Completion of the 2019 Community Health Assessment for Cleveland County and development of 2020 Community Health Improvement Plans have proven to be a challenge for participants as staff members of the Cleveland County Public Health Center’s health education/health promotion unit and community volunteers worked to identify and focus on health issues in the county.  The CHA process began in August 2019 with an oversight committee producing, distributing and publicizing a community survey to identify health issues in Cleveland County while staff members began the process of collecting secondary data from local, regional, state and federal sources.  However, even though survey results were compiled during September-October 2019, work on the document was suspended for two months as county leadership searched for a new health director in response to the retirement of the sitting director.  In January 2020 staff members were introduced to a set of 21 health indicators, closely aligned to indicators used in the County Health Rankings and easily tied to data to measure progress in meeting health issues.  Healthy North Carolina 2030:  A Path Toward Health was presented at the North Carolina Public Health Leadership Conference presented the indicators with 10-year targets to guide state efforts to improve the health and well-being of residents of the state.  CCPHC staff members recommended adoption of this set of indicators to identify and address health priorities for the county over the next three to five years.  Using ballots defining each indicator along with state and local baseline data measures, participants in the CHA process selected their top five priorities to be considered with each response weighed on a scale of one to five points. 

Indicators for the Healthy North Carolina 2030 initiative include those directly addressing a health issue such as limited access to healthy food or sugar-sweetened beverage consumption. Other indicators addressed indicators to measure progress in addressing the social determinants of health such as poverty, severe housing problems and unemployment.   Social determinants of health are defined by the World Health Organization as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.  These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” The Centers for Disease Control and Prevention published a simpler definition as “conditions in the places where people live, learn, work and play which affect a wide range of health risks and outcomes.”  These indicators affect one’s ability to live a healthy lifestyle and are considered critical to addressing health issues.  For example, in the coming year in North Carolina, providers of healthcare will be required to query patients about four social determinants:  access to food, access to housing, access to transportation and personal safety.  The Cleveland County Public Health Center has completed a pilot project asking patients at their initial encounter ten questions about these issues and offering assistance in resolving problems in these areas. 

When participants in the CHA process moved to select their top five priorities, they considered all 21 indicators, including those having an indirect effect on health.  The top priorities from this process were selected from the social determinants of health indicators: (1) individuals living at or below 200% of federal poverty level with a weighted score of 155 and (2) adverse childhood experiences with a weighted score of 133. Cleveland County Public Health Center staff and community stakeholders will work with a variety of partners to address these issues over the next few years as they are critical to efforts to improve the quality of life for residents in the county.  Two indicators with specific health factors were selected as priorities for the development and implementation of Community Health Improvement Plans.    These indicators are tobacco use with a weighted score of 74 and the teen birth rate with a weighted score of 70. 

Addressing tobacco as the first priority, secondary data indicates that 18% of adults over 18 continue to smoke and information from the 2019 PRIDE Student Drug Use Survey indicated that 11.6% of 9^th grade students and 17.4% of 12^th grade students used tobacco products in the 30 days prior to survey completion.  From the same survey, 5% of 6^th grade students, 30.3% of 9^th grade students and 35.3% of 12 grade students indicated using e-cigarettes or vape products in that 30-day period.   Tobacco is a major contributor to chronic disease, especially heart disease, cancer and asthma.  According to data from the Centers for Disease Control and Prevention, smoking-related illness in the United States costs more than $300 billion each year including nearly $170 billion for direct medical care for adults and more than $156 billion in lost productivity.  North Carolina’s annual healthcare costs related to smoking total $3.8 billion annually.  In addition, North Carolina spends another $300 million on health care costs related to secondhand smoke.  North Carolina data also showed a reduction in average weekly emergency room visits for heart attacks of 21% during the first year of our smoke-free restaurant law.  Reduction in tobacco use improves health and increases life expectancy, lowers the risk of 12 types of cancer, lowers the risk of chronic obstructive pulmonary disease and lowers the risk of cardiovascular diseases. 

Addressing the teen birth rate as a second priority, Cleveland County Public Health Center staff members have been focusing on this issue since 2008 when the pregnancy rate was 84 pregnancies per 1000 girls ages 15-19.  Currently the teen pregnancy rate in the county is 34.5 per 1000 girls ages 15-19 and the birth rate for the same age group is 30.4 per 1000 girls.  The state goal for this indicator is 10 births per 1000 girls ages 15-19 by 2030.  For Cleveland County, the shift from focusing on the pregnancy rate to the birth rate provides opportunities to continue working on reducing teen pregnancies using the resources of the Teen Pregnancy Prevention Initiative grant while expanding efforts to reduce overall births to the teen population.  In addition, this also allows increased attention to related indicators such as increasing the provision of early prenatal care, reducing infant mortality especially where significant racial disparities occur and reducing the percentages of low birth weight and premature births in the county. 

By a unanimous vote of the Cleveland County Public Health Board on March 10, 2020, the rank order of health indicators was affirmed to set priorities for future actions in Cleveland County.  On further discussion, tobacco was identified as the priority for a short-term Community Health Improvement Plan and the teen birth rate was adopted for a long-term Community Health Improvement Plan to be submitted to the Division of Public Health for approval.  On March 10, 2020 Governor Roy Cooper declared a State of Emergency over coronavirus to ensure that the state was prepared to respond to the virus.  CCPHC administrators began planning for telework options and many non-clinical staff members of the Cleveland County Public Health Center began to work from home.  Health education/health promotion staff members used this at-home interval to become familiar with adapting Results-Based Accountability as presented in Mark Friedman’s book Trying Hard Is Not Good Enough as a format for evaluating current programming offered by unit members as well as using the format to develop programming addressing newly identified health priorities.  Using three questions as key to this process – “How much did we do?”  “How well did we do it?” and “Is anyone better off?” – staff members began to identify local measures that would allow them to measure progress in meeting program goals for their existing service array.  As staff members returned to their offices in late May, they used this format to evaluate and modify a student diversion program for substance abuse policy violations to make the program more accessible and practical for students and families participating in this service.  As completion of the CHA document moved forward and with participation by the new health director, health education staff members moved forward in using Results-Based Accountability to evaluate the limited services being provided to the community.  A challenge came as COVID-19 cases in the county rose to higher levels and health education staff members were diverted to providing support in case management, contact tracing and COVID-19 helpline activities.  Publication and distribution of the Cleveland County 2019 Community Health Assessment occurred in August, 2020 with a renewed emphasis on developing Community Health Improvement Plans for the two priority health issues. 

Initial work on the 2020 CHIPs began using the paper format to identify potential results, indicators, programs and performance measures.  Staff members participated in web-based training on the 2030 health indicators as well as use of the Clear Impact Scorecard format.  Initially the process required a thoughtful assessment of the three-question consideration, especially the question ‘Is anyone better off?” However, as staff moved through the process, the logical progression of reviewing the current status of programs, evaluating what had and had not been working, looking forward to identifying alternatives and new partners and establishing the result-indicator-program-performance measure continuum brought new clarity to selecting the strategies with the most potential for success in addressing tobacco and teen births in the county.  Developing the paper format for the CHIPS involved a range of staff members across health education, clinical areas and administration as evidenced by the signatures of the individuals involved.  Developing the Clear Impact Scorecard for Cleveland County became the responsibility of Zakoya Spikes, a health educator who combined computer skills and logical thinking, into the first draft of a scorecard along with data analysis and narrative development provided by Anne Short, Director of Community Health Services.  The process was slow, especially in the selection of indicators, but has been helpful in providing a realistic assessment of agency capacity and community acceptance of the proposed strategies.  In its finished format, the scorecard will provide a clear and concise picture of what has been accomplished in the past and what needs to be accomplished in the future to address both tobacco use and teen births in the county.  The 2020 CHIPS in paper format were presented to the Cleveland County Public Health Board for review on February 9, 2021. 

COVID-19 has significantly impacted the ability of the staff members at the Cleveland County Public Health Center and its partners in developing and implementing the strategies proposed in the 2020 CHIPS.  CCPHC staff members have been heavily involved in testing, case investigation, contact tracing and comprehensive community education campaigns especially during the November-January surge of cases.  Currently this level of involvement has shifted to the delivery of vaccines at designated sites across the county accompanied by an ongoing effort to keep the public informed about vaccine availability and to provide information and guidance to schools, businesses and faith communities as they begin to consider service expansions in the coming months.  Most of the on-going health education programs normally provided to community members through coalition activities and through school-based instructions were suspended from March 2020 through January 2021 as staff members focused their energy on supporting agency COVID-19 activities.  During the case surge health educators tracked 25-30 hours weekly working on COVID-related activities and are only now planning a return to community and school-based services which will be critical to the success of the 2020 CHIPS.  Our community partners are slowly opening to the potential of reviving in-person activities and staff members are eager to move forward in providing support to our partners across the county. 

The most current mortality data for Cleveland County is available in the 2019 CHA on pages 26-28 as this was drawn from the North Carolina County Health Data Book 2020 for Cleveland County.  The leading causes of death using unadjusted death rates per 100,000 population are found for two five-year periods:  2013-2017 and 2014-2018.  In both data sets the leading cause of death in Cleveland County is diseases of the heart followed by cancer (all sites), chronic lower respiratory diseases, cerebrovascular disease and Alzheimer’s disease.  For both males and females in Cleveland County the most prevalent cause of death from cancer was for lung cancer followed by colorectal cancer for men and breast cancer for women. 

According to the County Health Rankings, premature death is defined as the years of potential life lost before age 75 per 100,000 population.  Measuring years of potential life lost allows communities to target resources to high-risk areas and investigate the causes of premature death or YPLL.  In 2020, the years of potential life lost for Cleveland County was 10,500 years compared to North Carolina’s 7,700 years.

                The most current morbidity data is also found in the 2019 CHA on pages 30-38.  This data focuses information on heart disease and stroke, diabetes and pre-diabetes and cancer.  Data on maternal health, teen pregnancy and sexually transmitted diseases are found on pages 38-46.  The abuse and misuse of substances has also affected the health of Cleveland County residents with information relating to both intentional and unintentional drug overdose deaths, opioid prescription rates and syringe exchange programs detailed on pages 56-60 in the 2019 CHA. 

                Cleveland County has felt significant impact from the COVID-19 pandemic as evidenced by the following charts: 

The emerging health issue having the most impact on Cleveland County since publication of the 2019 CHA has been the COVID-19 pandemic as county leadership worked to educate, test, treat and vaccinate residents of the county.  Following the governor’s State of Emergency Declaration on March 10, the Cleveland County Board of Commissioners issued a proclamation declaring a state of emergency in Cleveland County due to the COVID-19 pandemic.  Cleveland County Government, including the Cleveland County Public Health Center, began adapting operations by expanding telework options, adjusting existing leave policies, staggering shifts and adjusting operations as needed to ensure essential services were provided to residents of the county.  CCPHC responded by moving non-essential units to teleworking options and adjusted clinical operations to include telephone contacts with patients to reduce face-to-face visits.  While clinical operations slowed due to the public’s reluctance to visit healthcare facilities, staff members adjusted their work responsibilities to provide testing options, case monitoring and case investigation processes as the county began to be impacted by cases of COVID-19.  CCPHC began a regular posting of information about COVID-19 cases in the county and implemented a community education campaign using print and social media to keep residents informed about case numbers and guidance released by both the North Carolina Department of Health and Human Services as well as the Centers for Disease Control and Prevention.          

                As COVID-19 cases slowly increased across the state and in the county, Governor Roy Cooper issued an initial Stay-At-Home order on March 29, 2020.  By April CCPHC and Cleveland County government issued regular postings on social media to inform residents about cases, precautions to follow and testing options with priority being given to individuals with more severe symptoms, high risk populations, first responders and health care workers.  By June a voluntary program – You Can Count on Us Cleveland County – was developed and implemented to ensure that local businesses and organizations were equipped to meet standards of public health and safety during the reopening process. Restaurants, summer camps and places of worship registered for window clings, informational materials and a limited supply of masks and cleaning materials distributed in a drive-through format.  An additional distribution of free cloth masks occurred in July in a drive through event with five free masks available for each vehicle.  The months of October, November and December saw a rise in COVID-19 cases and CCPHC increased their print and social media posting as well as access to a telephone helpline to answer questions about testing and symptoms for county residents.  CCPHC administration published COVID-19 testing locations and eligibility guidelines for testing sites across the county and developed new partnerships with Kintegra Health and StarMed to schedule and conduct additional drive-through testing events. As vaccine became available, CCPHC staff focused on scheduling clinics both on-site and other locations in the county and developed a specific telephone line for appointment scheduling.  CCPHC also worked with partners from Atrium HealthCare to obtain and administer additional doses of vaccine at pop-up clinics in the county targeting specific population groups. 

                CCPHC received extensive support from other departments within Cleveland County Government to address emerging needs as the pandemic affected Cleveland County.  Staff members from other county departments have assisted at testing and vaccine clinics, manned both the helpline and appointment scheduling line and provided support in distribution of educational materials to county residents.  Cleveland County government launched a Cleveland County COVID-19 Community Relief Fund with an initial $75,000 gift to United Way of Cleveland County in April 2020 to channel community caring and support in the most efficient and effective way.  The fund offered emergency relief to families and individuals in need.  The intent of this fund was to provide for major expenses that, if not paid, could have long-term negative impacts on credit such as housing payments, car payments or necessary medical expenses.  Over $100,000 was raised for this fund and to date all of the funds allocated to community relief have been used.  The HealthCare Foundation of Cleveland County established the “Vaccinations Without Limitations” initiative to remove any social, economic or logistical barriers to providing the COVID-19 vaccine to all eligible Cleveland County residents wishing to receive it.  Funding of $50,000 has been designated to support transportation to and from vaccination sites, assist with costs related to establishing and operating vaccine sites, establishing a centralized volunteer registry to support vaccination sites, ensure that necessary PPE is provided to individuals staffing vaccination sites and continuing expanded vaccination education and communication to the community.  Funding is available through December, 2021. 

                Data from the WIC program in Cleveland County shows an increase in demand for services during the COVID-19 pandemic.  In January 2020 Cleveland County’s WIC program served a total of 1,203 children and by July of the same year the number of children served rose to 1,806.  Data from the November report indicate that 2,049 children were served by WIC.  Total participation in the WIC program, including pregnant women, rose from 2,845 in July 2020 to a high of 3,669 in December 2020.  Cleveland County Public Health Center staff reported more inquiries from patients requesting information on food pantries, hot meal programs and housing assistance as COVID-19 cases increased in the county.  Resource lists were available to staff members to assist patients in securing basic services during this time frame.  As the pandemic continued through the summer and into the fall, especially during the holiday season, more county residents reported anecdotally increased feelings of isolation and stress during this time, a situation heightened by limited mental health services available in the county. 

                Data provided by the Cleveland County Department of Social Services indicates a substantial decrease in clients who came into the agency due to the pandemic.  North Carolina allowed DSS clients to complete applications for economic benefits on-line, via telephone and by mailing in or dropping off paperwork for Medicaid, Food and Nutrition, Low Income energy Assistance program and CRISIS Energy Assistance.  Cleveland County experienced a 10% increase in recipients of Food and Nutrition Services (FNS) and Medicaid.  FNS benefits increased as all eligible households were given the maximum allotment without regard to income beginning in April 2020.  The total dollar amount for FNS benefits increased from $27,211,868 in 2019 to $31,415,352 in 2020 – a 14.4% increase.  Any household with a child attending school who was deemed eligible for the free/reduced lunch program was issued Pandemic FNS support automatically without any additional paperwork.  Cleveland County DSS saw an increase in child support payments collected during 2020 due to interception of stimulus funds.  Child support payments rose from $6.7M in 2019 to $9.4M in 2020, a 29% increase.  DSS also reported a decrease in reports to Child Protective Services and Adult Protective Services likely due to a decrease in face-to-face interactions with educators and/or medical providers.  DSS staff members stated that the complexity of cases has significantly changed.  Staff members also saw an increase in reports once the school system resumed classes in August. 

 Clinical services and selected health education/health promotion activities continued on a limited basis since the last Community Health Assessment was published more due to the public’s reluctance to engage in these services than anything else.  Some units were busier than ever in dealing with the COVID-19 pandemic response such as communicable disease and adult health staff and staff members from the Environmental Health unit.  In other clinical areas such as child health and dental clinic, encounters decreased significantly especially during the last six months of 2020 as cases of COVID-19 increased in the county and state regulations concerning limits on activities increased.  Coalitions suspended in-person meetings and met via technology when participants were able to access programs such as Zoom or TEAMS.  Even in-house management team meetings were conducted via conference call or ZOOM.  Significant efforts were made to continue interaction with our community stakeholders through social media outlets as well as print media and weekly participation in podcasts or through local cable access using the Cleveland Community College TV channel were provided in the county.  Staff members began using more telehealth options with patients when appropriate to stay in touch and to resolve health problems. 

                Among initiatives paused since publication of the CHA are the following:

• Dental Clinic collaboration with elementary schools in Cleveland County to screen students at the school site and transport to the Dental Clinic with parental permission for treatment;
• Expansion of the school telehealth program in collaboration with Atrium Health and Shelby Children’s Clinic; currently the program serves fifteen elementary schools, one intermediate school, the system’s alternative school, Cleveland Early College High School, and North Shelby School for students with mental and physical challenges.  Three middle schools were added this year.  However, due to the options for remote learning and/or hybrid two-day on-site scheduling, the number of students seen through this service has been reduced from previous years;
• Delivery of classroom-based instruction for students in reproductive health and safety classes as well as substance abuse prevention/education classes with the hope of reinstating these programs in the second semester of the 20-21 academic year;
• Implementation of a joint tobacco-cessation program with Atrium HealthCare using physician practices and public health providers to treat nicotine dependence using assessment, counseling, pharmacology options and educational material;
• Delivery of the Safe Sitter program designed to provide life skills, safety skills and child care training to youth in order to build safer communities and taught in collaboration with staff from the Safe Kids Coalition;
• Collaborative work on policy development to promote tobacco-free environments with governmental entities in the county; and
• Community engagement activities led by stakeholders in coalitions such as the Substance Abuse Prevention Coalition, the Minority Health Council, the Teen Pregnancy Prevention Coalition, the Eat Smart Move More Coalition and the Alliance for Health. 

One clinical service, the Diabetes Clinic, was discontinued during 2020 due to staff retirements but plans are underway to rebuild this clinic as staff can be recruited to serve in this area.  The Eye Clinic was discontinued as the ophthalmologist who staffed this clinic retired and the need for this service is under assessment.  As the state of North Carolina moves to open more community options for work and recreation, and as more individuals receive vaccinations to combat COVID-19, Cleveland County Public Health Center staff members and administrators look forward to moving ahead with a new strategic plan using Results-Based Accountability to offer services that will positively improve the lives of residents of Cleveland County.