Executive Summary

Vision Statement

Franklin County Health Department promotes healthy lifestyles and disease prevention activities in order to enhance the quality of life for the citizens of Franklin County. Health Department programs provide a holistic approach to healthcare, emphasizing physical, intellectual, and emotional health to protect against public health threats. These programs include: Women’s Health, Maternity Care, Child Health, WIC, Communicable Disease, STD, Adult Health, Home Health, Environmental Health, and Community and Health Education.

Leadership

The Community Health Needs Assessment has been a collaborative process with leadership across stakeholder and partner organizations.  These leadership groups include:

Community Health Assessment Management Team

• Scott LaVigne - Franklin County Health Department Health Director
• Betsy Hunt - Chairperson of the Franklin County Board of Health and Chief Nursing Officer Maria Parham Health
• Graham Bundy - Franklin County Health Department Public Health Education Supervisor

Steering Committee

• Loftin Wrenn - Franklin County Health Department Nursing Supervisor
• Lauren Pace - Franklin County Health Department Director of Nursing
• Mary Jo Michalski - Franklin County Home Health Nursing Supervisor
• Whitney Holmes - Franklin County Health Department Health Equity Coordinator
• Lana Cooper - Franklin County Health Department Women’s Health Provider
• Chastity West - Impact Healthcare Practice Manager
• Brittany Newell - Impact Healthcare Nurse Practitioner
• Jennifer Clement - Maria Parham Director Growth and Outreach
• Monica Kearney- SafeSpace Executive Director
• Traci Dunston - SafeSpace
• Dawn Goodwin - NC DHHS Central Region Pharmacist
• Katie Taggett - Franklin County Emergency Management
• Lisa Pursell-Morris - Franklin County Schools Lead Nurse
• Meg Wyatt - Franklin County Cooperative Extension Agent
• Dominque Simon - Franklin County Cooperative Extension Area Agent
• Virginia Campbell - Franklin County Emergency Services
• Christy Southall - Franklinton Senior Center Program Supervisor

Community Health Assessment Team

• Elane Edwards - Franklin County Health Department Triple P Coordinator
• Roxie Packer -Franklin County Health Department Health Education
• Antrel Branch -Franklin County Health Department (Health Education Supervisor 2019-2021)

Partnerships/Collaborations

Collaborative Process Summary

Community Health Needs Assessments are required to be completed every three years. These health assessments involve identifying and prioritizing the health needs of the county and creating strategies to address those needs. This process is collaborative including agencies and stakeholders from across public health and social services.  This process included the direct involvement of the county’s residents through surveys and public engagement.  Each of these collaborations allowed the department to identify those health priorities of greatest need and importance to the county.  The CHA is an ongoing continuous improvement process that remains community centered and focused on improving the overall health and well-being of Franklin County.

Key Findings and Health Priorities

Based on analysis of the secondary data and the input gathered from community residents and partnering agencies, the following significant health needs were identified for Franklin County:

• Access to Primary Care
• Adult Obesity
• COVID-19
• Suicide
• Substance Abuse
• Adult Tobacco Use
• Cancer
• Exercise, Nutrition, and Weight
• Heart Disease
• Health Outcome Disparities for Communities of Color

Details of the process used to prioritize these health needs is included later in this report.  In short, the steering committee met to discuss the preliminary 2021 CHNA report, primary and secondary data sources, and the community input surveys.  After discussion and input, the committee evaluated the needs and determined the following four health priorities for the community as described in the 2021 CHNA.

• Access to Care
• Heart Disease
• Exercise, Nutrition, and Weight
• Health Outcome Disparities in Communities of Color

Access to Care

Define issue:  Access to care priority includes data pertaining to how and why people use or do not (cannot) use healthcare.  How many primary care and specialty providers are in the county?  How many people have health insurance?  How much healthcare, across specialty, is there in the community?  How much information is there about healthcare and are residents able to easily access that information?

Key themes from primary and secondary sources:

There is a clear need for primary care providers since the ratio for Franklin County is 1 provider per 13,510 people compared to the NC ratio of 1 per 1,400 (County Health Rankings, 2018).  Franklin County does not meet the NC Institute of Medicine’s target ratio of 1 primary care provider to every 1,500 people (Center for Health Services Research UNC, 2017).  Rates of uninsured persons in the county are higher than the state average.

Heart Disease

Define issue: This health care priority includes data pertaining to key risk factors and outcomes of heart disease. Heart disease refers to a group of conditions that affect the heart and blood vessels, such as coronary artery disease, heart failure, stroke, and cerebrovascular disease. Outcomes of heart disease can result in poor quality of life, disability, and death – but can be prevented by controlling key risk factors like high blood pressure, smoking, unhealthy diet, and obesity.

Key themes from primary and secondary data:

Heart disease is the leading cause of death in Franklin County with a mortality rate of 206.64 per 100,000 population in 2019 (NC-DHHS State Center for Health Statistics, 2019).  Also, Franklin County’s mortality rate for heart disease was higher than the state rate of 187.00 per 100,000 population in 2019 (NC-DHHS State Center for Health Statistics, 2019).

Exercise, Nutrition, and Weight

Define issue: This health care priority includes data pertaining to key risk factors (obesity) and modifiable behaviors (exercise & nutrition) that contribute to chronic diseases. Healthy eating and physical activity can help individuals reach and maintain a healthy weight. Also, obesity can increase the risk of serious health problems such as heart disease, cancer, and diabetes.

Key themes from primary and secondary data:

There is an increased rate of adult obesity at 41% among Franklin County residents compared to the state rate of 32% for 2017 (County Health Rankings, 2017). Also, the top three leading causes of death in Franklin County are respectively heart disease, cancer, and cerebrovascular disease (NC-DHHS State Center for Health Statistics, 2019). These are chronic diseases that can be prevented through healthy lifestyle changes like exercise and nutrition.

Health Outcome Disparities for Communities of Color

Define issue:  Health outcome disparity priority includes data pertaining to differences in health outcomes that adversely affect specific, potentially disadvantaged, racial, or ethnic populations.  Outcomes could include:

• Higher incidence and/or prevalence and earlier onset of disease

• Higher prevalence of risk factors, unhealthy behaviors, or clinical measures in the causal pathway of a disease outcome

• Higher rates of condition-specific symptoms, reduced global daily functioning, or self-reported health-related quality of life using standardized measures

• Premature and/or excessive mortality from diseases where population rates differ

• Greater global burden of disease using a standardized metric

Key themes from primary and secondary sources:

Overall, there are health disparities present in Franklin County among racial/ethnic groups. Specifically, when examining the top three leading causes of death in Franklin County – heart disease, cancer, and cerebrovascular disease – the mortality rate for African Americans or Blacks is higher than the White population for each health outcome. For heart disease, the mortality rate for African Americans was 252.9 per 100,000, while the rate for Whites was lower at 210.6 per 100,000 in 2019 (NC-DHHS State Center for Health Statistics, 2019).  For cancer, the death rate for African Americans was 211.8 per 100,000 and 197.9 per 100,000 for Whites. Also, for cerebrovascular disease, the mortality rate was higher for African Americans at 88.2 per 100,000 compared to Whites at 55.3 per 100,000 (NC-DHHS State Center for Health Statistics, 2019).  

Conclusion and Next Steps

This report describes the process and findings of a comprehensive community health needs assessment for the residents of Franklin County.  The final steps in the CHNA process is to develop community-based health improvement strategies and action plans to address the four priorities identified in this assessment.  The strategies identified in the CHNA will be implemented through use of the Community Health Improvement Plan (CHIP), which will include targeted measurable efforts of the Health Department, partnering agencies, and community stakeholders. 

Priorities

Franklin County Priority Health Issues

• Access to Care
• Heart Disease
• Exercise, Nutrition, and Weight
• Health Outcome Disparities in Communities of Color

Why Is This Important?

Good nutrition and physical activity play an important role in the overall health and well-being of individuals. Together, exercise and eating well can prevent the development of serious chronic diseases such as heart disease, cancer, diabetes, and stroke. Also, physical activity has a positive impact on mental health conditions like depression and anxiety. 

If we are successful in achieving this result, we anticipate a Franklin County where: 

• Every citizen has a safe place to be physically active like community centers or parks  

• Healthy, nutritious foods are accessible to all citizens  

• Supportive services that educate and address the benefits of exercise and nutrition are available to all  

County Health Ranking Map

Access to Exercise Opportunities

Percentage of population with adequate access to locations for physical activity.

The 2020 County Health Rankings used data from 2010 & 2019 for this measure.

For 2019, 61% of the Franklin County population had adequate access to locations for physical activity. This is below the state average with the percentage for North Carolina at 74% in 2019. The HNC 2030 target for this indicator is 92%. 

CHR Link to County Level Data

County Health Ranking Map

Limited Access to Healthy Foods

Percentage of population who are low-income and do not live close to a grocery store.

The 2020 County Health Rankings used data from 2015 for this measure.

CHR Link to County Level Data

Action Plan

Project Title  

Med Instead of Meds 

Objective  

Med Instead of Meds was created by a group of nutrition and health professionals from NC State University and NC Division of Public Health. Eating the Med Way has been proven to protect against chronic illness. In some cases, eating the Med Way may even result in decreasing medications taken for blood pressure, high cholesterol, or diabetes. The goal is to provide the citizens of Franklin County with the information and tools needed to make healthy and delicious meals for themselves and their families. 

What Will We Do 

The Med Instead of Meds program is designed to address healthy eating within the population of Franklin County. The program is meant to raise awareness of health issues and alternative eating habits that may not be utilized. The Franklin County Cooperative Extension offers the program to address health needs and offers ways for the population to adapt to lifestyle changes or seek medical help.   

Who Is Involved    

North Carolina Cooperative Extension, Franklin County Center 

Franklin County Health Department

When This Takes Place 

In 2022, the classes were provided once a year over a 6-week increment. In 2023, the class structure changed to be able to better meet the needs of the community and increase participation. Classes are no longer offered over a 6-week period, instead individual sessions are offered at a variety of locations throughout the county.  

How We Will Do It  

The NC Cooperative Extension has partnered with the Franklin County Department of Aging and the Franklin County government employees to host lunch and learn sessions where one individual session of the curriculum is provided in an interactive format.  

The "Med Instead of Meds" curriculum focuses on: 

- Eating primarily plant-based foods and limiting red meat 

- Choosing whole grain foods  

- Consuming 5 servings of fruits and vegetables per day 

- Using olive oil and fresh herbs instead of solid fats or seasonings high in sodium  

- Limiting high processed food, fast food, and sugar-sweetened beverages and snacks 

Results/Planned Measures of Impact  

Data has been collected to assess the number of participants at each presentation. In 2022, each participant was asked about their satisfaction with the current process of the Med Instead of Meds classes and what might work better for them in a post-survey. Program attendees were surveyed and educated on this program throughout a 6-week period and data was collected to gauge interest in these programs. In 2023, since individual sessions were offered instead of the whole 6-week course, program satisfaction surveys were not administered. 

Action Plan

Project Title 

The Journey Ministry Pantry 

Objective 

The mission of The Journey Ministry Pantry is to provide and serve healthy and nutritious food to those with food insecurities, so no one goes hungry. They also educate clients about nutrition and life skills in hopes it improves their lives and our communities as a whole and provides a welcoming environment filled with love and compassion. 

What We Will Do 

Food insecurity is defined as “a household-level economic and social condition of limited or uncertain access to adequate food”. The Journey Ministry Pantry is designed to address food insecurities and raise awareness to the lack of resources to low income or poverty residents in Franklin County.  

In Franklin County,  

• 13.0% of the population lives below the poverty level (ACS, 2015-2019) 

• 16.0% of households receive SNAP benefits (ACS, 2015-2019) 

• 18.5% of children live in households that are food insecure (2019) 

Food insecurity can increase the risk of a variety of negative health outcomes and health disparities. Overall, the Journey Ministry Pantry is working to reduce household food insecurities by providing a stable stream of nutritious foods to families in Franklin County.  

Who Is Involved 

Franklin County Health Department 

The Journey Ministry Pantry Board Members 

Franklinton Community Garden 

When This Takes Place 

These services are ongoing. The pantry distributes food to Franklin County residents every Tuesday from 2:30 – 5:00 pm.  

How We Will Do It 

The Journey Ministry Pantry is a non-profit, 501(c)(3) organization. It has created partnerships with local farmers, community gardens, and grocery stores to be able to provide fresh produce and meat in every box they distribute. The pantry is supported mostly by volunteers. They currently have about 14 volunteers who help prep the food boxes and prepare for distribution. They also have three drop-off donation sites where people can provide nonperishable food donations.  

Their first distribution took place on June 28th, 2022, in Youngsville, NC and has been occurring weekly since the start date.  

Results/Planned Measures of Impact 

Data will be collected monthly to assess the number of people that are receiving food pantry items each week. Individuals who qualify for receiving services at the pantry must show a photo ID and complete a short intake form when they arrive. The intake form helps collect information on who is using the services by asking for demographic data and household size.  

Discussion/Next Steps 

To date, the program has been established in Franklin County. Information about the program is advertised on social media and signs throughout Youngsville. The pantry hopes to expand their services by providing nutrition education, preparing premade meals to those who are unable to cook, and hosting specific outreach days where other agencies in the community can promote and provide their services.  

Sources 

U.S. Department of Agriculture, Economic Research Service. Definitions of food security, https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security/

Food Insecurity & Poverty Rates - U.S. Census Bureau, ACS 5-year Estimate 2015-2019

Food Insecurity Children - https://ncchild.org/what-we-do/insights/data/2021county-data-cards/ 

Why Is This Important?

Heart disease has been one of the top leading causes of death in Franklin County for the past few years. It’s important to focus our efforts on the prevention of heart disease due to the negative impact it can have on an individual’s quality of life. Also, tobacco users are more likely to develop heart disease so it’s crucial to target tobacco cessation programs to help reduce the burden of this health condition.  

If we are successful in achieving this result, we anticipate a Frankin County where:  

• Individuals are living healthy lifestyles that promote heart health  

• Adults and adolescents do not use tobacco or e-cigarette products 

• There is access to high quality tobacco cessation services for treatment and recovery  

• All individuals are free from the burden of chronic diseases  

Action Plan

Project Title

“CATCH My Breath” 

Objective

Based on the Community Health Assessment that was completed in 2021, the leading cause of death in Franklin County was heart disease. In Franklin County, 144 people died from heart disease in 2019, which is 13 deaths higher than the second leading cause of death, cancer. The rate of these deaths is comparable to the other Health ENC counties and significantly higher than the rate of heart disease deaths in North Carolina. Approximately 21% of adults in Franklin County are smokers, which is 3% higher than the state average. It was also reported that approximately 25.2% of high school students in Franklin County are using tobacco products and is comparable to the state average of 28.8%.  

Cigarette smokers are 2 to 4 times more likely to get heart disease than nonsmokers. One out of every 5 smoking related deaths is caused by heart disease. According to the CDC, heart disease is the single largest cause of death in the United States, killing more than 800,000 people per year.  

Heart disease is affecting people at younger ages each year. Underlying risk factors such as high blood pressure, high cholesterol, diabetes, obesity, and smoking are contributing to these alarming numbers.  

“CATCH My Breath” is an evidence-based program used to teach youth about the effects of tobacco use. More than 15,000 schools use this program, and it is proven that 45% fewer kids go on to try e-cigarettes one year after completing "CATCH My Breath".  CATCH health behavior changes have been shown to persist for 3 years post implementation. Our goal is to reduce the prevalence of e-cigarette use in teens that will persist through adulthood.  

What We Will Do

The "CATCH My Breath" program is designed to address e-cigarette use among adolescents and teens in Franklin County. The program is meant to raise awareness of health issues that result from e-cigarette use among 6th and 8th grade students in Franklin County.  

Who Is Involved

Franklin County Health Department 

Franklin County Schools  

When This Takes Place

This program was first implemented into 6th grade at all 4 middle schools in Franklin County in the spring semester 2023. We will continue to deliver this annually to our 6th grade students. In Fall 2023, we also expanded the program to be delivered to 8th grade students in Franklin County schools. The curriculum for 6th and 8th grades is slightly different but both focus on the negative consequences of vaping, identifying positive alternatives to vaping, and making personal goals to not use e-cigarettes. 

How We Will Do It

Health educators from FCHD will be trained to deliver the "CATCH My Breath" program to 6th and 8th grade students enrolled in Franklin County Schools. The program will be implemented over a four-week period each semester.  

Results/Planned Measures of Impact

In the spring of 2023, data was collected through pre- and post-surveys given to students and turned back into us. Through these surveys we were able to see student engagement and overall success of the program. However, during the fall of 2023, we were no longer able to provide pre- and post-surveys to collect program data due to new policies in the school system. While we do not expect numbers to change overnight for tobacco usage in Franklin County, we do expect that through continued efforts of this program that we will continue to see a change in the perception of using e-cigarettes among youth.

Discussion/Next Steps

To date, we have successfully implemented this program into 6th grade for both the spring and fall semesters of 2023. We expanded this program into the 8th grade beginning in Fall 2023 and will continue to offer the program each semester.  

Sources 

https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/pdfs/fs_smoking_CVD_508.pdf

https://nciom.org/counties/franklin-county/

https://catch.org/program/vaping-prevention/

Action Plan

Objective 

Based on the Community Health Assessment that was completed in 2021, the leading cause of death in Franklin County was heart disease. In Franklin County, 144 people died from heart disease in 2019, which is 13 deaths higher than the second leading cause of death, cancer. The rate of these deaths is comparable to the other Health ENC counties and significantly higher than the rate of heart disease deaths in North Carolina. Approximately 21% of adults in Franklin County are smokers, which is 3% higher than the state average. It was also reported that approximately 25.2% of high school students in Franklin County are using tobacco products and is comparable to the state average of 28.8%.   

Cigarette smokers are 2 to 4 times more likely to get heart disease than nonsmokers. One out of every 5 smoking related deaths is caused by heart disease. According to the CDC, heart disease is the single largest cause of death in the United States, killing more than 800,000 people per year.   

Heart disease is affecting people at younger ages each year. Underlying risk factors such as high blood pressure, high cholesterol, diabetes, obesity, and smoking are contributing to these alarming numbers.   

“Set the B.A.R.” is a program designed by our Health Education staff that discusses vaping use and prevention amongst high schoolers. This program was based on different evidence-based programs and combined information from both to best suit the needs of our students. It discusses vaping and tobacco use, cessation of these products as well as preventative measures.  

What We Will Do 

The "Set the B.A.R.” program is designed to address the rising numbers of e-cigarette/vape use amongst High School Students and set up the next generation with proper preventative measures to reduce overall e-cigarette and tobacco usage in Franklin County. 

Who Is Involved 

Franklin County Health Department  

Franklin County Schools   

When This Takes Place 

This program was first implemented into 9th grade Health and P.E. classes at 3 High Schools in Franklin County in November 2023. We plan to return every semester and teach this class to ensure all 9th grade students receive the curriculum. We also plan to include the Early College in this class in the Spring Semester.  

How We Will Do It 

Health educators from FCHD will be trained to deliver the "Set the B.A.R.” to 9th grade students enrolled in Franklin County Public Schools. This will take place over 2 days in the Health and P.E. classrooms. 

Results/Planned Measures of Impact 

Due to new regulations, we are unable to give surveys to students regarding their current vape usage. After each class we have an open discussion about the class and receive feedback from students on how to improve the class since this is a new class. Our planned measure of impact is to track vaping suspension numbers within the school system over the next few years.  

Discussion/Next Steps 

To date, we have successfully implemented this program in 9th grade Health and P.E. classes for Fall 2023. Due to high school schedules all of 9th grade will not receive this until after spring semester. We plan to continue to attend and implement this class each semester for the foreseeable future.  

Sources  

https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/pdfs/fs_smoking_CVD_508.pdf 

https://nciom.org/counties/franklin-county/ 

Why Is This Important?

As defined by the CDC, “health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations”. These disparities are directly related to the unequal distribution of social and economic resources and ultimately lead to negative health outcomes.  

Overall, there are health disparities present in Franklin County among racial/ethnic groups. Specifically, when examining the top three leading causes of death in Franklin County – heart disease, cancer, and cerebrovascular disease – the mortality rate for African Americans or Blacks is higher than the White population for each health outcome. We want to reduce these disparities and inequities by addressing social determinants of health in Franklin County.  

If we are successful in achieving this result, we anticipate a Franklin County where:  

• Every mother has access to quality prenatal and postnatal care in order to create a strong start for the health and well-being of their children  

• All individuals have strong financial security and economic stability  

• All citizens have reliable health coverage and access to quality preventative health care and specialized services when necessary  

• Child and adults receive high-quality, affordable educational opportunities  

Sources:

Definition of Health Disparities- https://www.cdc.gov/healthyyouth/disparities/index.htm#:~:text=Health%20disparities%20are%20preventable%20differences,experienced%20by%20socially%20disadvantaged%20populations.  

Action Plan

Project Title  

Reducing Infant Mortality in Communities (RIMC)  

Objective:  

To address the critical need for reducing infant mortality rates and improving birth outcomes in Franklin County. 

According to the North Carolina Division of Public Health's County Health Data Book and the NC State Center for Health Statistics on NCDHHS, the infant death rate per 1,000 live births by race/ethnicity from 2017 to 2021 in Franklin County was 7.5. Notably, the rate in Franklin County is higher than the state average, which was 6.9 in 2020.

In Franklin County, specifically in 2019, the infant mortality rate was 5.2 per 1,000 live births. To compare by ethnicity, the non-Hispanic White infant mortality rate was 0, the African American non-Hispanic infant mortality rate was 10.7, and the Hispanic infant mortality rate was 8.1 (per 1,000 live births). There is a large disparity in infant mortality rates from African American and Hispanic infants when compared to White infants in Franklin County. This data underscores the urgency of the RIMC program, which aims to provide evidence-based strategies for safe infant sleep practices and promote breastfeeding support to pregnant women and their family members/support persons in Franklin County.  

What We Will Do:  

Safe Infant Sleep Practices and Breastfeeding Support:  

• Provide current infant safe sleep education to pregnant women and their family members/support persons through monthly group sessions.  
• Provide Ready, Set, BABY Breastfeeding classes to pregnant women and their family members/support persons through monthly group sessions. 
• Offer breastfeeding support services in a one-on-one setting to pregnant and postpartum women served at the LHD and in the community.  
• Conduct three-month follow-up safe sleep education surveys and breastfeeding support assessments.  

Community Engagement:  

• Develop program and advertising materials to promote safe infant sleep practices and breastfeeding support.  
• Conduct community outreach and education activities, including participating in community events and advocating for breastfeeding-friendly spaces in the community and workplace.  

Collaboration:  

• Partner with local providers, community members, and organizations to implement safe infant sleep practices. 
• Collaborate with the LHD's WIC Breastfeeding Peer Counselor (BFPC) Program to provide additional support to BFPC program participants.  

Who Is Involved:  

Franklin County Health Department  

Pregnant women and their family members/support persons  

Local community partners  

FCHD WIC Breastfeeding Peer Counselor (BFPC) Program  

NC Department of Health and Human Services  

When this Takes Place: 

Service Period: 6/1/2023 - 5/31/2026 

Results/Planned Measures of Impact:  

• Collect demographic data on program participants, including prenatal and postpartum contacts, breastfeeding initiation and duration, and safe sleep knowledge and practices.  
• Conduct program participant satisfaction surveys to evaluate program services and submit an annual satisfaction survey summary report.  

Discussion/Next Steps:  

• Monitor and analyze the collected data to assess the impact of the program.  
• Continuously adapt and improve program strategies based on survey feedback and data analysis.  
• Consider expanding program activities and partnerships to further reduce infant mortality rates in Franklin County.  

Sources: https://schs.dph.ncdhhs.gov/data/databook/ 

Action Plan

Project Title

Transforming prenatal education to reduce health disparities

Objective

Deliver a quality prenatal education curriculum that is relevant, evidence-based, and easy to reference for all patient groups in order to reduce maternal morbidity and mortality. 

What We Will Do

The State of North Carolina’s Public Health Department under The Maternal Health Program (administered within the Women’s Health Branch (WHB), Perinatal Health Unit) has “the primary mission to ensure that all low-income pregnant women have access to early and continuous prenatal and postpartum care.” In addition, [the FCHD] will work to enhance public education and community awareness regarding risk prevention and reduction strategies.” The March of Dimes 2021 Report Card gave North Carolina a grade of “D” for maternal care. Poor education contributes to these failing efforts of North Carolina’s annual statistics regarding maternal morbidity and mortality. The annual report revealed stark disparities across race and ethnicity in prenatal outcomes. The following statistics show a desperate need for change:

• NC preterm birth rate= 10.8%
• NC preterm birth rate among Black women= 48% higher than all other women
• NC infant mortality rate= 6.8% compared to a national rate of 5.6%
• NC Inadequate prenatal care= 17.1% compared to a national average of 14.9%

In obstetrics and gynecology, basic prenatal counseling is the answer to healthy pregnancies and families. Patients need to understand their care, screenings, labs, and signs and symptoms of a normal and abnormal pregnancy in a way that is up-to-date, accessible, and easy to comprehend. The purpose of this project is to improve prenatal care and decrease disparities at the rural health department located in Franklin County, as a means of addressing the needs of the increasing population.

Who Is Involved

Lana Cooper, PA-C - FCHD Maternal Health Provider 

Franklin County Health Department Clinic Staff 

Campbell University 

Program Design

Primary stakeholders, specifically the nurses, providers, health director, director of nursing, and nurse supervisor were interviewed to better understand their current knowledge base regarding prenatal counseling and the method of patient education being delivered. Obstetric patients were asked about their satisfaction with the current process of patient education during clinic visits and what might work better for them. The data gathered was used to develop a new maternal health curriculum that utilizes electronic resources, as well as traditional handouts and oral communication for consistent delivery. The different types of resources for patient education were: 

• Mobile phone apps
• Clinic videos shown on tablets 
• Paper handouts 
• Nurse counseling 
• Provider counseling 
• Posters on the walls

All educational materials was analyzed to ensure they were evidence-based, presented at an appropriate health literacy level, and available in English and Spanish. Staff were trained on the new program and implementation of the new curriculum started on June 13th, 2022 for all patients seeking prenatal.

When this Takes Place

This was a pilot program to determine the effectiveness of using the new prenatal patient education in our maternal health clinic. The pilot program ran from June to October 2022. However, even though the pilot program has ended, the prenatal curriculum is still provided to all of the FCHD's maternal health patients on an ongoing basis. 

Results/Outcomes

Patient surveys were given at the end of the second and third trimester and were available in English and Spanish. Surveys utilized a likert-scale model and the inquiries focused on how patients felt the staff did in delivering the material. In this curriculum, the “staff” consisted of the nurses, educators on the digital videos, and the provider in the clinic. The care evaluation also attempted to understand how patients preferred to be educated during their pregnancy and what resources they found most useful. Finally, the evaluation ended with a free text box for patients to provide any positive or negative feedback.

Discussion/Next Steps

The curriculum is a living document and will continue to be studied, evaluated, and updated as needed. With time, more languages will be incorporated, and supplementary resources will be included as they are discovered. The maternal health curriculum being implemented into the prenatal clinic has high hopes of decreasing the social vulnerability index, reducing health disparities among women of color and low socioeconomic status, and improving maternal and infant outcomes.

References

1. Division of public health agreement addendum FY 21-22. https://whb.ncpublichealth.com/provpart/docs/101-MH-GenericAA-FY-2022.pdf. Accessed January 16, 2022.

2. Premature birth report card. https://www.marchofdimes.org/peristats/tools/reportcard.aspx?frmodrc=1®=37. Accessed January 18, 2022.

3. Bryson B. The body: A guide for occupants. Transworld Digital; 2019.

4. Murdock N, Batch S, Salvador D. North Carolina Momnibus Act. 2021;1.1(SESSION 2021).

5. de Leeuw RA, van der Horst, Sabine, Fiona Bianca, de Soet AM, et al. Digital vs face-to-face information provision in patient counselling for prenatal screening: A noninferiority randomized controlled trial. Prenat Diagn. 2019;39(6):456-463.

6. Car J, Carlstedt-Duke J, Car LT, et al. Digital education in health professions: The need for overarching evidence synthesis. Journal of Medical Internet Research. 2019;21(2):e12913. https://www.jmir.org/2019/2/e12913. Accessed Mar 4, 2022. doi: 10.2196/12913.

Action Plan

Project Title 

The Prevention and Thrive Team (PATT) 

Objective  

Establish a community-level initiative to prevent violence in Franklin County by identifying the risk and protective factors that impact the perpetration of sexual and domestic violence.  

What Will We Do  

PATT was established in 2018 through Injury-Free NC as a collaborative effort between Safe Space, Inc., Franklin-Granville-Vance Smart Start, and the Franklin County Health Department. The team was put on hold during the COVID-19 pandemic but reconvened in 2022 to continue its efforts. Many people face challenges and dangers they can’t control – like unsafe neighborhoods, discrimination, or trouble affording the things they need, which can have a negative impact on health and safety throughout life. The PATT team wants to focus its efforts on addressing the root causes that have contributed to health disparities in Franklin County and have negatively affected the health and well-being of people in Franklin County. The following statistics show a need for change in addressing those social determinants of health: 

In Franklin County,  

• 44.9% of children are living in poor or low-income homes (2020).  

• 18.5% of children are in households that are food insecure (2019).  

• A rate of 35.9 per 1,000 children were assessed for abuse or neglect in 2020. 

The purpose of this team is to bring together a task force of community members that will help plan and carry out activities that prevent violence among youth, address the social determinants of health that influence people’s quality of life, and fill the gaps and needs of our citizens that impact their ability to thrive and be safe. 

Who Is Involved  

Franklin County Health Department  

Safe Space, Inc.  

Franklin-Granville-Vance Smart Start 

The United Way of Franklin County  

WellCare 

Franklin County Department of Social Services  

Franklin County Emergency Management  

Franklin County Schools  

NC Cooperative Extension, Franklin County Center 

Coaching Boys into Men Program – Franklinton Parks & Recreation  

When This Takes Place 

This is an ongoing initiative. The PATT team meets every month to create action steps and discuss progress made.  

How We Will Do It  

The PATT Team will work in a multilevel approach:  

• Bring together key community partners and stakeholders in Franklin County  

• Identify the risk factors that are affecting our community and the protective factors that are currently present in Franklin County  

• Build upon the prevention programs and resources in Franklin County that are already available  

• Identify the gaps in our social support system and what resources are needed to fill those gaps 

  

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  At the first PATT team meeting, the group identified specific risk factors and protective factors that are affecting our community. Those factors are outlined below:  

  Risk Factors	Protective Factors
  Only 28.5% of 3rd-grade students scored proficient in reading	Triple P Parenting Program
  36 out of 1,000 students accessed for Child/Abuse/Neglect	LoveLevelUp.Org healthy relationship website
  COVID-19 Natural Disaster	Little Libraries in various parts of the community.
  44.9% Live in poor or low-income homes	Evidenced-based curriculums administered to Boys and Girls Club (Art Heals/Coaching Boys to Men/STEAM Mobile Innovations)
  18% Food Insecure	Franklin County Public Library Bookmobile
  Mental Health/Substance Abuse Access	FCPSS PK-12th 16 schools and 3 Charter Schools with 81% of students graduate high school

   

From these factors, the group determined areas that were a priority. The priority areas that the team will focus on are:  

• Diversity, Equity, Inclusion Training  
• Academic support inside and outside of school  
• Social, Emotional, and Behavioral skills 

The goal of this team is to use a community-centered approach and create social support systems that will connect youth and families to evidence-based, culturally appropriate resources. The team will model their efforts based on the work that has been done in Harlem, NY with the Harlem Children’s Zone program and in Wilmington, NC with the Voyage Wilmington program. These model programs offer a variety of services like mentoring, tutoring, leadership and summer employment programs, career support, physical and emotional support programs, family nights, and so much more. The ultimate goal is to create a similar program in Franklin County that will provide a variety of support services to create long-term, sustainable prevention solutions that address ACEs and social determinants of health.  

The PATT team applied to complete the Strengthening Systems for North Carolina Children (SYNC) project as one of our first main initiatives. The goal of SYNC is to support North Carolina communities disproportionately affected by ACEs in furthering their understanding of how community systems and structures influence ACEs. This project will help the PATT identify ways to strengthen systems and build community resilience to prevent ACEs. The SYNC project consists of completing workshops and ongoing technical assistance in creating, testing, and refining a causal loop diagram for the various systems and structure that influence ACEs in Franklin County. The project started on January 23rd, 2023 and a total of three workshops will take place from February to April with a year of ongoing technical assistance after the workshops. To learn more about the SYNC project, read the informational packet here. 

Sources 

https://ncchild.org/publications/2020-data-cards/  

Progress on CHIP

Our Scorecard outlines the efforts being made in Franklin County to address three of the four health priorities identified in the CHA: 

• Exercise, Nutrition, and Weight 
• Heart Disease 
• Health Outcome Disparities in Communities of Color

We strive to keep our scorecard as up to date as possible. Click the document symbol beside each program to learn more about the programs and initiatives taking place to improve health outcomes in Franklin County. You can read the story about progress on each performance measure by opening the "plus" sign next to each performance measure.

Morbidity and Mortality Changes Since Last CHA

COVID-19

In the year 2021, Franklin County experienced a total of 7,831 COVID-19 cases among residents. One year later, in 2022, the number of COVID-19 cases doubled to over 14,000 cases among residents, meaning that we saw a significant increase in morbidity from the COVID-19 virus. Looking at the graph below, we see that there was a significant spike in cases between January and February 2022.This increase could be referenced to the Omicron variant that was prevalent during this time period. However, there seemed to be no significant mortality changes from 2021 to 2022. 

Source: https://covid19.ncdhhs.gov/dashboard/cases-and-deaths 

We did not identify any other major morbidity or mortality changes in the year of 2022 in Franklin County.

Emerging Issues Since Last CHA

The Community Health Steering Committee met on February 16, 2023, to provide updates on our current CHIP and seek feedback regarding emerging issues that occurred during 2022 in Franklin County. The Steering Committee provides direction and leadership on community health initiatives across a variety of stakeholders and partner organizations. These organizations include:  

• Franklin County Health Department  

• Franklin County Emergency Management  

• Maria Parham Health 

• Safe Space, Inc.  

• Franklin County Schools  

• NC Cooperative Extension – Franklin County  

• Impact Healthcare  

Emerging Issues 

Sexual Assault 

One major emerging issue that was discussed was the increase in sexual assault cases in the county during 2022. Safe Space, Inc. is a non-profit organization that is committed to reducing relationship violence and sexual assault in Franklin County. Last fiscal year (July 2021 - June 2022), their organization had 16 documented cases of sexual assault between the ages of 16-25 years old. During this fiscal year (July 2022 - Present), so far they have documented 36 cases of sexual assault. The age breakdown of those cases is below: 

• 0-12 years old = 8 cases
• 13-17 years old = 6 cases
• 18-24 years old = 22 cases

Also, they emphasized that many sexual assault cases go unreported so this could a be larger issue in the community.  

Lack of Public Transportation

Another issue that was discussed was the lack of public transportation in the county. This is not a new issue, but it is something that is continuously impacting the Franklin County community. This issue was brought up by multiple stakeholders during the Community Health Steering Committe meeting. Also, the Franklin County Health Department has been surveying the community on what issues are impacting their health and transportation was mentioned multiple times in the responses. When asked "What is stopping you from getting the care you need?", a respondent wrote "not physically able to get there". Also, when asked "What other services do you wish the health department offered?", a respondent said having a "mobile health clinic that comes to various areas in the county for those with transportation issues". Currently, Franklin County has the Kerr Area Transportation Authority (KARTS) as the only source of public transportation in the county. KARTS is a public, rural transportation system that serves a 4-county region. However, there are limitations to this service since people must schedule/reserve rides and they only operate at certain times.   

Other issues that are impacting health in Franklin County that were discussed are: 

• Access to food – The extra benefits for COVID-19 (called “emergency allotments” or “maximum supplements”) in the Food and Nutrition Services program ends March 2023 and with the rising cost of food, our community is experiencing an increase in food insecurity.    

• Domestic Violence – There has been an increase in EMS reports involving domestic violence and substance abuse.  

• Increase in falls in the elderly population.  

• Mental health in youth – There is a lack of mental health services and programming to support youth in Franklin County.  

New/Paused/Discontinued Initiatives Since Last CHA

New Programs

Reducing Infant Mortality in Communities (RIMC) Program:

The RIMC program is an infant mortality program that awarded funds to the Franklin County Health Department to implement two evidence-based strategies (EBSs) that are proven to reduce infant mortality rates. The RIMC program focuses on addressing the disparity ratio between non-Hispanic White and non-Hispanic African American births while addressing the overall infant mortality rate in Franklin County. The two EBSs that FCHD will implement are Breastfeeding Support Services and Infant Safe Sleep Services.

Under the Breastfeeding Support Services EBS, we will be offering Ready, Set, BABY classes to pregnant women in the community.  Ready, Set, BABY counsels' prenatal families about the benefits and management of breastfeeding. Participants will attend a group session to learn about the importance of breastfeeding. Once they complete the session, they will receive a breastfeeding bag with items that will help support them on their breastfeeding journey.

Under the Infant Safe Sleep Services EBS, we will be establishing an Infant Safe Sleep program which will provide safe sleep education classes to pregnant women and family members in Franklin County. Participants will attend a group session to learn the current guidelines on safe sleep for infants to reduce the risk of sudden infant death syndrome (SIDS). Once participants complete the session, they will receive a portable crib, so they have a safe sleep space for their baby.

We are currently in the planning process and hope to begin implementation of these two programs in June 2023.  

Discontinued Programs 

Transforming Prenatal Education to Reduce Health Disparities:

This was a pilot program to determine the effectiveness of using new prenatal patient education in our maternal health clinic. The program ran from June to October 2022. Program data is no longer being tracked so we will not have participant data going forward, which is why we are considering this a discontinued program. However, all FCHD’s maternal health clinic patients are still being offered the curriculum.

Progress on CHIP

Our Scorecard outlines the efforts being made in Franklin County to address three of the four health priorities identified in the CHA: 

• Exercise, Nutrition, and Weight 
• Heart Disease 
• Health Outcome Disparities in Communities of Color

We strive to keep our scorecard as up to date as possible. Click the document symbol beside each program to learn more about the programs and initiatives taking place to improve health outcomes in Franklin County. You can read the story about progress on each performance measure by opening the "plus" sign next to each performance measure.

Morbidity and Mortality Changes Since Last CHA

Increase in Syphilis Cases

Franklin County has witnessed a concerning uptick in confirmed syphilis cases over the past year. This trend mirrors a statewide surge, with early syphilis cases in North Carolina soaring by a staggering 631% in 2022. Locally, Franklin County has also experienced a notable rise in reported cases.

According to data from the NC Electronic Disease Surveillance System (NCEDSS), there were 18 confirmed syphilis cases in 2022 for Franklin County. As of the latest reports for 2023, this figure has climbed to 28 confirmed cases. It's crucial to note that these numbers may not fully capture the extent of the issue, as many cases likely go unreported due to individuals not seeking testing or diagnosis. Furthermore, the 2023 case count is still preliminary, and ongoing investigations may uncover additional cases, suggesting that the actual number could be higher than currently indicated.

Adding to the complexity of the situation, 2023 also saw a shortage of Bicillin-LA, the primary clinical treatment for syphilis. The heightened demand for this medication has exacerbated the challenges posed by the surge in syphilis cases, underscoring the need for proactive measures to address both the increase in infections and the accessibility of essential treatments.

We did not identify any other major morbidity or mortality changes in the year 2023 in Franklin County.

Sources: 

https://epi.dph.ncdhhs.gov/cd/stds/annualrpts.html

Emerging Issues Since Last CHA

The Community Health Steering Committee met on February 13, 2024, to provide updates on our current CHIP and seek feedback regarding emerging issues that occurred during 2023 in Franklin County. The Steering Committee provides direction and leadership on community health initiatives across a variety of stakeholders and partner organizations. These organizations included:  

• Franklin County Health Department   

• Safe Space, Inc.  

• Franklin County Schools  

• At-Home Counseling Services, Inc.

• Franklin County Department of Social Services 

• Franklin County Library 

Emerging Issues 

Lack of affordable housing and apartments 

One of the pressing issues highlighted in discussions is the shortage of affordable housing in Franklin County. Despite a surge in residential development over the past year, characterized by the construction of numerous new subdivisions throughout the county, the resultant housing boom has led to a significant escalation in home prices. For instance, in February 2022, the average selling price of a house in Franklin County stood at $313,000. By February 2023, this figure had surged to $359,000, and as of January 2024, it has further climbed to $373,000.

This rise in home prices has not only affected newly constructed homes but has also resulted in appreciable increases in property values for long-term homeowners, consequently raising their monthly housing expenses. This is due to properties being assessed at record-high values, directly leading to heightened property taxes and escalating homeowners' insurance costs.

Moreover, Franklin County faces a shortage of rental options, with limited availability of both apartment complexes and rental houses. This scarcity has driven up demand, subsequently pushing rental prices higher. As of January 2024, the median rent for all bedroom counts and property types in Louisburg, NC (the county seat), stands at $1,397, marking a 16% increase compared to the previous year.

Affordable housing plays a pivotal role in shaping the overall health and well-being of individuals and communities. Access to affordable housing not only ensures a roof over one's head but also frees up household resources that can be allocated towards other essential needs such as healthcare, nutritious food, and medications. This, in turn, contributes to improved health outcomes and fosters a healthier, more resilient population.

Substance Use and Overdose

The group discussed the alarming surge in substance abuse, with particular attention drawn to the widespread prevalence of Fentanyl and its devastating impact on communities. Of particular concern is the rise in overdoses among vulnerable demographics, including young parents and teenagers. Numerous agencies reported a noticeable uptick in substance use and drug-related overdoses throughout 2023. In Franklin County, the escalation of this crisis is reflected in the escalating statistics of drug overdose deaths. In 2020, there were 17 reported drug overdose deaths, a figure that rose to 24 in 2021 and further climbed to 29 in 2022.

Substance abuse exacts a profound toll on individuals and communities, extending far beyond the immediate risk of overdose. The health effects of substance abuse are multifaceted, encompassing physical, mental, and social dimensions. Prolonged substance abuse can lead to severe health complications, including but not limited to cardiovascular disease, respiratory issues, liver damage, and neurological impairment. Additionally, substance abuse often co-occurs with mental health disorders, exacerbating symptoms and complicating treatment efforts. Moreover, substance abuse undermines social cohesion and erodes community well-being. It strains familial relationships, disrupts educational and occupational pursuits, and perpetuates cycles of poverty and instability. The ripple effects of substance abuse resonate throughout society, imposing significant economic burdens on healthcare systems and law enforcement agencies.

Other issues that are impacting health in Franklin County that were discussed are: 

• Religious Exemptions for Immunizations and Vaccine Hesitancy - In 2023, there was a notable increase in religious exemptions for immunizations for Franklin County schools and there has been the increasing challenge of vaccine hesitancy within the community post-COVID.
• Access to Transportation - Access to transportation has had some improvements with the increase in pre-paid health plans, individuals can set up transportation to and from appointments as a part of their benefits. However, there are still transportation challenges, especially concerning safety and accessibility issues for individuals requiring assistance beyond county borders.
• Homelessness - Homelessness emerged as a countywide problem with contributing factors such as mental health issues, substance abuse, domestic violence, inflation, and insufficient disability resources. Participants emphasized the need for both short-term and long-term solutions to address this concern.
• Mental Health Services for Children - Concerns were raised about the increasing need for mental health services for children under five years old. There are very limited resources in Franklin County and surrounding counites for this population.
• Recent Closure of Adult Assisted Living Center and Aging Population - The closure of an adult assisted living center in Franklin County underscored the challenges associated with an aging population and sparse resources for residents.

Sources: 

https://www.rockethomes.com/real-estate-trends/nc/franklin-county#Overview

https://www.zumper.com/rent-research/louisburg-nc 

https://www.ncdhhs.gov/opioid-and-substance-use-action-plan-data-dashboard

New/Paused/Discontinued Initiatives Since Last CHA

New Programs

Set the B.A.R. (Breaking all Reasons for Teen Vaping) Program: 

Set the B.A.R. (Breaking All Reasons for Teen Vaping) is a vaping prevention/cessation program created to specifically fit the needs of Franklin County High Schools. This program is designed to address the rising numbers of e-cigarette/vape use amongst high school students and set up the next generation with proper preventative measures to reduce overall e-cigarette and tobacco usage in Franklin County. This program is broken into four sections and focuses on breaking common misconceptions around vaping and alerting teens to what nicotine addiction can do to them. 

The four key lessons are:

1. "Getting the Facts" debunks vaping misconceptions and exposes marketing tactics aimed at teens.
2. "Nicotine Dependence" explores addiction and emphasizes the concept of dependence.
3. "Alternatives to Vaping" addresses peer pressure and offers strategies to resist vaping temptations.
4. "Student's Future" involves students in envisioning their life goals and discusses how vaping can hinder their aspirations. 

This program was first implemented into 9th grade Health and P.E. classes at 3 high schools in Franklin County in November 2023. We plan to return every semester and teach this class to ensure all 9th grade students receive the curriculum. We also plan to include the Early College in this class in the 2024 Spring Semester.