access. (2014). Data Sources, Resource List, and Reports. Retrieved from: http://www.aurorahealthaccess.org/resources/data-sources-and-reports/

Baron, S., Beard, S., Davis, L., Delp, L., Forst, L., Kidd-Taylor, A., Liebman, A., Linnan, L., Punnett, L., Welch, L. (2014). Promoting Integrated Approaches to Reducing Health Inequities Among Low-Income Workers: Applying a Social Ecological Framework. American Journal of Industrial Medicine, 57:539–556.

Center for Disease Control and Prevention. (2014). Breastfeeding. Retrieved from: http://www.cdc.gov/breastfeeding/

Centers for Disease Control and Prevention. (2014) Nutrition, Physical Activity, and Obesity. Retrieved from:

http://www.cdc.gov/winnablebattles/obesity/index.html

Centers for Disease Control and Prevention. (2014). School Connectedness: Strategies for Increasing Protective Factors Among Youth. Retrieved from: http://www.cdc.gov/healthyyouth/protective/pdf/connectedness.pdf

City of Aurora. (2014). Community Facts. Retrieved from: https://www.auroragov.org/cs/groups/public/documents/document/005454.pdf

City of Aurora, Planning & Development Services Department (2012). Who Is Aurora, An Overview of demographic and social data and trends. Retrieved from:

https://www.auroragov.org/cs/groups/public/documents/document/013586.pdf

Communities for Public Health. (n.d.). Brainstorming Techniques. Retrieved on November 12, 2014 from: www.cdc.gov/phcommunities/docs/launch_brainstorming_techniques.doc

Colorado Department of Education. (2012). High School Completion Rates. Retrieved from, http://www.chd.dphe.state.co.us/HealthIndicators/Default.aspx

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Colorado Department of Public Health and Environment, Health Equity Model. (2014).Retrieved from: http://www.chd.dphe.state.co.us/healthindicators/

Colorado Department of Public Health and Environment. (2011). Colorado Health Assessment and Planning System. Retrieved from: http://www.chd.dphe.state.co.us/chaps/phases.aspx?phaseID=phase3

Colorado Department of Public Health and Environment. (2012). Colorado Health Indicators: Colorado Behavioral Risk Factor Surveillance System 2011-2012. Retrieved from: http://www.chd.dphe.state.co.us/healthindicators/indicators.aspx

Colorado Department of Public Health and Environment. (2012). Colorado Health Indicators: Colorado Behavioral Risk Factor Surveillance System 2010-2012. Retrieved from: http://www.chd.dphe.state.co.us/healthindicators/indicators.aspx

Colorado Department of Public Health and Environment, Health. (2012). Colorado Health Indicators: Statistics and Vital Records, 2010-2012. Retrieved from: http://www.chd.dphe.state.co.us/HealthIndicators/Default.aspx

Colorado Health Information Dataset. (2013). Leading Causes of Death QuickReport. Retrieved from: http://www.chd.dphe.state.co.us/cohid/topics.aspx?q=Death_Data

Colorado Health Institute. (2013). Analysis of CHAS data. Retrieved from: http://www.coloradohealthinstitute.org/data-repository/detail/mental-health

Economou, A. & Theodossiou, I. (2011). Poor and Sick: Estimating the Relationship Between Household Income and Health. Review of Income and Wealth, 57(3). DOI: 10.1111/j.1475-4991.2010.00416.x roiw_416 395..411 Google Maps (2014). Retrieved from: https://www.google.com/maps/place/Aurora,+CO/data=!4m2!3m1!1s0x876c588622ba2b9b:0x8441e0688ba2e678?sa=X&ei=8P19VMOuAsKqNo7SgrgI&ved=0CB0Q8gEwAA

Freudenberg, N., Ruglis, J. (2007). Reframing School Dropout as a Public Health Issue. Preventing Chronic Disease, 4(4): A107

Heath G., Brownson R., Kruger J, et al. (2006). The Effectiveness of Urban Design and Land Use and Transport Policies and Practices to Increase Physical Activity: a Systematic Review. Journal of Physical Activity and Health, 3(Suppl 1):S55-76. Available at: http://www.aapca3.org/resources/archival/060306/jpah.pdf

Heinrich, C., & Holzer, H., (2009) Improving Education and Employment for Disadvantaged Young Men: Proven and Promising Strategies. Institute for Research on Poverty. Conference on “Young Disadvantaged Men: Fathers, Families, Poverty, and Policy,” held September 14–15, 2009.

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U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Retrieved from: https://www.healthypeople.gov

Kahn, E., Ramsey, l., Brownson, R., Heath, G., … Rajab, M., (2002) The Effectiveness of Interventions to Increase Physical Activity – A Systematic Review. American Journal of Preventive Medicine, 22 (45) p. 73-107.

Larson, N., Story, M., Nelson, M. (2009). Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S. American Journal of Public Health, 36(1) 74-81.

National Association of County and City Health Officials. (n.d.). First Things First: Prioritizing health problems. Retrieved from: http://www.naccho.org/topics/infrastructure/accreditation/upload/Prioritization-Summaries-and-Examples.pdf

National Institute of Health and Science Research. (2014). Retrieved from: http://search.nih.gov/search?utf8=✓&affiliate=nih&query=educatioin+is+a+risk+facotr&commit.x=0&commit.y=0&commit=Search

New York Department of Mental Health and Hygiene. (2007). healthcare Access Among Adults in New York City: The Importance of Having Insurance and a Regular healthcare Provider. Retrieved from: http://www.nyc.gov/html/doh/downloads/pdf/hca/hca-nyc-adults.pdf

Pew Research Center. (2012). Mobile Health 2012. Retrieved from: http://emr-matrix.org/wp-content/uploads/2012/12/PIP_MobileHealth2012.pdf

Swartz, K. (2009). healthcare for the Poor: For whom, what care and whose responsibility? Focus. Vol. 26 (2), 2009. Retrieved from: http://www.irp.wisc.edu/publications/focus/pdfs/foc262l.pdf

Tran, B., Ohinmaa, A., Johnson, J., Veugelers, P. (2014). Life Course Impact of School-Based Promotion of Healthy Eating and Active Living to Prevent Childhood Obesity. PLOS ONE, 7. DOI: 10.1371/journal.pone.0102242

U.S. Census Bureau. (2010). Profile of Population and Housing Characteristics. 2010 Demographic Profile Data. Retrieved from: http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF

U.S. Census Bureau. (2012). Population Age American Community Survey 5-Year Estimates 2008-2012. Retrieved from: http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk

U.S. Census Bureau. (2012). Poverty, American Community Survey 5-Year Estimates 2008-2012. Retrieved from http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml

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U.S. Census Bureau. (2013). Uninsured, American Community Survey 1-Year Estimates. Retrieved from: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml

U.S. Census Bureau. (2014). City of Aurora Quick Facts. Retrieved from: http://quickfacts.census.gov/qfd/states/08/0804000.html

U.S. Bureau of Labor Statistics. (2013). A Profile of the Working Poor, 2011, Report 1041. Retrieved from: http://www.bls.gov/cps/cpswp2011.pdf

45

health outcome Obesity Tobacco EDUCATION POVERTY PHYSICAL INACTIVITY

HCE COVERAGE

MENTAL HEALTH

REGULAR HC

PROVIDER CANCER Heart

Disease

Mortality

Cancer Heart Disease Chronic lower resp. diseases Unintentional injuries Alzheimer's disease Cerebrovascular diseases Suicide Diabetes mellitus Chronic liver dis. and cirrhosis Influenza and Pneumonia

YPLL

Unitentional Injury Malignant Neoplasms Suicide Heart Disease Perinatal period conditions Homicide/legal intervention Chronic liver disease/cirrhosis Congenital malformations,deformations Cerebrovascular diseases Diabetes Mellitus

Morbidity

Stroke hospitalizations *Heart disease hospitalizations *Acute myocardial infarction hospitalizations Heart failure hospitalizations Percent of adults aged 18+ years with diabetes Motor vehicle accident hospitalizations Incidence rate of invasive cancer all ages Rate of major congenital anomalies (per 10,000) incidence rate of invasive cancer of the female breast among females of all ages incidence rate of invasive cancer of the prostate among males of all ages

10. Appendices

Appendix A: Matrix of Health Concerns and Associations with Mortality, Morbidity, and YPLL

46

Appendix B: AHA Informational Handout

Leading causes of death:

1. Cancer

2. Heart Disease

3. Chronic Lower Respiratory Disease

4. Unintentional Injuries

5. Alzheimer's Disease

6. Cerebrovascular Disease

7. Suicide

8. Diabetes mellitus

9. Chronic Liver Disease

10. Influenza and Pneumonia

Leading causes of chronic illness:

1. Stroke hospitalizations

2. Heart Disease hospitalizations

3. Acute myocardial infarction hospitalizations

4. Heart Failure hospitalization

5. Percent of adults with diabetes

6. Motor vehicle accident hospitalizations

7. Invasive cancers

8. Congenital anomalies (differences at birth)

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9. Breast cancer

10. Prostate cancer

Leading Causes of Years Potential Life Lost

1. Unintentional Injury

2. Cancer

3. Suicide

4. Heart Disease

5. Perinatal Period Conditions

6. Homicidal/Legal Intervention

7. Chronic Liver Disease

8. Congenital Malformation, deformations, and chromosomal anomalies

9. Cerebrovascular disease

10. Diabetes Mellitus

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Appendix C: Top Health Concerns for Aurora

Top Health Concerns for Aurora:

1. Regular healthcare Provider: nearly 23% of adults are without a regular

healthcare Provider

2. Obesity: affects 22% of the adult population and 16% of children aged 2-14

3. Healthcare Coverage: 21% of adults are without health insurance

4. Educational Attainment: With 9% of adults over the age of 25 having no high

school diploma and with high school incompletion rates of 27% of expected

high school graduates, it is likely that over 10% of the adult population has

not completed high school or its equivalency.

5. Tobacco Use: 18% of adults smoke cigarettes everyday

6. Poverty: 12% of the population of Aurora is living below the poverty level

7. Physical Inactivity 19% of adults reported no physically activity other than

their job in the last month.

8. Cancer: we estimate that approximately 10% percent of adults are affected by

cancer

9. Heart Disease: we estimate that approximately 10% percent of the adult

population is affected by heart disease

10. Mental Health: 12% of adults suffer from poor mental health including stress,

depression, and emotional problems

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Appendix D: Magnitude and Severity Score Assessment

Magnitude Assessment

Health concern % of population affected Magnitude Score

educational attainment 27% 3

regular healthcare provider 23% 4

healthcare coverage 21% 4

tobacco use 17% 3

poverty 12% 3

physical inactivity 19% 3

cancer 10% 3

heart disease 10% 3

obesity 22% 4

mental health 12% 3

Severity Assessment

Health concern

# of associated causes of mortality

# of associated causes of morbidity

# of associated

YPLL Severity Score

educational attainment 8 10 8 5

regular healthcare provider 7 9 7 5

healthcare coverage 7 9 10 5

tobacco use 6 5 5 4

poverty 5 9 6 4

physical inactivity 6 8 4 3

cancer 3 3 4 2

heart disease 3 4 2 2

obesity 6 6 5 4

mental health 2 1 3 2

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Understanding Population Health in Aurora Scope of Work

Appendix E: Scope of Work

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Community Information Aurora is primarily an urban city. The U.S. Census Bureau estimates the 2013 population to be approximately 345,800 making it the third largest city in Colorado and the fifty-fifth largest in the Country, roughly the size of New Orleans and Tampa (2014, US Census Bureau, State and County Quick Facts, http://quickfacts.census.gov/qfd/states/08/0804000.htm.) According to 2010 Census data, the age distribution of persons in Aurora is as follows: children under the age of 5 represent 8.4%, persons under the age of 18 represent 27.3% of the population, persons 65 and older total 8.9% of the population and female persons represent 50.8% of the population of Aurora. Census data for 2010 also report the racial demographics of the City of Aurora as 61.1% white, 15.7% African American or Black, 1.0% American Indian and Alaska Native, 4.9% Asian, 0.3% Native Hawaiian or Other Pacific Islander, and 28.7% as Hispanic or Latino. The geographic boundaries of Aurora lie within Adams, Arapahoe, and Douglas counties. The city extends to the north as far as 70th Avenue, into Adams County, south to County Line Road, where it slightly crosses into Douglas County, and West to East from Yosemite Street to Schumacher Road, which is predominantly Arapahoe County. Adams and Arapahoe counties contain the majority of Aurora geographically, and depending on the availability of secondary data, county level data may be used to describe the sociodemographics of the City of Aurora. Ongoing discussions with Aurora Health Access will help to determine the appropriateness of data sources. Northwest Aurora: Northwest Aurora (NWA) is an urban neighborhood located within the Aurora city limits. It is defined geographically by 26th Avenue to the North, 6th Avenue to the South, Potomac to the East, and Yosemite to the West. NWA has been the focus of Aurora Health Access priorities due to the high rates of poverty, health inequity, and uninsured/underinsured experienced by the residents. Significant demographic changes over the past 15 years, combined with depressing economic and environmental conditions have contributed to these high rates. Aurora Health Access is committed to partnering with this community and addressing the health equity issues facing NWA. Aurora Health Access: Aurora Health Access (AHA) is community coalition comprised of community members, health care providers, and multiple agencies committed to improving health inequities in Aurora, CO. AHA has identified that the current health care system in Aurora is not meeting the needs of all its residents. AHA is dedicated to solving this urgent problem while continuing to strengthen community partnerships. AHA has partnered with the Colorado School of Public Health Community Health Assessment class in order to make data-driven decisions for planning purposes. The students taking the Community Health Assessment course have carried out six assessments for AHA focusing on NWA. Projects include defining NWA, identifying key health related priorities specific to NWA, identifying health resources in NWA, identifying themes and strengths that aid in the health of NWA, identifying barriers and facilitators to access specialty care and identifying the impact of the Patient Protection Affordable Care Act in NWA. AHA is considering expanding its efforts and widening its scope to encompass the entire City of Aurora and not limiting its focus specifically to NWA.

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Team Information UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS COLORADO SCHOOL OF PUBLIC HEALTH Erin Bomberger, RN, BSN, MPH Candidate Email: Erin.bomberger@ucdenver.edu ! 402-601-7950

Erin Bomberger is a working on a Masters in Public Health, with a concentration in Community and Behavioral Health, at Colorado School of Public Health. She is interested in working with the urban underserved population in and around Denver and Aurora. Erin has a Bachelor of Science in Nursing, has eight years of experience, and is currently a Registered Nurse with University of Colorado Hospital. She plans to expand her assessment skills to population based, and will work with programs in public health addressing health equity and access as well as chronic disease prevention. In her free time she enjoys traveling, cycling, and hiking with her dog Daisy. Chris Tyszka, MPH Candidate Email: christine.tyszka@ucdenver.edu ! 303-903-4335

Chris is working on a Masters in Public Health with a concentration in Community and Behavioral Health. She expects to complete her degree in the summer of 2015. She earned a Bachelor of Arts in Biology (pre med) and a Bachelor of Arts in Psychology. She is interested in community behavior and health education, especially as it relates to nutrition as a means of disease prevention (both acute and chronic). She is very impressed with AHA’s commitment to transform Aurora’s health care system. She has been a resident of Southeast Aurora for 16 years and is excited to contribute to your efforts to improve the health of residents of Aurora. In her spare time, she enjoys oil painting, writing fiction and cookbooks, home improvement projects and gardening.

Misha (Michaela) Brtnikova, PhD, MPH Candidate Email: michaela.brtnikova@ucdenver.edu ! 970-393-0611

Misha is working on a Masters in Public Health with concentration in Community and Behavioral Health, and expects to complete in winter 2014. Misha completed her PhD

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in Kinanthropology in 2009 and currently works as a project manager for the Children’s Outcomes Research Program at the UCD. She will bring her experience with project management including planning, timelines, data collection, analyses and evaluation. In her free time Misha plays sand volleyball or explores the mountains either by foot, mountain bike, motorcycle, skis or snowboard. Misha’s non-professional goal is to summit all 58 fourteeners in CO. Michael Wallingford, MPA, CPH Email: michael.wallingford@ucdenver.edu ! 303-505-0134

Michael is completing his Masters in Public Health in Community and Behavioral Health with a concentration in Epidemiology. Prior, Michael worked for local public health agencies in both Colorado and Washington State, where he planned and implemented new or revised public and environmental health programs. Michael has earned a Bachelor of Science in Environmental Health, a Masters in Public Administration and a Certificate in Public Health. Michael will use his experience in program implementation and scholastic knowledge to work for a community health center implementing programs in public health, especially addressing childhood obesity. Michael enjoys running, cycling, backpacking and most anything outdoors.

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Mary Newell Email: maryvn@yahoo.com ! 804-432-0055

Mary is expecting to complete the Colorado School of Public Health Masters in Public Health program with a concentration in Community and Behavioral Health in December 2014. She has an AAS in Early Childhood Development and a Bachelor of Science in Anthropology. Mary spent much of her early career working in the preschool environment with children aged 6 weeks to 5 years, in many varying capacities. Here she developed her interest in child health and safety policy, regulation, and best practices. Recently, Mary has been working with a local health department to evaluate the effectiveness of a breastfeeding friendly childcare center program. This entailed developing, distributing and collecting, and analyzing two evaluation instruments. Her primary career interests are in Child Health Promotion and Maternal Child Health. Mary enjoys a good cup of coffee, rafting, hiking, reading non-fiction, and the theater. Talia L. Brown, MS - primary UCD instructor Email: talia.brown@ucdenver.edu ! 818-451-3387

Talia Brown is a PhD student in Epidemiology at the Colorado School of Public Health. She is interested in applied epidemiology, especially using surveillance data to answer novel and immediately relevant research questions. She has four years of experience in epidemiology research and program evaluation, and currently works for the Community Epidemiology and Program Evaluation Group at the University of Colorado Cancer Center. She also worked on community needs assessments for the Center for Public Health Practice. In her spare time, she enjoys rock climbing, watching Gordon Ramsey reality shows, and playing with her cat.

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Holly Wolf, PhD, MSPH - secondary UCD instructor Email: holly.wolf@ucdenver.edu ! 303-724-1273 Holly Wolf is an assistant professor in Community and Behavioral Health and Epidemiology in the Colorado School of Public Health and teaches community health assessment, program evaluation and project management. She is interested in public health and health reform, especially as it relates to chronic disease prevention and control and community mobilization. She directs the Colorado Colorectal Screening Program for the medical underserved and is principal investigator, project epidemiologist and/or project manager for several research and public health service programs focused on cancer prevention and control including several assessments around cancer screening and delivery of care. She is an active member of state and national coalitions, including the Colorado Cancer Coalition, serving as past Chair and executive committee member, as well as the National Colorectal Cancer Roundtable steering committee and Co-Chair of the Policy Task force. She believes it is a very exciting time to increase the role of public health in improving the health of Americans and looks forward to working with you and your community.

AURORA HEALTH ACCESS Rich McLean - AHA primary contact Email: rich502aha@q.com ! 909-884-6751 Rich is a parishioner at St. Therese Catholic Church in Aurora, and longtime Aurora resident. Rich helped bring community residents and partners together to form Aurora Health Access in 2009. Rich serves on the boards of Aurora Health Access, Together Colorado, and the Aurora Community Connection Family Resource Center. He has received several awards for his work in social justice and health care. He resides in Aurora with his lovely wife of over 40 years, Mina, an education assistant for Aurora Public Schools. Denise Denton - AHA secondary contact Email: ddenton@aurorahealthaccess.org ! 303-941-0181 Denise joined Aurora Health Access as the Executive Director in March 2014. Denise’s areas of focus have been board and staff leadership, training, and development, team building and collaboration, project planning, grant writing coaching, meeting facilitation, community capacity building, and workforce recruitment and retention. Denise has a Master’s Degree in Human Resource Management from the University of Utah.

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Project Description The goal of this project is to identify the key health issues and suggest priorities related to the City of Aurora as a whole. The findings will be used to guide the strategic directions of Aurora Health Access related to their current focus on NWA rather than the entirety of the City of Aurora. The first component of this project will be to conduct a modified community health assessment for the City of Aurora as defined by its city limits. The group will define the community, sociodemographics, and list the leading causes of morbidity and mortality. In order to define the population and sociodemographic data, the most locally relevant and specific secondary data available will be analyzed. Based on the leading mortality and morbidity rates, the group will select health indicators pertinent to the target population. A modified health assessment on the target population will be carried out. The results of the assessment will then be used to compare the City of Aurora to the existing community health assessment of the NWA. In this comparison, any underserved pockets located within Aurora, but not included in NWA, will be identified and discussed using the health equity framework. The second component of this project will be hosting a group meeting with the AHA steering committee. During this meeting, the results of the modified health assessments will be shared with the members of the AHA steering committee and other invited community members in a presentation format detailing a summary of the health assessment and comparison findings. A facilitated group discussion among the participants will identify the community’s resources, strengths, and assets. Finally, a feasibility assessment will be facilitated for the AHA steering committee to address the key health concerns in Aurora using magnitude, severity, and feasibility as criteria. The third component of this project is an executive summary and final report. This report will detail the results of the community health assessment, the feasibility assessment, and the prioritization process. Finally, the team will make recommendations based on the information collected throughout the assessment and prioritization processes.

Project Deliverables Deliverable 1: Presentation summarizing a modified community health assessment of the City of Aurora and results of a comparison to NWA assessments delivered to the AHA steering committee. (November 12, 2014) Deliverable 2: Executive summary and final report discussing the findings and recommendations of the modified health assessment and group methods. (December 12, 2014)

Team organization Misha Brtnikova will be the liaison representing this team in communications with Rich McLean, the point person for AHA. The primary mode of communication with Rich will be email, however he is available for cell phone calls when necessary. Misha will report the group progress, updates, and findings to Rich regularly and as needed to remain on track with the scope of work. The team members will meet at least once per week and will also be in contact regularly

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via email and cell phone. The AHA secondary contact, Denise Denton, will be included in all email communication with Rich. The team members’ roles will continue to revise during the project, however, several members are bringing expertise from different fields: Misha will contribute with her project management skills and will help analyze secondary data. Together with Michael, Misha will develop a guide to facilitate a discussion/brainstorming session identifying the resources, strengths and assets of Aurora during the AHA meeting. Michael will contribute with his qualitative data collection/analyses expertise as well as his prior experience with Colorado Department of Health and Environment (CDPHE) data. Michael will also take charge in collecting mortality and morbidity data for the target population. Chris will present the health assessment data and comparison at the AHA meeting. Chris will also be in charge of defining the target population and selecting sociodemographic information on the population of interest. Erin will be in charge of contacting liaisons at the CDPHE, Tri-County Health Department and Colorado Health Institute (CHI) to help define the sociodemographic indicators of the target population. Erin will also take the lead in identifying health indicators to compare between the NW Aurora (NWA) and the entire city of Aurora. Mary will take a lead in developing a prioritization guide and facilitating the prioritization process at the AHA meeting. Mary will also assist Erin with health indicators identification and comparison as well as supportive literature search and other data selection and search. Talia Brown will serve as an experienced support and mentor throughout the project. Dr. Holly Wolf will be the secondary support leader. All of the group members will participate in drafting, editing, and revising the final report.

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Project Timeline:

Project Months October 2014 November 2014 Dec 2014 Project Days 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 3 6 9 12 Deliverable 1: Compare health assessment of NWA with all Aurora (within city limits) Define population’s sociodemographic data (E) Select health indicators to collect and compare (A) Identify leading mortality and morbidity rates (M,C) Carry out health assessment (A) Compare assessment results with NW Aurora (E,C) Develop a group discussion guide (m,M) Develop a prioritization guide (MN) Prepare a presentation for AHA (A) Present at the AHA meeting (A) ! Deliverable 2: Deliver a final report incorporating AHA meeting feedback Summarize feedback from the AHA meeting (A) Formulate suggested solutions (A) Write final report (A) Submit final report to CSPH (m) ! Deliver final report to AHA (m) !

! = deliverable; A = All team members; E = Erin Bomberger; C = Chris Tyszka; M = Michael Wallingford; m = Misha Brtnikova; MN = Mary Newell

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Appendix F: Presentation to AHA and the community members

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58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

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Appendix G: Selected Health Indicators for Aurora Health Assessment