Completion of the 2019 Community Health Assessment (CHA) for Cleveland County has proven to be a challenge for all participants in the process but has resulted in a timely and comprehensive document highlighting health issues in the county. While the process began in August 2019 work was suspended during November and December of that year when staff members and leadership focused on participation in the process of naming a new health director in response to the retirement of Dorothea Wyant. The second pause in the process occurred in mid-March with the onset of the COVID-19 pandemic when health education staff members began to work primarily from home. Face-to-face meetings were suspended and while technology offered options for communication, limitations in Internet access in the county occasionally complicated ongoing work on the assessment. When health education staff members returned in mid-May, priorities shifted and while work continued on the assessment, staff members also supported agency responses to the growing COVID-19 pandemic in the county. Operating under the vision statement of the Cleveland County Public Health Center to “create a healthy and safe community in which to live” and addressing the agency’s mission statement “to assure, enhance and protect the health of Cleveland County citizens through education and prevention,” participants in the 2019 process completed a comprehensive community survey, led focus groups, reflected on secondary data collected from local, regional, state and federal resources and ultimately prioritized health concerns using the framework of the Healthy North Carolina 2030: A Path Toward Health document published in January 2020.

Leadership for the process was provided by staff from the Cleveland County Public Health Center composed of Anne Short, Director of Community Health Services, Deshay Oliver, Coordinator of Health Services and Dorothea Wyant, Health Director for the Cleveland County Public Health Center. These individuals were ably supported by staff members from the Health Education unit: Tania Dixon, Dana Hamrick, Zakoya Spikes and Grant Wilson. The Core Oversight Committee, whose members represented major community stakeholders and who offered expertise in data analysis and strategic planning was named and led the process. The Core Committee members also received advice from members from the Cleveland County Board of Health as well as members of the Board of Directors for the Alliance for Health in Cleveland County, Inc. Two community organizations – Atrium Health sites in Shelby and Kings Mountain and the Alliance for Health – played major leadership roles in supporting the 2019 process. Community partners represented in the Core Committee, Board of Health and Alliance for Health included: Partnership Number of Partners Public Health Agency 1 Hospital/Health Care System 1 system – 2 sites Healthcare Providers 4 Behavioral Healthcare Providers 1 Dental Health Providers 1 Community Organizations 9 4 Colleges and Universities 2 Public School System 1 Local Government Entities 3 Law Enforcement 2 Faith Communities 2 Public Members 6 The 2019 CHA received financial support from the Alliance for Health in Cleveland County for food for committee meetings and focus group sessions, incentives for focus group participants, use of the SurveyMonkey system, support for print advertisements and hard copies of the survey and publication of limited copies of the final document. The Alliance receives financial support from Atrium Health as well as services provided by staff members from that organization both in Cleveland County and the main offices in Charlotte, North Carolina. The Cleveland County Public Health Center’s contribution was a major assignment of staff time for the process ranging from expertise in media placement, data entry and analysis, graphic work and support for committees and focus groups participating in the process.

Cleveland County’s 2019 CHA process followed the recommendations for a community assessment published by the North Carolina Department of Health and Human Services, Division of Public Health in 2015. Participants in the 2019 process focused on a socio-ecological model for survey development and data collection to result in a comprehensive illustration of community needs. As noted earlier, the 2019 CHA process began in August 2019 with survey development and media outreach in the community. The survey was published in September 3, 2019 and left open for responses through October 15, 2019. Both electronic and paper versions of the survey were used in the county with links to the survey distributed across a variety of websites and published in print format in local media. Responses from print copies were entered into the SurveyMonkey data base by staff members from the Health Education unit. 765 responses were processed for the survey. Six focus groups were conducted with specific target audiences in the county including minorities and veterans’ groups. Data from the focus groups was also compiled by Health Education staff members. Work on the CHA halted in November-December 2019 during the search process for a new health director but resumed in January 2020 when staff members were introduced to the Healthy North Carolina 2030: A Path Toward Health document identify 21 health indicators to be used in measuring North Carolina’s progress toward a healthier population. This framework was adopted for use in determining priorities for Cleveland County as it offered the opportunity to identify and, in partnership with multiple organizations, address social determinants of health as well as specific health issues. Stakeholders were identified and sent ballots defining these indicators as well as current local data for each issue and were asked to identify their top five priorities overall. Sixty-five responses were compiled and weighted to produce the rankings with individuals living at or below 200% of federal poverty level and adverse childhood experiences ranking #1 and #2. The next identified priorities directly addressed health issues: tobacco as #3 and teen birth rate as #4. Both of these identified issues 5 represent areas of work that were selected for Community Health Action Plans after the 2011 and 2015 CHAs were completed and represent ongoing concerns in the community.

Key findings from the 2019 Community Health Assessment include: • Chronic health conditions continue to drive the leading causes of death in the county with variables like age, gender, income levels and race/ethnicity as well as risky behaviors like smoking, fast food choices and lack of physical activity factor into the prevalence of heart disease and stroke, cancer and diabetes among county residents. • Mental health issues are major concerns of county residents with many reporting actual diagnoses of anxiety and depression and more residents indicating concerns with personal stress management and anger management issues. Data also indicates frustration with the lack of affordable mental health services provided locally for county residents. • Substance abuse is still a major health issue in the county with tobacco and vaping using electronic cigarettes as well as marijuana use among students a primary concern and an ongoing concern about opioid use among adult residents. • Data identifies resources to promote healthy food choices and increased levels of physical activity available in the county and survey responses indicate a concern with learning more about nutrition, weight management and physical activity options. However, many county residents do not seem to make a connection with these issues and higher levels of hypertension, high cholesterol and other symptoms of chronic disease. • Teen pregnancies have decreased over a ten-year period in the county but still remain a concern based on the number of teen births and the need for comprehensive reproductive health and safety education. Continuing work on teen pregnancies and births will increase the potential to positively impact the rate of infant mortality and reduce the prevalence of low birthweight and pre-term babies in the county. The overall weighted rankings of the 21 selected indicators were presented to the Cleveland County Public Health Board for approval as priorities to focus on improvements to community health over the next ten years. On March 20, 2020 the rank order of indicators was affirmed by the Cleveland County Public Health Board as priorities for future action. Tobacco and the teen birth rate were approved as priorities for Community Health Improvement Plans, both short- and long-term, as Cleveland County moves forward in addressing community health. Work is underway using the resources of the Substance Abuse Prevention Coalition to drive further discussion about tobacco use and using the expertise of the Teen Pregnancy Prevention Coalition to move forward in addressing the priority of the teen birth rate. Both of these community coalitions will partner with the Cleveland County Public Health Center staff, the Cleveland County Public Health Board, the Alliance for Health in Cleveland County and Atrium Health to develop and implement impact-focused Community Health Improvement Plans for Cleveland County. 6

COMMUNITY HEALTH ASSESSMENT PROCESS The Community Health Assessment (CHA) is conducted every four years by the Cleveland County Health Department in collaboration with the Alliance for Health in Cleveland County, Inc. and representatives from other community agencies. The purpose of a CHA is to identify factors that affect the health and well-being of a community. These factors are determined through a comprehensive analysis of primary data collected in a community survey and through focus groups as well as secondary data from local, regional, state and national sources. The information is compiled in a report that may be used for planning by local and state organizations to protect and promote the health of Cleveland County residents. Cleveland County has traditionally planned for health and human service needs based upon data collected within the county and then compared to regional and state information. A good community assessment allows leaders to answer four basic questions about their community: (1) “What are the strengths of our community?” (2) “What concerns do county residents have about a variety of issues?” (3) What are the emerging issues in our community?” and (4) “What other resources are needed to address these concerns?” The first comprehensive Community Needs Assessment was conducted by United Way of Cleveland County in 1985 using a survey mailed to county residents. Additional “needs-driven” assessments were conducted in 1989, 1993, 1999 and 2002 specifically focusing on identifying unmet needs in the county. In the surveys conducted in 2002, 2007, 2011 and 2015 with collaborative community partners, a greater emphasis was made on identifying the county’s strengths and resources as well as continuing to identify emerging needs and addressing gaps and barriers to services. Oversight for the 2019 CHA was provided by a Core Committee composed of individuals from across Cleveland County with expertise in data analysis and strategic planning. These individuals represented major community stakeholders. Membership included: Kim Clemmons, Cleveland County Head Start Program Kizzy Clark Corry, Washington Outreach Ministry, Inc. Ryan Etheridge, Cleveland County Schools Chris Gash, Partnership for Community Prosperity Katie Harris, Greater Cleveland County Baptist Association Dotty Leatherwood, Chair, Alliance for Health in Cleveland County, Inc. Ron McCollum, Foothills Farmers’ Market Deshay Oliver, Coordinator of Health Services, Cleveland County Public Health Center Jeff Ross, Community Engagement, Atrium HealthCare Western Region Masonya Ruff, Turning Point Academy, Cleveland County Schools Katie Swanson, Director, Cleveland County Department of Social Services Alan Toney, Planning & Development, City of Shelby Paula Vess, Cleveland Community College Holly Wall, Cleveland County Government 7 Rev. Wade Wallace, Green Bethel Baptist Church Dorothea Wyant, Health Director, Cleveland County Public Health Center Additional guidance was provided by the Board of Health for Cleveland County: Elizabeth Kathleen Borders, M.D. Cameron Street Hamrick, O.D. Sara Karner, D.D.S. Kale Meade, P.E. Robert Miller, Chair, Minority Health Council Deanna Moseley Lawrence, D.V.M. James S. Pitts, P.Rh. Dianne Sanders, RN. Tom Spurling, Chair Randall H. Sweeting, Alliance for Health Board of Directors Ronnie Whetstine, County Commissioner The 2019 Board of Directors for the Alliance for Health, the county’s Healthy Carolinians Partnership, also participated in discussions about the survey process and the selection of the final health priorities for the county. Membership included: Richard Baker, Executive Director, HealthCare Foundation of Cleveland County Susan Borders, Vice-Chair, Minority Health Council Jessica Bridges, Health Promotion Coordinator, Piedmont Pharmaceutical Care Network, LLC Scott Champion, City of Shelby Police Department Margie Christopher, Retired, Children’s’ Homes of Cleveland County Tiffany Crank, Cancer Program Development Specialist, Levine Cancer Center Judy Hawkins, Retired, Safe Kids Coalition of Cleveland County Dr. Brian Hunnell, Cleveland County Schools Dotty Leatherwood, Retired, Chair, AFH Board of Directors John McIntyre, Cleveland County Sheriff’s Office Dr. Elizabeth Pack, Gardner-Webb University Cynthia Proctor, Atrium HealthCare-Kings Mountain Jeff Ross, Community Engagement, Atrium HealthCare Western Region Andrew Schrag, Partners Behavioral Health MCO Jane Shooter, Retired, Episcopal Church of the Redeemer Katie Swanson, Director, Cleveland County Department of Social Services Randy Sweeting, Retired, Cleveland County Board of Health Dorothea Wyant, Health Director, Cleveland County Public Health Center Direction for the 2019 CHA process was provided by Anne Short, Director of Community Health Services for the Cleveland County Public Health Center. Staff support was provided by individuals from the Health Education/Health Promotion/CODAP Services unit of the Cleveland County Health Department: Dana Hamrick, Tania Dixon, Grant Wilson and Zakoya Spikes. 8 The Core Committee began work in July 2019 to review previous survey documents and develop a work plan for the 2019 CHA. Committee members were reminded that responses from the community survey were self-reported and reflected the perceptions of the respondents. Those perceptions may be affected by the respondent’s personal circumstances regarding education, employment, health politics or faith issues. Accordingly, survey data was reviewed along with secondary data from local, state or federal sources to present a balanced picture of the issue or topic under discussion. The 2019 Community Assessment survey was built upon a template provided in the Community Health Assessment Guidebook published by the Division of Public Health, North Carolina Department of Health and Human Services and included questions from the 2015 CHA. Additional questions were included to measure emergency preparedness among residents as well as questions drawn from the Behavior Risk Factor Surveillance Survey in order to make specific comparisons to data presented in the annual report of the County Health Rankings published by the University of Wisconsin and the Robert Wood Johnson Foundation. Committee members agreed to use both electronic and paper versions of the survey in order to penetrate multiple segments of the population in Cleveland County. The 2019 CHA Survey was published in an electronic format using Survey Monkey to calculate responses and analyze results. SurveyMonkey had been used in previous assessments and was selected again because of the reasonable cost, ease in formatting and ability to segment survey responses for selected populations. A timely response to obtain the results as well as the development of graphics identifying responses were also factors in choosing this format. The survey was open for responses from September 3 through October 15, 2019. The electronic survey was published on multiple sites in the county: CCPHC web site and Facebook pages, the website for Cleveland County Government, the website for the City of Shelby, the website for Cleveland County Schools and the website for Atrium Health-Cleveland. The link to the survey, as well as flyers, small posters, and church bulletin inserts were distributed to elected officials, community agencies, faith associations, various coalitions including the Minority Health Council, students at Cleveland Community College and Gardner-Webb University and to the consumers of Cleveland County Water System. Hard copies of the survey were also distributed to the public libraries, three YMCA facilities in the county, the office of the county manager, the offices of CLECO Primary Care Clinic in Shelby, the Head Start office, Washington Outreach Ministry food pantry and the lobby of the Cleveland County Public Health Center. Responses from hard copies were entered by Health Education staff members. 765 responses to the survey were received. To further publicize the survey, a series of ads was developed for publication in four local print outlets and a flyer was posted on Channel 19, Cleveland Community College’s public access station. A Talk of the Town presentation on the purpose of community health assessments with Anne Short and Tiffany Crank was also broadcast in September. Incentives were offered to individuals who completed the survey. The Alliance for Health in Cleveland County provided a $300, a $200 and a $100 Wal-Mart gift card for incentives with winners drawn November 2019 so that the cards could be used for holiday shopping. 9 In addition to the information collected from survey responses, six focus groups were conducted in September through November to collect information from targeted segments of the population. Fifty-two individuals participated in the focus groups conducted by health educators and Core Committee Members. Focus groups included participants in the Grandparents Raising Grandchildren Support Group, the Minority Health Council, the Accelerate Cleveland Program offering job skill training for high-risk individuals, the Nurse-Family Partnership, one graduate level psychology class at Gardner-Webb University and a group composed of veterans. Participants in the Leadership Cleveland County program sponsored by the Cleveland Chamber also completed a specific survey on quality of life issues. Data from the focus groups was compiled by Health Education staff members and compared to data from the community survey. Work on the CHA process was suspended temporarily in November and December as staff and community members were involved in the search process to identify a new health director for Cleveland County as Dorothea Wyant announced her retirement effective January 15, 2020. During this time frame, the Cleveland County Public Health Center transitioned from local control under a Board of Health to functioning directly under the county manager with a Public Health Board serving in an advisory capacity. In January 2020, Healthy North Carolina 2030: A Path Toward Health was presented at the North Carolina Public Health Leadership Conference. This document includes a set of health indicators with 10-year targets to guide state efforts to improve the health and well-being of residents of the state. After reviewing these indicators, which closely align to some of the indicators used in the County Health Rankings, CCPHC staff members determined that this array of issues would be useful in identifying health priorities for work over the next three to five years in the county. There are 21 health indicators identified for which data can easily be collected to measure progress. Consequently, a ballot listing each indicator, the definition of each indicator, the desired result or impact for each indicator, the current status of the indicator in North Carolina, the most relevant Cleveland County data for each indicator and the North Carolina 2030 target was developed for distribution among community stakeholders. Each stakeholder was asked to select from all of the indicators their top five priorities, even if the indicator was not directly addressing a health issue. A copy of the ballot is included in the Appendices of this document. Ballots were distributed to a variety of individuals including members of the Public Health Board of Cleveland County, the Alliance for Health Board of Directors, the Board of the HealthCare Foundation of Cleveland County, the 2019 CHA Core Committee, the Minority Health Council, the Department of Social Services Advisory Board, the Management Team for the Cleveland County Public Health Center and the School Health Advisory Council. Sixty-five responses were received at the close of balloting on February 14, 2020. The responses were tallied by the Health Education staff. Each response was weighted with a first priority given 5 points, second priority give 4 points, third priority given 3 points, fourth priority given 2 points and a fifth priority given one point. A chart was published listing the indicators in rank order with weighted results for each indicator. Rankings directly related to potential work for the Cleveland County Public Health Center are highlighted in yellow.

Tobacco and Teen Births