In 2021, due to ongoing COVID-19 efforts, it had been challenging to work on the community health improvement plans (CHIP).  The Richmond County Health Department was able to:

• Open clinics to the public, with COVID-19 restrictions 

• Run programs virtually or with COVID-19 social distancing restrictions 

• Develop detailed results, indicators, programs, and performance measures in Clear Impact Scorecard

• Link Clear Impact Scorecard to the HNC 2030 Scorecard to create greater awareness of population accountability

• Establish a health equity workgroup to assess and improve internal equity practices

COVID-19 Efforts

In 2021, Richmond County Health Department continued the battle against COVID-19 with masking, social distancing, and limited clinic capacity, with a primary focus on vaccination. Mass vaccinations were carried out with the collaboration of the FirstHealth of the Carolinas hospital system on the First Health Moore Richmond Memorial Hospital campus. As mandated by the NC DHHS, vaccinations were carried out in a specific order; the first groups were first responders, healthcare professionals working with covid patients, and those who worked with vulnerable populations such as nursing home staff. County populations were then divided by birth year and vaccinated in chronological order, starting with the earliest years. Richmond County Vaccination Rate goal is 66%; by December 2021, the rate was 46%, 53% for those 12 years and older. The following graphs show the disaggregated data (November 2021) for those vaccinated. The most vaccinated racial group is the Asian or Pacific Islander at 43%, followed by the White at 34%, Black or African American at 28%, and the lowest being Native American or Alaskan Native at 12%.   The racial vaccination rates follow the general racial makeup of the county. While Asian or Pacific Islanders may have the highest rates of vaccination could be due to all of that 1% of the population becoming vaccinated. In addition, 4.3% of the local Spanish population were vaccinated.

Vaccination by age groups slightly decreases within the upper age groups and dramatically reduces as age does. By far, more women, 37%, are vaccinated than men, 31%, at any age. Low vaccination rates among underserved populations may be due to a lack of transportation to vaccination sites, social media misinformation regarding vaccines, or a lack of trust in local and state governments. To overcome this, the Richmond County Health Department did several vaccination sites, including Hoffman, Dobbin Heights, Ellerbe, Cordova, and the central Richmond County Senior High, to promote awareness and distribute vaccines to underserved populations. In addition, due to ongoing infections, drive-thru COVID testing sites were increased to a second site in the parking lot of the Robert L. and Elizabeth S. Cole Auditorium in Hamlet, which offered Rapid and PCR testing. Daily updates were issued using countywide social media and websites to increase transparency to the public regarding COVID infections, deaths, and vaccinations. A county zip code map was also distributed that displayed the number of cases in each area of the county. Examples are given below. 

Figure 1                                                                              Figure 2
Vaccination by Race                                                           Vaccination by Age
          
Note: COVID-19 Vaccine Management System (CVMS), November 2021              Note: COVID-19 Vaccine Management System (CVMS), November 2021

Figure 3                                                                                 
Vaccination by Gender                                                          
              

Note: COVID-19 Vaccine Management System (CVMS), November 2021      

Figure 4
Vaccination by Ethnicity

Note: COVID-19 Vaccine Management System (CVMS), November 2021   

Figure 5                                                                          
Example of Richmond County COVID Updates 
     
Note: Distributed daily through county social media, news media, and webpages

Community Health Improvement Plan: Substance Use Disorder

COVID-19 pandemic challenges affected those who suffered from substance use disorders, their families, and those in recovery. It is well known that many mental health disorders such as depression, bipolar disorder, anxiety disorder, schizophrenia, borderline personality disorder, and post-traumatic stress disorder contribute to substance misuse (NIDA, 2021). COVID pandemic restrictions included social isolation, closed mental health facilities, and closed outpatient treatment centers; which, combined with other stressors such as ongoing life disruption, changes to daily routines, job loss, and financial problems, aggravated already fragile individuals who suffer from ongoing mental health issues and substance misuse. This is undoubtedly true in Richmond County. Data has shown a sharp increase in annual overdose death rates from 2019 at 15.6% to 2020 at 53.5% and seems to be holding steady at that upper rate which is 20 points higher than the state rate at 32%. Fatal overdose events were 90% unintentional. The increase may have been due to the increased availability of illicitly manufactured fentanyl, fentanyl analogs, and the lack of a preferred substance. The rate of opioid overdose emergency department visits also escalated during the pandemic. Richmond County had a rate of 339% in 2020 to 420% in 2021. The Richmond County Emergency Medical Systems, operated by FirstHealth of the Carolinas, collects and reports data regarding naloxone distribution. These numbers should be interpreted with caution and may not be compared to numbers from 2020 because law enforcement also reported their naloxone reversals while 2021 data is only from emergency services. Richmond County Department of Social Services tracks infants born positive for substances and reflects on a case-by-case basis. Not all mothers and babies are tested. Reports have indicated that the major contributor was marijuana by 51% and usually one other substance such as methadone or an opioid. This also correlates with the increase of children in foster care from 34.1% in 2020 to 43.7% in 2021.

 Drug Endangered Family Taskforce (DEFT) worked remotely behind the lines of the pandemic by developing a webpage (https://www.richmondnc.com/489/DEFT) with public access to our local data and a listing of area resources and contact information of area recovery groups. The page also contains information from the National Institute on Drug Abuse regarding addiction science. Addiction awareness information comes in different formats for teens, parents, and teachers. The DEFT Peer Counselors set up FaceBook Live for private groups for daily counseling sessions since the weekly Addiction Recovery Support Group every Wednesday at the health department was paused due to COVID. DEFT also distributed medication lock boxes and naloxone kits to the community's individuals who may have a loved one in crisis. The cost of substance misuse has no limits and affects family, friends, relationships, and the community. Addiction can cause emotional pain for loved ones, particularly children, affecting their future lives and relationships. Due to the ongoing stigma around addiction, it may be challenging to bring up the subject or help. When loved ones are struggling with an addiction, one of the more essential things that can be done is learning more about the problem. 

Figure 7                                                                                                                                          
Annual Overdose Deaths                                                                                                         
 
Note: Data from North Carolina Opioid Action Plan Dashboard     

Figure 8
Opioid Overdose Emergency Department Visits

 Note: Data from North Carolina Disease Event Tracking and Epidemiologic Collection Tool 

Figure 9                                                                                              Figure 10                                                                                                                            
Naloxone Distribution                                                                        Infants Affected by Substance Use
              
Note: Data from the Richmond County Emergency Medical Systems                                                                        Note: Data from the Richmond County Child Protective Services                           

 Figure 11
Children in Foster Care Due to Parental Substance Use 

Note: Data from the Opioid and Substance Use Action Plan Data Dashboard

National Institute on Drug Abuse. (2021, December 15). Mental Health. Drug Facts. https://teens.drugabuse.gov/drug-facts/mental-health#topic-5

Community Health Improvement Plan: Teen Pregnancy 

Although the CDC (2021) reports that the national teen pregnancy rate has declined, evidence points to more teens abstaining from sexual activity, while other teens who are sexually active use birth control than in previous years. Richmond County teen pregnancy rates are still higher than the NC rates, historically accurate for the 15-19 age group. Through valiant efforts of the REACH program, teen pregnancy in the 15-17 age group has seen a decrease overall. The middle and high school students were educated on positive reproductive health practices and informed of local health services. The number drop from 2019 to 2021 indicates that COVID-19, when the health department health professionals were engaged in COVID testing and vaccinations and the clinic services, were temporarily discontinued. The age group, 18-19, has remained consistently high, which may be because this age group is going to college, getting married, and joining the workforce. Other contributing factors, low education, and low-income levels are two social determinants of health that may contribute to high teen births (CDC, 2021).

Table 1
Teen Pregnancy Rates 

Note: Data obtained from NC Division of Statistics Rates based on small numbers (<20 pregnancies) are unstable and not provided.

Figure 12                                                                                                       Figure 13
Long-Acting Reversible Contraceptive                                                           Family Planning Clinic 
                          
Note: Data from Richmond County Health Department Patagonia Electronic Health Records                      Note: Data from Richmond County Health Department Patagonia Electronic Health Records

Center for Disease Control and Prevention. (2021, December 12). About Teen Pregnancy. Reproductive Health. https://www.cdc.gov/teenpregnancy/about/index.htm
 

Community Health Improvement Plan: Smoking and Vaping

Richmond County Health Department Public Health Education Department has escalated its community smoking cessation efforts with an adaption of the American Cancer Society FreshStart program. The smoking cessation program consists of four sessions, one hour each using the 5 A's, practical counseling, motivational interviewing, and stages of change counseling. Counseling sessions were provided one-on-one or small socially distanced group sessions (3-4 individuals). Funding was provided by the Healthy Beginnings Infant Mortality Grant (IMR), which provided training from the Duke-UNC Tobacco Treatment Specialist Training program as well as provided incentives and nicotine replacement therapy for participants. Program promotion and advertisements were done with social media as well as encouraged through participant word of mouth. Referrals were unnecessary since anyone seeking help combating nicotine addiction can access the program; however, local primary care providers, health department clinic providers, and WIC participants were encouraged to ask patients who use tobacco to seek our program. Unfortunately, due to COVID restrictions, we could not promote the program by attending any community events this past year.

Richmond County Health Department, Smoking Cessation program, collaborated with the NC North Carolina Tobacco Prevention and Control Branch-Region 6, including Cumberland, Hoke, Harnett, Lee, Moore, Montgomery, Randolph, Richmond, Anson, and Scotland Counties. Region 6 Tobacco Control's goals are to build the communities capacity to implement and carry out effective, culturally appropriate strategies to reduce chronic tobacco-related health issues, tobacco-related death and prevent the initiation of tobacco use. In addition, funding provided by the Region 6 Tobacco Control enabled training for the Tobacco Treatment Specialist in the CATCH My Breath youth vaping prevention program as a community trainer. The free CATCH My Breath Curriculum is offered to the Richmond County School district and includes community and teacher workshops, webinars, and resources to support tobacco and e-cigarette education.   

COVID -19, although not an emerging issue for 2021, brought about other health conditions which the National Institutes of Health refer to as long-term COVID-19 symptoms as PASC, which stands for post-acute sequelae of SARS-CoV-2 (Troxel et al., 2021). Common names include post-COVID syndrome, long COVID, or long-term COVID, and those with this condition are sometimes called “long haulers” (CDC, 2021). Symptoms can last weeks or months after the initial infection or appear weeks afterward. Long COVID could happen to anyone who has had COVID, even if their illness was mild or no symptoms. Most reported symptoms were:

• Difficulty breathing or shortness of breath

• Tiredness or fatigue

• Symptoms that get worse after physical or mental activities (post-exertional malaise)

• Difficulty thinking or concentrating (“brain fog”)

• Cough

• Chest or stomach pain

• Headache

• Fast-beating or pounding heart (heart palpitations or tachycardia)

• Joint or muscle pain (Arthralgia or Myalgia)

• Pins-and-needles feeling (Paresthesia)

• Diarrhea

• Sleep problems

• Fever

• Dizziness on standing (lightheadedness)

• Rash (hives or urticaria)

• Mood changes

• Change in smell or taste (Anosmia or Dysgeusia)

• Changes in menstrual cycles

The CDC (2021) emphasizes that understanding post-COVID conditions remains incomplete, and guidance for healthcare professionals will likely change over time as the evidence evolves. Long COVID can be challenging as well as caring for a loved one with the condition, especially when there are few to no answers or solutions. However, there are ways to help relieve the burden of experiencing or caring for a loved one with such conditions as joining support groups.   

Hamlet Senior Center offers a local COVID Support Group that meets on the last Wednesday of each month.

Other support groups include

Body Politic (https://www.wearebodypolitic.com/campaign),

 Survivor Corps (https://www.survivorcorps.com/), 

Long COVID Kids (https://www.longcovidkids.org/).

Centers for Disease Control and Prevention. (2021 Dec 15). COVID-19. Post-COVID Conditions. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/

Troxel, A. B., Frontera, J. A., & Mendoza-Puccini, C. (2021). The National Institutes of Health COVID-19 NeuroDatabank and NeuroBiobank: A National Resource for Learning, Discovery, and Progress. Frontiers in neurology, 11, 615061. https://doi.org/10.3389/fneur.2020.615061

The COVID pandemic drew attention to pre-existing conditions this past year. Stress was placed on families, children, and vulnerable populations due to insufficient traditional school support, social isolation, racial injustice, economic distress, and lack of technological resources. These issues impacted the low-income, racial, and ethnic communities and highlighted disparities. 

To help overcome these and other disparities, the NC Division of Public Health received federal funding, known as the Advancing Equity Grant. This new funding initiative will be used to address local COVID-related health disparities and advance health equity by improving the Richmond County Health Department’s capacity to serve those at higher risk or underserved, which includes those of historically marginalized populations. HMPs or Historically Marginalized Populations as defined by the NC DHHS (2021) are those individuals, groups, and communities that have been denied access to services, resources, and power relationships across economic, political, and cultural dimensions due to systemic, durable, and persistent racism, discrimination, and other forms of oppression. HMPs are usually identified by their race, ethnicity, socioeconomic status, geography, religion, language, sexual identity, and disability status. In addition, the Advancing Equity grant has enabled the health department to establish a permanent internal workgroup, Advancing Health Equity Workgroup (AHEW), to assess and improve the internal equity practices and track equity efforts. These practices will include an examination and modification, if needed, of the organizational mission, vision, culture, policies, as well as the recruiting and hiring practices. Another facet of the grant is establishing or joining a local equity council in Richmond County. In this instance, the Richmond County Health Department has partnered with the Richmond County Partnership for Children to create a coalition to address Adverse Childhood Experiences (ACEs) and build community resilience. This coalition is still in the planning stages.

North Carolina Department of Health and Human Services. (2021, December 15). Healthier Together - Health Equity Action Network. https://covid19.ncdhhs.gov/HealthierTogether