HNC 2030 Scorecard: Transylvania County (2021 - 2023)

Executive Summary

The executive summary can be found on pages i-iii of the 2021 Transylvania County Community Health Assessment report.

CHA Priorities

The 2021 Transylvania County Community Health Assessment priorities are:

• Mental Health
• Substance Use
• Obesity

These priority areas are continuing from the 2015 and 2018 CHAs, although the names of the priorities have changed slightly.

Why Is This Important?

Mental health is connected to issues that include suicide deaths, substance use, depression, anxiety, physical activity, and employment. However, residents have limited options for treatment and counseling options, especially for those who have lower incomes, no insurance, or transportation issues. Interest in youth mental health is growing, but there is still much work to be done in this area.

• 10% of county residents reported that their typical day is extremely or very stressful
• 19% of county residents reported 7+ days of poor mental health in past month
• 20% of county residents reported currently taking medication or receiving treatment for mental health

Partners with a Role to Play

Partners in our Community Health Improvement Process:

• TC STRONG
• Transylvania Regional Hospital
• Veterans Administration
• Blue Zones Project - Brevard
• CARE Coalition
• Transylvania County Schools
• Sharing House / Transylvania Christian Ministry
• Lutheran Church of the Good Shepherd
• WNC Healthy Impact

Partners with a Role in Helping Our Community Do Better on This Issue:

• NAMI Transylvania
• Providers: Meridian, Blue Ridge Health, RHA, Mountain Counseling, Hendersonville Pediatrics
• Transylvania Regional Hospital & Mission Health Partners
• VAYA Health
• Brevard Academy, Mountain Sun Community School
• School nurses
• Potential funding sources (e.g. Pisgah Health Foundation, Dogwood Health Trust)
• Faith community
• Sports coaches & extracurricular leaders
• Businesses (e.g. barber shops and salons)
• Social service organizations
• Law enforcement and school resource officers
• EMS and first responders
•  

What Works to Do Better?

The following actions have been identified by our team and community members as ideas that can work in our community to make a difference on improving mental health.

Actions and Approaches Identified by Our Partners These are actions and approaches that our partners think can make a difference on mental health.

• Destigmatization
• Community education and awareness
• Create opportunities for connection and interaction (youth-focused events, neighborhoods)
• Advocate for mental health funding to increase provider ratios
• Support for vulnerable/at-risk teens, single parents,
• Intentional relationship-building/mentoring
• Explore sense of purpose and build opportunities for empowerment
• Whole-family programs, support for parenting
• Assure basic needs are being met
• Normalize accessing therapy - like a yearly checkup
• Support for justice-involved individuals
• Help people know how to respond to a mental health crisis
• Innovative mental health resources like equine therapy, art therapy, respite care

What is Currently Working in Our Community These are actions and approaches that are currently in place in our community to make a difference on mental health.

• Embedded therapists on-campus in public schools
• Behavioral health staff at Blue Ridge Health and Hendersonville Pediatrics
• Community support groups - some meeting again in person
• Social-emotional learning in some preschools and public schools; alternative school certified as trauma-informed school
• Blue Zones Project - Brevard holding purpose workshops
• CIT certified law enforcement officers (some)
• TC STRONG activities underway to address awareness and destigmatization

Evidence-Based Strategies These are actions and approaches that have been shown to make a difference on mental health.

What Community Members Most Affected by Mental Health Say These are the actions and approaches recommended by members of our community who are most affected by mental health.

• Stigma prevents people from seeking needed care. Some youth say their parents dismiss their concerns or won't allow access to care.
• People don't know where to go for help or how to navigate the system.
• Healthcare providers are reporting more visits related to mental health.
• Emergency department personnel and law enforcement report being frustrated from dealing with issues beyond their "scope" and have asked for resources to address mental health.
• Teachers and schools have been traumatized by threats and complaints. They are reporting more behavior problems and impaired coping skills.
• Young people report feeling under immense pressure, from themselves, their peers, their parents, and society.
• Some community members are well-connected with good social support. Others are dealing with social isolation, loneliness, and lack of resources.

Process for Selecting Priority Strategies

The Transylvania County CHA team worked with community members to better understand the story and root causes behind mental health concerns and identify potential strategies including evidence-based strategies, what is working in other communities, and ideas generated by people who are most affected by the issues. Public health staff met with the TC STRONG steering team (including student delegates), faith-based representatives, healthcare providers, and other concerned community members to select strategies based on feasibility, impact, alignment with community values, and focus on addressing one or more root causes. Public health staff also worked with project leadership to help develop performance measures to help us know if people are better off because of the implementation efforts and will be involved in evaluating ongoing implementation efforts and making changes when needed.

What Is It?

Mental health and suicide prevention training was identified by community members as an action, that when combined with other actions in our community, that has a reasonable chance of making a difference in suicide rates in our community. This is an expansion of ongoing programs in our community.

The priority population for this program includes teachers and other school staff, faith leaders (inlcuding clergy and lay leaders), and other interested community members. These trainings aim to make a difference at the individual/interpersonal level, but will also involve policy changes and environmental changes in some settings. Implementation will take place in schools, churches, and community settings.

Evidence-based trainings, such as QPR (Question, Persuade, Refer), ASIST (Applied Suicide Intervention Skills Training), and Mental Health First Aid have been shown to improve outcomes related to suicide death rates. Other trainings, including Reconnect for Resilience and DBT Skills have been shown to improve responses to stressful situations and better manage emotions to avoid crisis and improve overall wellbeing. Our community will seek to implement several of these trainings, as appropriate for various individuals based on their level of need and interest.

Partners

The partners for this program include:

Story Behind the Curve

The "Story Behind the Curve" helps us understand the causes and forces at that work that explain the data behind suicide intervention training and the resources that our community plans to commit to address this health issue.

What's Helping What We Do? These are the positive forces at work in our program that influence how much we do or how well we do it.

• Strong community partnerships and variety of funding and support resources.

• Community interest in participating.

• Trained participants would recommend programs to others.

What's Hurting What We Do? These are the negative forces at work in our program that influence how much we do or how well we do it.

• Capacity for implementation stretched thin; need dedicated personnel to focus on mental health programs

• Challenging to recruit participation within faith community.

What's Helping Communities Served? These are the positive forces at work in our program that influence changes in skills, knowledge, attitudes, opinions, behavior, and/or circumstance.

• Trained peers results in increased access to care and support, reducing demand on professional therapists and counselors.

• Trained peers have fewer barriers such as cost and waiting lists.

What's Hurting Communities Served? These are the negative forces at work in our program that influence changes in skills, knowledge, attitudes, opinions, behavior, and/or circumstance.

• Challenging to connect those who need help with trained peers in the community.

• Trainings are just beginning, so only a few people have been trained so far.

What Works to Do Better?

The following actions have been identified by our community as ideas for what can work for this performance measure to make a difference on suicide mortality.

Actions and Approaches Identified by Our Community These are actions and approaches that we think can make a difference for this performance measure.

• Plan to offer multiple options for suicide prevention and mental health training based on the needs of the person or their organization

• Use existing resources from Healthy Communities and ongoing community work to support initial trainings.

• Partner with TC STRONG and other community members to recruit interested community members and volunteers.

No-cost and Low-cost Ideas Identified by Our Community These are no-cost and low-cost actions and approaches that we think can make a difference for this performance measure.

• Access training resources provided by VAYA Health.

• Partner with government, schools, non-profits, and churches for training locations.

What Our Community Thinks Would Work To Do Better These are actions and approaches that our communities served think can make a difference for this performance measure.

• Develop an overall plan for suicide prevention and mental health training rather than one-off options supported by various agencies.

• Develop training recommendations for organizations to implement.

• Develop a referral pathway to connect people who have mental health concerns or are in crisis with trained peers.

• Curate additional funding resources to continue expansion.

• Offer basic, age-appropriate mental health training to students in partnership with schools.

List of Questions/Research Agenda These are questions or research items to follow-up on for this performance measure. 

• Need to conduct long-term follow-up after training to assess impact.

Progress Made in 2022

Several evidence-based suicide prevention trainings were held in 2022, designed to expand awareness of warning signs and build skills in responding appropriately. A total of 44 people were trained in ASIST in partnership with the Lutheran Church of the Good Shepherd, Transylvania Public Health, and other community partners. In addition, 29 school personnel and community members were trained in Youth Mental Health First Aid, offered by Vaya Health in partnership with Transylvania County Schools and TC STRONG.

Progress Made in 2023

Transylvania Public Health sponsored a workshop hosted by Soul Shop to develop a suicide training plan for county schools and the community-based agencies that support them.In late 2023, TC STRONG received a 3-year grant to support mental wellness for students and staff of "After 3" programs throughout the community; this support includes training such as YMHFA, teenMHFA, and resilience skills that has been shown to support suicide prevention.

TC STRONG staff were certified as trainers in Youth Mental Health First Aid, teen Mental Health First Aid, and the "Be There" social support curriculum. These staff offered 2 YMHFA courses in 2023 and trained a total of 23 individuals, including school personnel, those who work with youth in other settings (such as camps and after school programs), community members, and parents. They also trained a total of 21 students and staff in Be There, in partnership with Brevard College. Planning efforts are underway to offer teen MHFA in early 2023. TC STRONG is also working with the Transylvania County Library to regularly offer QPR for interested community members.

The TC STRONG collaborative was selected as 1 of 15 teams representing 24 counties statewide to participate in the "Our State, Our Wellbeing" inititative from UNC Chapel Hill. This 12-month program works to identify and implement strategies to improve mental health and reduce suicides, launched by Carolina Across 100 and the UNC Suicide Prevention Institute.

In addition, Transylvania Public Health worked with WNC Health Network to support a social media campaign that promoted normalization of seeking care for mental health concerns and provided information on how to find needed help. This campaign reached approximately 28,000 individuals and resulted in over 11,000 post engagements.

Why Is This Important?

Substance use is connected to mental health concerns, overdose deaths, adverse childhood experiences, depression, anxiety, liver disease, alcohol-related motor vehicle crashes, lung cancer, COPD, and employment. However, residents have limited options for treatment and counseling options, especially for those who have lower incomes, no insurance, or transportation issues. Despite promising community efforts to address substance use, there is still much work to be done in this area.

• 10% of county residents reported excessive drinking
• 14% of county residents reported using opiates in the past year (with or without a prescription)
• 14% of county residents reported being current smokers (decrease from 23% in 2018)
• 41% of county residents reported that their life was negatively affected by own or someone else’s substance use
• 69% of children in foster care were placed due to parental substance use
• 19% of babies were born to moms who smoked while pregnant

Partners with a Role to Play

Partners in our Community Health Improvement Process: 

• CARE Coalition
• Blue Zones Project – Brevard
• Healthy Communities
• WNC Healthy Impact

Partners with a Role in Helping Our Community Do Better on This Issue: 

• Meridian
• Blue Ridge Health
• VAYA Health
• CMARC/CMHRP-case management
• MAHEC
• Land of Sky (transportation to AA mtgs)
• Jail re-entry programs
• ABC Board
• SAFE Inc.
• Businesses/employers
• Law enforcement
• People who use substances
• People in recovery

What Works to Do Better?

The following actions have been identified by our team and community members as ideas that can work in our community to make a difference on improving substance misuse.

Actions and Approaches Identified by Our Partners These are actions and approaches that our partners think can make a difference on substance misuse.

• Regional work to improve treatment and reduce stigma through media campaign
• Adoption of additional tobacco-free/smoke-free policies
• Distribution of Naloxone to justice-involved and vulnerable populations
• Quitline and its resources
• Training and education for parents to reduce access and availability of nicotine and alcohol for youth
• Increased access to medication-assisted treatment / medication for opioid use disorder
• Re-entry assistance including care navigation and mental health treatment
• Access to behavioral health treatment and services
• Resiliency and coping skills

What is Currently Working in Our Community These are actions and approaches that are currently in place in our community to make a difference on substance misuse.

• Existing tobacco-free/smoke-free policies in schools, government settings, and multi-unit housing
• Substance education in schools (DARE in 5th grade and grade alcohol, tobacco, and other drugs curriculum in 9th grade)
• Tobacco/vaping intervention strategies in schools
• Naloxone access for law enforcement officers and first responders
• CARE Coalition work to reduce access to alcohol
• Distribution of lockboxes to reduce access to prescription medications
• Working to develop infrastructure to use opioid settlement funding
• Resilience skills training and capacity building for youth
• Awareness events and media campaigns to encourage parent involvement
• Social supports and warm handoffs from Sharing House
• Support for grandparents raising grandchildren

Evidence-Based Strategies These are actions and approaches that have been shown to make a difference on substance misuse.

Process for Selecting Priority Strategies

The Transylvania County CHA team worked with community members to better understand the story and root causes behind substance misuse concerns and identify potential strategies including evidence-based strategies, what is working in other communities, and ideas generated by people who are most affected by the issues. Public health participated in meetings of the CARE Coalition and Blue Zones Project – Brevard to select strategies based on feasibility, impact, alignment with community values, and focus on addressing one or more root causes. Public health staff also worked with CARE Coalition staff to help develop performance measures to help us know if people are better off because of the implementation efforts and will be involved in evaluating ongoing implementation efforts and making changes when needed.

What Is It?

Advocacy for expanded access to substance use disorder treatment is an action, that when combined with other actions in our community, that has a reasonable chance of making a difference in substance misuse in our community. This is a new program in our community.

The priority population/customers for this program include people with substance use disorder, families and friends of those who have substance use disorder, decision makers, and general community members. The program aims to make a difference at the intrapersonal/interpersonal and environmental change levels. Implementation will take place in community venues and on broadcast and social media.

Transylvania Substance Awareness Team is working to host events to promote community understanding of how stigma impacts folks with substance use disorder and creates barriers to appropriate support and treatment. The team will also be providing community presentations about the causes and impacts of substance use, as well as evidence-based treatment and harm reduction strategies.

Transylvania Public Health and the CARE Coaliiton will be supporting a regional communications campaign led and developed by WNC Health Network. This campaign is a strategy to support local efforts to address stigma and cultivate support and compassion for people most affected by substance misuse and their families.

Partners

The partners for this program include:

Story Behind the Curve

The "Story Behind the Curve" helps us understand the causes and forces at that work that explain the data behind access to substance use disorder treatment and the resources the coalition plans to commit to address the health issue.

What's Helping What We Do? These are the positive forces at work in our program that influence how much we do or how well we do it.

• Regional support for anti-stigma campaign - and past regional communications partnerships
• Strong community participation in TSAT workgroup, including individuals with lived experience and county leadership
• Funding and staffing to support work - including new re-entry counselor

What's Hurting What We Do? These are the negative forces at work in our program that influence how much we do or how well we do it.

• Stigma limits resources available to support people who use substances
• Beliefs that MAT/MOUD is "enabling" use or leads to misuse and crime
• Limited resources for substance use treatment in our county/region

What's Helping Communities Served/Customer Change? These are the positive forces at work in our program that influence customer change.

• Increased awareness of available services 

What's Hurting Communities Served/Customer Change? These are the negative forces at work in our program that influence customer change.

• Ingrained habits and beliefs can be slow to change.

What Works to Do Better?

The following actions have been identified by our coalition as ideas for what can work for this performance measure to make a difference on emergency department visits related to substance use.

Actions and Approaches Identified by Our Community These are actions and approaches that we think can make a difference for this performance measure.

• Develop infrastructure to use opiate settlement funding

No-cost and Low-cost Ideas Identified by Our Community These are no-cost and low-cost actions and approaches that we think can make a difference for this performance measure.

• Involve people with lived experience and their families
• Use social media to share messages

What Our Communities/Customers Think Would Work To Do Better These are actions and approaches that our communities served/customers think can make a difference for this performance measure.

• Address myths and stigma associated with substance use disorder and treatment options

List of Questions/Research Agenda These are questions to follow-up on for this performance measure. 

• none at this time

Progress Made in 2022

Efforts are underway to support MAT/MOUD access for county residents through the CARE Coalition's TSAT workgroup. CARE provided trainings from MAHEC on substance use disorder to providers and community members.

Transylvania County's jail-based re-entry program helped to create access to support services in the Transylvania County Detention Center. This partnership between the Transylvania County Sheriff's Office and CARE Coalition received funding in 2022 through a federal grant from the Bureau of Justice Assistance and hired 2 staff positions located within the local detention center. These staff provide case management, behavioral health assessment and counseling, and in-jail programming, as well as connections to community treatment providers and other resources upon release. 

CARE Coalition hosted "Transylvania CARES: Stories of Addiction and Hope" to raise awareness of how stigma impacts people who use drugs. The event was attended by 70 individuals and featured 5 panelists who discussed the ways that stigma affects lives from their personal and professional perpectives. Transylvania Public Health and CARE are also working with WNC Health Network to develop anti-stigma communications intended to reduce barriers to help seeking behaviors.

CARE staff and volunteers developed and finalized community presentation content on substance use that will be presented to churches, volunteer groups, nonprofits, and businesses upon request.

WNC Health Network formed an advisory group and coordinated efforts to develop an anti-stigma communications campaign. In 2022, this group held listening sessions, identify audiences, determined key messages, designed sample content, and tested messages.

In addition, CARE Coalition received a grant to plan for the best use of opioid settlement funds. This process may identify activities that can help increase access to substance use disorder treatment.

Progress Made in 2023

CARE Coalition staff and coalition members began presenting community information sessions on substance use disorder and treatment to community groups. In 2023, presentations were made to law enforcement, non-profit agencies, and church groups. Coalition member Jim Hardy also presented "Understanding Trauma: The Path to Healing" which highlighed the impact of trauma in mental health and substance use.

In its first year of operation, Transylvania County's jail-based re-entry program. served a total of 283 detainees with case management and/or reentry programming within the detention center. Of the 181 inmates screened for substance use disorder, 74% were positive for at least 1 SUD and 64% met criteria for multiple SUDs. Staff identified a need for SUD treatment upon release for around 39% of detainees. The re-entry coordinator initiated 64 applications for in-patient substance use treatment, and 38 applications were accepted. Staff are also participating in a community-based re-entry council to help support detainees with practical needs and ease the transition after release, and advocate for additional resources.

CARE Coalition staff created and distributed resource cards with information on SUD treatment and recovery services to officers in the Brevard Police Department and the Transylvania County Sheriff's Office.

WNC Health Network received funding to conduct a pilot of its "See Me WNC" anti-stigma communications campaign and selected Transylvania as 1 of 4 pilot counties. Staff from Transylvania Public Health and the CARE Coalition provided feedback and selected 4 ads that ran on Facebook and Instagram in October and November 2023. These ads were then incorporated into the regional "View From Here" communications campaign. 

In addition, CARE Coalition staff also took the lead in developing recommendations for the local use of national opioid settlement funds, helping community members understand the process, and managing compliance with state reporting requirements. 

What Is It?

Alternatives to suspension for tobacco/vaping in schools was identified by our community as an action, that when combined with other actions, has a reasonable chance of making a difference in nicotine use among students in our community. This is an expansion of an ongoing program in our community.

The priority population/customers for this program are school administrators, and the program aims to make a difference at the organizational level. Implementation will take place in middle and high schools. The program's outcomes, however, will have the biggest effects at the personal level for students.

This program will be implemented through a partnership between the CARE Coalition of Transylvania County, the Healthy Communities program of Transylvania Public Health, Blue Zones Project - Brevard, and Transylvania County Schools. It aims to provide comprehensive nicotine services to teens, including a prevention curriculum (CATCH My Breath) for all students, alternatives to suspension (Vapeducate, In-Depth) for students who have been caught smoking/vaping on campus, and cessation programs (NOT on Tobacco) for students who want to quit or reduce their nicotine use.

Partners

The partners for this program include:

Story Behind the Curve

The "Story Behind the Curve" helps us understand the causes and forces at that work that explain the data behind youth use of tobacco/nicotine and the resources the coalition plans to commit to address the health issue.

What's Helping What We Do? These are the positive forces at work in our program that influence how much we do or how well we do it.

• School administration requests for help address student vaping
• Educational curricula available for use as needed by schools (licenses can be purchased ahead of time and used on demand)
• Program funding and staff support from CARE Coaltion, Healthy Communities, and Blue Zones Project - Brevard
• Past work by student coalition members to promote anti-vaping messages
• Support by students and staff for education rather than punishment

What's Hurting What We Do? These are the negative forces at work in our program that influence how much we do or how well we do it.

• Slow process to adopt new methods for addressing substance use on campus
• Cost to purchase licenses
• Limited staff capacity to implement universal educational curriculum

What's Helping Communities Served/Customer Change? These are the positive forces at work in our program that influence customer change.

• Some students want to quit or reduce tobacco/nicotine use
• Support by students and staff for education rather than punishment

What's Hurting Communities Served/Customer Change? These are the negative forces at work in our program that influence customer change.

• Some students don't want to quit or reduce tobacco/nicotine use

What Works to Do Better?

The following actions have been identified by our coalition as ideas for what can work for this performance measure to make a difference on youth tobacco/nicotine use.

Actions and Approaches Identified by Our Coalition These are actions and approaches that we think can make a difference for this performance measure.

• Building relationships with school administration and staff to ease adoption of new programs
• Student-led advocacy for new programs and policy

No-cost and Low-cost Ideas Identified by Our Coalition These are no-cost and low-cost actions and approaches that we think can make a difference for this performance measure.

•   none identified at this time

What Our Communities/Customers Think Would Work To Do Better These are actions and approaches that our communities served/customers think can make a difference for this performance measure.

• none identified at this time

List of Questions/Research Agenda These are questions to follow-up on for this performance measure. If you still need more information about what works to do better, make these questions part of your information & research agenda.

• none identified at this time

Progress Made in 2022

New staff at Transylvania County Schools were trained to offer tobacco cessation counseling to students. Additional licenses were purchased for schools to use for students who are caught using vapes/tobacco on campus as an alternative to suspension.

Healthy Communities staff partnered with MountainWise Tobacco staff and the CARE Coalition to present a speaker on vaping addiction to approximately 1,900 middle and high school students in the county and offered "Quit Kits" with information and cessation tools to interested students.

Progress Made in 2023

Two new staff were hired by the CARE Coalition in mid-2023. These staff were trained to deliver nicotine prevention and alternative to suspension programs, and 1 staff was trained to offer a nicotine cessation program.

CARE Coalition staff delivered the "Catch My Breath" vaping prevention curriculum to all health classes at Rosman Middle School, and began planning efforts to deliver this curriculum at Brevard Middle School in early 2024. The coalition also purchased "Vape Educate" licenses for Transylvania County middle and high schools, which is an online curriculum to be used as an alternative to suspension for students who were caught vaping.

In addition, CARE partnered with MountainWise, the Healthy Communities program at Transylvania Public Health, and the regional tobacco control manager to support a Tobacco 21 resolution presented to and adopted by both the Transylvania County Board of Education and the Transylvania County Board of Health.

Why Is This Important?

Obesity is a main chronic health condition of concern in Transylvania County. Our top two causes of death and many of our morbidity statistics including type 2 diabetes, high blood pressure, heart disease, certain cancers, and stroke are directly affected by nutrition and physical activity. Residents report having trouble accessing healthy food and getting the recommended amount of physical activity.

• 70.6% of county residents are overweight or obese
• 29.5% of county residents are obese
• 32.2% of children ages 2-4 are overweight or obese
• 20% of county residents reported no leisure-time physical activity
• 23% of county residents met physical activity recommendations
• 6% of county residents reported consuming 5+ servings of fruit and vegetables per day (down from 14% in 2018)

Partners with a Role to Play

Partners in our Community Health Improvement Process: 

• Blue Zones Project - Brevard
• Transylvania County Parks and Recreation
• Hunger Coalition of Transylvania County 
• WNC Healthy Impact

Partners with a Role in Helping Our Community Do Better on This Issue: 

• MANNA, Sharing House, Bread of Life, food pantries
• Hendersonville Pediatrics
• Local physicians
• Transylvania Regional Hospital: cardiac rehab, congregate meal program
• City of Brevard
• Transylvania County Parks and Recreation
• Transylvania County Library
• Boys & Girls Club, Rise & Shine, other youth-serving organizations
• Schools
• Large employers
• Local gyms
• Grocery stores
• Restaurants

What Works to Do Better?

The following actions have been identified by our team and community members as ideas that can work in our community to make a difference on improving obesity.

Actions and Approaches Identified by Our Partners These are actions and approaches that our partners think can make a difference on obesity.

• Healthier food choices for students while at school and out of school (after-school programs like Rise and Shine and Boys and Girls Club, and backpack buddies)
• Healthier options in childcare settings to meet nutritional needs and establish healthy habits
• Education and demonstrations to improve food knowledge and cooking skills
• Access to community gardens
• Support local sourcing of produce
• Access to fresh produce at food pantries
• Complete streets, including bike lanes and multi-use paths
• Access to parks, playgrounds, and recreation centers
• Affordable access to gyms, fitness classes, and sports teams
• Social support for walking or physical activity

What is Currently Working in Our Community These are actions and approaches that are currently in place in our community to make a difference on mental health.

• Blue Zones Project - Brevard strategies on food policy and built environment 
• County policy around fast food and dollar stores
• Access to playgrounds, muti-use paths, trails for hiking and biking
• Community gardens
• Library programs that include physical activity classes and resources
• Meal kits from Hunger Coalition and Bread of Life
• Fresh produce at food pantries and mobile markets
• Local physicians promoting healthy lifestyles/diets
• Physical activity and gardening at Boys & Girls Club, El Centro, Rise and Shine

Evidence-Based Strategies These are actions and approaches that have been shown to make a difference on obesity.

Process for Selecting Priority Strategies

The Transylvania County CHA team worked with community members to better understand the story and root causes behind mental health concerns and identify potential strategies including evidence-based strategies, what is working in other communities, and ideas generated by people who are most affected by the issues. Public health staff met with the Blue Zones Project – Brevard food policy committee, the Hunger Coalition of Transylvania County, and other concerned community members to select strategies based on feasibility, impact, alignment with community values, and focus on addressing one or more root causes. Public health staff also worked with project leadership to help develop performance measures to help us know if people are better off because of the implementation efforts and will be involved in evaluating ongoing implementation efforts and making changes when needed.

What Is It?

Collaborative, community-based policies can foster a healthier local food system, improving access and making produce more visible via schools, corner markets, farmers markets, neighborhood gardens, mobile businesses, and more.

Supporting increased access to fruits and vegetables was identified by our community as an action, that when combined with other actions in our community, that has a reasonable chance of making a difference in obesity in our community. This is a new program in our community.

The priority population for this program is decision-makers at various community organizations, and the program aims to make a difference at the organizational/policy level. Implementation will take place in schools, childcare facilities, restaurants, and community organizations.

This program will support the efforts begun by BZP Food Action Committee, which addresses food retail, food and nutrition in schools and childcare facilities, and access to local sources of food. Policies might include examples such as menu changes to include healthier and/or plant-based options, promotion of sourcing from local farms, or supporting access to community gardens. 

Partners

The partners for this program include:

Story Behind the Curve

The "Story Behind the Curve" helps us understand the causes and forces at that work that explain the data behind food policies and the resources the community plans to commit to address the health issue.

What's Helping What We Do? These are the positive forces at work in our program that influence how much we do or how well we do it.

• Support from Blue Zones Project - Brevard and Healthy Communities staff. Partnerships with staff at schools, restaurants, food pantries, and community organizations. Support from community organizations like Hunger Coalition.
• Momentum driven by enthusiasm around Blue Zones Project and adoption of policies by other community organizations

What's Hurting What We Do? These are the negative forces at work in our program that influence how much we do or how well we do it.

• Relunctance to adopt "restrictions" on food and beverage options. Resistance to outsider advice. 
• Concern that increased cost and possibly less demand for healthier options could lead to revenue loss
• Limited capacity and turnover of staff who assist with food policy work

What's Helping Communities Served/Customer Change? These are the positive forces at work in our program that influence customer change.

• Popular interest in healthy eating among some populations - support for making "the healthy choice the easy choice"

What's Hurting Communities Served/Customer Change? These are the negative forces at work in our program that influence customer change.

• Ingrained habits and behaviors

What Works to Do Better?

The following actions have been identified by our community as ideas for what can work for this performance measure to make a difference on obesity.

Actions and Approaches Identified by Our Community These are actions and approaches that we think can make a difference for this performance measure.

• Collaboration across sectors and organizations to work together
• Adoption of best practices for schools and childcare centers

No-cost and Low-cost Ideas Identified by Our Community These are no-cost and low-cost actions and approaches that we think can make a difference for this performance measure.

• Offering water instead of sweetened beverages or juice

What your communities served/customers think would work to do better These are actions and approaches that our communities served/customers think can make a difference for this performance measure.

• Support access to food from community gardens and local farms
• Pursue funding to support implementation of policies

List of Questions/Research Agenda These are questions to follow-up on for this performance measure.

• none identified at this time

Progress Made in 2022

Work continues in partnership with Blue Zones Project - Brevard to support "making the healthy choice the easy choice" as well as access to locally sourced foods in schools, businesses, and restaurants. This includes shaping food policy to increase consumption of fresh fruits and vegetables and ensuring access for all residents. Blue Zones Project – Brevard helped create the Transylvania County Food Coalition to serve as a mechanism to assess food needs and focus resources to areas that need help most.

In addition, collaboration with Hunger Coalition of Transylvania County supports access to healthy food options at food pantries and mobile markets.

Progress Made in 2023

The Blue Zones Project - Brevard received certification and the project ended in March 2023. Through its support of the Transylvania County Food Coalition, a total of five policies were adopted in 2022 and 2023 to improve the local food system. A new non-profit, "Sparkpoint" was formed in April 2023 to expand similar efforts to the entire county. SparkPoint was awarded a CDC grant in partnership with the Town of Rosman to support healthier eating and community connections involving multiple community partners.

Collaboration with Hunger Coalition of Transylvania County continues to supports access to healthy food options at food pantries and mobile markets.

What Is It?

Strong social connections help people move more, eat better, and affect happiness.

Encouraging social support for physical activitiy was identified by community as an action, that when combined with other actions in our community, that has a reasonable chance of making a difference in obesity in our community. This is an ongoing program in our community.

The priority population for this program is adult residents of Transylvania County, and the program aims to make a difference at the individual/interpersonal behavior level. Implementation will take place in community settings, including neighborhoods and organizations.

Social support for physical activity is an evidence-based strategy that has been shown to encourage participation compared to solitary activity. Walking groups known as "moai" are one of the practices identified by Blue Zones as contributing to living better longer. Group events based on physical activity such as worksite-sponsored 5K events encouage participation in the event itself as well as preparation ahead of time.

Partners

The partners for this program include:

Story Behind the Curve

The "Story Behind the Curve" helps us understand the causes and forces at that work that explain the data behind social support for physical activity and the resources the community plans to commit to address the health issue.

What's Helping What We Do? These are the positive forces at work in our program that influence how much we do or how well we do it.

• Desire to participate in something new and exciting
• Success of past programs in own organization and other community organizations

What's Hurting What We Do? These are the negative forces at work in our program that influence how much we do or how well we do it.

• Perception that certain activities are not for everyone ("people like me don't do that")
• Capacity of staff to support multiple programs
• Capacity of group physical activity programs to serve large populations

What's Helping Communities Served/Customer Change? These are the positive forces at work in our program that influence customer change.

• Peer pressure to participate in social activities and not miss out on planned events
• Benefits of participation (e.g. stress relief, improved energy, social connection) increase desire to participate more

What's Hurting Communities Served/Customer Change? These are the negative forces at work in our program that influence customer change.

• Barriers to participating, including lack of energy or time
• Not making good connections within a specific group

What Works to Do Better?

The following actions have been identified by our community as ideas for what can work for this project to make a difference on obesity.

Actions and Approaches Identified by Our Community These are actions and approaches that we think can make a difference for this performance measure.

• Support activities sponsored by community groups and employers
• Provide support for individuals who want to start a moai

No-cost and Low-cost Ideas Identified by Our Community These are no-cost and low-cost actions and approaches that we think can make a difference for this performance measure.

•  Share information through partner organizations and on social media

What Our Communities/Customers Think Would Work To Do Better These are actions and approaches that our communities served/customers think can make a difference for this performance measure.

•  Promote success of ongoing groups 

List of Questions/Research Agenda These are questions to follow-up on for this performance measure. 

•  none identified at this time

Progress Made in 2022

Work continues in partnership with Blue Zones Project - Brevard to support social support for group activities, as well as policies and changes that improve access and safety in the built environment. Blue Zones Project - Brevard worked to help form "moais" modeled after groups of about 5 people who commit to support each other in Okinawa. These Walking Moais created throughout the community are intended to build long-lasting friendships while exploring our community on foot.

Progress Made in 2023

The Blue Zones Project - Brevard received certification and the project ended in March 2023. More than 25 Walking Moais were created during the Blue Zones Project, attended by a total of 333 people who met up to move naturally together. Since 2020, physical activity is up 7.9% (the number of people who report exercising 30+ minutes, 3+ days/ week), and 6% more residents reported having someone in their lives encouraging them to be healthy.

A new non-profit, "Sparkpoint" was formed in April 2023 to expand similar efforts to the entire county. SparkPoint was awarded a CDC grant in partnership with the Town of Rosman to support healthier eating and community connections involving multiple community partners.

Communities Served

View From Here WNC is the product of a 19 county collaboration spreading from Cherokee to McDowell, including the Eastern Band of Cherokee Indians and community based organization, UNETE. This umbrella social media campaign focuses on improving the lives of WNC residents by addressing the top three shared health priorities in our region, Substance Use, Mental Health, Healthy Eating/ Active Living as well as COVID/Flu Vaccinations.

Progress Made in 2022

Click on each program/strategy below to review progress and updates for 2022 under the "Progress Made in 2022" note tabs.

Mental Health

• Support implementation of mental health trainings for schools and community members

Substance Use

• Advocate for expanded access to substance use disorder treatment
• Offer alternatives to suspension for tobacco/vaping in schools

Obesity

• Support increased access to fruits and vegetables through food policy
• Encourage social support for physical activity

Significant/Notable Changes in Morbidity and Mortality

The following represent significant or notable morbidity and mortality changes in our community in 2022:

• Overall causes of death as reported by the latest County Health Data Book from NCDHHS remained largely similar to the 2015-2019 data reported in the 2021 Community Health Assessment. However, there were a few notable changes for data collected in 2016-2020. (Source: 2022 County Health Data Book, North Carolina State Center for Health Statistics)
  • Cancer and heart disease remain the leading causes of death. Deaths from cancer decreased slightly, while deaths from heart disease increased slightly, but both remain well below the state rates.
  • Deaths from diabetes; pneumonia and influenza; nephritis, nephrotic syndrome, and nephrosis; and unintentional motor vehicle injuries all decreased and remain below the state rates.
  • For the three causes of death where Transylvania County rates were higher than state rates in the 2015-2019 data, all had smaller discrepancies from the state rate in 2016-2020. Deaths from chronic liver disease and cirrhosis fell, resulting in lower rate that is now the same as the state rate. The rate of all other unintentional injuries rose, but is now less than 1 point higher than the state rate. The number of deaths from suicide remained the same (40 total over 5 years); the death rate decreased but remains about 66% higher than the age-adjusted state rate.
  • Septicemia was included as a leading cause of death, with a county rate of 7.1 compared to a state rate of 12.5.
  • Deaths from homicide and COVID-19 were also recorded in the 2016-2020 data, but the number of cases (6 and 14) were too small to be calculated as a rate.

Emerging Issues Impacting Health Since Last CHA

The following are new or emerging health issues in our community in 2022 that were not identified as priorities in our CHA:

• Transylvania Public Health continued its response to the COVID-19 pandemic throughout 2022. A total of 3,552 cases, 70 hospitalizations, and 20 deaths among Transylvania County residents were reported from January 1 to December 31, 2022. Of these, 210 cases and 5 deaths were associated with 8 separate outbreaks at 5 skilled nursing and assisted living facilities and congregate living settings. Clusters of 5 or more cases were identified at 1 worksite, 1 college athletic team, 1 school athletic team, and 2 classrooms. Data integrity for cases and percent of positive tests decreased with the increased use of home tests.

• The nationwide infant formula shortage impacted WIC clients. Local WIC staff responded with increased contact with local vendors, frequent scans of store inventory, and communication to clients on where to access formula and alternatives to their regular brands and sizes as approved by a federal waiver.

• Our local vital records staff and funeral homes are moving ahead with use of the state's new electronic death certificate system. However, errors and other delays are creating problems for some families.

• Communicable disease staff monitored a county resident with recent travel to Uganda in connection to the Ebola outbreak starting in September. This person had no symptoms and no suspected exposures. Staff prepared for monkeypox response, but no cases were identified among county residents. One suspect case was assisted with accessing testing and follow-up. Staff identified multiple cases of Campylobacter, C. perfringens, Cryprosporidosis, Norovirus, probable E. coli, and Salmonella, including one case associated with a nationwide outbreak. In addition, staff identified cases of active and latent tuberculosis, haemophilus influenza, vector-associated encephalitis, Strep A invasive, and probable Creutzfeldt-Jacob. Cases of Hepatitis and sexually-transmitted diseases are trending downward.

New/ Paused/ Discontinued Activities Since Last CHA

The following are new initiatives or changes in our community in 2022:

• CARE Coalition received funding to support a behavioral health clinician and a re-entry coordinator for the county detention center late in 2021. Both positions were filled in 2022 and staff are working to support evidence-based treatment services to detainees with mental health and substance use disorders and to provide re-entry coordination and linkages to care to support recovery and reduce crime risk factors and recidivism. 

• Transylvania County is serving as the fiscal agent for $1 million in ARPA Public Health Workforce Initiative funding that will support workforce development for local public health departments in Region 1. This funding will support a regional project director and projects focused on shared communication efforts around regional health priorities and legal training for public health employees to be implemented through June 2023.

• A community collaborative was formed to bring together schools and community to support the emotional wellness of our school-aged youth. Known as TC STRONG, this collaborative began meeting in January 2022, with Transylvania Public Health, Transylvania County Schools, and The Family Place serving as lead organizations. The leadership team meets weekly; the steering team meets 6 times a year with delegates from schools, community sectors, parents, and youth themselves; and the "network" meets monthly with nearly 180 interested community members. TC STRONG prioritized, developed, and implemented a number of projects in 2022, and was awarded a $100,000 grant from Dogwood Health Trust to pursue project implementation and hire program staff. In addition, public health staff advocated for use of selected COVID-19 funding to support population-based mental health programs for students in K-12 school settings.

• Community interest is also growing for work around mental health for all ages, supported by a research project from Georgia Insititute of Technology to map access points for mental health care. An initial convening was scheduled for early 2023 to move forward.

• Transylvania Public Health began to ease its COVID-19 response efforts and return to normal operations for personal health services and immunizations. In early 2022, communicable disease staff continued work to track cases, conduct case investigations, perform contact tracing, keep an internal line list, and report to NCDHHS using the COVID-19 electronic surveillance system. The agency received assistance with contact tracing and case investigations through state CCTO contracts. Nurses continued to work with the county’s 6 skilled nursing and assisted living facilities to prevent and mitigate outbreaks. School nurses and the agency’s childcare consultant continued providing technical assistance and conducting case investigations and contact tracing for their populations. Staff also communicated guidance and provided technical assistance to the general public and to stakeholder groups including physicians, schools, churches, and businesses. As the year progressed, the scale and scope of these efforts began to be reduced in response to lower COVID-19 case numbers and as normal health department services began to resume. The agency continued offering COVID-19 vaccinations and boosters (along with flu vaccines) via in-office appointments. Transylvania Public Health provided a total of 1,281 COVID-19 vaccinations in 2022, including 187 first and second doses and 1,094 additional or booster doses. Uptake of the new bivalent vaccines and for vaccines for young children has been much lower compared to initial vaccines. Local data updates moved to a monthly distribution. COVID-19 vaccines remain available through in-office appointments that can be scheduled online or by phone. 

• WIC continued to offer its services via telephone, email, and automatic voucher renewal, and continued to maintain a client load of over 100% of the state allocation. WIC clients also continued to receive additional benefits.

• Affordable workforce housing remains a concern for residents and local government. Transylvania County SCORE hosted a roundtable to discuss barriers and strategies to overcome them in October. Two proposed sites for an affordable housing development were rejected, but a 60-unit complex to be constructed on Asheville Highway received $12 million in federal housing tax credits over 10 years through the North Carolina Housing Finance Agency. Applications for new septic and well installation remains high, which is indicative of demand for new residential construction.

Progress Made in 2023

Click on each program/strategy below to review progress and updates for 2023 under the "Progress Made in 2023" note tabs.

Mental Health

• Support implementation of mental health trainings for schools and community members

Substance Use

• Advocate for expanded access to substance use disorder treatment
• Offer alternatives to suspension for tobacco/vaping in schools

Obesity

• Support increased access to fruits and vegetables through food policy
• Encourage social support for physical activity

In addition, Transylvania County partnered with WNC Health Network and other counties in our region to support the "View From Here" social media campaign, which addresses the top three shared health priorities in our region (Substance Use, Mental Health, and Healthy Eating/Active Living), as well as COVID/Flu Vaccinations.

Significant/Notable Changes in Morbidity and Mortality

The following represent significant or notable morbidity and mortality changes in our community in 2023:

• Transylvania County was ranked #19 in the state for overall health outcomes and health factors, down slightly from #18 in 2022. (Source: 2023 County Health Rankings, Robert Wood Johnson Foundation)
  • Fewer county residents reported being in poor or fair health (13% in 2023 compared to 18% in 2022).
  • Adult obesity has declined from 32% in 2022 to 29% in 2023. Transylvania residents have a healthier food environment, less physical inactivity, and more access to exercise opportunities.
  • Although rates of excessive drinking remain steady and higher than state and national rates, alcohol-impaired driving deaths are about half of the state and national rates.
• Public health staff were notified of and investigated nearly 350 cases of communicable disease in 2023. (Source: 2023 Communicable Disease Report, Transylvania Public Health) Notable trends and data include the following:
  • Total numbers of sexually-transmitted diseases among Transylvania County residents increased slightly from 2022, but remain lower than the high in 2019 and much lower than state rates. (However, these data could be under-reported due to limited access to testing services in recent years caused by COVID-related interruptions.)
  • Staff initiated 190 rabies investigations in 2023, up from 146 in the previous year. No animals tested positive for rabies and 15 individuals started post-exposure prophylaxis.
  • Staff investigated several cases of tick-borne disease, including 6 Lyme disease and 5 Spotted Fever Rickettsiosis. No cases of encephalitis were reported in 2023.
  • A total of 3 cases of toxic shock syndrome were reported in 2023, including 2 cases of streptococcal TSS.
  • There were no cases of pertussis reported to public health for the first time in a decade. 
• Overall cause of death data from the NC Center for Health Statistics is now available for the years 2017-2021. This data shows some notable trends compared to the data reported in the 2021 Community Health Assessment for years 2015-2019. (Source: 2023 County Health Data Book, North Carolina State Center for Health Statistics)
  • Cancer and heart disease continue to be the leading causes of death. Deaths from heart disease increased, but remain well below the state rates.
  • Trends are improving for all three causes of death where Transylvania County rates were higher than state rates in the 2015-2019 data. The death rate from chronic liver disease and cirrhosis and for all other unintentional injuries are now lower than the state rate. The number of deaths from suicide fell from 40 over 5 years to 33 over 5 years; the death rate decreased from 10.4 points higher than the state rate to only 3.9 points higher.
  • Deaths from chronic lower respiratory disease fell, but the age-adjusted rate increased slightly. It continues to remain lower than the state rate.
  • The number of deaths and age-adjusted death rates from Alzheimer's disease, diabetes, and nephritis all decreased.
  • Septicemia deaths were not included as a leading cause of death for 2016-2020. The county rate is increasing, but remains lower than the state rate. 
  • Deaths from COVID-19 were not included in the 2015-2019 data. In 2016-2020, the number of cases (14) was too small to be calculated as a rate. For 2017-2021, the county rate was about half of the state rate.

Emerging Issues Impacting Health Since Last CHA

The following are new or emerging health issues in our community in 2023 that were not identified as priorities in our CHA:

• Environmental health staff are seeing increased numbers of repair requests for on-site wastewater (septic) systems. This is mostly due to failures of older systems as they age, systems being used for purposes other than their intended use (e.g. more water flow, more residents, commercial versus residential), and the overall number of systems that increases every year.

• WIC caseloads have dropped to pre-COVID levels after the required return to in-person services, resulting in fewer women, infants, and children being served each quarter. However, breastfeeding rates among local WIC clients remain significantly higher than the state with support from the agency's Breastfeeding Peer Counselor.

• Affordable workforce housing remains a concern for residents and local government. The City of Brevard is continuing to work on possible sites for development. Applications for new septic and well installation remain high, which is indicative of demand for new residential construction. However, properties in Transylvania County are becoming increasingly harder to evaluate and permit for on-site systems, as the "easy" sites have been built on already.

• Traffic volume on major roadways in Transylvania County has increased, but remains lower than the state and nation. Changes to traffic patterns by the installation of roundabouts on main thoroughfares and bumpouts in downtown have increased safety and walkability, but have also caused concerns among local residents about expense, inconvenience, and the loss of parking spaces.

New/ Paused/ Discontinued Activities Since Last CHA

The following are new initiatives or changes in our community in 2023:

• Transylvania Public Health transitioned its response to the COVID-19 pandemic into a routine part of public health activities. In response to testing and reporting changes at the national and state level, staff ended local data reporting and shifted away from case investigation activities. The agency offered COVID-19 vaccines in early 2023 with little uptake, and opted to not provide the 2023 single-strain vaccine due to distribution and sourcing requirements. COVID-19 vaccine records were integrated into North Carolina's regular vaccine registration system. TPH began resuming normal operations around clinical services and expanded outreach and education efforts to encourage client participation. WIC clients retuned to in-person services in fall 2023 and continued to receive additional benefits for fruits and vegetables.

• CARE Coalition is assisting the county with the allocation process for national Opioid Settlement Funds. This includes coordinating the stategic planning process and developing recommendations based on local needs, best practices, impacts, and a cost-benefit analysis. CARE staff hosted a "Community Information Session" in November 2023 to share these recommendations with the public and local decision-makers. They presented the recommendations to the Board of Commissioners in December 2023 and have been available to answer questions from commissioners and county personnel as they determine the best use of the settlement funds.

• TC STRONG hired its first full-time director and half-time support staff in early 2023. These staff, along with lead organization personnel and community volunteers, have shared information at community and school events; provided training for school staff, community members, and youth; facilitated small groups; and supported wellness clubs (Voice of the Students) in local middle and high schools, with an estimated reach of 10,000 total contacts. TC STRONG was selected as 1 of 15 teams across the state to participate in a suicide prevention initiative by Carolina Across 100 and the UNC Suicide Prevention Institute. In November, the collaborative was awarded a 3-year, $300,000 grant from Dogwood Health Trust to support mental health and wellness for staff and students attending out-of-school programs. This funding also expanded the half-time position into a full-time Training and Project Manager. 

• Work continued on mental health support for all ages, dubbed "TREND 2.0" after a former mental health agency that served the county until the 1990s. Several meetings were held to begin projects around an interactive directory of mental health services, 

• Transylvania Public Health continued to lead the regional Workforce Development Agreement Addredum, which provided legal training to local public health staff (including 13 from TPH); developed a Public Health Workforce Strategic Plan to support interest, training, and competitive compensation for public health jobs; and supported a regional public health communications campaign developed and disseminated through WNC Health Network.

• CARE Coalition's partnership with the Transylvania County Sheriff's Office to provide counseling and re-entry support at the local detention center served 181 detainees in its first year of operations. This effort was highlighted in the 2023 Re-Entry Convening report from Appaclachia Funders Network, and staff have provided assistance to other counties around starting similar programs.