Executive Summary

The Community Assessment is a collaborative effort between the Chatham Health Alliance, the Chatham County Public Health Department (CCPHD), and Chatham Hospital, in addition to community members throughout the county, with the goals of:

• • understanding the needs of the community
  • identifying factors that affect health and well-being in Chatham County
  • determining the availability of resources within the community to support optimal health for all

The results of this process are used to:

• • Meet accreditation requirements for the CCPHD and Chatham Hospital
  • Identify priority areas for Chatham Health Alliance
  • Understand changes in community health over time
  • Identify and understand any inequities between different populations in Chatham
  • Improve services and supports to address community needs
  • Pursue funding to support these services by a number of agencies and organizations

A primary source of data used in this Community Assessment is the Chatham County Community Survey, which gathers responses from a representative cohort of residents who reflect the adult population of the county. This survey was developed by the Chatham County Public Health Department and North Carolina Institute for Public Health, along with community members who participated in a Community Action Team organized by the Chatham Health Alliance. Data from this survey is complemented by numerous other sources, including contributions from community partners, qualitative data, and secondary data sources such as the U.S. Census.

Key Findings

Key themes and findings from the 2021 Community Assessment include:

• Historic and continued systemic racism persists in driving health inequities across nearly all facets of health and well-being in Chatham County.
• The COVID-19 pandemic affected nearly every area of health and well-being of Chatham County, mostly in a negative way.
• Priorities identified in the previous Community Assessment remain concerns, including access to health care, healthy eating and active living, and economic resilience. New topics also emerged as priorities, including mental health and substance use, transportation, and employment.
• Growth and development in Chatham County present both opportunities and challenges for the future.

Health Impact Priorities

Findings from the 2021 Community Assessment continue to highlight the importance of the Health Impact Priorities originally selected in 2018: Access to Comprehensive Health Services, Healthy Eating, Active Living (formerly Obesity), and Economic Resilience (formerly Poverty).

Access to Comprehensive Health Services

• More than 3 in 10 Chatham County households (30.9%) reported facing some kind of barrier to healthcare in 2021.[1]
• As of 2020, 9.9% of all Chatham County residents and 11.2% of Chatham County adults do not have health insurance.[2]
• Some groups in Chatham County are much more likely to not have health coverage. That includes non-citizens (58.2%), foreign-born residents (39.0%), Hispanic/Latinx residents (32.8%), those living in poverty (25.6%), and those who worked less than full time in the past year (25.3%).2
• Approximately 1 in 11 Chatham County adults (8.7%) said they did not have a health provider they usually visited when they were sick or needed advice about their health.1 That’s a decrease from 2018 (9.8%).[3]
• Of adults who did not have a regular provider, almost half said this was because they did not have health insurance (47.2%).1

Economic Resilience

• In 2020, Chatham County’s poverty rate was 10.7%, meaning that around 7,700 people in Chatham are living at or below the national poverty line. The national poverty rate was 12.8% and the state rate was 14.0%.[4]
• Black/African American and Hispanic/Latinx residents were nearly four times as likely to experience poverty in 2020 compared to the overall county average.4
• Nearly 1 in 3 Chatham adults report money as a primary cause of stress, while nearly 3 in 10 either agreed or strongly agreed that Chatham County has good economic opportunities for them.1

Healthy Eating, Active Living (formerly “Obesity”)

• More than 1 in 3 Chatham County adults (34.1%) say that they have ever been told they are overweight or have obesity1, an increase from 28.8% in 2018.3
• Nearly 1 in 3 Chatham County high school students (32.1%) were either overweight or had obesity in 2019.[5]
• More than 1 in 8 Chatham County households (12.8%) reported that they worried that they would run out of food before they had money to buy more within the past year.1
• Many Chatham County adults cite convenience (41.3%), cost (17.3%), or not having enough time to shop for or prepare healthy foods (18.9%) as a reason they do not eat healthy snacks and meals.1
• More than half of Chatham County adults (53.7%)1 and around 1 in 4 Chatham high schoolers (23.1%)7 report spending at least an hour doing physical activity in a day.
• Many Chatham County adults cite not having time (36.7%) or being too tired (30.5%) as barriers to physical activity.1

2021 Priority Topics

The Chatham Health Alliance highlighted three topic areas to be the focus of strategic planning within their subcommittees for the next planning and implementation cycle: mental health and substance use, transportation, and employment.

• Mental Health and Substance Use:
  • Several key mental health indicators worsened in results from the 2018 CCCS to the 2021 CCCS, including the percentage of residents reporting “high” day-to-day stress levels (9.1% to 10.7%), “fair” or “poor” self-reported mental health (7.4% to 11.3%), and ever having anxiety or depression (20.1% to 33.3%).1
  • 7% of Chatham County adults reported increased use of drugs or alcohol as a result of the COVID-19 pandemic.1
  • Unintentional overdose death rates have increased substantially in Chatham County in recent years.[6]
• Transportation:
  • 1 in 6 adults in Chatham County reported that there were no sidewalks where they needed to walk as a barrier to transportation, including 1 in 4 Hispanic/Latinx adults.1
  • 95% of adults in Chatham County usually use a car or truck to get around, but in some areas of the county, up to 5 to 7% of households do not have a car.1^,[7]
• Employment:
  • 55.6% of employed Chatham County residents work outside of the county, compared to 28.5% of North Carolina workers overall who work outside of their home counties.[8]
  • The median household income for White, non-Hispanic/Latinx residents is 1.6 to 2.7 times higher than other demographic groups in the county.[9]
  • Loss of employment or switching jobs was a factor for many who reported not having health insurance at any point in the past year.1

Next Steps

Following the publication of this report, the data and findings will be shared with community members and organizations throughout the county. The Chatham Health Alliance will lead the development of Community Health Improvement Plans (CHIPs) which outline strategies for addressing the priority topics that emerged from this assessment. These plans will be completed in Fall 2022. CCPHD, Chatham Hospital, and other organizations will also use these findings to inform their strategic plans.

Health Impact Priorities

Overview

The quantitative and qualitative data that is collected and analyzed as part of the Community Assessment is used to identify the top health priorities affecting Chatham County. The Chatham Health Alliance organizes sub-committees around these topics and will focus its work and resources on these priorities for the next strategic planning period. Prioritization happens at the culmination of each Community Assessment, every three years. Members of the Alliance and Chatham Community Members are invited to participate in the prioritization process. This prioritization process began with a Task Force of Alliance members that came together to review initial data, discuss avenues for community input in the process, and plan the prioritization meeting.

The Task Force first discussed how to change or update the current health priorities: Access to Comprehensive Health Services, Healthy Eating and Active Living, and Economic Resilience. Due to the short 3-year timeframe of the Community Assessment process and the fact that the COVID-19 pandemic rerouted a lot of the community’s and Alliance’s focus and efforts, it was decided that keeping the current three health priorities and prioritizing strategic areas of focus would be the best course of action for this round of the Assessment and prioritization process. The specific language of their proposal is below:

"The current Alliance subcommittees/health priorities will stay as they are. Once the data is analyzed and reviewed, if a new subcommittee/health priority is needed, one can be created. This decision is only for this prioritization year, and not binding for future Alliance prioritization."

In addition to the health priorities identified through the prioritization process, the Chatham Health Alliance has a standing Equity Subcommittee. This group serves to grow and promote equity in the Alliance, in Alliance programs, and publications through review, training, and member engagement. The Equity Subcommittee serves to engage with other subcommittees to ensure equity is at the forefront of planning and implementation of Alliance work, and to provide expertise and support to other Alliance members and committees.

The prioritization meetings took place on Tuesday, May 3rd and were scheduled for the morning and evening to increase accessibility of these meetings. Also, to help increase accessibility of the meetings, participants could choose to join in-person or virtually, could bring children, and Spanish translation and interpretation was provided.

During the meeting, an overview was given about the Chatham Health Alliance, the Community Assessment, and the prioritization process; data collected in the CA was highlighted, as well as data presented by Alliance member agencies and partners. The full presentation can be found as an appendix to this report. Meeting participants then broke into small groups with representation from different agencies with different topic area expertise to identify their top three choices. The top three choices overall based on group votes were chosen as the priorities for the strategic planning process. Those strategic priorities are:

1. Mental Health & Substance Use (9 group votes): Several key mental health indicators worsened in results from the 2018 CCCS to the 2021 CCCS, including the percentage of residents reporting “high” day-to-day stress levels (9.1% to 10.7%), “fair” or “poor” self-reported mental health (7.4% to 13%), and ever having anxiety or depression (20.1% to 33.3%). YRBS results from 2019 also indicated that youth in Chatham County are experiencing high levels of depression and other mental health stresses. Women and residents of color were disproportionately affected. Substance use and access to services were also concerns, particularly the sharp increase in unintentional overdose death rates in recent years. For further information, see the Mental Health and Substance Use sections.

2. Transportation (5 group votes): Issues with transportation can limit access to many services, activities, and opportunities, such as work, physical activity, healthy food stores, and health care. In many parts of the county, access to a vehicle is crucial; additionally, Chatham County has just one public transportation service, which many residents reported not knowing about or felt was not convenient for their needs. Sidewalks were a common topic of concern in the 2021 CCCS, with 16% of adults saying there were no sidewalks where they needed to walk, including 26%  of Hispanic/Latinx adults. For more information, see the Transportation section.

3. Employment (5 group votes): Employment is a cross-cutting issue that is intertwined with many other health priorities. While Chatham County has a relatively low unemployment rate (6% as of March 2022), more than half of Chatham County workers work outside of the county (55.6%), according to the U.S. Census. Average weekly wage in the county is $839, compared to the state average of $1,111, as of Q3 2021. There are also stark disparities in median household income within the county, with White, non-Hispanic/Latinx residents making 1.6 to 2.7 more per year than other demographic groups, according to the U.S. Census. Loss of employment or switching jobs was also a factor for many who reported not having health insurance in the 2021 CCCS. For more information, see the Employment and Income section.

Access to Comprehensive Health Services

Access to comprehensive health services, including physical health services, mental health services, and other support services and resources, are hugely impactful on the health of an individual and the community as a whole. Lack of access due to cost, insurance status, language, or other barriers ranging from complex referral systems to lack of available services altogether can prevent many from attaining their best health; this access is also unequal among all members of the community, which can create or worsen existing health disparities. More than 3 in 10 Chatham County households (30.9%) faced some barrier to healthcare in 2021, especially primary care and dental care.[1] This section will provide updates on measures related to health services in Chatham County and work done by the Chatham Health Alliance since the last Community Assessment in this area.

Health Insurance

Nearly 1 in 10 (9.9%) in Chatham County do not have health insurance coverage, slightly more than the percentage of uninsured in the United States (8.7%); around 1 in 9 Chatham County adults (11.2%) do not currently have health insurance. Some groups have far less access to this crucial benefit—among the populations with the highest uninsured rate:

• Noncitizens: 58.2%
• Foreignborn residents: 39.0%
• Hispanic/Latinx residents: 32.8%
• Those below 100% of the poverty line: 25.6%
• Those who worked less than full time in the past year: 25.3%[2]

Of Chatham County adults who report not having a regular health care provider, almost half say they do not have one because they don’t have health insurance (47.2%) or their insurance is not taken by their preferred provider (15.2%). Nearly 1 in 5 Chatham County adults (18.1%) said the county should focus on more affordable healthcare to improve health and quality of life in the community, with around 1 in 6 (15.4%) saying more affordable health coverage/insurance should be a focus.[3]

Healthcare Providers

Less than 1 in 11 Chatham County adults (8.7%) said they did not have a health provider they usually visited when they were sick or needed advice about their health. This is a decrease from 2018 (9.8%), which is a positive change. Of adults who did not have a provider, almost half said they did not have one because they did not have health insurance (47.2%), while more than 1 in 3 said they went to urgent care or the emergency room if they were sick (35.9%). It takes the average Chatham County adult 19.4 minutes to travel to a health care provider if they have one.1

Four in five Chatham County adults (80.0%) said it has been less than a year since they visited a doctor for a routine checkup, with another 12.0% saying it had been 1-2 years. Many residents reported not visiting a doctor’s office recently due to concerns over the spread of COVID-19. Nearly 7 in 10 Chatham adults (69.2%) said it had been less than a year since their last trip to a dentist for a routine checkup or cleaning.1

More than 1 in 5 Chatham County households (20.5%) reported seeking mental health services at some point while living in the county. Of those, more than 7 in 10 found them available (74.4%), but only 36% described them as easy to find and 26% called them affordable. Additionally, some Chatham households have sought help for alcohol (2.9%), drug (1.3%), or tobacco use (1.9%) since they’ve lived in the county. Around half of those seeking help for alcohol use called the services available and affordable, but a much smaller number said they were easy to find and high quality.1

Finally, around 1 in 5 Chatham County adults (19.8%) said the county should focus on having more healthcare options to improve health and quality of life in Chatham. Additionally, 17.0% said mental health care should be a focus, and 11.0% cited substance use support/treatment as a desired focus.1

Economic Resilience

Poverty is an issue that underlies many health outcomes. Many of the sections in this report cover the relationship between poverty and health. The American Academy of Family Physicians says: “Poverty occurs when an individual or family lacks the resources to provide life necessities, such as food, clean water, shelter, and clothing. It also includes a lack of access to such resources as health care, education, and transportation.”[4]

Since the 2018 Community Assessment process, the Chatham Health Alliance re-titled their Poverty priority and corresponding subcommittee to Economic Resilience. According to the American Psychological Association, “resilience [i]s the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress—such as family and relationship problems, serious health problems, or workplace and financial stressors.”[5] When shifting its focus from Poverty to Economic Resilience, the Chatham Health Alliance considered the factors facing Chatham County and worked on practical solutions.

In 2020, 10.7% of Chatham County’s population was living below the poverty line. This was a decrease from 13.0% in 2012. It is also lower than the North Carolina rate (14.0%) and national rate (12.8%). However, the county rate belies significant disparities in poverty rate based on race/ethnicity, education, and location, among other factors.[6]

The sharp disparities in income in Chatham County stem from historic and continued systemic racism, disenfranchisement, and disinvestment in some communities. The county’s median household income, adjusted for inflation, was $69,799 in 2020, slightly higher than the U.S.’s median ($64,994) and much higher than the North Carolina median income ($56,642). The median household income for White, non-Hispanic individuals ($81,165) was nearly twice that for Black/African American individuals ($41,498) and more than 60% higher than that of Hispanic/Latinx individuals ($50,461).[7]

The 2021 Chatham County Community Survey gave county residents an opportunity to share how often money, or lack thereof, was a barrier to accessing certain services or goods. Of Chatham adults:

• Nearly 1 in 3 (30.4%) reported “money” as a primary cause of stress.
• More than 1 in 6 (17.45) reported cost as a barrier to eating healthy snacks and meals.
• Around 1 in 15 (6.6%) reported cost as a barrier to physical activity.
• Around 1 in 15 (6.5%) reported that, due to COVID19, they have not had enough money to make ends meet.

However, many county residents are optimistic about their futures. Nearly 3 in 10 (29.2%) said they either agreed or strongly agreed that Chatham County has good economic opportunities for them, though more than 24.3% disagreed or strongly disagreed.3

Additionally, in Story Circles held as part of the Community Assessment process, some residents expressed feelings of hope and a brighter future, and many felt like they could give more in volunteering and helping others. Persistence and resilience were identified as positive things about Chatham County.

Healthy Eating, Active Living

The 2018 Chatham County Community Assessment listed “Obesity” as the No. 2 Health Impact Priority for Chatham County, continuing the topic’s long placement as a priority as far back as 2006.18 Since then, the Chatham Health Alliance has re-framed this priority as Healthy Eating, Active Living (HEAL), in recognition of the many complex factors that affect an individual’s diet, physical activity, and lifestyle. All of these are in turn far more impacted by structural elements such as environmental, economic, and societal factors, including racism, sexism, and others, than individual-level choice. [8]

More than 1 in 3 Chatham County adults (34.1%) say that a medical professional has told them that they are overweight or have obesity3, in line with national figures.[9] However, that percentage increased from 28.8% in 2018.[10]

Healthy Eating and Active Living for Adults

In 2021, 4 in 10 Chatham County adults (40%) reported eating three or more servings of fruits and vegetables every day.3 This was a decrease from 2018, when 46.1% of adults reported eating three or more servings each day.18 Only 17.2% of Chatham adults said they “always eat healthy snacks and meals,” while the remainder cited a number of factors preventing them from doing so, like convenience (41.3%), taste (23.4%), not having enough time to shop for or prepare those foods (18.9%), and cost (17.3%).3

A 2013 study by the Harvard School of Public Health found that the healthiest diets cost about $1.50 more per day than the least healthy diets. The report’s authors suggested that “food policies have focused on the production of ‘inexpensive, high volume’ commodities, which has led to ‘a complex network of farming, storage, transportation, processing, manufacturing, and marketing capabilities that favor sales of highly processed food products for maximal industry profit.’”[11] This can place an especially heavy burden on low-income families who have to consider many things when spending their limited funds.

Further, more than 1 in 8 Chatham County households (12.8%) reported that they worried that they would run out of food before they had money to buy more within the past year.3

Even if the healthy food is affordable, it needs to be accessible and easy to find. The CDC reports that 40 percent of all U.S. households do not live within one mile of healthier food retailers.17 More than 2 in 5 Chatham County adults (22.2%) say the county should focus on affordable healthy food in Chatham, while more than a quarter (26.4%) said there needed to be more places to buy groceries in the county.3 Certain areas of the county have access to multiple grocery stores, while others have to drive further to find groceries, which can limit the amount of healthy food in a household.

Most Chatham County adults engage in some physical activity during a typical day. More than half spend at least an hour doing physical activity in a day (53.7%), while a small amount does less than 30 minutes (15.7%). The main reasons why adults did not engage in physical activity at some point in the last month include not having time to do so (36.7%), having no one to exercise with (30.5%), not liking to exercise (30.5%), and having an injury (10.3%). Notably, more than a quarter of Chatham County adults (25.4%) said they exercised less than usual due to the COVID-19 pandemic which started in 2020.3

There are also many barriers to physical activity. Safe, accessible places to exercise are not available to all;  more than half of Americans don’t live within half a mile of a park.17 More than 1 in 5 Chatham County adults (21.2%) think the county should focus on improving sidewalks and bike lanes to improve health and quality of life in the Chatham community.3

Healthy Eating and Active Living for Adolescents

Almost 1 in 3 Chatham County high school students described themselves as slightly or very overweight (32.5%) in 2019[12], a slight increase from 2017 (31.6%).[13] Their perceptions are almost spot-on; 16.6% of students were overweight and 15.5% had obesity. Hispanic/Latinx and Black/African American students and males were more likely than their peers to both be overweight and have obesity, due to the same factors referenced above. Chatham’s rates are similar to the national and state averages.19

The USDHHS recommends that children ages 6 to 17 engage in up to 60 minutes of physical activity or more per day.[14] Just 23.1% of Chatham County high school youth reported this level of physical activity, with male students (29.9%) almost twice as likely as female students (16.6%) to do so. Almost 1 in 5 Chatham County high schoolers (19.0%) did not engage in at least 60 minutes of physical activity on any day in the past week.19

The U.S. Department of Agriculture recommends that adolescents aged 14-18 eat 1.5 cups of fruit and 2.5 cups of vegetables per day for females, and 2 cups of fruit and 3 cups of vegetables per day for males.[15] More than 1 in 5 Chatham high schoolers (22.8%) reported eating vegetables at least twice per day, while around 1 in 11 reported not eating vegetables at all within the last week (8.9%). Black/African American and Hispanic/Latinx students were each more than twice as likely (13.5% each) to not eat vegetables at all in the last week than White students (5.8%).19