Cape Girardeau County, Missouri

Community Health Needs Assessment

This assessment will identify the health esidents needs of the r of Cape Girardeau County, Missouri, and those needs will be prioritized and recommendations programs will be made for to be implemented to meet these . needs

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Table of Contents

LIST OF FIGURES ...... 5

LIST OF TABLES ...... 6 EXECUTIVE SUMMARY ...... 8

KEY FINDINGS ...... 10 PRIORITY NEEDS ...... 12

CHAPTER 1: COMMUNITY HEALTH NEEDS ASSESSMENT INTRODUCTION AND METHODS ...... 13

COMMUNITY H EALTH N EEDS A SSESSMENT D ESCRIPTION ...... 13 COMMUNITY H EALTH N EEDS A SSESSMENT R EQUIREMENTS ...... 13 IMPLEMENTATION S TRATEGY R EQUIREMENTS ...... 14 COMMUNITY H EALTH N EEDS A SSESSMENT P ROCESS ...... 15 Defining “Community” ...... 15 Identifying Partners and Individuals Representing the Broad Interests of the Community ...... 15 Gather Available Data and Current Assessments ...... 16 Develop and Conduct Primary Research ...... 17 Aggregate Primary and Secondary Research ...... 17 Identify and Prioritize the Health Needs in the Community ...... 17 Develop and Implement a Strategy to tified Address the Iden Priority Health Issues ...... 18 Widely Disseminate the CHNA...... 18 CHAPTER 2: COMMUNITY PROFILE ...... 19

BACKGROUND I NFORMATION FOR C APE G IRARDEAU C OUNTY ...... 19 City of Cape Girardeau ...... 19 City of Jackson ...... 20 Smaller Cities and Towns in Cape Girardeau County ...... 20 DEMOGRAPHIC C HARACTERISTICS ...... 21 Population Growth ...... 21 Race ...... 21 Ethnicity ...... 22 Age Distribution ...... 22 Gender ...... 23 Household/Family Configuration ...... 24 Religion ...... 24 SOCIAL C HARACTERISTICS ...... 25 Education ...... 25 Language ...... 27 Literacy ...... 28 Marital Status ...... 28 ECONOMIC C HARACTERISTICS ...... 28 Income ...... 28 Employment ...... 29 Poverty Status ...... 29

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Medicaid and ublic P Assistance Participation ...... 30 Hunger and Food Uncertainty ...... 31 Women, Infants, and Children (WIC) Participation...... 31 Housing ...... 31 Transportation ...... 32 ENVIRONMENT ...... 32 Water Quality ...... 32 Air Quality ...... 33 Lead Poisoning ...... 34 BUILT E NVIRONMENT ...... 34 Healthy Food Availability ...... 34 Recreational Activities Available ...... 34 PUBLIC S AFETY ...... 35 Crime Index ...... 35 Juvenile Crime Rates ...... 36 FAMILY AND D OMESTIC V IOLENCE ...... 36 Child Abuse and Neglect ...... 36 Child Out-‐of-‐Home Placement ...... 37 Domestic Violence ...... 37 HEALTH P ROMOTION ...... 38 Community Health Programs ...... 38 HEALTH C ARE S YSTEM ...... 39 Access to Health Care ...... 39 Uninsured Population ...... 39 Health are C Providers ...... 39 Community Health Resources/Services ...... 44 Emergency Services ...... 44 Long-‐Term Care Facilities ...... 47

CHAPTER 3: HEALTH OUTCOMES ...... 48

MORTALITY ...... 48 Leading Causes of Death ...... 48 Cancer ...... 49 Chronic Disease ...... 50 Years of Potential Life Lost...... 51 Infant Mortality ...... 51 Motor Vehicle Accidents ...... 52 MORBIDITY ...... 52 Obesity and Overweight ...... 52 Diabetes ...... 52 Infectious Disease ...... 53 Unintentional Injuries ...... 57 Health Status at Birth ...... 60 HEALTH S TATUS ...... 63 MENTAL H EALTH ...... 63 PREVENTABLE H OSPITALIZATIONS ...... 64

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CHAPTER 4: HEALTH HAVIORS BE ...... 65

DIET & EXERCISE ...... 65 TOBACCO U SE ...... 65 SUBSTANCE A BUSE ...... 65 MATERNAL H EALTH ...... 65 Prenatal Care ...... 65 Smoking during Pregnancy ...... 66 Breastfeeding ...... 66 SEAT B ELT U SE ...... 67 PREVENTION & SCREENING ...... 67 Preventative Practices ...... 68 Diabetes ...... 70

CHAPTER 5: HEALTH ASURES ME ...... 71

CHILD AND A DOLESCENT H EALTH ...... 71 Infant Immunization Rates ...... 71 Causes of Death – Child ...... 71 Causes of Death -‐ Adolescents ...... 72 Teen Substance Abuse and Smoking ...... 72 Teen Pregnancy ...... 73 STDs in Teens ...... 74 SENIOR H EALTH ...... 74 Missouri Senior Report ...... 74

CHAPTER 6: PRIMARY RESEARCH ...... 76

FOCUS G ROUPS ...... 76 Methodology ...... 76 Question -‐ 1 What do people in this community do to people stay healthy? How do get information about health? ...... 76 Question -‐ 2 In this group’s nion, opi what are the serious health problems in your community? What are some of the causes of these problems?...... 77 Question -‐ 3 What keeps people in your community hy? from being healt ...... 77 Question -‐ 4 What could be done to solve these problems?...... 78 Question -‐ 5 Is there any group not receiving enough health care? If so, why? ...... 79 Question -‐ 6 Of all the issues we have talked ssues about today, what i do think you are the most important for your community to address? ...... 79 Checklist Exercise ...... 79 SURVEYS ...... 80 Survey Layout and Design ...... 80 Methodology ...... 81 Participants ...... 81 Access to Health Services ...... 84 Health Beliefs and Behaviors ...... 87 Health Issues ...... 92 Community Health Concerns ...... 94

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CHAPTER 7: SUMMARY OF FINDINGS ...... 100

USING THE D ATA TO D ETERMINE N EEDS ...... 100 SECONDARY D ATA ...... 100 PRIMARY D ATA ...... 101 CONCLUSION ...... 102 APPENDIX – A SURVEY ...... A-‐1

APPENDIX -‐ B FOCUS GROUP QUESTIONS ...... B-‐1 APPENDIX – C FOCUS GROUP PARTICIPANT INFORMATION ...... C-‐2

APPENDIX – D SURVEY TRACKING DATABASE ...... D-‐1

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List of Figures FIGURE 1: POPULATIONS OF C APE G IRARDEAU C OUNTY C ITIES/TOWNS/VILLAGES ...... 20 FIGURE 2: CAPE G IRARDEAU C OUNTY P OPULATION ...... 21 FIGURE 3: RACE D ISTRIBUTION OF C APE G IRARDEAU C OUNTY -‐ 2010 ...... 21 FIGURE 4: HISPANIC M AKEUP OF C APE G IRARDEAU C OUNTY . VS MISSOURI – 2010 ...... 22 FIGURE 5: AGE D ISTRIBUTION FOR C APE G IRARDEAU C OUNTY C OMPARED TO M ISSOURI -‐ 2010 ...... 22 FIGURE 6: PERCENTAGE OF P OPULATION – MALE . VS FEMALE – CAPE G IRARDEAU C OUNTY . VS MISSOURI -‐ 2010 ...... 23 FIGURE 7: HOUSEHOLDS BY T YPE – CAPE G IRARDEAU C OUNTY . VS MISSOURI – 2010 ...... 24 FIGURE 8: MEMBERSHIP BY R ELIGIOUS C ONGREGATION – 2010 – CAPE G IRARDEAU C OUNTY ...... 24 FIGURE 9: EDUCATIONAL A TTAINMENT (P OPULATION 25 YEARS AND OLDER) – CAPE G IRARDEAU VS. MISSOURI -‐ 2010 ...... 25 FIGURE 10: HIGH S CHOOL D ROPOUT R ATES BY C APE G IRARDEAU C OUNTY S CHOOL D ISTRICTS VS. MISSOURI ...... 26 FIGURE 11: DROPOUT R ATES PER R ACE/ETHNICITY FOR C APE G IRARDEAU C OUNTY S CHOOL D ISTRICTS VS. MISSOURI -‐ 2011 ...... 26 FIGURE 12: DEMOGRAPHIC B REAKDOWN OF C APE AND J ACKSON S CHOOL D ISTRICTS BY R ACE . VS MISSOURI -‐ 2011 ...... 27 FIGURE 13: LANGUAGE S POKEN AT H OME – MISSOURI & CAPE G IRARDEAU C OUNTY ...... 27 FIGURE 14: MARITAL S TATUS (POPULATION 15 YEARS AND OLDER) – CAPE G IRARDEAU C OUNTY . VS MISSOURI -‐ 2010 ...... 28 FIGURE 15: CHANGE IN P ER C APITA I NCOME FROM 2008 – 2009 – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 28 FIGURE 16: UNEMPLOYMENT R ATES FOR C APE G IRARDEAU C OUNTY . VS MISSOURI: 2006-‐2010 ...... 29 FIGURE 17: MEDICAID P ARTICIPATION BY R ACE AND A GE FOR C APE G IRARDEAU C OUNTY AND M ISSOURI -‐ 2008 ...... 30 FIGURE 18: PERCENTAGE OF S TUDENTS E NROLLED IN F REE/REDUCED L UNCH P ROGRAM BY S CHOOL D ISTRICT IN C APE G IRARDEAU COUNTY . VS MISSOURI ...... 31 FIGURE 19: CHILD A BUSE & NEGLECT (R ATE PER 1,000 CHILDREN) – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 37 FIGURE 20: OUT-‐OF-‐HOME P LACEMENT E NTRIES (R ATE PER 1,000 CHILDREN) – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 37 FIGURE 21: INFANT M ORTALITY R ATE – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 52 FIGURE 22: DEATH R ATE BY U NINTENTIONAL I NJURY T YPE (2007 -‐2009) – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 58 FIGURE 23: ER VISITS R ATE BY U NINTENTIONAL I NJURY T YPE (2007 -‐2009) – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 58 FIGURE 24: HOSPITALIZATIONS R ATE BY U NINTENTIONAL I NJURY T YPE (2007 -‐2009) – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 59 FIGURE 25: WORK I NJURIES R ATE – MACHINERY T YPE – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 59 FIGURE 26: LOW B IRTH W EIGHT P ERCENT – CAPE G IRARDEAU C OUNTY VS. MISSOURI ...... 60 FIGURE 27: PRETERM B IRTHS (P ERCENT OF TOTAL LIVE BIRTHS) – CAPE G IRARDEAU C OUNTY . VS MISSOURI – 3 YEAR M OVING A VERAGE ...... 61 FIGURE 28: BIRTH D EFECTS R ATE ( PER 10,000 LIVE BIRTHS) – CAPE G IRARDEAU C OUNTY . VS MISSOURI – 3 YEARS M OVING A VERAGE 62 FIGURE 29: PERCENTAGE OF M OTHERS THAT S MOKED D URING P REGNANCY – CAPE G IRARDEAU C OUNTY . VS MISSOURI – 3 YEAR MOVING A VERAGE ...... 66 FIGURE 30: RATE OF MOTHERS WHO BREASTFED S THEIR BABIE SOMETIME DURING – INFANCY CAPE G IRARDEAU C OUNTY . VS MISSOURI 67 FIGURE 31: UP-‐TO-‐DATE ON I MMUNIZATIONS (R ATE PER 100 INFANTS) – WIC INFANT P ARTICIPANTS – CAPE G IRARDEAU C O. & MISSOURI ...... 71 FIGURE 32: BIRTHS TO T EENS (R ATE PER 1,000 FEMALES AGES 15 -‐19) – CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 73

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List of Tables TABLE 1: ZIP CODES IN C APE G IRARDEAU C OUNTY ...... 20 TABLE 2: % BELOW P OVERTY L EVEL B ROKEN O UT BY C EACH ITY IN C APE G IRARDEAU C OUNTY ...... 29 TABLE 3: % BELOW P OVERTY L EVEL BY O THER C ATEGORIES ...... 30 TABLE 4: PUBLIC D RINKING W ATER S YSTEM V IOLATIONS C APE G IRARDEAU C OUNTY, 2006 -‐ 2011 ...... 33 TABLE 5: OFFENSES AND A RRESTS BY C RIME T YPE IN C APE G IRARDEAU C OUNTY -‐ 2009 ...... 36 TABLE 6: JUVENILE C OURT R EFERRALS -‐ CAPE G IRARDEAU C OUNTY . VS MISSOURI -‐ 2009 ...... 36 TABLE 7: DOMESTIC V IOLENCE I NCIDENTS IN C APE G IRARDEAU C OUNTY -‐ 2009 ...... 38 TABLE 8: DENTISTS IN C APE G IRARDEAU C OUNTY THAT A CCEPT MO HEALTHNET (M EDICAID) ...... 43 TABLE 9: OPTOMETRISTS IN C APE G IRARDEAU C OUNTY THAT A CCEPT MO HEALTHNET (M EDICAID) ...... 44 TABLE 10: FIRE D EPARTMENTS IN C APE G IRARDEAU C OUNTY, MISSOURI & EMERGENCY M EDICAL R ESPONSE A GENCIES ...... 45 TABLE 11: LONG -‐ TERM C ARE F ACILITIES IN C APE G IRARDEAU C OUNTY, MISSOURI ...... 47 TABLE 12: LEADING C AUSE OF D EATH P ROFILE 1999 -‐ 2009 (RATES PER 100,000 POPULATION) -‐ CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 48 TABLE 13: CAPE G IRARDEAU C OUNTY, TOP T EN C ANCER I NCIDENCE S ITES (2004 -‐2008) ...... 49 TABLE 14: CHRONIC D ISEASE C OMPARISON: CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 50 TABLE 15: NEW & LIVING HIV & AIDS CASES & RATES FOR C APE G IRARDEAU C OUNTY . VS MISSOURI, 2010 ...... 56 TABLE 16: PREVENTABLE H OSPITALIZATIONS 2009 -‐ CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 64 TABLE 17: 2007 HEALTH & PREVENTATIVE P RACTICES -‐ CAPE G IRARDEAU C OUNTY . VS MISSOURI ...... 68 TABLE 18: CAUSES OF D EATH: AGES 1-‐ 14 ...... 71 TABLE 19: CAUSES OF D EATH: AGES 15 -‐19 ...... 72 TABLE 20: CURRENT S UBSTANCE U SE FOR G RADES 6 -‐12 – CAPE G IRARDEAU C OUNTY & MISSOURI ...... 72 TABLE 21: SEXUALLY T RANSMITTED D ISEASES: AGES 15 -‐19 ...... 74 TABLE 22: QUALITY OF L IFE FOR S ENIORS ...... 75 TABLE 23: HEALTH AND W ELLNESS FOR S ENIORS ...... 75 TABLE 24: CAPE G IRARDEAU C OUNTY R ESULTS ...... 80 TABLE 25: GENDER ...... 82 TABLE 26: YOUR RACE/ETHNICITY ...... 82 TABLE 27: AGE ...... 82 TABLE 28: RACE/ETHNICITY OF C HILDREN L IVING AT H OME ...... 82 TABLE 29: MARITAL S TATUS ...... 82 TABLE 30: EDUCATION L EVEL ...... 82 TABLE 31: ANNUAL H OUSEHOLD I NCOME ...... 82 TABLE 32: EMPLOYMENT S TATUS ...... 83 TABLE 33: NUMBER OF P EOPLE C URRENTLY L IVING IN H OUSEHOLD ...... 83 TABLE 34: NUMBER OF A DULTS 65 AND O LDER C URRENTLY L IVING IN H OUSEHOLD ...... 83 TABLE 35: NUMBER OF C HILDREN U NDER 18 CURRENTLY L IVING IN H OUSEHOLD ...... 84 TABLE 36: WHAT KINDS OF CE INSURAN DO ( YOU AND/OR YOUR FAMILY) CURRENTLY HAVE? ...... 84 TABLE 37 : SELECT THE PREVENTIVE PROCEDURES YOU HAD HAVE IN THE LAST : YEAR ...... 85 TABLE 38: WHERE DO YOU OUTINE GO FOR R HEALTH ? CARE ...... 86 TABLE 39: IF YOU ANSWERED SELDOM OR , NEVER WHY? ...... 86 TABLE 40: WHAT SERVICES DO SEEK YOU OUTSIDE THE COUNTY? ...... 87 TABLE 41: WHY DO OU Y TRAVEL OUTSIDE THE COUNTY? ...... 87 TABLE 42: WHAT IS YOUR CURRENT HEALTH ? STATUS ...... 87

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TABLE 43: SAFETY B EHAVIOR ...... 88 TABLE 44: HEALTHY L IFESTYLE B EHAVIORS ...... 89 TABLE 45: SMOKE C IGARETTES ...... 89 TABLE 46: HEALTHY L IFESTYLE B EHAVIORS ...... 90 TABLE 47: HYGIENE/COMMUNICABLE D ISEASE C ONTROL ...... 90 TABLE 48: GET A FLU SHOT EACH YEAR ...... 91 TABLE 49: HYGIENE/COMMUNICABLE D ISEASE C ONTROL ...... 91 TABLE 50: MENTAL H EALTH I SSUES AND B EHAVIORS ...... 91 TABLE 51: MENTAL H EALTH I SSUES AND B EHAVIORS ...... 92 TABLE 52: ENVIRONMENTAL/HOME S AFETY ...... 92 TABLE 53: HEALTH I SSUES ...... 93 TABLE 54: PUBLIC S ERVICES C ONCERNS ...... 95 TABLE 55: CRIME & VIOLENCE C ONCERNS ...... 95 TABLE 56: SAFETY B EHAVIORS ...... 96 TABLE 57: HEALTH B EHAVIORS ...... 96 TABLE 58: HEALTH C ARE & SUPPORT S ERVICES C ONCERNS ...... 97 TABLE 59: ENVIRONMENTAL P ROTECTION C ONCERNS ...... 97 TABLE 60: HEALTH C ONDITIONS/ DISEASES C ONCERNS ...... 98 TABLE 61: MENTAL H EALTH C ONCERNS ...... 98 TABLE 62: SOCIAL & ECONOMIC I SSUES C ONCERNS ...... 99

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Executive Summary The two -‐ not for-‐profit hospitals in the city of Cape Girardeau, Saint Missouri, Francis Healthcare System and SoutheastHEALTH were partners in conducting Community this Health Needs Assessment (CHNA). Community Health Needs Assessment Process and Requirements A CHNA must be conducted every three -‐ years by not for-‐profit hospitals in order to comply with federal tax-‐exemption requirements under the Affordable Care Act. Following the CHNA, the hospital must adopt an implementation strategy to meet the community health needs identified through the assessment, and it must report how it is addressing the needs identified in the CHNA and provide a description of needs that are not being addressed with the reasons why such needs are not being addressed. The ultimate purpose of the CHNA is to improve community health. The Community Health Needs Assessment process s consist of the following steps: 1. Define the community ed serv by the hospital facility 2. Identify the partners and individuals representing the broad interests of the community 3. Gather available data and current assessments 4. Develop and conduct primary research 5. Aggregate primary and secondary research 6. Identify and oritize pri the health needs in your community 7. Develop and implement a strategy to tified address the iden priority health issues 8. Widely disseminate the CHNA All steps were completed for this assessment mplementation except that the i strategy is not included. That step will be completed separately by each hospital partner based on review of the CHNA. Community Profile Cape Girardeau County is located in southeast Missouri along the Mississippi River. The population of the county is currently 75,674. Whites mprise co 88.7% of the total population, ed with 7% compris of African Americans. The county has a higher percentage of ation, the younger popul ages – 15 24 than does the state of Missouri. Nearly 86% of esidents Cape Girardeau County r 25 years and over have graduated from high school, with 31.5% going on to receive a post-‐secondary degree. The unemployment rate was 7.6% in 2010, which is than considerably lower Missouri’s 9.4%. Cape Girardeau County has 14.2% of residents with in poverty, nearly 14% Med on icaid, 12% on Food Stamps, and 15% uninsured. The city of Cape Girardeau of offers an abundance health care providers as well two medium-‐sized not-‐for-‐profit hospitals, a county health department, a health federally qualified center, a free clinic, emergency services, and long-‐term care facilities. The community profile chapter also includes social, economic, and environmental ics, characterist information on public safety and crime, and community health programs. Health Outcomes The Health Outcomes chapter contains information on mortality, including leading causes of death, cancer incidence, chronic disease, infant mortality, and vehicle accidents, and on morbidity, including obesity, diabetes, infectious disease, unintentional injuries, lth and hea status at birth. The chapter also contains information on mental health and hospitalizations. preventable The leading causes of Cape death in Girardeau County are :

• Heart Disease 32% • All Cancers (Malignant Neoplasms) 21%

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• Stroke/Other Cerebrovascular Disease 7% • All Injuries and Poisonings 5% • Chronic Lower Respiratory Disease 5% Health Behaviors The chapter on Health Behaviors is comprised of information on diet and exercise, tobacco use, substance abuse, maternal health, and prevention and screening. In Cape Girardeau County, 28% of residents are physically inactive, 72% eat less than five fruits and vegetables per day, and 18% smoke cigarettes. Health Measures The chapter on Health Measures includes data ant regarding inf immunization , rates causes of death for children and adolescents, teen substance abuse, teen pregnancy, STDs in teens, and the health of senior citizens. The main causes of death for children and adolescents are unintentional injuries and motor vehicle accidents; however, “all cancers” as a cause of death rardeau is higher in Cape Gi County than the state of Missouri. Teen substance abuse is also a great concern as the percentage of in substance use the past 30 days is higher for most substances in Cape Girardeau County than in Missouri. Primary Research Five ocus f groups were held in Cape Girardeau County asked and the questions can be found below. Summaries of these focus groups are included in Chapter 6. 1. What do people in this community do to stay healthy? How do get people information about health? 2. In this group’s opinion, what are the serious health problems in your community? What are some of the causes of these problems? 3. What keeps people in your community hy? from being healt 4. What could be done to problems? solve these 5. Is there any group not receiving enough health care? If so, why? 6. Of all the issues we have talked ssues about today, what i do you think are the most important for your community to address? 118 surveys were completed by Cape Girardeau idents. County res The survey was very extensive and consisted of five different sections. The survey demographics were representative ardeau of Cape Gir County’s population. 1. Multiple Choice: questions to collect information on demographics, health care access, health status, and insurance. 2. Health Behaviors: questions to collect health behavior information. 3. Children’s Health Behaviors: questions to collect health behavior information about the participants’ children applicable if . 4. Health Issues: questions participants the about having particular health issues. 5. Community Health Concerns: questions the participants to choose how much of a problem they think particular issues are in their community. Summary of Findings The Summary of Findings chapter simply summarizes the needs determined by the assessment and how those needs were determined.

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Key Findings The following s list represent the key findings of this Community Health Needs Assessment by type of need: Health Needs • Cancer (leading cause of death) • Diabetes (leading cause of death) • High Blood Pressure/Strokes (leading cause of death) • Heart Disease (leading cause of death) • Overweight Adults • Overweight Children • Mental Health – anxiety and depression, poor mental health days, oviders mental health pr • Injuries/Poisonings (leading cause of death) • Chronic Lower Respiratory Disease (leading cause of death) • Alzheimer’s (leading cause of death) • Unintentional Injuries (leading cause of death) • Infectious Disease (Influenza) • High Cholesterol • Dental Health • Autism • Chronic Pain • Asthma/Respiratory Disorders (especially in children) • Sexually Transmitted Infections (especially in adolescents) • Allergies (especially food allergies in children) • Health Status at -‐ Birth low birth weight, preterm births, birth defects • Preventable Hospitalizations -‐ bacterial eumonia pn and congenital syphilis • Cause of Death for C hildren and A dolescents -‐ all cancers (malignant neoplasms) Behavioral Needs • Preventive Practices -‐ women age 18 and older who never had a pap smear and no pap smear in the last three years • Smoking • Alcohol/Drug Use • Poor Diet • No Exercise • Poor Lifestyle • Teen Substance Abuse -‐ use of cigarettes, alcohol, prescription drugs, marijuana , heroin, bath salts and binge drinking • Maternal Health –no prenatal care, living an unhealthy smoking lifestyle, and and using drugs while pregnant • Eating Disorders Community Needs • Access to Specialists for Medicaid/Uninsured • Child Abuse and Neglect – including Child Out of Home Placement • Domestic Violence

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• Health Care Affordability • Health Care Availability • Teen Pregnancy • Transportation (public) • Unemployment • Mosquitos • Job Availability • Job Security • Crime – theft offense rate • Juvenile Court Referrals – truancy and habitually absent from home • Property and Violent Crime committed against senior citizens • Housing Affordability • Racism • Child Care/Day Care • Murder or Intentional Injury • Secondhand Smoke • EMS called out for non-‐emergencies or repeat patients • High School Dropout -‐ Rate Cape Girardeau School District 63 cs for Hispani and Blacks • Food Stamps/SNAP – received by high a percentage of Cape Girardeau County residents • Free/Reduced-‐Lunch Program -‐ high percentage of Cape Girardeau School District 63 students enrolled • Lack of Communication and Resources • Lack of Education and Awareness • Unsafe Neighborhoods

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Priority Needs Prioritization Process

Members of the CHNA Team analyzed survey data, focus group data, and secondary data in the report to prioritize the community health needs for The each county. priority needs were fir st identified by the primary research or what the community finds most . important These high priority needs were then validated by the secondary – research looking at the community’s statistics and trends against the state’s statistics and trends. The priority needs were also based on he whether or not t hospital has the ability to have an impact on the need. Top 5 Priority Needs (and Associated Behavioral Needs) • Cancer (Smoking) • Obesity (Diet and Exercise) • Chronic Disease o Stroke (Healthy Lifestyle) o Heart Disease (Smoking) o Diabetes (Diet and Exercise) o Chronic Respiratory Disease (Smoking) • Substance Abuse/Mental Health (Drug and Alcohol, Anxiety and Depression) • Health Care Affordability (Uninsured)

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Chapter 1: Community Health Needs Assessment Introduction and Methods

Community Health Needs Assessment Description A community health needs assessment (CHNA) is a systematic process involving the community, to identify and analyze community health needs and assets in order to prioritize these needs, and to plan and act upon unmet community health needs.

Value of a Community Health Needs Assessment y to the Communit County  To share Background the assessment Information process and findings with the county residents and to educate local residents, health care providers, and students regarding pressing health problems  To empower community members to act on issues of concern  To identify emerging issues, to provide iding data for dec programmatic/organizational decisions, and to plan effective, Population collaborative Characteristics interventions to promot and Demographicse better health  To advocate for community change with d politicians an other local decision-‐makers  To promote collaboration and partnership nity among commu members and groups  To furnish a baseline by which to monitor changes  To serve as a reference d point an a historical perspective for future assessments  To provide a resource for activities such as writing grant applications

 To serve as a model for other counties who are planning an assessment

Source: North Carolina Public Health Community Health Assessment Guide Book

Community Health Needs Assessment Requirements A CHNA must be conducted every not three years by -‐for-‐profit hospitals in order to comply with federal tax-‐exemption requirements under the Affordable Care t Act. The firs CHNA must be completed by the end of the first taxable year beginning after March 23, 2012. The CHNA must take into account input from persons who represent the broad interests of the community tal served by the hospi facility, including those with special knowledge of or expertise in public health; and it must be made widely available to the public. Following the CHNA, the hospital must adopt an implementation strategy to meet the community health needs identified through the assessment, and it must report how it is addressing the needs identified in the CHNA and provide a description of needs that are not being addressed with the reasons why e such needs ar not being addressed. The ultimate purpose of the CHNA is to improve community health. The documentation of the CHNA must include the following information: 1. A description of the community served by the hospital it facility and how was determined 2. A description of the process and methods used to conduct the assessment, including: a. A description of the sources and dates of the data ed and other information us in the assessment, including primary and secondary sources b. The analytical methods applied to community identify health needs c. Information gaps that affect the hospital’s ability to assess the community’s health needs d. If a hospital collaborates with other organizations in conducting a CHNA, the report should then identify all of the community organizations that collaborated with the hospital e. If a hospital contracts with one or more third parties to assist in conducting a CHNA, the report should also disclose the identity and qualifications of the third parties

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3. A description of the approach used to op, plan, devel and conduct the assessment and how the hospital organization took into account input from individuals who represent the broad interests of the community served by the , hospital facility including: a. A description of when and how the organization d consulte with these individuals (whether through meetings, focus groups, interviews, written surveys, correspondence, etc.) b. Community leaders who were consulted and/or collaborated in the planning and implementation process c. Justification of why data sources were used and selected d. Justification of the approach for primary data collection e. Explanation of successful and non-‐successful approaches to seek broad-‐based community input, especially underserved or high-‐risk groups within the community f. If the hospital nto takes i account input from an , organization the written report should identify the organization and provide the name and title of at least one individual in that organization who consulted with the hospital g. Identification of any individual providing has input who special knowledge of or expertise in public health, and the report should list those people by name, title, affiliation, and include a brief description of the individual’s special knowledge or expertise 4. A prioritized description of all the community health needs identified through the CHNA, as well as a description of the process and criteria izing used in priorit such health needs a. Priorities identified through primary and secondary data b. Other processes used to rank priorities 5. A description of existing the health care facilities and other resources ommunity within the c available to meet the community health needs the identified through CHNA

Implementation Strategy Requirements The IRS guidance specifies that the CHNA results must be used to an develop implementation strategy that must be adopted by the hospital. The implementation strategy is defined as a written plan that addresses each of the community health needs that through were identified the assessment. Each hospital organization must the meet requirement to adopt an implementation strategy separately with respect to each hospital facility it operates. The Treasury and IRS expect the implementation strategy to: 1. Describe how the hospital facility plans to meet the health need; or 2. Identify the health need as one the hospital facility does not intend to meet and explains why the hospital facility does not intend to meet the health need In describing how a hospital facility plans to meet a health need identified through a CHNA, the implementation strategy must tailor the description to the facility, particular hospital taking into account its specific programs, resources, and priorities. The implementation strategy should also describe any planned collaboration with governmental, -‐ non profit, or other health care organizations, including related organizations, in meeting the health need. The IRS will allow hospital organizations ementation to develop impl strategies for their hospital facilities in collaboration with other organizations, including related organizations, other hospital organizations, for-‐profit and government hospitals, and state and local s agencies, such a local health departments. If a hospital does collaborate with other organizations in mentation developing an imple strategy, the strategy should identify all the organizations ch with whi the hospital collaborated.

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The implementation strategy is considered to be adopted on the date the implementation strategy is approved by an authorized governing body of ganization. the hospital or The authorized governing body means: 1. The governing body of the hospital organization (i.e. board of directors, board of trustees, or equivalent controlling body) 2. A committee of the governing body, which may be duals comprised of any indivi permitted under state law to serve on such committee, committee to the extent is permitted by state law to act on behalf of the governing body; or 3. To the extent permitted under state law, authorized other parties by the governing body of the hospital organization ct to a on its behalf by following procedures specified by the governing body in approving an implementation strategy The hospital organization must adopt an implementation ategy str to meet the community health needs identified in a CHNA by the taxable end of the same year in which it conducts that CHNA.

Community Health Needs Assessment Process The Community Health Needs Assessment process consist should of the following steps: 1. Define the community served by the hospital facility 2. Identify the partners and iduals indiv representing the broad interests of the community a. Individuals with special knowledge or expertise in public health b. Federal, tribal, regional, state, or local health or other departments or agencies, with current data or other information relevant to the health needs of the community served by the hospital facility c. Leaders, representatives, or members of medically underserved, low income and minority populations, as well as populations ronic with ch disease needs 3. Gather available data and current sments asses 4. Develop and conduct primary research 5. Aggregate primary and secondary research 6. Identify and prioritize the health needs in your community 7. Develop and implement a strategy to tified address the iden priority health issues 8. Widely disseminate the CHNA

Defining “Community” The two -‐ not for-‐profit hospitals in the city of Cape Girardeau, Saint Missouri, Francis Healthcare System and SoutheastHEALTH, made the decision to define “community” y as their primar service area, which consists of four counties: Cape Girardeau, Bollinger, Scott, and Stoddard. The primary service area for both hospitals is based on the number of inpatient visits discharges and outpatient by patients that reside in each of these four counties. For SoutheastHEALTH, 75% of its e patients ar from these four counties and for Saint Francis Healthcare System, 68% of its patients are from these four counties. This information is provided by the Hospital Industry Data Institute (HIDI) that is founded by the Missouri Hospital Association. each Since county differs greatly from one another aphics, in terms of demogr health care providers, education, etc., four separate sessment written as reports will be created and made available to the public identifying eds specific ne per county.

Identifying Partners and Individuals Representing the Broad Community Interests of the Saint Francis Healthcare System and SoutheastHEALTH (“Community Health Needs Assessment Team”) were partners in conducting this CHNA.

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The individuals representing the broad interests f o Cape Girardeau County included involving people from the following organizations when the primary research was conducted: • Cape Girardeau County Public Health Center • Cape Leaders Alliance • Cape Girardeau City Fire Department • Saint Francis Medical Center • SoutheastHEALTH • Samaritan Regional Health Clinic • City of Jackson • First Presbyterian Church • Jackson Chamber of Commerce • Jackson Family Care • Jackson R-‐2 Public School District • Jackson Senior Center • Oak Ridge -‐ R VI School District • Community Caring Council • Cross Trails Medical Center • MERS/Goodwill • City of Cape Girardeau • The Salvation Army • SEMO Area Agency on Aging • United Way of Southeast Missouri • Cape Girardeau Police Department • Family Support Division • St. Vincent de Paul Catholic Church Efforts were made lude to inc at-‐risk, targeted populations and principle specialty areas that are served by the hospital and present within the community, y such as the medicall underserved, low income persons, minority groups, and those with chronic disease needs.

Gather Available Data and Current Assessments Secondary data are existing data that are collected by someone else for a purpose other than the one being pursued. Secondary research was obtained from sources various credible and is included in this written assessment report. Some areas arched that were rese include demographics, the physical environment, social factors, the economy, the transportation system, the education system, the health care system, and public safety. The assessment ing also includes exist health status and public health data. Ex amples of the data sources used are as follows: • U.S. Census Bureau • Missouri Department of Health and Senior Services • Missouri Department of Elementary and ation Secondary Educ • Missouri Economic Research and Information RIC) Center (ME • U.S. Bureau of tatistics Labor S • Environmental Protection Agency • Centers for Disease Control and Prevention • University of Wisconsin’s County Health Rankings

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• Missouri Department of Mental Health • Missouri State Highway Patrol • Annie E. Casey Foundation Kids Count Data Center • Other Local Websites

Develop and Conduct Primary Research Primary data are data collected specifically for the purpose of answering project-‐specific questions. Primary data should be collected after the al collection and initi review of secondary data and should add breadth, depth, and qualitative information to the mary secondary data. Pri research was obtained in Cape Girardeau County through individu al public surveys and focus groups. Public Surveys Surveys provide a flexible means of assessing ive a representat sample of the population to gather information about attitudes and opinions, as well as measure behaviors and population characteristics. The individual survey that was used was created by the Community Health Needs Assessment Team and can be found Appendix in A. Advantages of surveying for individual responses include: • Obtaining direct feedback from clients, ts key informan and target populations about specific issues • Developing public awareness problems • Building a consensus for solutions or actions • Comparing the -‐ self reported incidence and prevalence with more sources objective data • Improving perception of quality of local health care services • Improving perception on the need of specific services either in existence or under consideration Focus Groups Group surveys in the form of focus conducted. groups were also A focus group is defined as people who possess certain similar characteristics that d are assemble as a group to participate in a focused discussion to help understand the topic of interest. in The questions asked each focus group can be found in Appendix B and a list of all focus group participants r along with thei experience, if any, can be found in Appendix C. Data was collected from the focus groups primarily through note-‐taking. A writing exercise was also handed out and completed regarding ’s each participant top 5 serious issues. Aggregate Primary and Secondary Research An Access Database was created for the survey d data to be entere and tracked. Screenshots of that tracking database n ca be found in Appendix D. The Community Health Needs Assessment Team entered the surveys into the CHNA Survey Tracking was Database, which a very tedious -‐ and time consuming process due to the amount of questions asked and vey. data collected by the sur llowing Fo the entry of all surveys, the data was then exported from ated Access and manipul into usable information in Excel. The survey data will ented be pres and discussed in Chapter 6 – Primary Research of this report. The information that was collected from the focus groups will also be presented and discussed in Chapter 6 – Primary Research of this report.

Identify and Prioritize the Health the Needs in Community From the analysis of this research, community ned needs were determi based on what the community finds most important and by what the community ng is most lacki in that could have an impact on the health of citizens. its These needs were primarily determined imary by the pr research – what the

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 17 community finds most important – along with tying that information to what the secondary research shows -‐ looking at the community’s statistics and trends against the state’s statistics and trends. Develop and Implement a Strategy to tified Address the Iden Priority Health Issues The implementation strategy will be developed separately by each hospital partner involved in creating this CHNA. Each hospital partner will will decide what needs be addressed and how those needs will be addressed.

Widely Disseminate the CHNA The CHNA is not considered “conducted” until the written report is made widely available to the public. Fulfilling the “widely available” requirement requires the following: 1. Posting the CHNA on a website that clearly informs users that the document is available and provides instructions for loading. down 2. The document is posted in a format that es exactly reproduc the image of the report when accessed, downloaded, viewed, and printed. 3. Allows individuals with Internet access to access, download, view, and print the report without the use of special hardware or software. 4. The hospital or other organization distributing the report will provide the direct website address to individuals who request a copy of the report. 5. The CHNA must remain widely available to l the public unti the next CHNA hospital for that is conducted and made widely available.

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Chapter 2: Community Profile Background Information for Cape Girardeau County Cape Girardeau County was officially formed in 1812 and is located in Southeast Missouri . The county was named after Ensign Sieur Jean Baptiste Girardot, a French officer that developed a trading post on the site of present day Cape Girardeau around 1733. The “cape” in the county name was after a rock bluff overlooking the Mississippi River and is the world’s only inland cape. Part of the actual cape was destroyed in the 1800s to make way for the railroads, yet a memorial “Cape Rock” sits at the top of the bluff that was used as the trading post. The county is bordered by the Mississippi River and the state of Illinois to the east, Perry County to the north, Scott County and a portion of Stoddard County to the south, and Bollinger County to the west. The land area of Cape Girardeau County is 579 square miles and the water area is 7.7 square miles. Interstate 55 is the major route running north and south through the county. State highways also run through the county connecting the smaller cities and towns, such as highways 72, 34, 25, and 61. The cities of Cape Girardeau and Jackson are the largest cities in the county, but other smaller cities in the county include: Delta, Gordonville, Oak Ridge, Pocahontas, Whitewater, Allenville, Dutchtown, and Old Appleton. The populations of these cities can be found in Figure 1 along with the population considered to be rural living outside of these cities. Approximately 70% of residents live in the areas of urban development, including the cities of Cape Girardeau and Jackson along with a other few smaller towns and villages . The population density in 2010 was 129 people per square mile. City of Cape Girardeau The largest city in the Cape county is Girardeau; however, county the seat is actually held by the city of Jackson . Cape Girardeau is located along the Mississippi River in the southeastern part of the county. Cape Girardeau became a river boom town when the steamboat arrived in 1835 and was the est busi port between St. Louis and Memphis. by After being occupied Union forces during the Civil War, Cape Girardeau saw continued establishment growth with the of public education in 1867, the introduction of rail services, and riculture with advances in ag and industry. In 1873, Southeast Missouri State University was founded as a teaching university. The city of Cape Girardeau has evolved from a tiny trading thriving, post to a culturally rich community of almost 38,000 residents, serving as a regional hub for education, commerce, and medical care: • Education includes a public and private high , school many elementary schools, a university, a college of nursing and health services, and several smaller trade schools/colleges.

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• Commerce is available throughout with a variety of grocery stores, restaurants, convenience stores, retail stores, and a large l. shopping mal • Medical care services range from two medium-‐sized hospitals to long-‐term care facilities to public health services to an abundance of specialists.

Figure 1: Populations of Cape Girardeau County lages Cities/Towns/Vil 37,941 Populaons of Cape Girardeau County Cies/Towns/Villages*

22,369

13,758

438 391 243 125 116 114 94 85

Cape Jackson city Delta city Gordonville Oak Ridge Whitewater Allenville Pocahontas Dutchtown Old Rural Girardeau village town town village town village Appleton city town

Source: U.S. Census Bureau, 2010 Census *Populations for – 2001 2009 are estimates by United States Census Bureau, 2010 is actual population based on the 2010 census

City of Jackson The second largest city in the county is Jackson which is also the county seat. Jackson was incorporated in 1814 and the first community in the nation to bear the name of President Andrew Jackson. Jackson is located in the center of Cape Girardeau County and has a population of 13,758. The city of has Jackson the largest school district in Cape Girardeau County with 4,664 students coming from a large geographical portion of the county. Jackson offers a suitable amount of education, commerce, and medical care as well.

Smaller Cities and Towns in Cape Girardeau County The towns of Delta and each Oak Ridge host the other two school districts rardeau found in Cape Gi County with 325 and 389 students, respectively. Neither of these towns offers much in regards to commerce, but each has a few small businesses. s Medical care i not available and must be sought out in one of the larger cities close by. Gordonville has one of the ions higher populat of the smaller villages, but does not have many businesses since it is relatively close to both cities of Jackson and Cape Girardeau. There are ifteen f zip codes found in Cape Girardeau County and those are listed below:

Table 1 : Zip C odes in Girardeau Cape County Zip Code City Zip Code City Zip Code City 63701 Cape Girardeau 63744 Delta 63766 Millersville 63702 Cape Girardeau 63745 Dutchtown 63769 Oak Ridge 63703 Cape Girardeau 63747 Friedheim 63770 Old Appleton 63739 Burfordville 63752 Gordonville 63779 Pocahontas 63743 Daisy 63755 Jackson 63785 Whitewater

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Demographic Characteristics

Population Growth According to the U.S. Census Bureau: • In 2010, Cape Girardeau County had a population of 75,674. • The population has .0 grown 10 0% since the year , 2000 compared to 6.83% statewide. • Cape Girardeau County is th the 16 largest county in the state of Missouri. Figure 2: Cape Girardeau County Population Cape Girardeau County Populaon 75,674 73,957 73,217 72,149 72,643 71,141 70,622 69,813 69,231 69,514

Year Year Year Year Year Year Year Year Year Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: U.S. Census Bureau, Population Estimates nstats.census.gov/cgi (http://ce -‐bin/usac/usatable.pl)

Race • The race distribution of Cape Girardeau County is not as diverse as the state of Missouri. • The percentage of the population that is white in Cape Girardeau County (88.7%) is considerably higher than the Missouri percentage (82.8%) and the percentage f o the population that is black in Cape Girardeau County (7.0%) is considerably lower than the Missouri percentage (11.6%). Figure 3 : Race Distribution of Cape Girardeau -‐ County 2010 Race Distribuon -‐ Cape Girardeau County White 1.2% 0.9% 0.2% Black or African 7.0% 0.0% American 1.8% American Indian and Alaska Nave 88.7% Asian

Some Other Race

Nave Hawaiian and Other Paciﬁc Islander Two or More Races

Source: U.S. Census Bureau, 2010 Census

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Ethnicity • Figure 4 shows that the Hispanic population percentage in Cape Girardeau County is lower than the state percentage.

Figure 4 : Hispanic Makeup of Cape Girardeau County vs. Missouri – 2010 Hispanic Populaon of Cape Girardeau County vs. Missouri -‐ 2010

3.5% 2.0%

Cape Girardeau County Missouri

Source: U.S. Census Bureau, 2010 Census

Age Distribution • Cape Girardeau County has a slightly younger the population than state with its median age being 36.4, compared to 37.9 for Missouri. • Cape Girardeau County has a higher -‐ percentage of 15 24 year olds than , the state due to the student population of Southeast Missouri State y. Universit • In all other age groups, Cape Girardeau County and Missouri are closely matched, rarely differing by more than 1%. • 26.11% of the county’s population is 19 or younger. • 14.32% of ounty’s the c population is 65 or older. Figure 5 : Age Distribution for Cape Girardeau County Compared to Missouri -‐ 2010

Age Distribuon for Cape Girardeau County -‐ 2010 Cape Girardeau County Missouri

Cape Girardeau County has a higher percentage of the younger populaon (ages 15-‐24) than Missouri 16%

14%

12%

10%

4% Percent Total of Populaon 2%

0% <5 5-‐14 15-‐19 20-‐24 25-‐34 35-‐44 45-‐54 55-‐64 65-‐74 75-‐84 85+ Age Group Source: U.S. Census Bureau, 2010 Census

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Gender • The overall percentage of males in Cape Girardeau County is slightly lower than the percentage of females. • Looking at the percentage 65 of males and older compared to females 65 and older, there is a much larger gap with an average of an 16% more females th males. • The percentage of the population that . is male vs female in Cape Girardeau County very closely matches the average for the state of Missouri. Figure 6 : Percentage of Population – Male vs. Female – Cape Girardeau County vs. -‐ Missouri 2010

Percentage of Populaon -‐ Male vs. ardeau Female -‐ Cape Gir County vs. Missouri -‐ 2010

Cape Girardeau County Missouri 58.2% 57.0% 51.6% 51.0% 48.4% 49.0% 41.8% 43.0%

Male Female Male 65+ Female 65+

Source: U.S. Census Bureau, 2010 Census

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Household/Family Configuration • The household configuration for Cape Girardeau osely County cl matches the percentages for the state of Missouri. • Almost exactly half of the population is considered a husband-‐wife family, slightly higher than the state percentage.

Figure 7 : Households by – Type Cape Girardeau County vs. – Missouri 2010

Households by Type* -‐ Cape Girardeau uri County vs. Misso -‐ 2010 49.8% 48.4% Cape Girardeau County Missouri

35.1% 34.7%

11.0% 12.3% 4.1% 4.6%

Husband-‐wife family Male householder, no Female householder, Nonfamily wife present no husband present households Source: U.S. Census Bureau, 2010 Census *Husband-‐wife family includes those with own children under 18; Male householder, no wife present includes h those wit own children under 18; Female householder, no husband present includes those with own -‐ children under 18; Non family households include those living alone. Religion The following figure shows the membership by religious congregation Cape in Girardeau County. Membership is counted ngregational as co adherents which include all full members, en, their childr and others who regularly attend services. 77 Nearly % of Cape Girardeau County’s population belongs to a religious congregation.

Figure 8: Membership by Religious Congregation – 2010 – Cape Girardeau County 17,494 Membership by Religious Congregaon -‐ 2010 11545 11,162 Cape Girardeau County 10,823 9,952 6,989 4,178 1,717 787 636 150 113 101 27

Source: Association of Religion Data Archives

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Social Characteristics Education • 14.2% of Cape Girardeau County adults age 25 and older did not graduate from high school; this is slightly higher than the state average of 13.9%. • The remaining 85.7% graduated from high school and 31.5% of those adults received -‐ a post secondary degree, with a 2% higher average in the Bachelor’s degree category than the state.

Figure 9 : Educational Attainment (Population 25 years er) and old – Cape Girardeau vs. Missouri -‐ 2010 Educaonal Aainment (Populaon 25 years and over) -‐ Cape Girardeau County vs. Missouri -‐ 2010

33.9% Cape Girardeau County 32.6% Missouri

22.0% 20.3% 17.7% 15.8%

8.7% 9.2% 9.2% 9.2% 6.6% 5.5% 4.7% 4.6%

Less than 9th 9th to 12th High school Some Associate's Bachelor's Graduate or grade grade, no graduate college, no degree degree professional diploma (includes degree degree equivalency)

Source: U.S. Census Bureau, 2010 Census Figure 10 shows the high school dropout rates for Cape Girardeau County by school district. • In 2011, Delta did not have any dropouts. • All school districts except Cape Girardeau dropout 63 had lower rates than the state average. • Cape Girardeau 63 has a much higher dropout rate trict than any other school dis and Missouri, ranging from over 9% in 2008 to just s over 5% in 2011. Thi school district is broken down by race in Figure 11 to show what groups are included in the high dropout percentage.

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Figure : 10 High School Dropout Rates by Cape Girardeau County School Districts vs. Missouri

High School Dropout Rates by Cape Girardeau chool County S District vs. Missouri

MISSOURI CAPE GIRARDEAU 63 DELTA R-‐V JACKSON R-‐II OAK RIDGE R-‐VI

10 8 6 4 2 0 Year 2008 Year 2009 Year 2010 Year 2011

Source: MO Dept. of Elementary and Secondary Education

• Cape Girardeau 63 has a 13.3% dropout Hispanic rate for the population and an 8.3% dropout rate for the black population causing the total dropout rate to be much higher than the state and other Cape Girardeau County school districts.

Figure 1 1 : Dropout Rates per Race/Ethnicity for Cape Girardeau County School Districts vs. Missouri -‐ 2011

Dropout Rates per Race/Ethnicity for Cape Girardeau County School Districts vs. Missouri -‐ 2011 13.3 Black Dropout Rate 9-‐12 (%)

Hispanic Dropout Rate 9-‐12 (%) 8.8 8.3 White Dropout Rate 9-‐12 (%) Total Dropout Rate 9-‐12 (%)

5.2 4.8 4.4 3.8 3.4 2.2 1.6 1.7 0.9 0.9 0 0 0

MISSOURI CAPE GIRARDEAU 63 JACKSON R-‐II OAK RIDGE R-‐VI

Source: MO Dept. of Elementary and Secondary Education

• Figure 12 shows the demographic breakdown by race rardeau for the Cape Gi 63 and Jackson -‐ R II school districts, and Missouri.

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Figure 2 1 : Demographic Breakdown of Cape and Jackson School Districts by Race -‐ vs. Missouri 2011

Demographic Breakdown of Cape and Jackson stricts School Di by Race vs. Missouri -‐ 2011

MISSOURI CAPE GIRARDEAU 63 JACKSON R-‐II

Cape Girardeau 63 has a signiﬁcantly higher percentage of black students than Missouri 93.5 and Jackson R-‐II in this comparison. 74.7 60.3

33.0 17.1

2.6 4.5 3.5 1.6

Black Percent Hispanic Percent White Percent

Source: MO Dept. of Elementary and Secondary Education

Language As is shown below 13 in Figure , Cape Girardeau County has a higher percentage of English being the only language spoken at home than Missouri as a whole.

Figure : 13 Language Spoken at Home – Missouri & Cape Girardeau County Language Spoken at Home -‐ Missouri Language Spoken at Home -‐ Cape Girardeau County

5.9% 3.6%

94.1% 96.4%

Speak only English Of the 5.9% that speak a language Speak only English Of the 3.6% that speak a language other than English, 61.9% speak other than English, 59.6% speak English "very well" and 38.1% English "very well" and 40.4% Speak a language speak English less than "very well" Speak a language speak English less than "very well" other than English other than English Source: U.S. Census Bureau, -‐ 2006 2010 American Community Source: U.S. Census Bureau, -‐ 2006 2010 American Community Survey 5-‐Year Estimates Survey 5-‐Year Estimates

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Literacy According to the National Center for Education essment Statistics’ 2003 Ass of Adult Literacy, the estimated percentage of those 16 and older considered to be lacking basic prose literacy skills in Cape Girardeau County is 6%, compared to 7% for Missouri.

Marital Status • Over half of the that population is 15 years was and over currently married, not separated in 2010. • Almost 30% has never been married, slightly e higher than the stat average, due to the younger population residing in Cape Girardeau County. Figure 14 : Marital Status (Population 15 years and over) – Cape Girardeau County vs. -‐ Missouri 2010 Marital Status (Populaon 15 years and older) -‐ 51.8% 51.7% Cape Girardeau County vs. Missouri -‐ 2010 Cape Girardeau County Missouri 29.6% 28.3%

11.5% 6.8% 6.5% 10.2% 1.6% 2.0%

Now married (not Widowed Divorced Separated Never married separated) Source: U.S. Census Bureau, 2010 Census Economic Characteristics Income According to the U.S. Census Bureau, the median household nflation income (in 2010 i -‐adjusted dollars) in Cape Girardeau County is $44,479 compared to the state median of $46,262. The per capita income is found in Figure 15 below. From 2008 to 2009, the per capita income has decreased in Cape Girardeau County and in Missouri.

Figure 5 1 : Change in Per Capita Income from 2008 – 2009 – Cape Girardeau County vs. Missouri Change in Per Capita Income from 2008 -‐ 2009 Cape Girardeau County vs. Missouri

$36,884 $36,181 $34,385 $34,282 2008 PCI 2009 PCI

-‐.3% -‐1.94%

Cape Girardeau County Missouri

Source: MERIC

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Employment • The unemployment rate in Cape Girardeau has County remained lower than the state rate in the past five years and did not see as much state of a jump in 2009 as the of Missouri.

Figure : 16 Unemployment Rates for Cape Girardeau County vs. Missouri: 2006-‐2010 Unemployment Rates for Cape Girardeau County ouri: vs. Miss 2006 -‐ 2010 9.4 9.4

5.9 4.8 5 7.3 7.6 5.1 4.1 4.3

Year 2006 Year 2007 Year 2008 Year 2009 Year 2010

Missouri Cape Girardeau County

Source: U.S. Bureau of Labor Statistics, Local Unemployment Area Statistics

Poverty Status According to the U.S. Census – Bureau’s 2006 2010 American Community Survey, the percentage of people below the poverty level in Cape Girardeau 14.2% County for 2010 was compared to the state percentage of 14%. ables The t below show the percentage below poverty , level for each city town, or village in Cape Girardeau County and the percentage below poverty level for several other categories.

Table 2: % Below Poverty Level E Broken Out by ach City Cape in Girardeau y Count Cape Girardeau County City % Below Poverty Level Dutchtown village 42.2% Cape Girardeau city 19.8% Pocahontas town 15.3% Old Appleton town 11.5% Allenville village 10.3% Delta city 9.7% Jackson city 8.1% Oak Ridge town 6.5% Gordonville village 3.2% Whitewater town 0.0% Source: U. S. Census Bureau, – 2006 2010 American Community Survey

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Table 3: % Below Poverty Level by Other Categories Category Cape Girardeau County Missouri Under 18 years 21.1% 19.3% 65 years and over 7.6% 9.3% White 12.0% 11.6% Black or African American 40.9% 28.0% Hispanic or Latino origin (of any race) 20.8% 24.3% Less than high school graduate 18.3% 25.2% Unemployed 30.0% 31.5% Source: U. S. Census Bureau, – 2006 2010 American Community Survey Cape Girardeau County has a considerably higher poverty state level than the in the categories of: • Under 18 years • Black or African American Medicaid and Public Assistance Participation Medicaid According to the Missouri Department of Health in and Human Services, 2008, 13.72% of Cape Girardeau County residents were on Medicaid, s which i slightly lower than the state 0 rate of 14.5 %. Over 76% of those on Medicaid were white, 21% were black, and 53.15% were under age 18.

Figure 7 1 : Medicaid Participation by Race and Age for Cape Girardeau County and Missouri -‐ 2008 Missouri Cape Girardeau African-‐ African-‐ Age Groups Number % White Number % White American American

Total Under 18 54.82% 53.15% 473,288 5,339

Total 18-‐64 35.07% 35.70% 302,790 3,586

65 and Over 10.11% 11.15% 87,321 1,120

TOTAL 70.01% 26.22% 76.07% 21.01% 863,399 10,045 Population -‐ 2008 5,956,335 73,217 % of Medicaid Participation 14.50% 13.72% Source: Department of Health and Human Services, 2008.

SNAP/Food Stamps According to the U.S. Census Bureau’s 2006-‐2009 American Community Survey, 3,545 households or 11.97% in Cape Girardeau County were SNAP/ receiving food stamps. That was slightly higher than the state percentage of 11.4%. Free/Reduced-‐Lunch Program Children from households with incomes less than 130 re percent of poverty a eligible for free lunches; those from households below 185 percent of ble poverty are eligi for reduced price The lunches. ate r is expressed as percent of total school enrollment. F igure 18 shows the percentage of students enrolled in

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 30 the Free/Reduced Lunch program by school – district the percentage for Cape Girardeau 63 is much higher than the state rate and much higher than icts all other school distr in Cape Girardeau County.

Figure 18: Percentage of Students Enrolled in Free/Reduced Lunch Program by School District in Cape Girardeau County vs. MO

Percentage of Students Enrolled in the Free/Reduced Lunch Program by School District in Cape Girardeau ouri County vs. Miss 2008 2009 2010 2011 Cape Girardeau 63 had over 61% of its students enrolled in the program in 2011 -‐ much higher than any other school district in the county and Missouri. 61.5 65 60 52.1 55 47.8 50 45 38.6 40 33.4 33.8 35 30 25 20 15 10 5 0 MISSOURI CAPE DELTA R-‐V JACKSON R-‐II NELL OAK RIDGE R-‐ GIRARDEAU 63 HOLCOMB R-‐IV VI

Source: MO Dept. of Elementary and Secondary Education Hunger and Food Uncertainty The Missouri Hunger Atlas from 2010 Need used three Indicators to determine the extent of food insecurity and hunger in each Missouri County. For Percent Households Food Uncertain, Cape Girardeau County has 2 1 .4% compared to 15.8% for Percent the state; Households with Children Food Uncertain, Cape rardeau Gi County has 6.6 1 % compared to 23.4% for the Percent state; and Households Food Uncertain with Hunger, Cape Girardeau County 2 has 4. % compared to 7.2% for the state. Women, Infants, and Children (WIC) Participation The Women, Infants, and Children (WIC) program provides federal to grants states for supplemental food, health care referrals, and nutrition education for low-‐income pregnant, breastfeeding, and non-‐ breastfeeding postpartum women, and to infants and children of up to the age five who are found to be at a nutritional risk. According to the Missouri Hunger 08 Atlas, in 20 , Cape Girardeau County had 1,486 monthly participants in the WIC program and 1,054 of those were infants and children (under the age of ). 5

Housing According to the Census U.S. Bureau, the majority of homes in Cape Girardeau , County are single detached units (70.6%). Cape Girardeau County homes han tend to be newer t the state as a whole, yet are less expensive, and the county has a age slightly higher percent of those who rent their homes when compared to the state.

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In Cape Girardeau County, 113 households lack complete plumbing facilities and 163 households lack complete kitchen facilities. Also, another ds 1,107 househol do not have any telephone service available. Cape Girardeau County offers several housing resources for the homeless, abused, low-‐income, and for those recovering from addiction and seeking ess treatment. Homel shelters available include the Shelter of Hope, Salvation Army, New Beginnings House of of Refuge in the city Cape Girardeau and the Revival Center in the city of Jackson. The Safe ty House for Women in the ci of Cape Girardeau welcomes women who have suffered from domestic Family violence. The Counseling Center, Mending Hearts Recovery, and Vision House offer housing for -‐ women post substance abuse treatment. The Gibson Recovery Center and Teen Challenge offer housing -‐ for men post substance abuse treatment. Several options are available for low to moderate income ies seniors in the cit of Cape Girardeau and Jackson with some having handicap accessibility rtment and a few apa complexes offer affordable housing options for low to moderate -‐ income non seniors.

Transportation Several types of transportation services are available in Cape Girardeau County. The Cape Girardeau Regional Airport is located approximately five miles from downtown Cape Girardeau and is easily accessible from Interstate 55. The -‐ airport is a full service airport and currently offers four to daily flights Lambert International Airport in St. Louis for around $50. These short one-‐hour flights offer convenience for passengers including parking, baggage claim, and security lines that are hassle-‐free. Bus transportation is also available on local to The national levels. Cape Girardeau County Transit Authority offers bus transportation around the city of Cape Girardeau s. on fixed route Southeast Missouri State University also offers shuttle services on fixed routes around campus as well as a shuttle bus that takes students off campus and to ty. certain areas of the ci BART Transportation is based in Jackson, Missouri, and has a total of 17 vans offering transportation to the St. Louis Airport from the Cape Girardeau -‐ Jackson area along with other areas in Illinois. The Greyhound Bus ne Li also has a stop located in the city of Cape Girardeau and offers bus transportation on a national level. The Cape Girardeau County Transit Authority also offers taxi services around the city of Cape Girardeau in which individual passengers can request transportation from any location in Cape Girardeau at any time for a fare. Environment Adequate environmental quality in terms of good air are and water quality prerequisites for good health. Poor air or water quality can be l particularly detrimenta to very the young, the old, and those with chronic health conditions.

Water Quality According to the United States Environmental Protection Agency (EPA), a public water system is a system that serves at least 25 people or e services 15 or mor connections at least 60 days per year. There are three types of public water systems: a community water system hat is one t serves the same people year-‐round, such as homes and businesses; a non-‐transient, non-‐community system serves the same people, but -‐ not year round, such as schools; and a transient, non-‐community system does not consistently serve the same people, such as a campground or rest stop. According to the EPA’s Safe Drinking Water Information DWIS), System (S Cape Girardeau County has 20 community water systems, three non-‐transient, non-‐community water systems, and five transient, non-‐ community water systems. The SDWIS contains information about public water systems and their violations of the EPA’s drinking water regulations. These statutes and accompanying regulations

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establish maximum contaminant levels (MCL), treatment techniques, and monitoring and reporting requirements to ensure that water provided to customers is safe for human consumption. During the past five years, – 2006 2011, five community systems and two transient, non-‐community water systems in Cape Girardeau County had health-‐based violations, where the amount of contaminant exceeded safety standard (MCL) or the water was y. not treated properl Those systems are listed in the following table:

Table 4 : Public Drinking Water System Violations Cape Girardeau County, -‐ 2006 2011 System Name Type of Violation Month/Year CAPE GIRARDEAU CO PWSD 4 COLIFORM (TCR)** SEPTEMBER 2007 CAPE PERRY CO PWSD 1 SOUTH COLIFORM (TCR)** JUNE 2006 MID AMERICAN TEEN CHALLENGE COLIFORM (TCR)** NOVEMBER 2008; DECEMBER 2008 MAY 2009; SEPTEMBER 2010; MAY PARKWOOD LAKE ESTATES COLIFORM (TCR)** 2011; JUNE 2011; JULY 2011 GROSS ALPHA, EXCL. RADON & U; COMBINED RADIUM -‐ ( 226 -‐ & 228)*; JANUARY 2006 -‐ JUNE 2011 (44 WESTLAKE MEADOWS SUBDIVISION COLIFORM (TCR)** violations) CLASS ACT FAMILY FITNESS COLIFORM (TCR)** MAY 2010 RONS BUTCHER SHOP & GROCERY COLIFORM (TCR)** DECEMBER 2010 Source: U.S. EPA SDWIS *Combined Radium 226/228: Some people who drink water containing radium 226 of or 228 in excess the Maximum Contaminant Level over many years may have an increased risk of getting cancer. **Total Coliform: Coliforms are bacteria that are naturally present in the environment and are used as an indicator that other, potentially-‐harmful, bacteria may be present. Coliforms were found in more samples than allowed and this was a warning of potential problems.

Air Quality According to the County Health Rankings developed by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health , Institute air quality is represented by the population health risks from ambient air pollution. Several pollutants, including ozone and fine particulate matter (particulates less than 2.5 micrometers in diameter), can contribute bidity to increased mor and mortality. The County Health Rankings uses those ured two commonly meas pollutants to assess the health risks of ambient air pollution, including the of estimated number days that a county’s air quality is unhealthy for sensitive populations due to either one of those pollutants. The County Health Rankings reports that Cape Girardeau County has an annual number of unhealthy air quality days due to fine particulate matter equal to one and an annual number ity of unhealthy air qual days due to ozone equal to zero. Cape Girardeau County is one of only 12 counties i in the state of Missour to have at least one unhealthy air quality day due to fine particulate matter. The negative consequences of ambient air pollution include decreased lung hitis, function, chronic bronc asthma, and other adverse pulmonary effects. levels Exposure to excess of ozone or fine particulate matter are correlated with an increase mergency in hospital e room ts visi and hospitalizations among asthmatics and others with compromised respiratory function. Increases in these pollutants are associated with greater risk of death due to cardiopulmonary and cardiovascular conditions and ischemic heart disease. The clear impact that air quality has on human health and the importance EPA places on monitoring select pollutants shows that q the air uality focus area is a critical one to include among the County Health Rankings’ environmental measures.

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Lead Poisoning Lead poisoning is one of the most common and preventable ems environmental health probl today. The primary lead hazard to children in Missouri -‐ is deteriorated lead based paint. -‐ Lead based paint was banned for residential use nationwide in 1978 t and any home buil before 1978 may contain leaded paint; however, the highest risk of lead exposure is found before in homes built 1950. Fine particles of processed or recycled lead ome and/or lead dust bec a health hazard when taken into the body through inhalation (breathing) and/or ingestion (swallowing). Lead affects almost every organ and system in the body and the effects are the same whether it is breathed or swallowed. Lead damages the brain, central nervous system, kidneys tem. and immune sys Lead in the y human bod is most harmful to young children under the age of 6 and is especially detrimental to children less than 3 years of age due to their rapidly developing systems. A blood test is used to determine blood levels ted and are measured repor as micrograms of lead per deciliter of whole µ blood ( g/dL). The 2010 Annual Report from the Missouri Childhood Lead Poisoning Prevention Program of the Missouri Department of Health and Senior Services reports that of 661 total tests done on children less than 6 years of age living in Cape Girardeau County, 650 had levels under 10, 8 had levels between -‐ 10 14.9, 1 had a level -‐ between 20 24.9, and 2 had levels -‐ between 25 44.9. Children are considered to have elevated blood lead level levels when the blood is µ 10 g/dL or greater. So, 11 children under the age of 6 had elevated Cape blood lead levels in Girardeau County. Built Environment The built environment refers to human-‐made (versus natural-‐made) resources and infrastructure designed to support human activity, s such a buildings, roads, parks, and other amenities. The characteristics of the built environment can affect the health of residents in multiple ways. As obesity rates have increased over the past decades, interest in looking at local food and recreational environments as potential contributors to obesity has also increased. The variety, price, and availability of healthy foods in the local environment can play hose a role in whether t foods are consumed. Additionally, the availability of recreational facilities can influence individuals’ and communities’ choices to engage in physical activity. Better information on the availability of healthy l food and recreationa facilities within the built environment will enable communities to take action to reduce the adverse health outcomes associated with poor diet, lack ty, of physical activi and obesity.

Healthy Food Availability According to the County Health Rankings developed by the Robert and Wood Johnson Foundation the University of Wisconsin Population Health ute, Instit Cape Girardeau County only 1% has of its residents with limited access o t healthy foods compared 8% to for the state. Limited access to healthy foods is defined as the proportion of the population that is both living in poverty and do to not live close a grocery store. Living close to a grocery store is defined as less than 10 miles -‐ in non metro counties. According to the Food Environment Cape Atlas, Girardeau County has en t grocery stores and four farmer’s markets. Also, according to the lth County Hea Rankings, 43% of restaurants Cape in Girardeau County -‐ are fast food establishments. Recreational Activities Available According to the County Health Rankings developed by the Robert and Wood Johnson Foundation the University of Wisconsin Population Health the Institute, rate of recreational activities available pe in Ca Girardeau County is 11, which is the a number of recre tional facilities per 100,000 population. The rate

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 34 for Missouri is 10, so Cape Girardeau County is right above the state rate. Recreational facilities are defined as establishments primarily engaged in operating and fitness recreational sports facilities, featuring exercise and other active physical fitness conditioning or recreational sports activities such as swimming, skating, or racquet sports. The availability of recreational facilities can ndividuals’ influence i and communities’ choices to engage in physical activity. Proximity to places with recreational opportunities iated is assoc with higher physical activity levels, which in turn is associated es with lower rat of adverse health outcomes associated with poor diet, lack of physical activity, esity. and ob Access to recreational facilities such as parks, sports fields and facilities, biking trails, public playgrounds pools, and can be improved by locating them closer to homes and schools, lowering costs to use the facilities, increasing hours ation, of oper and ensuring access to people with various ability levels and limitations. The C ity of Cape Girardeau Parks and Recreation Department offers many recreational activities to the public. A large assortment of youth and adult ailable, sports leagues are av such as baseball, softball, volleyball, flag football, tennis, golf, and basketball. Other activities available include martial arts, cheerleading, and art and cooking classes. Fitness classes are offered for Zumba, Yoga, Kickboxing, and others. Swimming pools, bike lanes, and walking trails can be found in Cape Girardeau County for physical activity as well. The Parks and Recreation Department also hosts a “Corporate Games” program each year to get teams from businesses involved in some sporting ompetitions. c Also, in Cape Girardeau County, as many as 27 city parks, two county parks, and three community centers can be found offering countless opportunities for residents to get out and about to enjoy some physical activity. Public Safety Crime Index The Crime Index is the sum of eight major offenses and is used to measure the magnitude of crime in the United States. Only eight major offenses n are included i the Index because of their frequency of occurrence and the fact they are most reported likely to be to law enforcement agencies. These Index offenses include: murder, forcible rape, robbery, ult, aggravated assa burglary, theft, motor vehicle theft, and arson. The first four make up the Violent Crime Index and the last four make up the Property Crime Index. The following table shows the total number of offenses for each of those crimes in Cape Girardeau County in 2009, as well as rrests the number of a for those offenses, and the . rate of offenses Also shown is the offense rate be for Missouri to compared to the county. Cape Girardeau County has a higher offense rate than Missouri in the categories ape, of forcible r aggravated assault, and theft.

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Table 5 : Offenses and Arrests by Crime Type in Cape Girardeau County -‐ 2009 Cape Girardeau County Missouri Type of Offense # of Offenses # of Arrests Offense Rate* Offense Rate* Violent Offenses Total: 340 185 473.8 521.0 Murder 2 2 2.8 7.1 Forcible Rape 24 2 33.4 28.6 Robbery 54 13 75.2 131.3 Aggravated Assault 260 168 362.3 354.0 Property Offenses Total: 2832 570 3946.4 3605.6 Burglary 534 42 744.1 770.4 Theft 2221 522 3095.0 2485.0 Motor Vehicle Theft 61 3 85.0 307.5 Arson 16 3 22.3 42.7 Total Offenses 3172 755 4420.2 4126.6 Source: Missouri State Highway ’s Patrol 2009 Crime Missouri in report *Offense Rate is per 100,000 population Juvenile Crime Rates The following table shows the number t of juvenile cour referrals in 2009 for Cape Girardeau County and Missouri. Cape Girardeau County’s rate is considerably higher otals in the overall t for law violation offenses and status offenses, with the rates for absent truancy and being from home being higher than the state rate specifically.

Table 6 : Juvenile Court Referrals -‐ Cape Girardeau County vs. -‐ Missouri 2009 Cape Girardeau County Missouri Offense # of Offenses Rate* Rate* Law Violation Offenses Total 849 11.2 5.4 Violent Offenses 114 1.5 1.6 Alcohol Offenses 23 0.3 0.2 Drug Offenses 24 0.3 0.4 Status Offenses Total 217 2.9 2.4 Truancy 108 1.4 0.6 Beyond Parental Control 27 0.4 0.5 Habitually Absent from Home 66 0.9 0.5 Injurious Behavior 16 0.2 0.7 Source: Missouri Department of Mental Health, t Status Repor 17th Edition *Offense Rate is per population 1,000 Family and Domestic Violence Child Abuse and Neglect The following figure shows the child abuse and neglect rates for Cape Girardeau County and Missouri for the years – 2004 2008. The rate for the county has been higher than the state rate since 2005.

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Figure : 19 Child Abuse & Neglect (Rate per 1,000 children) – Cape Girardeau County vs. Missouri

Child Abuse & Neglect (Rate per 1,000 Children) -‐ Cape Girardeau County vs. Missouri

41.6 Cape Girardeau County Missouri 41

40.5 34.9 34.8 35.2

34.7 33 32.6 32.1 Year 2004 Year 2005 Year 2006 Year 2007 Year 2008

Source: Annie E. Casey Foundation Kids Count Data Center Child Out-of-Home Placement The following figure shows the out-‐of-‐home placement entries rate for Cape Girardeau County and Missouri for the years – 2004 2008. The rate for the county has been considerably higher than the state rate since 2006 and while the state rate is trending downward, Cape Girardeau County’s rate is trending upwards.

Figure : 20 Out-‐of-‐Home Placement Entries (Rate per 1,000 Children) – Cape Girardeau County vs. Missouri Out-‐of-‐Home Placement Entries (Rate per en) 1,000 Childr -‐ Cape Girardeau County vs. Missouri

Cape Girardeau County Missouri Linear (Cape Girardeau County)

5.5 4.8 4.8 5.2 5.2

4.5 4.1 3.8 3.9 3.8 Year 2004 Year 2005 Year 2006 Year 2007 Year 2008

Source: Annie E. Casey Foundation Kids Count Data Center Domestic Violence Domestic violence incidents are reported not whether or an arrest is made and include any dispute arising between spouses, former spouses, persons with child ren in common regardless of whether they reside together, persons related by blood, persons related by marriage, non-‐married persons currently residing together, and non-‐married persons who have resided n together i the past. Domestic violence incidents are reported when an officer believes a dispute crosses an abuse threshold as indicated by harassment, stalking, coercion, assault, sexual ery, assault, batt or unlawful imprisonment. Domestic violence incidents are reported by the highest ranked relationship between victim and offender, regardless of the number of persons or potential onships multiple relati present during the incident. The following table shows the domestic violence incidents in Cape Girardeau County for 2009 by the victim/offender relationship. The Missouri 2009 rate for was 51.0 6 per 100,000 population, which is higher than the Cape Girardeau County rate of 589.4.

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Table 7: Domestic Violence Incidents in Cape Girardeau County -‐ 2009 Victim/Offender Relationship Cape Girardeau County Spouses 93 Former Spouses 28 Couples w/Child(ren) in Common 49 Blood Relatives 57 People Related Through Marriage 7 People Who Live Together 153 People Who Lived Together in the Past 36 Total Domestic Violence Incidents 423 Rate per 100,000 population 589.4 Source: Missouri State Highway ’s Patrol 2009 Crime in Missouri report Health Promotion Community Health Programs The two community hospitals in Cape Girardeau er County off many health programs, classes, and screening opportunities that are available ic, to the publ with many being free of charge. Some of those are as follows: • Support groups for breastfeeding, bariatric surgery, ients, heart pat cancer patients, and ostomy patients, diabetes self-‐management and grief support • Classes for parenting and childbirth including breastfeeding, re, infant ca infant massage, car seat installation, pregnancy and childbirth basics, infant and child CPR, and a sibling class to prepare siblings for the arrival of a new baby • Screening opportunities for diabetes, colorectal cancer, blood pressure, metabolic syndrome, abdominal aortic aneurysm, heart, and overall health • Fitness programs for adults and children • Smoking cessation programs • Camps for boys and girls that are interested ession in a health care prof • Asthma education • First-‐aid and CPR Other programs available in the community y provided b other community organizations include: • Alcoholics Anonymous • Parenting classes • Family skills classes • Grandparent support groups for grandparents acting as parents • Parents without partners • Building strong families • Postponing sexual involvement • Puberty classes • Nutrition classes for how to eat healthy • Youth Substance Abuse Prevention

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Health Care System Access to Health Care Access to health care is a broad concept that cessibility tries to capture ac to needed primary care, health care specialists, and emergency treatment. While having health insurance is a crucial step toward accessing the different aspects of the health care system, health insurance by itself does not ensure access. It is also necessary to have comprehensive iders coverage, prov that accept the individual’s health insurance, relatively close proximity of ents, providers to pati and primary care iders prov in the community. There are additional barriers to access in some populations due to lack of transportation to providers’ offices, lack of knowledge about preventive waits care, long to get an appointment, low health literacy, and inability to -‐ pay the high deductible of many insurance plans -‐ and/or co pays for receiving treatment.

Uninsured Population The County Health Rankings created by ohnson the Robert Wood J Foundation and the University of Wisconsin’s Population Health Institute s measure the uninsured population as the estimated percent of the population under age 65 that has no health insurance coverage. Using 2009 data from the U.S. Census Bureau, they determined that Cape Girardeau County has 15% of its population under age 65 uninsured, which is exactly the same as Missouri. Health Care Providers Hospitals Southeast Hospital is located in the city of Cape Girardeau, Missouri. It is a 266-‐bed medical center that serves more than 640,000 people in 25 counties in southeast Missouri and southern Illinois. The hospital staffs more than 200 physicians and over 2,200 employees and offers a full continuum of health care and wellness services designed to meet the needs of individuals, families, and businesses. Some of the major service lines found at Southeast include Oncology, Cardiovascular, Neurosciences, Women’s and Children’s, Orthopedics, and Emergency Services. at The 266 beds Southeast Hospital are divided among 158 Med/Surg beds, 10 Pediatric beds, 13 Rehabilitation beds, 15 Neonatal Intensive Care Unit beds, 26 Intensive Care Unit beds, 29 Obstetrics ychiatric beds, and 15 Ps Unit beds. Saint Francis Medical Center is also located in the city of Cape Girardeau, Missouri, and has become a progressive, innovative regional tertiary referral care center in the last 13 years that has nearly tripled in size. It is a 280-‐bed facility that serves more than 650,000 people i, throughout Missour Illinois, Kentucky, Tennessee, and Arkansas. The hospital staffs physicians more than 224 and more than 2,400 employees. Some of Saint Francis’ major service lines include Neurosciences, Orthopedics, Family BirthPlace, Cardiovascular, Oncology, Rehabilitation, Trauma, y and the had the region’s first Level III Neonatal Intensive Care Unit. The hospital rs also offe urgent care centers and a fitness facility. Saint Francis Medical Center’s 280 beds are divided out into 176 Med/Surg beds, 8 Pediatric beds, 23 Rehabilitation beds, 25 Neonatal Intensive Care Unit ive beds, 32 Intens Care Unit beds, and 16 Obstetrics beds. Landmark Hospital of Cape is Girardeau the premier Long Term Acute Care (LTAC) -‐ hospital of the four state area. This hospital has built a solid reputation for providing the very best patient care, and excellent customer service. The hospital operates as a -‐ joint venture between Landmark Holding of Missouri, LLC, and Saint Francis Medical pe Center in Ca Girardeau. The facility has 30 single-‐occupancy rooms, providing a more private, comfortable experience during the patient’s stay. A patient’s average length of stay is about 27 days, depending on the patient’s level of acuity. Primary diagnoses include: ventilator weaning, complex medical, and wound care. s Most patient come to Landmark from a short-‐

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 39 term acute care hospital, and are discharged skilled to home, nursing, or rehab. H Landmark ospital has developed strong relationships in the medical community, rtnership and works in pa with other hospitals and doctors. The care the hospital provides will continue to make a positive difference for critically ill patients and their families. Family Practice According to the University of Wisconsin Population Health Institute and Robert Wood Johnson Foundation’s County Health Rankings, Cape County Girardeau has a primary care physician ratio of 832:1, whereas he t state of Missouri has a ratio of 1,015:1. Cape Girardeau County has many family practices y that offer primar care. Some of the practices located in Cape Girardeau and Jackson, Missouri, are listed below. In Cape Girardeau, Missouri: • Southeast Primary Care • Cape Primary Care • Regional Primary Care • Riverside Family Practice • Cape Physician Associates • Cape Family Medical Clinic & Weight Loss Center • Cape Medical Group • Premier Family Physicians • Midwest Family Care • Cape Family Practice • Urgent Care: o Doctors Express o Immediate Convenient Care o Cape Urgent Care In Jackson, Missouri: • Jackson Primary Care • Heartland Family Physicians • Jackson Family Care • Jackson Medical Center • Urgent Care: o Prompt Care Cross Trails Medical Center is the only federally qualified health center located in Cape Girardeau County and is located in the city of Cape Girardeau. This facility has been providing patients with affordable health care and dental services for over 14 years. Some of the services offered include: • Primary medical – care dental care – preventive health screenings and adult immunizations • Acute care for minor illness – or injury children’s care, including immunizations and well child checks • Adolescent health – pediatrics – geriatrics – women’s health care, including planning family and annual gynecology exams • Participation in Show Me Healthy Women program to assist women in obtaining necessary exams

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• Full diabetes program, including education with a certified diabetes educator – laboratory services (on-‐site) – X-‐ray services (on-‐site) • Mental health counseling referrals – patient medication assistance – program telehealth (current dermatology – contract pharmacy program) • Emergency cases are referred to the nearest oom emergency r A Rural Health Clinic can be found at the Cape Girardeau County Health Department located in the city of Cape Girardeau. The clinic provides well ntment, and sick care by appoi including childhood immunizations and physical exams for children two weeks to 18 years of age. No emergency care is given, but minor illnesses can River be treated. City Clinic is another available clinic located in downtown Cape Girardeau. Samaritan Regional Health Clinic is a free clinic located in Cape Girardeau, Missouri, that just opened in 2012 and serves individuals who do not have medical who insurance and are not eligible for Medicare or Medicaid. This clinic is funded through nd donations a volunteers and is currently open two days per week. Mental Health According to Univers the ity of Wisconsin Population Health Institute and Robert Wood Johnson Foundation’s County Health Rankings, Cape Girardeau County has mental health provider ratio of 12,203:1, whereas the state of Missouri has a ratio of 9,561:1. The Community Counseling Center in Cape Girardeau County is a not-‐for-‐profit behavioral health organization that offers a full array of comprehensive lth mental hea services for several counties in southeast Missouri. They are dedicated , to the treatment support, and ultimate y recover of those afflicted with mental illness. The Community Counseling Center has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) d and is certifie by the Missouri Department of Mental Health. Some of the programs offered include the following: • CRISIS INTERVENTION • SUPPORTIVE COMMUNITY LIVING • PSYCHIATRIC SERVICES • EDUCATION • OUTPATIENT COUNSELING SERVICES • TRANSPORTATION • COMMUNITY PSYCHIATRIC REHAB CENTER • HOUSING • ADULT TARGETED CASE MANAGEMENT • CONSUMER EMPLOYMENT • LOUIS E. MASTERMAN -‐ GROUP HOME • CONSUMER ADVISORY BOARD • PSYCHOSOCIAL REHABILITATION PROGRAM • COMMUNITY OUTREACH • CHILDREN’S TARGETED CASE MANAGEMENT • INTEGRATED DUAL DIAGNOSIS TREATMENT • INTENSIVE IN-‐HOME SERVICES • DISEASE MANAGEMENT • FAMILY REUNIFICATION SERVICES • COMMUNITY BASED SOLUTIONS • CHILDREN’S ALTERNATIVE SERVICES • INTENSIVE RESIDENTIAL TREATMENT • CHILDREN’S INTENSIVE COMMUNITY SERVICES PSYCHIATRIC REHAB CENTER • EMERGENCY BEDS -‐ LOU MASTERMAN • HEALTHCARE HOME • DAY TREATMENT (InSTEPP) • PEER PHONE SUPPORT • PROMOTING OLDER ADULT WELLBEING • APARTMENT LIVING PROGRAM

Cottonwood Residential Treatment Center, located in the city of Cape Girardeau, is a residential program designed to meet the emotional and mental dren health needs of chil and adolescents (ages 6 -‐ 17) who meet the criteria for severe emotional onwoo disturbance. Cott d also serves children who are

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 41 dually diagnosed with emotional disturbance and mental retardation. The center is located on the campus of Southeast Missouri State University and provides employment and field experiences for many of the University’s ts. studen Education is provided on-‐site to the children through the Cape Girardeau Public School system, as well as Therapeutic Recreation ic and Therapeut Services. The purpose of Therapeutic Recreation is to develop skills independent for a more lifestyle and successful transition to community living and includes activities such as arts, crafts, basketball, and volleyball. Therapeutic Services include Psychiatric evaluation and monitoring, idual indiv therapy, recreation therapy, family therapy, group therapy, Milieu therapy, case management, -‐ 24 hour crisis intervention, and nursing and dietary assessment. Referrals to Cottonwood can an either come from Administrative Agent or the State of Missouri Children’s Division and iteria the admission cr are as follows: • The child must be between the ages of 6 and 17 • The child must have a serious psychiatric disorder as defined in Axis I of the Diagnostic and Statistical Manual of Mental i Disorders ( f the child has only a diagnosis of conduct disorder, mental retardation, developmental disorder, or substance abuse, they do not meet admission criteria) • The child needs a supervised residential setting – for treatment a less restrictive environment is unsuccessful or unsafe • The child must be able to independently ctivities accomplish a of daily feeding, living ( bathing and toileting) • Cottonwood must be appropriate to meet the safety and treatment needs of the ferred re child within the program • A discharge plan is identified with involved and parents, responsible parties ( guardians, Administrative Agent, etc.) providing needed assistance and support for discharge and aftercare Southeast Hospital also offers a 15-‐bed psychiatric unit that is a locked unit h and serves clients wit a mental illness. Common diagnoses n treated o the psychiatric unit include disorders such as depression, bipolar disorder, anxiety disorders, and psychosis. untary The unit is a vol unit serving adults on an inpatient basis. The unit is staffed with a multidisciplinary team comprised of a medical director, licensed clinical social workers, recreational therapists, and a nursing staff of RNs, LPNs, and Nurse Assistants. The primary mission of the psychiatric ovide unit is to pr a safe behavioral health care environment and treatment to individuals in need of inpatient mental health services.

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Dental Services According to the University of Wisconsin Population Health Institute and Robert Wood Johnson Foundation’s County Health Rankings, Cape Girardeau County has a dentist ratio of 31 1,5 :1, whereas the state of Missouri has a ratio of 3,198:1. Table 8 shows which dentists in the county accept MO HealthNet (Medicaid); there are 16 general dentists, two dentists specializing in children’s al teeth, and two or surgeons. Six of the general dentists are employed at Cross Trails Medical Center in the u, city of Cape Girardea which is a federally qualified health center. Table 8: Dentists in Cape Girardeau hat County T Accept MO HealthNet (Medicaid) Name of Provider Specialty ADEN, BYRON L., DDS DENTIST -‐ GENERAL BEGLEY, RANDAL L., DDS ORAL SURGEON BEUSSINK, COURTNEY L., DDS DENTIST -‐ GENERAL COTNER, DANNA P., DDS DENTIST -‐ GENERAL EDWARDS, JONATHAN WADE, DDS DENTIST -‐ GENERAL ETHERTON, ROBERT C., DMD DENTIST -‐ GENERAL FALLERT, KEVIN R., DDS DENTIST -‐ GENERAL FOX, JAMES L., DDS DENTIST -‐ GENERAL FOX, ROBERT G., DDS DENTIST -‐ GENERAL HABERKORN, ROBERT M., DDS DENTIST -‐ GENERAL LEWIS, T. WAYNE, DDS DENTIST -‐ GENERAL MERKLEY, PATRICIA J., DMD DENTIST -‐ GENERAL ROHLFS, LOUIS H., DDS DENTIST -‐ GENERAL RUOPP, JANET B., DDS DENTIST -‐ GENERAL RUOPP, PATRICK R., DDS DENTIST -‐ GENERAL SCHERRMAN, JAYNE F., DDS PEDODONTIST SCHOOLMAN, STEVEN RONALD, DDS DENTIST -‐ GENERAL SHEETS, SUSAN H., DDS PEDODONTIST WILSON, LEIGH GARLAND, DDS DENTIST -‐ GENERAL Source: Missouri Department of Social Services, MO HealthNet Provider Search

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Optometry Services Table 9 shows which optometrists in the county accept (Medicaid); MO HealthNet there are 18 optician/optometrists in total. Table 9: Optometrists in Cape Girardeau County MO that Accept HealthNet (Medicaid) Provider Name Specialty BILLINGS, MICHAEL K., OD OPTICIAN/OPTOMETRIST BLANKENSHIP, TIMOTHY J., OD OPTICIAN/OPTOMETRIST BLIESE, DAVID R., OD OPTICIAN/OPTOMETRIST DETRING, KENNETH C., OD OPTICIAN/OPTOMETRIST EVANS, LAURA R., OD OPTICIAN/OPTOMETRIST FOSTER, AMY M., OD OPTICIAN/OPTOMETRIST FOWLER, CHRISTY M., OD OPTICIAN/OPTOMETRIST HAGER, LISA A., OD OPTICIAN/OPTOMETRIST HALL, JAMES T., OD OPTICIAN/OPTOMETRIST KIPPENBROCK, ROBERT L., OD OPTICIAN/OPTOMETRIST LEET, GREGORY S., OD OPTICIAN/OPTOMETRIST MCDONALD, JR, EUGENE F., OD OPTICIAN/OPTOMETRIST MCDOUGAL, SCOTT A., OD OPTICIAN/OPTOMETRIST SHEWMAKE, RACHEL A., OD OPTICIAN/OPTOMETRIST SMITH, JANET H., OD OPTICIAN/OPTOMETRIST THOMA, KORY, OD OPTICIAN/OPTOMETRIST TYHURST, KEITH N., OD OPTICIAN/OPTOMETRIST WOOD, RYNE CHRISTOPHER, OD OPTICIAN/OPTOMETRIST Source: Missouri Department of Social Services, MO HealthNet Provider Search Community Health Resources/Services The Cape Girardeau County Health Department is also a great resource for public health, environmental health, and disaster and emergency management information and other resources. Emergency Services Cape County Private Ambulance Service, Inc. (CCPA) has been providing Emergency Ambulance Service to Cape Girardeau , County Missouri, since 1968. As a leader in the field of Emergency M edical S ervices, emergency calls are handled by full time certified Emergency Medical Dispatchers (EMD) using Medical Priority's EMD protocols. This provides the caller with life-‐saving and injury preventing -‐ pre arrival instructions, including phone instructions on critical -‐ life saving maneuvers such c as CPR, hoking, s erious bleeding and others. Each emergency ambulance is equipped with technology cutting edge including 12 lead EKG and telemetry capability, leading emergency drugs, and staffed with Missouri Licensed and National Registry certified Paramedics mergency and E M edical T echnicians. CCPA also provides Non -‐ Emergency M edical T ransportation within the Midwest ion. reg Non-‐emergency transportation may be provided using Advanced Life Support vehicles and advanced crews if special or services are required or may be provided by Basic Life Support priate. crews if appro Seven Fire Departments can be found in Cape au Girarde County located in several areas throughout the county. The following table shows those locations as well as other hose information about t departments. Firefighters have many responsibilities ust besides j putting out fires. One of those responsibilities may be to provide emergency care for people involved in accidents, and oftentimes, firefighters are the first emergency personnel on the scene.

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Table 10 : Fire Departments in Cape Girardeau County, Missouri & Emergency Medical Response Agencies # of # of Paid Non-‐ Non-‐ Type of Fire # of Fire # of Career Fire Department Volunteer per Call Firefighting Firefighting Department: Stations: Firefighters: Firefighters: Firefighters: Employees: Volunteers: Cape Girardeau Fire Department* Career 4 57 0 0 3 0 Cape Girardeau, MO 63703 Fruitland Area Fire Department Volunteer 2 0 27 0 0 3 Fruitland, MO 63755 Millersville Fire Rescue Department* Volunteer 3 0 20 0 0 0 Millersville, MO 63766 Whitewater Fire Protection District Volunteer 2 0 16 0 0 2 Whitewater, MO 63785 East County Fire Protection District* Volunteer 3 0 42 0 0 42 Cape Girardeau, MO -‐ 63702 0691 Jackson Fire & Rescue* Mostly 1 11 1 18 0 0 Jackson, MO 63755 Volunteer North Cape County Fire District Volunteer 1 0 19 0 0 0 Oak Ridge, MO 63769 *Licensed as an Emergency Medical Response Agency Source: Fire Departments Network, Fire Department s Listing by County Source: Missouri Department of Health & Senior Services, Emergency Medical Services, Directories ARCH Air Medical is Service a critical care air ambulance service that provides coverage for Cape Girardeau County. ARCH has eight base locations in Missouri and three base locations in Illinois. The service operates several rotary afts wing aircr and one fixed wing aircraft. The on-‐board flight team includes a highly trained EMS Pilot, Critical Care Flight Nurse, ritical and a C C are Flight Paramedic. Southeast Hospital offers Emergency Services in its 17,800 square ncy foot Emerge Department and is among the region ’s finest in terms of experience, expertise, equipment, lities. and faci The Emergency Department includes: • An Acute Care Facility that is open , and staffed 24/7 designated to care for patients with a wide range of medical problems arising from illness or injury, and includes 22 treatment rooms in a “center court” concept and one major treatment room with complete X-‐ray capabilities • The area’s first nationally credited ac Chest Pain Center with the back-‐up of a nationally recognized Heart Center • A nationally accredited Stroke Center • ERexpress, which is an area designated specifically he for t diagnosis and treatment of minor illnesses and injuries, minor lacerations, and splinting which may not require the full resources of the acute emergency treatment area

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Saint Francis Medical also Center offers Emergency Services and is the region’s only state-‐designated Level III Trauma Center. In early 2011, Saint Francis Medical Center completed a two-‐phase expansion and renovation project and added almost 30,000 square feet to the original facility’s 11,600 square . feet The new -‐ state of-‐the-‐art facility offers 26 private treatment rooms, three trauma rooms, two triage rooms, and a special procedures room for a total of 32 patient rooms. The Emergency and Trauma Center features hospital-‐based, board certified emergency medicine physicians geons and trauma sur who provide critical care 24 hours a day, seven days a week. F Saint rancis Medical Center also has a Convenient Care facility located within the Emergency nter, and Trauma Ce which is -‐ a walk in facility for treating minor illnesses and injuries.

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Long-Term Care Facilities The following describes three types of Long-‐Term Care Facilities: • Residential care facilities (RCFs) refer to facilities that provide long-‐term care to adults or children in a residential setting rather ent's than the pati home. People with disabilities, mental health problems, or learning are difficulties often cared for at home by paid or voluntary caregivers, such as family and friends, with additional support from home care agencies. • Assisted living residences or assisted living facilities (ALFs) provide supervision or assistance with activities of daily living (ADLs); coordination of services by outside health care providers; and monitoring of resident activities to help r to ensure thei health, safety, and well-‐being. • Skilled nursing facilities (SNFs), nursing homes, or convalescent homes provide a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living. Residents include the elderly and younger adults with physical or mental disabilities. Residents in a skilled nursing facility may cal, also receive physi occupational, and other rehabilitative therapies following an accident or illness.

Table 11 : Long -‐ Term Care Facilities in Cape Girardeau County, Missouri FACILITY NAME LEVEL OF LICENSURE CITY AUBURN CREEK-‐ASSISTED LIVING BY AMERICARE ASSISTED LIVING FACILITY OPTION 1 CAPE GIRARDEAU CAPETOWN ASSISTED LIVING ASSISTED LIVING FACILITY OPTION 2 CAPE GIRARDEAU CHATEAU GIRARDEAU SKILLED NURSING FACILITY CAPE GIRARDEAU CHATEAU GIRARDEAU ASSISTED LIVING CENTER ASSISTED LIVING FACILITY OPTION 2 CAPE GIRARDEAU COUNTRY GARDENS ASSISTED LIVING FACILITY OPTION 1 CAPE GIRARDEAU FOUNTAINBLEAU LODGE SKILLED NURSING FACILITY CAPE GIRARDEAU FOUNTAINBLEAU LODGE ASSISTED LIVING FACILITY OPTION 1 CAPE GIRARDEAU FREDERICK STREET MANOR RESIDENTIAL CARE FACILITY II CAPE GIRARDEAU HEARTLAND CARE AND REHABILITATION CENTER SKILLED NURSING FACILITY CAPE GIRARDEAU JACKSON MANOR NURSING HOME SKILLED NURSING FACILITY JACKSON JEFFERSON MANOR RESIDENTIAL CARE FACILITY I CAPE GIRARDEAU LIFE CARE CENTER OF CAPE GIRARDEAU SKILLED NURSING FACILITY CAPE GIRARDEAU LOUIS E MASTERMAN CENTER RESIDENTIAL CARE FACILITY II CAPE GIRARDEAU LUTHERAN HOME ASSISTED LIVING ASSISTED LIVING FACILITY OPTION 2 CAPE GIRARDEAU LUTHERAN HOME, THE SKILLED NURSING FACILITY CAPE GIRARDEAU MAPLE CREST MANOR RESIDENTIAL CARE FACILITY II CAPE GIRARDEAU MONTICELLO HOUSE SKILLED NURSING FACILITY JACKSON MONTICELLO HOUSE RESIDENTIAL CARE FACILITY II JACKSON OAK RIDGE MANOR ASSISTED LIVING FACILITY OPTION 1 OAK RIDGE PARKWOOD MANOR RESIDENTIAL CARE FACILITY II CAPE GIRARDEAU RATLIFF CARE CENTER SKILLED NURSING FACILITY CAPE GIRARDEAU SPRIGG STREET MANOR RESIDENTIAL CARE FACILITY I CAPE GIRARDEAU Source: Missouri Department of Health and Senior ho Services, S w Me Long Term Care in Missouri

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Chapter 3: Health Outcomes

Mortality

Leading Causes of Death The leading causes of Cape death in Girardeau County based -‐ on 11 year data (1999 -‐ 2009) from the Missouri Department of Health and Senior Services ws: are as follo • Heart Disease 32% • All Cancers (Malignant Neoplasms) 21% • Stroke/Other Cerebrovascular Disease 7% • All Injuries and Poisonings 5% • Chronic Lower Respiratory Disease 5% These five causes accounted for 70% of Cape all Girardeau County deaths in that time period. The table below shows all leading causes of death in Cape souri. Girardeau County and Mis The Cape Girardeau County rate is higher than the state rate oke/other in heart disease, str cerebrovascular disease, Alzheimer’s disease, and kidney disease. Table 12 : Leading Cause of Death Profile 1999 -‐ 2009 (rates per 100,000 population) -‐ Cape Girardeau County vs. Missouri Cape Girardeau County Missouri Cause of Death Compared to Number Rate Missouri Rate Rate All Causes 7596 843.8 Lower 871.5 Heart Disease 2409 260.7 Higher 245.6 All Cancers (Malignant Neoplasms) 1587 183.9 Lower 197.7 Smoking-‐Attributable (estimated) 1271 144.2 Lower 152.2 Stroke/Other Cerebrovascular Disease 552 59 Higher 54.9 Lung Cancer 462 54.2 Lower 61.4 All Injuries and Poisonings 381 47.4 Lower 67 Chronic Lower Respiratory Disease 377 42.3 Lower 48.7 Alzheimer's Disease 322 33.6 Higher 21.9 Total Unintentional Injuries 241 28.9 Lower 45 Pneumonia and Influenza 199 21.1 Lower 23.1 Diabetes Mellitus 183 20.8 Lower 23.8 Kidney Disease (Nephritis and Nephrosis) 163 17.7 Higher 17.2 Breast Cancer 115 13.3 Lower 14.6 Motor Vehicle Accidents 98 12.1 Lower 18.6 Suicide 77 10.1 Lower 12.8 Alcohol/Drug-‐Induced 75 10.2 Lower 16.4 Septicemia 72 8.4 Lower 11.5 Firearm 68 8.8 Lower 12.7 Chronic Liver Disease and Cirrhosis 39 4.8 Lower 7.3 Homicide 19 2.4 Lower 7.1 Injury at Work 16 2 Equal 2 HIV/AIDS 7 0.9 Lower 2.3 Source: Missouri Department of Health and Senior ommunity Services, C Data Profiles

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Cancer The table below shows the top ten es cancer incidence sit in Cape Girardeau County by all sexes and then breaks out the top ten sites by males and nd females. While lung a bronchus cancer makes up the greatest percentage among all sexes, when looking es at mal and females separately, breast the cancer is most prevalent for females and prostate cancer is the most prevalent for males.

Table 13 : Cape Girardeau County, Top Ten Cancer Incidence Sites (2004-‐2008) Cancer Site Percent Lung and Bronchus 16.95 Female Breast 13.91 Prostate 13.5 Colon and Rectum 10.87 All Sexes Thyroid 3.92 Urinary Bladder 3.92 Kidney and Renal Pelvis 3.74 Non-‐Hodgkin Lymphoma 3.74 Melanoma of the Skin 2.69 Oral Cavity and Pharynx 2.57 Cancer Site Percent Female Breast 27.9 Lung and Bronchus 15.83 Colon and Rectum 10.79 Thyroid 6.68 Females Corpus and Uterus, NOS 4.57 Non-‐Hodgkin Lymphoma 3.75 Ovary 2.7 Pancreas 2.88 Cervix Uteri 2.34 Melanoma of the Skin 2.23 Cancer Site Percent Prostate 26.92 Lung and Bronchus 18.07 Colon and Rectum 10.96 Urinary Bladder 5.83 Males Kidney and Renal Pelvis 5.71 Non-‐Hodgkin Lymphoma 3.73 Oral Cavity and Pharynx 3.38 Melanoma of the Skin 3.15 Leukemia 2.68 Liver and Intrahepatic Bile Duct 2.333 Source: Missouri Cancer Registry, Top Ten Cancer Incidence -‐ Sites (2004 2008)

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Chronic Disease The table below shows a comparison of es many chronic diseas for Cape Girardeau County and Missouri and the deaths, hospitalizations, and ER visits caused by those chronic diseases. Cape Girardeau County has worse rates than Missouri in only a few categories, which are highlighted in pink below.

Table 14 : Chronic Disease Comparison: Cape Girardeau County vs. Missouri

# of Events -‐ Cape Girardeau Missouri Chronic Disease Data Years Cape Girardeau Rate Rate

Heart Disease Deaths 1999-‐2009 2,409 260.7 245.6 Hospitalizations 2005-‐2009 4,904 121.7 152.38 ER Visits 2005-‐2009 4,211 11.6 12.95 Ischemic Heart Disease Deaths 1999-‐2009 1,741 189 170.32 Hospitalizations 2005-‐2009 1,539 38.4 55.25 ER Visits 2005-‐2009 68 0.2 0.82 Stroke/Other Cerebrovascular Disease Deaths 1999-‐2009 552 59 54.92 Hospitalizations 2005-‐2009 1,275 30.7 30.37 ER Visits 2005-‐2009 193 0.5 0.79 All Cancers (Malignant Neoplasms) Deaths 1999-‐2009 1,587 183.9 197.7 Hospitalizations 2005-‐2009 1,456 36.7 39.07 Colorectal Cancer Deaths 1999-‐2009 193 21.8 19.39 Hospitalizations 2005-‐2009 192 4.7 4.89 Colon and Rectum Cancer (SEER) Deaths 1999-‐2009 193 21.8 19.25 Lung Cancer (SEER) Deaths 1999-‐2009 462 54.2 61.41 Hospitalizations 2005-‐2009 185 4.6 5.18 Breast Cancer Deaths 1999-‐2009 115 13.3 14.55 Hospitalizations 2005-‐2009 77 1.9 2.2 Cervical Cancer Deaths 1999-‐2009 14 1.7* 1.41 Hospitalizations 2005-‐2009 17 0.5* 0.79 Prostate Cancer Deaths 1999-‐2009 95 10.6 9.1 Hospitalizations 2005-‐2009 171 4.2 2.78

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Diabetes Mellitus Deaths 1999-‐2009 183 20.8 23.78 Hospitalizations 2005-‐2009 523 13.8 17.32 ER Visits 2005-‐2009 530 1.5 1.7 Chronic Obstructive Pulmonary Disease Excluding Asthma Deaths 1999-‐2009 368 41.2 47.38 Hospitalizations 2005-‐2009 778 19.3 23.22 ER Visits 2005-‐2009 1,638 4.6 5.41 Asthma Deaths 1999-‐2009 9 1.1* 1.3 Hospitalizations 2005-‐2009 249 7.2 13.41 ER Visits 2005-‐2009 770 2.3 5.12 Smoking-‐Attributable (Estimated) Deaths 1999-‐2009 1,271 144.3 152.23 Arthritis/Lupus Deaths 1999-‐2009 25 2.8 3.55 Hospitalizations 2005-‐2009 1,564 39.8 41.01 ER Visits 2005-‐2009 5,333 14.9 8.67 Source: Missouri Department of Health and , Senior Services County Level Study, Chronic Disease Comparison Death rates are per year per 100,000 are population and age-‐adjusted to the U.S. 2000 standard population. Hospitalization rates are per year per tion 10,000 popula and are age-‐adjusted to the 2000 U.S. standard population. ER Visit rates are per year per 1000 -‐ population and are age adjusted to the U.S. 2000 standard population. Years of Potential Life Lost The County Health Rankings created by ohnson the Robert Wood J Foundation and the University of Wisconsin’s Population Health Institute measure ature prem death by the years of potential life lost before age 75 (YPLL). Every death occurring before the age of 75 contributes to the total number of years of potential life lost, so someone that dies at age 25 contributes 50 years of life lost to the county’s YPLL. According to the County Health Rankings, Cape Girardeau 938 County had 6, years of potential life lost before age 75 per 100,000 population in 2011, or compared to 8,043 f the state of Missouri.

Infant Mortality The figure below shows the infant mortality rate of Cape Girardeau County compared to the state of Missouri. The state rate has remained fairly steady with a slight decrease over the ten-‐year period, while the Cape Girardeau County rate has fluctuated up and down, trending downward overall.

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Figure 21 : Infant Mortality Rate – Cape Girardeau County vs. Missouri Infant Mortality Rate -‐ Cape Girardeau ouri County vs. Miss (per 1,000 live births)

Cape Girardeau County Missouri 8.8

7.7 7.8 7.7 7.7 7.7 7.5 7.5 7.4

7.6 7.5 7.7 7.6 7.2 6.8 6.5 6.5 6.2 5.6 Year 1997 Year 1998 Year 1999 Year 2000 02 Year 2001 20 Year 2003 Year 2004 Year 2005 Year 2006

Source: Annie E. Casey Foundation Kids Count Data Center Motor Vehicle Accidents According to the University of Wisconsin, Population and Health Institute the Robert Wood Johnson Foundation’s County Health Rankings, Cape Girardeau County has a motor rash vehicle c death rate per 100,000 of 13, compared to 19 in the state of Missouri.

Morbidity Obesity and Overweight Adult obesity is measured by those persons age 20 and older that have a body mass index (BMI) greater than or equal to 30 kg/m2. According Rankings to the County Health developed by the Robert Wood Johnson Foundation and the University of Wisconsin’s Population Health Institute, 28% of Cape Girardeau County sidents re are obese compared to 31% of Missouri residents. Obesity is often the end result of an overall energy imbalance due limited to poor diet and physical activity. Obesity increases the risk for health conditions such as coronary heart disease, type 2 diabetes, cancer, hypertension, dyslipidemia, stroke, liver and gallbladder disease, sleep apnea and respiratory problems, and osteoarthritis. Diabetes According to e th Centers for Disease Control and Prevention, diabetes ng is the leadi cause of kidney failure, non-‐traumatic lower-‐limb amputations, and new cases of blindness among adults in the United States and it is also a major cause of heart disease and stroke. Other complications that can be caused by diabetes include: hypertension, eye problems, kidney ous disease, nerv system disease, amputations, dental disease, and complications of pregnancy. Diabetes is a group of diseases marked s by high level of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can lead tions to serious complica and premature death, but people with diabetes, working together with their support heir network and t health care providers, can take steps to control the disease and lower the risk of complications. There is more than one type of diabetes:

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• Type 1 diabetes was previously called -‐ insulin dependent diabetes mellitus (IDDM) -‐ or juvenile onset diabetes. Type 1 diabetes develops when system the body’s immune destroys pancreatic beta cells, the only cells in the body that that make the hormone insulin regulates blood glucose. To survive, people with type 1 diabetes in must have insul delivered by injection or a pump. This form of diabetes usually strikes children and young adults, although disease at onset can occur any age. In adults, type 1 diabetes accounts for approximately 5% of all diagnosed cases of diabetes. Risk factors for type 1 diabetes may netic, be autoimmune, ge or environmental. There is no known way to prevent type 1 diabetes. als Several clinical tri for preventing type 1 diabetes are currently in progress or are being planned.

• Type 2 diabetes was previously called – non insulin-‐dependent diabetes mellitus (NIDDM) or adult-‐onset diabetes. In adults, type 2 diabetes accounts 95% for about 90% to of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it. Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, inactivity, physical and race/ethnicity. African Americans, Hispanic/Latino Americans, ican Amer Indians, and some Asian Americans and Native Hawaiians or other Pacific Islanders are at particularly high risk for type 2 diabetes and its complications. Type 2 diabetes in children and adolescents, although still rare, is being diagnosed more frequently among American Indians, African Americans, Hispanic/Latino Americans, and Asians/Pacific Islanders.

• Gestational diabetes is a form of glucose intolerance diagnosed during pregnancy. Gestational diabetes occurs more frequently among African Hispanic/Latino Americans, Americans, and American Indians. It is also more common among obese th women and wi a family history of diabetes. During pregnancy, gestational s diabetes require treatment to optimize maternal blood glucose levels to lessen the risk of complications in the infant.

• Other types of diabetes result from specific genetic conditions ity (such as matur -‐onset diabetes of youth), surgery, medications, infections, pancreatic and disease, other illnesses. Such types of diabetes account for 1% to 5% of all diagnosed cases.

According to the University of Wisconsin, Population and Health Institute the Robert Wood Johnson Foundation’s County Health Rankings, Cape Girardeau County has 10% of adults aged 20 and over that have been diagnosed with diabetes, 10 compared to % for the state.

Infectious Disease Communicable Diseases The Missouri Department of Health and Senior Services’ ommunicable Bureau of C Disease Control and Prevention put out an Annual Communicable Disease Surveillance Report summarizing the different communicable diseases reported across Missouri in 2009. The diseases were that reported in Cape Girardeau County are described below. Human ehrlichiosis and anaplasmosis are tick-‐borne diseases caused by several closely-‐related bacteria. The bacterium is maintained in nature -‐ in parasite host cycles involving ticks and mammals. Human infections are usually the result of a bite from an infected tick. Ehrlichiosis can lead to life-‐threatening illness in otherwise healthy adults and children. People over the age of 40 and people undergoing immunosuppressive therapy or with a preexisting immunosuppressive condition are especially vulnerable to serious infections and hospitalization. Some infected people, however, never develop

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 53 symptoms, and others experience only mild esolve symptoms that r without treatment. The greatest challenge to health care providers is diagnosing ehrlichiosis in early the course illness, of the when antibiotic therapy is most effective. There was one case of ehrlichiosis reported ardeau in Cape Gir County in 2009 for a rate of .48 per 100,000 population, compared to 2.8 per 100,000 . for Missouri Influenza (the flu) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. There are three types of influenza viruses, types A, B and C, with influenza A viruses being the most severe. Influenza is characterized by abrupt onset of fever, often with chills or rigors, headache, malaise, a, diffuse myalgi and nonproductive cough. Subsequently, as symptoms progress, sore throat, nasal congestion, rhinitis, and cough become more prominent. Influenza affects the health of a large number of people every year. Most people recover within a week, but a cough and tiredness can linger for two weeks or longer. Dehydration, bronchitis, and bacterial pneumonia, are examples of complications from flu. The flu can make chronic health problems worse. For example, people with asthma may experience asthma hey attacks while t have the flu, and people with chronic congestive heart failure may i have worsen ng of this condition that is triggered by the flu. Children may get sinus problems and ear infections rom as complications f the flu. Those persons 65 years and older, children under the age of two, and persons of any age with chronic medical conditions are at highest risk for serious complications of flu. The influenza season is defined as the period between week 40 (first week of October) of 20 one year and week (middle of May) of the next year. The rate per 100,000 population in Cape was Girardeau County 1090.2 with a total case count of 793 for the 2009 – 2010 influenza season, compared to a rate of 517.1 . per 100,000 for Missouri Pertussis, also known as whooping cough, is a highly contagious respiratory disease. It is caused by the bacterium Bordetella pertussis. Pertussis is only found in humans from and is spread person to person. People with pertussis usually spread the disease by coughing or sneezing while in close contact with others, who then breathe in the pertussis bacteria. Pertussis can cause serious and sometimes life-‐ threatening complications in infants and young children, especially those who are not fully vaccinated. Many infants who get pertussis are infected by older siblings, parents or caregivers who might not even know they have the disease. The disease usually starts with cold-‐like symptoms and a mild cough or fever. After one to two weeks, severe coughing can begin. Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks. In infants, the cough can be minimal or altogether absent. Infants may have a symptom known as "apnea." Apnea is a pause in the child’s breathing pattern. Pertussis is most dangerous for infants. More than half of infants younger than one year of age who get the disease must be hospitalized. Pertussis can cause violent and rapid coughing, over and over, until the air is gone from the d lungs and you are force to inhale with a loud "whooping" sound. This extreme coughing can cause you to very throw up and be tired. In teens and adults, especially those who have been vaccinated, the not "whoop" is often there and the infection is generally milder (less severe). Cape Girardeau County had two cases of pertussis in 2009 for a rate of .16 per 100,000 population, compared to 17.2 per 100,000 for Missouri. Shigellosis is an infectious disease caused by a group of bacteria called Shigella. Most people infected with Shigellosis develop diarrhea, fever, h and stomac cramps starting a day or two after they are exposed to the organism. Stools are frequent, loose to watery, of small en volume, and oft mucoid and/or bloody. The diarrhea is usually self-‐limiting, resolving in five to seven days. Young children and the elderly may be more severely affected, in some cases needing hospitalization. However, some individuals who are infected may have no symptoms at all, but could still pass the Shigella bacteria to others. Cape Girardeau County had four cases of shigellosis for 2009 for a rate of .31 per 100,000 population, compared to 17.7 per 100,000 for Missouri.

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Tuberculosis (TB) is a disease caused by the Mycobacterium bacterium called tuberculosis. The bacteria can attack any part of your body, but it ungs. usually attacks the l TB is spread through the air from one person to another. The bacteria are expelled into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks or sings. These bacteria can stay in the air , for several hours depending on the environment. People who become infected with TB bacteria usually lose, have had very c day-‐to-‐ day contact with someone who has TB disease r, (e.g. a family membe friend, r o close co-‐worker). In most people who become infected, the fight body is able to the bacteria to stop them from growing. The bacteria become inactive, but they remain alive in the body and can become active later. This is called latent TB infection (LTBI). These people do not have symptoms of y TB disease, and the cannot spread TB to others. According to Missouri the Department for Health and Senior Services s Tuberculosi Information Management System, Cape Girardeau County had one case of TB disease d an 43 cases of LTBI in 2010. Hepatitis Hepatitis A is a contagious liver disease that results from infection with the Hepatitis A virus. It can range in severity from a mild illness to lasting a few weeks a severe illness lasting several months. Hepatitis A is usually spread when a person ingests — fecal matter even in microscopic — amounts from contact with objects, food, or drinks contaminated eces by the f or stool of an infected person. Cape Girardeau County had zero reports of 009. Hepatitis A in 2 Hepatitis B is a contagious liver disease that results from infection with the Hepatitis B virus. It can range in severity from a mild illness to lasting a few weeks a serious, lifelong illness. Hepatitis B is usually spread when blood, semen, or another body fluid ted from a person infec with the Hepatitis B virus enters the body of someone who is not infected. This can happen through sexual contact with an infected person or sharing needles, syringes, or other drug-‐injection equipment. Hepatitis B can o als be passed from an infected mother to her baby at birth. Hepatitis B can be either acute or chronic. Acute Hepatitis B virus infection -‐ is a short term illness that occurs within the first 6 is months after someone exposed to the Hepatitis B virus. Acute infection — can but does not — always lead to chronic infection. Chronic Hepatitis B virus infection -‐ is a long term illness that occurs when the Hepatitis n B virus remains i a person’s body. Chronic Hepatitis B is a serious disease that -‐ can result in long term health problems, and even death. Cape Girardeau County had one report of and Hepatitis B Acute two reports of Hepatitis Chronic B Infection in 2009. Hepatitis C is a contagious liver disease that results from infection with the Hepatitis C virus. It can range in severity from a mild illness to lasting a few weeks a serious, lifelong illness. Hepatitis C is usually spread when blood from a person infected irus with the Hepatitis C v enters the body of someone who is not infected. Today, most le peop become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. Hepatitis C can be either “acute” or “chronic.” Acute Hepatitis C virus infection -‐ is a short term illness that occurs within the first six months after someone is exposed to the rus. Hepatitis C vi For most people, acute infection ds lea to chronic infection. Chronic Hepatitis C is a serious t disease tha can result in long-‐term health problems, or even death. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that ease can spread the dis , especially injection drug use. Cape Girardeau y Count had 114 cases of Chronic Hepatitis C Infection reported in 2009. HIV/AIDS HIV is the h uman i mmunodeficiency v irus. It is the virus that a can lead to cquired i mmune d eficiency syndrome, or AIDS . There are two types of HIV, HIV-‐1 and HIV-‐2. In the United States, unless otherwise

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 55 noted, the term “HIV” primarily -‐ refers to HIV 1. Both types of HIV damage a person’s body by destroying specific blood cells, called CD4+ T cells, which are crucial lping to he the body fight diseases. Within a few weeks of being infected people with HIV, some develop -‐ flu like symptoms that last for a week or two, but others have no symptoms at all. People living with HIV may appear and feel healthy for several years. However, even if they feel healthy, HIV is still affecting their bodies. All people with HIV should be seen on a regular basis by a health care provider experienced with on. treating HIV infecti Many people with HIV, including those hy, who feel healt can benefit greatly from current medications used to treat HIV infection. These medications can limit or slow down on the destructi of the immune system, improve the health of people living with HIV, and may reduce their ability to transmit HIV. Untreated early HIV infection is also associated with including many diseases cardiovascular disease, kidney disease, liver disease, and cancer. AIDS is the late stage of HIV infection, system when a person’s immune is severely damaged and has difficulty fighting diseases and certain cancers. Before the development of certain medications, people with HIV could progress to AIDS in just a few years. Currently, people can live much -‐ longer even decades -‐ with HIV before they develop AIDS. f This is because o “highly active” combinations of medications that were introduced in the mid-‐1990s. The table below shows the total new and rates living cases and of HIV and AIDS in Cape Girardeau County and Missouri for 2010. Cape Girardeau County te has a much lower ra of HIV and than AIDS the state of Missouri.

Table 15 : New & Living HIV & AIDS Cases & Rates for Cape Girardeau County vs. Missouri, 2010 Cape Girardeau County Missouri Case/Disease Number Rate Rate New HIV Cases 1 1.4 7.5 Living HIV Cases 24 32.5 84.9 New AIDS Cases 0 0 2.3 Living AIDS Cases 21 28.4 96.5 Source: Missouri Department for Health and s’ Senior Service HIV/AIDS Disease Surveillance System 2010 Epidemiologic ile Prof Other Sexually Transmitted Diseases Sexually transmitted diseases (STDs) is a term used to describe more than 20 different infections that are transmitted through exchange of semen, blood, and other body fluids; or by direct contact with the affected body areas of people with STDs. Sexually es transmitted diseas are also called venereal diseases. STDs can have very painful -‐ long term consequences as well as immediate They health problems. can cause: • birth defects • blindness • bone deformities • brain damage • cancer • heart disease • infertility and other abnormalities of the reproductive system • mental retardation • death

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 56

Some of the most sexually common transmitted diseases are described below as defined by the Centers for Disease Control and Prevention along with the number of cases reported in Cape Girardeau County by the Missouri Department for Health and Senior Services’ veillance HIV/AIDS Sur System STD by County report. Syphilis is a sexually transmitted disease bacterium caused by the Treponema pallidum. It has often been called "the great imitator" because so nd many of the signs a symptoms are indistinguishable from those of other . diseases In 2011, Cape Girardeau County had six cases of Syphilis reported. Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, eproductive moist areas of the r tract, including the cervix (opening to the womb), uterus (womb), and fallopian tubes (egg canals) in women, and in the urethra (urine canal) in women and men. The bacterium can also grow in the mouth, and throat, eyes, anus. Gonorrhea is a very common infectious disease. In 2011, Cape Girardeau County had 62 cases of Gonorrhea reported. Chlamydia is a common sexually transmitted disease caused by the bacterium, Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that versible cause irre damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man. Chlamydia is the most frequently reported bacterial nsmitted sexually tra disease in the United States. Under-‐reporting is substantial because most people with chlamydia are not aware of their infections and do not seek testing. Also, testing is not often done if patients are treated for their symptoms. In 2011, Cape Girardeau County had 240 cases ed. of Chlamydia report

Unintentional Injuries An unintentional injury is that one is not inflicted by deliberate means. This category includes those injuries and poisonings described as accidental, regardless of whether the injury was inflicted by oneself or by another person. The following figures show the Death Rate, e, ER Visits Rat and Hospitalizations Rate for Cape Girardeau County and Missouri by type of unintentional injury. Cape Girardeau County’s rate is either less than or equal to the gory state rate in every cate and type except for falls in the hospitalizations category. Falls and traffic motor vehicle are the largest causes of unintentional injuries.

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Figure 22 : Death Rate by Unintentional Injury Type (2007-‐2009) – Cape Girardeau County vs. Missouri Death Rate* by Unintenonal Injury Type (2007-‐2009) -‐ Cape Girardeau County vs. Missouri

15.5 Cape Girardeau County Missouri

11.6 10.2 8.6

5.2

1.5 1.2 1.4 1.6 0.5 0.8 0.0 0.3 0.9 0.0 0.3

Drowning Fall Fire/Burn Firearm Injury at Work Motor Vehicle Poison: Drugs/ Poison: Gas/ Traﬃc** Alcohol Cleaner

Source: Community Data Profiles -‐ Missouri Department of Health and Senior Services *Death rates are per year per 100,000 population -‐ and are age adjusted to the U.S. 2000 standard population.

Figure 23 : ER Visits Rate by Unintentional Injury Type (2007-‐2009) – Cape Girardeau County vs. Missouri ER Visits Rate* by Unintenonal Injury ) Type (2007-‐2009 -‐ Cape Girardeau County vs. Missouri

Cape Girardeau County Missouri 26.2 22.3

9.2 7.8

1.5 1.5 0.0 0.0 0.1 0.1 0.5 0.7 0.2 0.2

Drowning Fall Fire/Burn Firearm Motor Vehicle Poison: Drugs/ Poison: Gas/ Traﬃc** Alcohol Cleaner

Source: Community Data Profiles -‐ Missouri Department of Health and Senior Services *ER Visits rates are per year per 1,000 population and -‐ are age adjusted to U.S. the 2000 standard population.

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Figure 24 : Hospitalizations Rate by Unintentional Injury Type (2007-‐2009) – Cape Girardeau County vs. Missouri Hospitalizaons Rate* by Unintenonal Injury 07-‐2009) Type (20 -‐ Cape Girardeau County vs. Missouri 29.1 28.0 Cape Girardeau County Missouri

9.7 7.5

2.8 3.7 1.3 0.0 0.1 1.1 0.3 0.3 0.2 0.2

Drowning Fall Fire/Burn Firearm Motor Vehicle Poison: Drugs/ Poison: Gas/ Traﬃc** Alcohol Cleaner

Source: Community Data Profiles -‐ Missouri Department of Health and Senior Services *Hospitalization rates are per year 0,000 per 1 population and -‐ are age adjusted to the U.S. 2000 standard population.

Injuries at Work The rate of work injuries has fluctuated greatly for Cape Girardeau County while Missouri’s rate has been mostly trending down. Cape ty Girardeau Coun has had a much higher rate than the state from year to year except for a drastic drop t in 2001. The mos common injury location for machinery-‐related injuries is the wrists -‐hands which are at a much higher rate than all other injury locations.

Figure 25 : Work Injuries Rate – Machinery Type – Cape Girardeau County vs. Missouri

Work Injuries Rate -‐ Machinery Type -‐ Cape Girardeau Cape Girardeau County County vs. Missouri 113.1 Missouri

100.8

88.8 88.6 86.9 89.5 78.2 74.0 71.5 70.0 68.9 69.3 70.1 80.2 67.0

57.8 56.0 63.8 59.7 45.8

Year 2000 Year 2001 Year 2002 Year 2003 Year 2004 Year 2005 Year 2006 Year 2007 Year 2008 Year 2009

Source: Missouri Department of Health and , Senior Services MICA, Injury Rates per 100,000 population

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Health Status at Birth Health status at birth can a determine child’s current and future — morbidity or whether or not a child will have a “healthy start”. Low Birth Weight According to the University of Wisconsin’s Health ow Rankings, l birth weight (LBW) as a health outcome represents two factors: maternal exposure to and health risks the infant’s current and future morbidity, as well as premature mortality From risk. the perspective of maternal health outcomes, LBW indicates maternal exposure to health risks in of all categories health factors, including her health behaviors, access to health care, the social and economic environment the mother inhabits, and environmental risks to which she is exposed. Modifiable maternal health behaviors — including weight gain, smoking, and alcohol and substance — use account for more than 10% of the variation in birth weight. Maternal smoking alone accounts for 7% of variation in birth weight. In terms of the infant’s health outcomes, LBW serves as a predictor of premature mortality and/or morbidity over the life course. Gestational age, which is correlated with birth weight, is inversely related to psychological ss. distre LBW children have greater developmental and growth problems, k are at higher ris of cardiovascular disease later in life, and have a greater rate of respiratory conditions. LBW has also been associated with cognitive development problems. Several authors find that LBW r children have highe rates of sensorineural impairments, such as cerebral palsy, and visual, auditory, and intellectual impairments. The figure below shows the low birth weight percent of Cape d Girardeau County compare to the state of Missouri. From 1997 through 2004, unty Cape Girardeau Co went from being significantly lower than the state percentage to exactly equal and the percentage remained equal through 2006.

Figure 26 : Low Birth Weight Percent – Cape Girardeau County vs. Missouri Low Birth Weight Percent -‐ Cape . Girardeau County vs Missouri

Cape Girardeau County Missouri

8.1% 8.1% 8.1% 8.0% 7.9% 7.8% 7.8% 7.7% 7.7% 7.7% 8.1% 8.1% 8.1% 7.9% 7.7%

7.2% 7.1% 7.0% 6.9% 6.8% Year 1997 Year 1998 Year 1999 Year 2000 02 Year 2001 20 Year 2003 Year 2004 Year 2005 Year 2006

Source: Annie E. Casey Foundation Kids Count Data Center

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Pre-‐term Deliveries Preterm birth is the birth of an infant ation. prior to 37 weeks gest According to the CDC, preterm birth is the frequent most cause of infant death and is the leading cause of long-‐term neurological disabilities in children. A developing baby goes through important growth during the final weeks and months of pregnancy and many organ systems, including the brain, lung, and liver, need the final weeks of pregnancy to fully develop. Even infants born slightly preterm a are at greater risk than -‐ full term infants, but the earlier the delivery, the more likely the risk of serious disability or even death. Adverse health outcomes related to preterm cerebral birth include palsy, developmental delay, and vision and hearing impairment. Preterm births also may cause heavy emotional and economic burdens for families. Figure 27 shows the percent of preterm births in Cape Girardeau County compared to the state of Missouri. The -‐ three year moving average shows much fluctuation rardeau between Cape Gi County and Missouri as the county was higher than ut the state abo as many years as the state was higher than the county. Both Cape Girardeau County and Missouri are trending upward.

Figure 27: Preterm Births (Percent of total live births) – Cape Girardeau County vs. – Missouri 3 Year Moving Average Preterm Births (Percent of total live births) -‐ Cape Girardeau County vs. Missouri -‐ 3 Year Moving Average

Cape Girardeau County Missouri Linear (Cape Girardeau County) Linear (Missouri)

13.5 13.4 13.4 13.3 13.8 13.2

12.9 13.4 12.8 13.2 12.7 13.1 12.4 12.9 12.7 12.7 12.6

12.3 12.3

11.8

1998-‐2000 1999-‐2001 2000-‐2002 2001-‐2003 2002-‐2004 2003-‐2005 2004-‐2006 2005-‐2007 2006-‐2008 2007-‐2009

Source: Missouri Department Health of and Senior Services, Community Data Infant Profiles, Health

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Birth Defects Major birth defects are conditions that cause structural changes in ts one or more par of the body; are present at birth; and have a serious, adverse velopment, effect on health, de or functional ability. According to the bout CDC, a one in every 33 babies is born with a birth defect and birth defects are a leading cause of infant death, accounting for more than one of every five infant deaths. In addition, babies born with rth bi defects have a greater chance of illness sability and long term di than babies without birth defects. Figure 28 shows the rate of birth defects per or 10,000 live births f Cape Girardeau County and Missouri. The Cape Girardeau County rate has been higher than the state rate all years except for being close to equal in the 2003-‐2005 range. For most years, Cape Girardeau County was considerably higher than Missouri.

Figure 8 2 : Birth Defects Rate (per 10,000 live births) – Cape Girardeau County vs. – Missouri 3 Years Moving Average Birth Defects Rate (per 10,000 live births) -‐ Cape Girardeau County vs. Missouri -‐ 3 Year Moving Average

806.3 Cape Girardeau County Missouri 823.6

732.0 717.5

649.6 619.7 601.9

601.4 611.0 591.6 599.0 571.0 573.7 579.3

1999-‐2001 2000-‐2002 2001-‐2003 2002-‐2004 2003-‐2005 2004-‐2006 2005-‐2007

Source: Missouri Department of Health and , Senior Services Community Data Profiles, Infant Health

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Health Status The County Health Rankings created by The Robert Wood Johnson Foundation and the University of Wisconsin’s Population Health Institute has asures three me for which a county’s health status can be based on: 1. Poor or fair health 2. Poor physical health days 3. Poor mental health days “Poor or fair ” health is a -‐ self reported health status hat t is a general measure -‐ of health related quality of life in a population. The measure is based on survey responses to the question: “In general, would you say that your health is excellent, very good, fair, or poor?” The value reported unty in the Co Health Rankings is the percent of adult who respondents rate their health as “fair” or “poor.” For Cape Girardeau County in 2011, the percentage of adults who rated their ealth h as “fair” or “poor” was 14%, which is just slightly lower s than Missouri’ 16%. The “poor physical health ” days measure is based on responses to the question: “Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?” The valu e reported is average the number of days a county’s adult respondents report their physical health was not good. For Cape Girardeau County in 2011, the average number of days ysical that ph health was not good was 2.9 days, which is lower than the average state of 3.6 days. The “poor mental health ” days measure is based on responses to the question: “Thinking about your mental health, which includes stress, d depression, an problems with emotions, for how many days during the past 30 days was your mental health not good?” The value reported is the average number of days a county’s adult respondents eir report that th mental health was not good. For Cape Girardeau County, the average number of days that mental health was not good was 4.3 days, which is h hig er than the state average of 3.7 days.

Mental Health Cape Girardeau County is not considered a mental health professional shortage area by the Health Resources and Services Administration. According to alth the Behavioral He Profile for Cape Girardeau County created by the Missouri Department of Mental 9, Health, in 200 nine Cape Girardeau County residents committed suicide. In 2010, 1,051 Cape residents of Girardeau County received treatment for serious mental illness at publicly-‐funded facilities, with mood disorders being the most common diagnosis category. Mood disorders include mania, nd major depression, a bipolar disorder. Anxiety and psychotic disorders were the next most common diagnosis Anxiety category. disorders include panic, obsessive-‐compulsive, post-‐traumatic stress disorders, and phobias. Psychotic disorders include schizophrenia and delusional disorders. Individuals struggle that with a serious mental disorder are at a higher risk for homicide, suicide, and accidents c as well chroni conditions including cardiovascular and respiratory diseases and substance abuse disorders.

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Preventable Hospitalizations According to the University of Wisconsin, Population and Health Institute the Robert Wood Johnson Foundation’s County Health Rankings, Cape Girardeau County had a preventable hospital 63 stay rate of compared to 75 for the state of Missouri. Preventable hospital stays are measured as the hospital discharge rate for ambulatory -‐ care sensitive conditions per 1,000 Medicare enrollees. The Missouri Department of Health and Senior souri Services Mis Information for Community Assessment rates the 22 diagnoses in the table ble below as preventa hospitalizations. Cape Girardeau County has worse rates in only two diagnoses: bacterial pneumonia, an d congenital syphilis.

Table 16 : Preventable Hospitalizations -‐ 2009 Cape Girardeau County vs. Missouri Cape Girardeau Missouri Diagnosis Number Rate Number Rate Angina 0 @ 377 0.7 Asthma 41 6.9 6,763 13.1 Bacterial pneumonia 129 19.9 10,747 19.6 Cellulitis 67 10.9 7,366 13.9 Chronic obstructive pulmonary 77 11.1 7,049 11.7 Congenital syphilis 1 0.2 @ 11 0.0 @ Congestive heart failure 39 5.4 5,574 9.3 Convulsions 15 2.7 @ 1,628 3.1 Dehydration - volume depletion 179 27 17,736 32.3 Dental conditions 3 0.5 @ 550 1.1 Diabetes 59 8.6 5,954 11.2 Epilepsy 29 4.9 3,093 5.9 Failure to thrive 0 @ 212 0.4 Gastroenteritis 17 2.7 @ 2,124 4 Hypertension 9 1.4 @ 1,435 2.6 Hypoglycemia 0 @ 75 0.1 Immunization preventable 0 @ 87 0.2 Kidney/Urinary infection 42 6.1 4,298 8 Nutritional deficiencies 0 @ 1,545 2.7 Pelvic inflammatory disease 4 0.7 @ 490 1 Severe ENT infections 7 1.1 @ 915 1.8 Tuberculosis 0 @ 49 0.1 Total for Selection 718 110 78,078 142.9 Source: Missouri Department of and Health Senior Services, MICA, Preventable Hospitalizations Rates per 10,000, @ Rate considered unreliable -‐ numerator less than 20

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Chapter 4: Health Behaviors

Diet & Exercise According to the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation’s County Health Rankings, Cape Girardeau County 2 has 8% of its residents that are physically inactive. Being physically inactive is measured by the estimated percent of adults aged 20 and over that reported no leisure time physical inactivity. According to the Missouri Department of Health and Senior Services’ 2007 Health and Preventative Practices Profile, 72.4% of Cape Girardeau County residents reported eating less than five fruits and vegetables per day.

Tobacco Use Adult smoking prevalence is the estimated percent of the adult ently population that curr smokes every day or “most days” and has smoked at least their 100 cigarettes in lifetime. According to the County Health Rankings developed by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, 18% of Cape Girardeau County residents s smoke cigarette compared to 24% of Missouri residents. Cigarette smoking is ause identified as a c in multiple diseases including various cancers, cardiovascular disease, respiratory conditions, low birth weight, erse and other adv health outcomes.

Substance Abuse Substance abuse can have an impact on public safety, health care, crime, and public assistance. According to the Behavioral Health Profile Girardeau for Cape County created by the Missouri Department of Mental Health, in 2009, ounty Cape Girardeau C had 72 alcohol-‐related traffic crashes. This number was higher than 2008, which was e at 53. Two of thos 72 traffic crashes resulted in the loss of life and 29 resulted in injuries. Also u in 2009, Cape Girardea County had 617 DUI arrests, 200 liquor law violations, 383 drug arrests, and 52 methamphetamine lab seizures. In 2009, Cape Girardeau County residents had a total -‐ of 540 alcohol related and 462 drug-‐related hospitalizations and emergency room visits. In 2010, 556 Cape Girardeau County residents were admitted to substance abuse treatment at publicly-‐funded facilities. Some adverse effects excessive drinking can have on health and health outcomes lude inc alcohol poisoning, hypertension, acute myocardial infarction, sexually transmitted infections, unintended pregnancy, fetal alcohol syndrome, sudden infant death syndrome, suicide, interpersonal violence, as well as motor vehicle crashes. According to the County Health Rankings developed by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, 14% of Cape Girardeau County residents reported either binge drinking (consuming 4 drinks for women or 5 drinks for men on a single occasion) or heavy drinking (consuming 1 drink for women or 2 drinks for on men per day average) in the past 30 days, compared to 17% for Missouri.

Maternal Health

Prenatal Care According to the Centers for Disease Control and Prevention, nearly one third of pregnant women will have some kind of -‐ pregnancy related complication. Those women who do not get adequate prenatal care run the risk that such complications will go undetected or won't be dealt with soon enough, which, in turn, can lead to potentially serious consequences for both the mother and her baby. According to

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 65 the Prenatal Profile of the Missouri Department of Health and Senior Services, n i 2009, Cape Girardeau County had ten mothers who received no prenatal care, which is 1.1% births of resident live compared to .8% for the state of Missouri. Another 8.7% of mothers received late prenatal care nd (in the 2 or rd 3 trimester) and overall, 8.0% received inadequate prenatal care (<5 visits for a 37 week pregnancy or <8 for a pregnancy longer than 37 weeks). Smoking During Pregnancy Women who smoke during pregnancy put their themselves and unborn babies at risk for other health problems. Dangers of smoking during pregnancy include: • Higher risk for miscarriage • Premature birth or low birth weight • Birth defects, such as cleft lip or cleft palate • Infant death • Problems with the placenta, which is the source of the baby’s food and oxygen during pregnancy • Higher risk for Sudden Infant Death Syndrome The figure below shows the percentage of mothers who smoked during pregnancy in Cape Girardeau County compared to the state. Cape Girardeau County mained has consistently re above the state percentage.

Figure 29: Percentage of Mothers who Smoked During Pregnancy – Cape Girardeau County vs. – Missouri 3 Year Moving Average

Percentage of Mothers who Smoked During Pregnancy* -‐ Cape Girardeau County vs. Missouri -‐ 3 Year Moving Average

Cape Girardeau County Missouri 21.90% 20.80% 20.60% 21.00% 20.10% 19.90% 19.50% 19.30% 19.20% 19.20%

18.50% 18.30% 18.20% 18.10% 18.10% 18.10% 18.20% 18.10% 17.90% 17.40%

1998-‐2000 1999-‐2001 2000-‐2002 2001-‐2003 2002-‐2004 2003-‐2005 2004-‐2006 2005-‐2007 2006-‐2008 2007-‐2009

Source: Community Data -‐ Profiles Missouri Department of Health and Senior Services *Smoked during Pregnancy: Resident live births to mothers smoking and during pregnancy the percent this number is of total . resident live births

Breastfeeding According to the Centers for Disease Control and Prevention, both babies and mothers gain many benefits from breastfeeding. Breast milk is easy to digest and contains hat antibodies t can protect infants from bacterial and viral infections. Women who breastfeed may also have lower rates of certain breast and ovarian cancers. Also, a baby’s risk of becoming an overweight child goes down with each month of breastfeeding. In a report completed by the Robert Wood Johnson ust Foundation and Tr for America’s Health, research found many other benefits of breastfeeding for the child and the mother. For the child: reduced risk of ear, skin, stomach and respiratory infections, diarrhea, sudden infant death syndrome, necrotizing

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enterocolitis, and other bacterial and viral n infections; and i the longer term, reduced risk of obesity, type 1 and 2 diabetes, asthma, celiac disease, inflammatory bowel disease and childhood leukemia. For the mother: quicker loss of pregnancy weight, prevention of postpartum bleeding and reduced risk of breast cancer, ovarian cancer, type 2 diabetes ssion. and postpartum depre The following figure shows the rate nfants of mothers with i on the Women, Infants, and Children (WIC) program who breastfed their babies sometime during the infancy. Over years -‐ 2000 2008, Cape Girardeau County usual ly had a rate lower than the state rate, but was almost equal in 2004 and 2008 and has trended an increase throughout those years.

Figure 30 : Rate of mothers who breastfed their babies sometime – during infancy Cape Girardeau County vs. Missouri

Rate of mothers who breased their ring babies someme du infancy -‐ Cape Girardeau County vs. Missouri

Cape Girardeau County Missouri

54.5 56.0 52.1 52.4 49.2 48.4 48.5 47.1 46.8 56.2

49.1 49.5 46.4 42.5 44.0 43.4 40.6 37.8

Year 2000 Year 2001 Year 2002 Year 2003 05 Year 2004 20 Year 2006 Year 2007 Year 2008

Source: Missouri Department of Health and , Senior Services MICA, WIC Infant

Seat Belt Use According to the Missouri Department and of Health Senior Services’ Motor Vehicle Crash and Outcomes Statistics, in 2008, 95.7% of u Cape Girardea County residents involved in a motor vehicle crash reported wearing their seat belts, which is slightly higher than the state .6%. percentage of 94 Strikingly, of all the motor vehicle crashes that resulted 2003 in a fatality from -‐2008, even s out of of ten those people killed were not wearing their seat belts in Missouri and Cape Girardeau County. Prevention & Screening Health screenings are an important part ng of maintaini good health, especially as you get older. Many deaths could be prevented if people got simple, nings regular health scree as recommended by their doctor. Health screenings can detect problems en early, wh chances for successful treatment are greatest. For example, colon cancer is the most preventable type of cancer, but many times few symptoms occur early when it is most treatable. A routine exam can detect a colon polyp (growth) before it becomes erous, canc and it can be easily removed. Heart ause disease is the leading c of death in Missouri, but people who routinely have their blood pressure and cholesterol checked, and treated if necessary, improve their chances of preventing and ons controlling conditi that could cause a heart attack. When a person gets the health screenings recommended, they are taking a simple but very important step toward a better quality of life and quite possibly, a longer life.

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Preventative Practices The following table shows the weighted percent for Cape Girardeau Missouri County and for several health and preventative practices. The percent u for Cape Girardea County is better than the state percent in all areas except for women age ing 18 and older never hav a pap smear e don and not having a pap smear done within the past three years.

Table 17 : 2007 Health & Preventative -‐ Practices Cape Girardeau County vs. Missouri Cape Girardeau Compared to Missouri Indicator County Weighted %* Missouri % Weighted %* Did not get medical care 5.2 Better 7.5 Current cigarette smoking 19.9 Better 23.2 No leisure-‐time physical activity 21.6 Better 25.3 Less than 5 fruits and vegetables per day 72.4 Better 76.1 Overweight (25.0 -‐ 29.9 BMI) 35.0 Better 35.7 Obese ( >= 30 BMI) 26.5 Better 29.1 Current high blood pressure 18.3 Better 19.6 Ever had blood cholesterol -‐ checked age 35 and older 93.6 Better 89.3 Has high cholesterol -‐ age 35 and older 17.3 Better 20.2 Never had a mammogram -‐ women age 40 and older 3.2 Better 8.7 No mammogram or clinical breast exam -‐ in last year 23.1 Better 27.6 women age 40 and older Never had ap a P smear -‐ women age 18 and older 6.0 Worse 3.4 No pap smear in last -‐ 3 years women age 18 and older 24.6 Worse 19.5 Never had a blood -‐ stool test men and women age 50 51.9 Better 58.5 and older No blood stool test in -‐ last year men and women age 83.6 Better 87.1 50 and older Never had a sigmoidoscopy or -‐ colonoscopy men and 36.1 Better 36.6 women age 50 and older No sigmoidoscopy or colonoscopy in -‐ past 10 years 40.4 Better 40.4 men and women 50 and older Source: Missouri Department of Health and , Senior Services Community Health Profiles, Health and Preventative Practices *Weighted Percent: The proportion (usually of a percentage) a population that has a defined risk factor, disease, or condition at a particular point in time. The indicators are described as follows: Ø Did not get medical – care among those who needed medical care but could not get it in the past 12 months – due to cost of or no insurance, lack of transportation, or other reason • Derived from "Yes" response to: "Was there a time in the when past 12 months you needed medical care, but could not get it?" reason AND "What is the main you did not get medical care? Would you say cost/no e, insurance, distanc office wasn't open when I could get there, too long a wait for an appointment, too long a wait in waiting room, no childcare, transportation, no access for people with disabilities, medical provider didn't speak my language, or other?"

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Ø Current cigarette smoking • Derived from Y " es" response to: “Have you smoked at least 100 cigarettes re in your enti life?” AND "Every day" or "some days" response to the : following question “Do you now smoke cigarettes every day, some days, or ” not at all? Ø No leisure time physical activity • Derived from "No" response to the following question: “During the past 30 days, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?” Ø Less than 5 fruits and vegetables per day • Derived by calculating number of fruits es and vegetabl eaten per day using the following questions: “How often do you drink fruit juices grapefruit such as orange, or tomato?” AND Not “ counting juice, how often do ” you eat fruit? AND “How often do you eat green salad?” AND “How often do you eat potatoes not including French fries, fried potatoes or potato ” chips? AND “How often do you eat carrots?” AND “Not counting carrots, potatoes or salad, how many servings of vegetables do you usually eat?” Ø Overweight (25.0 -‐ 29.9 BMI) • Derived by calculating BMI responses using to the following questions: “About how much do you weigh without ” shoes? AND “About how tall are you ” without shoes? Ø Obese (>= 30 BMI) • Derived by calculating BMI using o responses t the following questions: “About how much do you weigh shoes? without ” AND “About how tall are you ” without shoes? Ø Current High Blood Pressure (Among those who had ever had blood pressure checked) • Derived from a response of any length of time to the question: "About how long has it been since you last had ressure your blood p checked?” AND Y " es" responses to the following questions: “Have you ever been told by a doctor, nurse, or other health professional that you have high blood ” pressure? AND “Do you still have high blood pressure?” Ø Ever had blood cholesterol checked -‐ among age 35 and older • Derived from es" "Y response from respondents age 35 and older to the following question: “Have you ever had your blood cholesterol checked?” Ø Has high cholesterol -‐ among age 35 and older who have had cholesterol checked • Derived om fr es" "Y responses from respondents age 35 and older to the following questions: “Blood cholesterol is a fatty substance found in the had blood. Have you ever your blood cholesterol checked?” AND “ Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol ” is high? AND “Do you still have high blood cholesterol?” Ø Never had a mammogram -‐ among women age 40 and older • Derived from "No" response from women age 40 and older to “ the following question: A mammogram is an X-‐ray of each breast to look for breast cancer. Have you ever had a mammogram?” Ø No mammogram or clinical breast exam in last year -‐ among women age 40 and older • Derived from a response of ">1 year" on the following questions: “How long has it been since you had your last mammogram?” AND “How long has it been since your last breast exam (clinical breast exam by a doctor or onal)? other health professi ” Ø Never had a Pap -‐ Smear among women 18 and older • Derived from "No" response to the following “ question: A Pap smear is a test for cancer of the cervix. Have you ever ” had a Pap smear?

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Ø No Pap smear in last -‐ 3 years among women age 18 and older • Derived from response of ">3 years" to the following question: “ How long has it been since you had your last Pap smear?” Ø Never had a blood -‐ stool test among men and women age 50 and older • Derived from "No" response to the following “ question: A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?” Ø No blood stool test in -‐ last year among men and women age 50 and older • Derived from response of ">1 year" question: to the following “How long has it been since you had your last blood stool test ? using a home kit ” Ø Never had ig a s moidoscopy or Colonoscopy -‐ among men and women age 50 and older • Derived from "No" response to the following “s question: igmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the bowel for signs of cancer or other health problems. Have you ever had ” either of these exams? Ø No s igmoidoscopy or colonoscopy in past 10 years among men and women age 50 and older • Derived from response of ">10 years" g to the followin question: “ How long has it been since you had your last sigmoidoscopy ” or colonoscopy?

Diabetes Diabetic screening is calculated as the percent re of diabetic Medica patients whose blood sugar control was screened in the past year using glycated a test of their hemoglobin (HbA1c) levels. According to the County Health Rankings, 86% of Medicare enrollees in Cape Girardeau County received such diabetic screening, compared to only 83% statewide. Evidence suggests that improvements in quality can of care be seen through implementation ase of dise management programs that target multiple components of chronic diseases. The use of HbA1c testing to measure glycated hemoglobin for long-‐term monitoring of diabetes is widely accepted as one component e of a comprehensiv disease management program. HbA1c testing is recommended for all patients t with diabetes as par of the initial assessment after a diabetes diagnosis, and then on a routine basis nt’s as a part of the patie comprehensive diabetes care plan.

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Chapter 5: Health Measures Child and Adolescent Health Infant Immunization Rates The up-‐to-‐date on immunizations rate for WIC infant participants deau in Cape Girar County has been substantially higher than the Missouri rate for the years – 2004 2008.

Figure : 31 Up-‐to-‐Date on Immunizations (Rate per s) 100 Infant – WIC Infant Participants – Cape Girardeau Co. Missouri &

Up-‐to-‐Date on Immunizaons (Rate per 100 Infants) -‐ WIC Infant Parcipants -‐ Cape Girardeau County & Missouri

Cape Girardeau County Missouri 97.1 96.2 95.5 93.1

80.4 79.2 79.3 77.6 78.6

2004 2005 2006 2007 2008

Source: Missouri Department of Health and , Senior Services MICA, WIC Infant Causes of Death – Child According to the Missouri Department Health of and Senior Services’ Child Health Profile, Cape Girardeau County has slightly a higher rate of death for Total Unintentional Injuries and motor vehicle deaths, and a considerably higher rate for All Cancers than the state of Missouri for children ages 1-‐14. Table 18 : Causes of : Death Ages 1-‐ 14 Deaths Ages -‐ 1 14 Data Years # of Events Cape Girardeau County Rate Missouri Rate All Causes 1999-‐2009 27 19.8 22.6 Total Unintentional Injuries 1999-‐2009 12 8.8* 8.7 Motor Vehicle Deaths 1999-‐2009 6 4.4* 4.3 All Cancers (Malignant Neoplasms) 1999-‐2009 5 3.7* 2.2 Birth Defects 1999-‐2009 2 1.5* 1.7 Homicide 1999-‐2009 1 0.7* 1.9 Heart Disease 1999-‐2009 0 0.0* 0.9 Source: Community Data -‐ Profiles Missouri Department of Health and Senior , Services Child Health * Fewer than 20 events in numerator; rate is unstable.

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Causes of Death - Adolescents According to the Missouri Department of Health ervices’ and Senior S Child Health Profile, Cape Girardeau County has lower rates of deaths for adolescents age 15-‐19 than the state of in Missouri all categories except all cancers.

Table 19 : Causes of Death: Ages 15-‐19 Deaths Ages -‐ 15 19 Data Years # of Events Cape Girardeau County Rate Missouri Rate All Causes 1999-‐2009 31 47.3 81.3 Total Unintentional Injuries 1999-‐2009 15 22.9* 44.1 Motor Vehicle Deaths 1999-‐2009 10 15.3* 35.8 Homicide 1999-‐2009 3 4.6* 12.6 Suicide 1999-‐2009 3 4.6* 9.1 All Cancers (Malignant Neoplasms) 1999-‐2009 4 6.1* 3.4 Heart Disease 1999-‐2009 0 0.0* 2 Source: Community Data -‐ Profiles Missouri Department of Health and Senior , Services Child Health * Fewer than 20 events in numerator; rate is unstable. Teen Substance Abuse and Smoking According to the Department of Mental Health’s from Behavioral Profile 2012, the availability county of -‐ level data on substance abuse is limited. However, the Missouri Student Survey that is administered to 6th through 12th grade students can provide estimates for youth in most counties. In Cape Girardeau County: • 58.5% of youth believe that it would ettes be easy to get cigar and 49.9 % have friends who smoke. • 61.1% of youth believe that it would ol be easy to get alcoh and .0 62 % have friends who drink alcohol. • 19.4% of youth believe that it would be easy to get other drugs such as cocaine, methamphetamine, and ecstasy. The table below shows current substance 6 use for grades – 12 in Cape Girardeau County and Missouri. 30-‐day use of cigarettes, alcohol, binge marijuana, drinking, and OTC abuse is higher Cape in Girardeau County than in the state.

Table 20 : Current Substance Use for -‐ Grades 6 12 – Cape Girardeau County & Missouri Substance 30 Day -‐ Use Cape Girardeau County 30 Day -‐ Use Missouri Cigarettes 14.3% 13.7% Alcohol 20.3% 19.8% Binge* 11.9% 11.4% Marijuana 10.2% 9.4% Inhalants 2.5% 3.0% Rx Abuse 4.9% 6.7% OTC Abuse 5.2% 4.8% Source: Department of Mental Health, Behavioral le Health Profi * 5+ drinks on a single occasion

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Teen Pregnancy Teen pregnancy can be associated with poor prenatal care and pre-‐term delivery. Pregnant teens are more likely than older women to receive enatal late or no pr care, have gestational hypertension and anemia, and achieve poor maternal weight gain. kely They are also more li to have a pre-‐term delivery and low birth weight, which increases the risk of child developmental delay, illness, and mortality. The prevention of teen pregnancy is very t important as i brings substantial social and economic costs through immediate and long-‐term impacts on teen parents and According their children. to the Centers for Disease Control and Prevention: • Teen pregnancy accounts for nearly $11 billion costs per year in to U.S. taxpayers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers. • Pregnancy and birth are significant ontributors c to high school drop-‐out rates among girls. Only about 50% of teen mothers receive a high school s diploma by 22 year of age, versus approximately 90% of women who had not given birth during adolescence. • The children of teenage mothers are more likely to have lower school achievement and drop out of high school, have more health problems, be ime incarcerated at some t during lescence, ado give birth as a teenager, and face unemployment . as a young adult The following graph shows the Teen Birth rardeau Rate in Cape Gi County versus Missouri for the years 1999 – 2008. The Cape Girardeau County rate has always te been lower than the sta rate, but saw a significant increase in 2008.

Figure 32: Births to Teens (Rate per 1,000 females ages 15-‐19) – Cape Girardeau County vs. Missouri

Births to Teens (Rate per 1,000 females ages 15-‐19) -‐ Cape Girardeau County vs. Missouri 49.8 48.6 Cape Girardeau County Missouri 46.0 45.6 45.7 45.4 44.0 43.4 43.1 42.4

40.9 41.1 38.7 32.7 38.2 36.1 36.5 35.2 34.9 33.9

Year 1999 Year 2000 Year 2001 Year 2002 04 Year 2003 20 Year 2005 Year 2006 Year 2007 Year 2008

Source: Annie E. Casey Foundation Kids Count Data Center

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STDs in Teens According to the Missouri Department of Health and Senior Services’ Child Health Profile, Cape Girardeau County has lower rates of Sexually Transmitted Diseases for 15 -‐ 19 year olds than the state of Missouri.

Table 21: Sexually Transmitted Diseases: -‐ Ages 15 19 STDs: Ages -‐ 15 19 Data Years # of Events Cape Girardeau County Rate Missouri Rate Chlamydia 2005-‐2009 389 1,281.8 2,129.10 Gonorrhea 2005-‐2009 119 392.1* 625.3 Syphilis 2005-‐2009 0 0.0* 4.2 Source: Community Data Profiles -‐ Missouri Department of Health and Senior , Services Child Health STD rates are per 100,000 residents age 15-‐19 using population estimates for the noted years. * Fewer than 20 events in numerator; rate is unstable. Senior Health Missouri Senior Report The Missouri Department of Health and Senior the Services and University of Missouri Office of Social and Economic Data Analysis (OSEDA) generated a Missouri Senior Report in 2009 to inform state and local audiences about the contributions and needs of seniors in Missouri. Some of the findings from that report are found below: Cost Burdened by Housing. The U.S. Department of Housing and Urban Development considers families who pay more than 30% of their income “cost for housing as burdened” since these families may have more difficulty affording necessities such clothing, as food, transportation, and medical care. Housing costs include mortgage or rent, taxes, insurance, ties. and utili Seniors that are living on fixed incomes are especially vulnerable to fluctuations in housing Cape costs. Girardeau County has 24 .7% of its seniors cost burdened by housing compared ssouri. to 28.2% for Mi Transportation. Transportation is necessary in order to services obtain goods and and to participate in work and social activities. Whether e seniors have th capacity to meet their transportation needs is often measured by how many hold a valid driver’s license. Holding a valid driver’s license is especially indicative in more rural areas where mass transit often doesn’t exist or isn’t as abundant. Cape Girardeau County has 82.9% s of it seniors with a valid driver’s license for compared to 84.2% the state. Safety. This report measured safety by the rate of property and violent crimes per 1,000 he persons in t county. Seniors who are physically or cally psychologi vulnerable are at an increased risk of suffering accidents and abuse within their own homes. rate The overall crime in a county combined with the cases of abuse and neglect reported to the Missouri Department of Health and Senior Services’ Elder Abuse and Neglect Hotline were used to determine the indexed rate per 1,000 persons. Cape Girardeau County had a property and rime violent c rate per 1,000 persons of 37.6 compared to 35.4 for the state. Health Care Access. Health e car access is essential for the overall well-‐being of seniors. Reliable, convenient access to primary care increases the s capacity of senior to live independently. This report measured the health care access for e seniors as a rat of the number of primary care physicians per 1,000 seniors. Cape Girardeau County has .9 13 primary care physicians per 1,000 compared seniors to 13.1 for the state. The Missouri Senior Report includes six peak measures that s to the overall quality fe of li for seniors and those statistics are below found in Table . 25 Cape Girardeau County is very comparable to the state in

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 74 most categories and notably has a higher average income of senior households and a much lower percentage of seniors in poverty.

Table 22: Quality of Life for Seniors Cape Girardeau Missouri Senior Owner-‐Occupied Housing, 2008 85.1% 80.9% Seniors Living in Families, 2008 61.3% 62.6% Median Value of All Owned Housing, 2008 $139,700 $141,500 Seniors in Poverty, 2008 4.2% 9.3% Average Income of Senior Households, 2008 $45,617 $44,665 Seniors with a College Education, 2008 14.1% 16.4% Source: Missouri Senior Report 2009, Missouri Department of Health and Senior Services and the Office of Social and Economic Data Analysis, University of Missouri 1. Owner-‐Occupied Housing: Seniors’ housing needs are more likely to be -‐ met if they live in owner occupied housing. 2. Seniors Living in : Families Family life enhances the senior -‐ population’s well being. Seniors who live alone are more likely to be socially isolated and at greater risk of accidental injury and physical and mental illness. 3. Median Value of -‐ Owner Occupied Housing: The ownership of a house represents a significant asset for most seniors, and the relative a value of housing is useful indicator of both seniors’ and community assets. 4. Seniors in Poverty: The proportion of seniors living in ct poverty is a dire measure of economic need. 5. Average Income of Senior Households 6. Seniors with a College Seniors Education: with a education higher generally tend to fare better on household and community wealth, -‐ and well being. The Missouri Senior Report seven includes measures that speak to the overall lness health and wel for seniors and those statistics are shown in Table 26 below. Girardeau Cape County is only slightly worse than the state in obesity and high blood pressure.

Table 23: Health and Wellness for Seniors Cape Girardeau Missouri No Exercise, 2007 30.1% 38.5% No Sigmoidoscopy or Colonoscopy, 2007 35.4% 36.8% High Blood Pressure, 2007 40.7% 40.1% Obesity, 2007 27.0% 25.2% Smoking, 2007 9.0% 10.8% No Mammography, 2007 39.4% 50.0% High Cholesterol, 2007 14.6% 25.1% Source: Missouri Senior Report 2009, Missouri Department of Health and Senior Services and the Office of Social and Economic Data Analysis, University of Missouri

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Chapter 6: Primary Research Focus Groups Methodology Five focus groups were done for Cape Girardeau County on various dates and in various n locations and i total, forty-‐one participants took part. The focus group process began with the h Community Healt Needs Assessment Team and/or some community members compiling a list of potential participants and then inviting those participants to the focus group via email, letter, phone call, or in person. oximately Each event took appr an hour and a half and was held over lunch. Members of the Community Health Needs Assessment Team hosted the event, with one member serving as moderator, another member as co-‐moderator taking notes on a flip chart to make references for the group, and another member as the primary note-‐taker/recorder of the entire event. Materials that were provided to the group included a participant information form, a checklist , exercise and a of list questions asked. The participant information participant’s form asked for each name, company/organization, job title, credentials, education, affiliations, experience, and what makes them an expert – not all forms were filled , out completely but some of the information collected can be found in Appendix C. The checklist exercise asked the participants to choose ve their top fi concerns from a list the Community Health Needs Assessment Team created; the results of that exercise are provided in the Checklist Exercise section following the question summaries ahead. The questions asked by the moderator are listed below. Prompts were also used to get more detailed answers from the groups and to help the group along if they were not providing much information. The moderator did his best to ask all questions and to stay on track in with the topics, but some cases the group wandered off track and not all questions were answered completely. 1. What do people in this community do to stay healthy? How do people nformation get i about health? 2. In this group’s opinion, what are the serious health problems in your community? What are some of the causes of these problems? 3. What keeps people in your community hy? from being healt 4. What could be done to solve these problems? 5. Is there any group not receiving enough health care? If so, why? 6. Of all the issues we have talked ssues about today, what i do you think are the most important for your community to address? Each question is broken out into the dual following indivi sections and includes a summary of all five focus groups regarding the particular question. Question - 1 What do people in this community do to stay healthy? How do people get information about health? According to the focus group participants, one of the most common ways to get in exercise the community is simply to walk. People take advantage of the ound walking trails ar town and some people just walk out of necessity to get from place to place because of a lack of transportation. In the Jackson area, people are even able to walk or jog at night because the area is so safe. Other people take part in fitness clubs for exercise and some kids ride bikes, skateboard, and play sports such as basketball (although this tends to be more for fun and recreation than for just getting exercise). In the rural areas of Cape Girardeau County, many adolescents work on cise farms and get exer in that way. Many of the

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 76 rural schools also offer open gyms before and the after school for students to get in some physical activity. her Ot ways people stay healthy in the community h, is by getting healt dental, and vision screenings and by eating healthy food. are Senior Citizens able to stay healthy by going to the senior center for meals and for activities such as bin playing cards and go, quilting, and dances. The community is able to get health information through health education provided by the hospitals, schools, churches, and the county health department. Social media ovider is also a main pr of health education, including the Internet, TV, radio, and . newspaper Family , neighbors, and of course physicians and nurses provide the community with health , information too. Question 2 - In this group’s opinion, what are the serious health problems in your community? What are some of the causes of these problems? Some of the health conditions e that wer mentioned in the focus groups included diabetes and pre-‐ diabetes, hypertension/high blood pressure, heart disease, dhood adult and chil obesity, cancer, high cholesterol, dental health, autis m, dementia, arthritis, and chronic pain. lth Mental hea was cited also as a problem and includes anxiety and depression. Some behavioral problems that were pointed out include smoking, alcoholism for older males, substance abuse, and high risk pregnancies caused by expectant mothers using drugs and smoking, getting no prenatal care, and living an unhealthy lifestyle while pregnant. Some problems stated specific to adolescents include gies, food aller asthma, STDs including chlamydia and gonorrhea, and drug use – prescription drugs, marijuana, heroin, and bath salts. Another very specific problem discussed was how Medical often the Emergency Services (EMS) get called for non-‐emergencies, mainly due to the elderly’s inability to care for following themselves a hospital discharge. Causes that were mentioned for some of the health conditions include lack of exercise, being overweight, smoking, poor diet, poor lifestyle, on, lack of motivati lack of trust in health care, and lack of education. More specifically, some of the dental issues can be caused by drug use, lack of fluoride in water, and lack of education about how to brush properly. Childhood obesity can be caused f by a lack o exercise, lack of education about how to eat healthy and why exercise is important, and lack of support and knowledge from the child’s parents about how to be healthy. are STDs more prominent with adolescents because of their lack of concern and awareness about how serious disease the can be. The EMS issue seems to because occur the elderly do not get the 24/7 care ir that is needed in the homes after being discharged from the hospital and they are often unable to afford nursing home care. Question 3 - What keeps people in your community hy? from being healt Finances are a recurring reason that keeps people from being healthy in the . community Low income often leads to no insurance or Medicaid which limited often leads to or no health care services. Some people must sometimes choose between buying groceries and buying needed medications. When they choose to buy food, they may end up sick or sicker since they cannot afford their medications, and then they may not be able to work so they never seem to catch up financially. Another reason that relates to finances is that people think healthy food is expensive, so they often go for the cheaper, less healthy options, including fast food. Being uninsured or underinsured can keep people from being healthy because it can lead to a lack of preventive care since people often cannot afford co-‐pays or sliding scale fees and they often cannot afford prescription drugs either. even Also, with Medicaid , access can become a problem since not all doctors accept Medicaid, especially specialists and dentists. Psychiatry for all ages is another specialty mentioned as difficult to access with thout Medicaid or wi insurance. Not having insurance also takes away the doctor/patient relationship since most uninsured do not have a regular primary care physician

Community Health Needs Assessment – Cape Girardeau County, Missouri Page 77 that they can go to for questions or that will tell the person what to do and ng what not to do regardi their health and health conditions. Other factors that keep people from clude being healthy in a lack of transportation – people are not always able to get to a doctor or clinic when needed or to a fitness club or to a grocery store or pharmacy or sports activity to keep them healthy. Living stressful, busy lives is something people else that keeps from being healthy. This seems to be an excuse almost everyone uses for why they do not have time to exercise and eat healthy. Also, from living stressful lives, kids are not always supervised parents and are not always as involved in their kids’ lives to be able to teach them how to be healthy or to set a good example of how to be healthy. One other thing mentioned was that women do not they cook as often used to since they often work outside of the home; therefore, those -‐ healthy home cooked meals seem to becoming a thing of the past. One participant stated “Life keeps people from being healthy – something more important always comes up” and they are exactly riorities right, as p are out of line and many -‐ people lack self discipline. Video games and TV are things that draw people inside and keep them there which keep them from going outside taking and part in physical activity. Unsafe neighborhoods are another thing that keeps people inside. Some people do not feel safe or comfortable to be outside and those people will not send their kids out to play either. Lack of education and awareness was brought up numerous times in all five focus groups. Oftentimes, people do not know what programs and services are available in their communities. An example of this came up in one of the focus groups, in which the group was representative of one of Cape Girardeau’s low-‐income areas, having no idea that a free clinic was now available in Cape Girardeau and that there was a federally-‐qualified health center available also that primarily takes Medicaid patients. This proved how the community has ack a strong l of communication about available resources. ion Lack of educat can also lead to misconceptions about health care as one participant described how they know many people that are afraid of doctors and hospitals they because of stories heard from people they know about bad experiences they had, so now those people have a negative connotation about those facilities. Recognizing symptoms of health conditions can also be difficult for anyone and then navigating through health conditions can be difficult as well so people need to know where to go for help and need basic education about symptoms of common health conditions. Question 4 - What could be done to solve these problems? One of the most common recommendations e that were mad to olve s many of these problems was simply to provide basic health education y to the communit – to explain why healthy habits are needed. Another piece of education is to marry the people hat to the resources so t everyone knows where to go to find the information they need and people need to know who they can contact at the hospitals and clinics when they need help. Someone mentioned that education needs to come from all directions, including schools, churches, health care facilities, employers and other businesses. In the low income areas, it was suggested that s the health educator go to the in people those low income areas that need to be educated instead ose of expecting th people to come to the educator in a place outside of their “comfort zone.” This will help establish a relationship with the low income areas and start building up trust. Also, some other g ood ways to reach this group are to provide health information on TV and the radio, through churches and schools, and by handing out flyers and informing them that the information included is very important so that they will read it. Training and educating church leaders to become health leaders is another option so that when people in those areas get sick, they have someone to turn to ce. for help and advi

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Other suggestions included having employers h establis wellness programs that provide incentives to achieve better health, having schools mandate more physical activity and Life Skills and classes, having hospitals offer more free screenings at a health fair and scholarship programs to their owned fitness facilities. Collaboration between the health department, hospitals, schools, churches, and other -‐ not for-‐ profit organizations was also mentioned. Building community ardens g was suggested as the a way for community to access healthy food and more organized activities were suggested to increase physical activity. These could both help combat the that obesity epidemic is occurring. Some other recommendations made were for the community to start offering assessments for mental health problems and for the hospitals to work on re their transitions of ca so that patients are not discharged to their homes before they are capable of of taking care themselves. One last good idea cited was to do -‐ a well check on adults like they do for children. Adults need to know what types of preventive tests they should have by what age and not how often so they do miss out on what could be critical life-‐saving preventive measures. Question 5 - Is there any group not receiving enough health care? If so, why? A few groups mentioned by the participants of the focus groups as not receiving enough health care include the following: • River Corridor (geographic area) • Low income areas • Single moms – some have Medicaid for their children, but not for themselves • Youth – those with generational issues • Uninsured – some just barely miss the Medicaid requirements • Part-‐time workers that are unable to get insurance • Hispanic population – especially those that are undocumented • Senior itizens c – many are on a fixed income • Rural areas • Mentally i ll Question 6 - Of all the issues we have talked ssues about today, what i do you think are the most important for r you community to address? This question did not get answered in roups all five focus g due time to constraints. However, when it did get answered, some of the most important issues mentioned were: • Healthy ifestyles l • Obesity • Making sure people have a primary care regular physician or walk-‐in clinic to visit as needed • Health care affordability • Education and awareness

Checklist Exercise The table below summarizes the Checklist Exercise that was handed out in all five focus groups held in Cape Girardeau County. The concerns are ranked n from the highest concer to the lowest. Alcohol/drug use and health ffordability care a were tied for first as the greatest concern. Overweight adults, mental illness, and overweight children rounded up the top five concerns.

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Table 24: Cape Girardeau County Results Concern Group 1 Group 2 Group 3 Group 4 Group 5 Total Alcohol/Drug Use 6 8 4 6 3 27 Health Care Affordability 6 6 3 6 6 27 Overweight Adults 6 6 5 3 3 23 Mental Illness 5 5 1 6 3 20 Overweight Children 4 4 5 3 2 18 Smoking/Smokeless Tobacco 4 3 5 2 0 14 Health Care Availability 3 2 1 3 2 11 Transportation (public) 1 2 1 3 3 10 Teen Pregnancy 1 1 2 0 4 8 Eating Disorders 0 1 1 1 2 5 Allergies 0 0 2 0 2 4 Health Facilities 0 0 2 0 2 4 Clean Water/Water Pollution 0 0 0 0 3 3 Sexually Transmitted Infections 0 1 0 1 1 3 Child Abuse 0 1 0 0 1 2 Domestic Violence 0 0 1 0 1 2 Prenatal Health 0 0 0 0 2 2 Highway Safety 0 0 0 0 1 1 Infant Health 0 0 0 0 1 1 Mosquitoes 0 0 0 0 0 0 Childhood Immunization Rates* 1 1 Dental/Dentures Affordability* 1 1 *Concern added in by focus group These participant. were not included on original list provided. Surveys Survey Layout and Design The Community Health Needs Assessment Survey ionnaire was a quest -‐style, self-‐administered survey, available only to those ticipants par that a -‐ hospital hired intern came into contact with at certain locations. Since the survey was only completed on paper, data entry was necessary to track, and then extract the data to be in a usable format. The survey was designed data to collect on health beliefs, health behaviors, access of to and utilization health care services, and concerns about community The health issues. survey consists of five different sections: 1. Multiple Choice: There are 32 questions that are multiple part choice with of the questions asking demographic information about the participant r and thei household and the remaining questions centering on health care access, health nce. status, and insura 2. Health Behaviors: This section lists 24 behaviors ipants and asks the partic to mark how often they do this behavior, with options of “Almost Always,” “Sometimes,” “Never,” or “N/A”.

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3. Children’s Health Behaviors: This section lists 17 behaviors and asks the participants to mark how often any children living in this their home do behavior, with the same options as listed above. Many of the behaviors listed are the the same or similar to Health Behaviors Section. 4. Health Issues: This section lists 27 health problems or diseases and asks the participant if they have ever been iagnosed d by a doctor with any of those problems or diseases. If the participant chooses “Yes”, they are then supposed to check “I see a doctor” if they see a doctor, “I am taking medications or getting treatment” if they cations are taking medi or getting treatment, and “I feel the disease is well managed” if they feel as such. 5. Community Health Concerns: This section lists 56 community issues and the participants are asked to choose how much of a problem is they think each issue in their county, with options of “Serious Problem,” “Moderate Problem,” “Not a Problem,” or “Not Sure.” Methodology A total of 118 surveys were completed by Cape Girardeau County residents, with a few surveys having some unanswered questions. A actual number of responses was determined for each question and the percentage of each answer was calculated based ponses. on the number of res The survey sample was not a random sample, but more of a targeted ertain sample to ensure that c populations were surveyed. Also, some of the questions asked in the survey of had an option choosing multiple answers, which means that not all of the questions t have answers tha are mutually-‐exclusive, so some of the total percentages will not add up to 100 percent. Does When an answer of “ Not Apply” or “N/A” was chosen, those answers were excluded from calculating the percentages also since the question did not apply to the survey participant. The process for conducting these surveys intern involved an hired by one of the partnering hospitals who then traveled to different locations the throughout county, including community businesses, organizations, and health care facilities, asking face participants -‐to-‐face to complete the survey. The intern did not verbally ask the questions to the participants, but did offer help if the participant had questions about the survey. Participants Key Characteristics • 69% re a women • A mere 7% are a race other than White or Black • 45% are single/not married • 64.35% have at least some college, d while 9.57% di not finish high school • Almost 62% have a household income less than $25,000 • 72% are employed at -‐ least part time, 10% are at -‐ least part time students, and 11% are considered unemployed • 51% live in households with three or more members Details The tables and graphs below show certain demographic characteristics the of survey participants in Cape Girardeau County, including the survey takers gender, marital status, age, education level, race/ethnicity, employment status, household income, and household size and age of members. The number of responses ranged 60 from to 118 and the percentages of each demographic also category are listed.

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Table 25: Gender Table 26: Your Race/Ethnicity Female 69.03% White or Caucasian 70.69% Male 30.97% Black/African American 22.41% N=113 Hispanic 1.72%

Table 27: Age Asian or Pacific Islander 1.72% 18-‐24 33.05% Native American 0.86% 25-‐44 29.66% Other 0.86% 45-‐64 22.03% 2 or more races 1.72% 65+ 15.25% N=116 N=118 Table 28: Race/Ethnicity of Children Living Home at

Table 29: Marital Status White or Caucasian 63.33% Single/Not Married 44.83% Black/African American 25.00% Married 34.48% Hispanic 0.00% Divorced 9.48% Asian or Pacific Islander 1.67% Living with Partner 3.45% Native American 1.67% Widowed 6.90% Other 0.00% Other 0.86% 2 or more races 8.33% N=116 N=60

Table 30 : Education Level Table 31: Annual Household Income Did not finish high school 9.57% Less than $5,000 10.78% High school graduate/GED 26.09% $5,000-‐$14,999 28.43% Some college 46.09% $15,000-‐$24,999 22.55% College graduate 18.26% $25,000-‐$49,999 16.67% N=115 $50,000-‐$74,999 10.78% $75,000-‐$99,999 7.84% $100,000 or higher 2.94% N=102

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Table 32: Employment Status Employed Full -‐Time 64.66% Employed full-‐time 90.67% Employed full-‐time, full-‐time student 4.00% Employed full-‐time, part-‐time student 4.00% Employed Full-‐time, Employed part-‐time, full-‐time student 1.33% Employed Part-‐Time 7.76% Employed part-‐time 44.44% Employed part-‐time, full-‐time student 22.22% Employed part-‐time, part-‐time Student 11.11% Employed full-‐time, employed -‐ part time, full-‐time student 11.11% Unemployed due disability to or illness, employed art p -‐time 11.11% Full-‐time Student 6.90% Full-‐time student 25.00% Employed full-‐time, full-‐time student 37.50% Employed part-‐time, full-‐time student 25.00% Employed full-‐time, employed -‐ part time, full-‐time student 12.50% Part-‐time Student 3.45% Employed part-‐time, part-‐time student 25.00% Employed full-‐time, part-‐time student 75.00% Unemployed 11.21% Unemployed 15.38% Unemployed due to disability or illness 53.85% Unemployed less than one year 7.69% Unemployed more than one year 15.38% Unemployed due to disability or illness, Employed Part-‐time 7.69% Full-‐time Homemaker 3.45% Retired 12.93% *Please note, percentages do not add up he to 100% because of t option to select multiple answers to the question. N=116

Table 33: Number of People Currently Living in Household 1-‐2 48.28% 3-‐5 45.69% 6+ 6.03%

Table 34: Number of Adults 65 and Older Currently sehold Living in Hou 0 78.95% 1-‐2 20.18% 3-‐5 0.88%

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Table 35: Number of Children Under 18 Currently old Living in Househ 0 54.31% 1-‐2 31.90% 3-‐5 13.79% Number of People Living in Household: ; N=116 Number of Adults 65 and Older Living in Household: N = 114; Number of Children Under 18 Currently Living in Household: N = 116 Access to Health Services Insurance, Utilization, and Access to Care Individual and Family Insurance Nearly 70% of survey respondents have ce health insuran with 36% also having dental insurance and 28% also having vision insurance along with health insurance. Of the 30% that do not have insurance, 29% are black and 54% are white. Also, of those without health insurance, a significant 80% have an annual household income of less than $25,000.

Table 36: What kinds of insurance do you (and/or currently your family) have? Health 69.57% Health 46.25% Health, Vision 2.50% Dental, Health 13.75% Dental, Health, Vision 37.50% Dental 35.65% Dental, Health 26.83% Dental, Health, Vision 73.17% Vision 27.83% Health, Vision 6.25% Dental, Health, Vision 93.75% Do not have insurance 30.43% *Please note, percentages do not add because up to 100% of the option to select multiple answers to the question. N=115

Of those with health 40 insurance, % have a government health insurance plan (Medicaid, Medicare, VA/CHAMPUS) and 0 4 % have employer-‐provided health insurance. Of those households without health insurance, 12% have all insurance, adults without 27% have at least one adult without insurance, and 14% have the nsurance. entire family without i Over 44% were not sure who was not covered by insurance in their household. Health Services Utilization It appears that most survey participants have sufficient access to medical services as 74% had a routine doctor’s visit within the last 12 months. An ine additional 7% had a rout doctor’s visit within -‐ 13 24 months. Of the 74% of participants at th had a routine doctor’s visit in the past 12 months, 76% of those were female and only 24% In were male. the 65 and older age group, nearly 90% had a routine doctor’s visit within the past 12 months.

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Preventive Services Adult Preventive Procedures The ollowing f table shows the preventive procedures the the participants had in last year. Some procedures are broken down by age and certain procedures rticular only apply to a pa gender. Nearly 77% of women over 45 have had a mammogram nearly in the past year and 69% of women over 18 have had a pap smear within the last year. icipants Over half the part had a dental exam and nearly a quarter of them had an STD screening in the last year. Higher percentage differences can be noticed between the general roup age g and the age 45+ group in the glaucoma blood test, pressure check, flu shot, cholester ol screen, cardiovascular screen, and blood sugar check.

Table 37: Select the preventive procedures you have year: had in the last Mammogram Pap smear Females 45+ 76.92% Females 18+ 68.57% Glaucoma test Blood sugar check General 14.74% General 40.00% Age 45+ 26.32% Age 45+ 60.53% Blood pressure check Skin cancer screening General 70.53% General 7.37% Age 45+ 86.84% Age 45+ 7.89% Flu shot Colon/rectal exam General 42.11% General 8.42% Age 45+ 55.26% Age 45+ 15.79% Prostate cancer PSA blood screen Prostate cancer digital screen Males 45+ 25.00% Males 45+ 25.00% Cholesterol screen Hearing screening General 31.58% General 6.32% Age 45+ 60.53% Age 45+ 7.89% Cardiovascular screening Vision screening General 11.58% General 53.68% Age 45+ 21.05% Age 45+ 55.26% Bone density test Dental exam General 6.32% General 51.58% Age 45+ 13.16% STD screening General 22.11% *Please note, percentages do not add up he to 100% because of t option to select multiple answers to the question. General Population N = 95; All Age 5+ 45+ N = 38; Males 4 N = 8; Females 18+ N = 70; Females 45+ N = 26 Childhood Immunizations Of the 54 responses by those having ly children current living in their home, over 96% re of the children a current on immunizations, with only 3.7% not being current.

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Type of Provider for Routine Health Care For individual participants and their children, the physician’s office is the most predominant source for seeking routine medical care. Interestingly for adults, the hospital emergency room is the second most predominant source for seeking routine medical ahead care, greatly of urgent care centers, and also a very common source for children as well rd as it is the thi most predominant source.

Table 38: Where do you go for routine health care? You Children Physician's office 67.83% 84.31% Hospital emergency room 14.78% 15.69% Urgent care center 9.57% 3.92% Health department clinic 8.70% 17.65% Community clinic 6.09% 3.92% Chiropractor 3.48% 0.00% Other 2.61% 0.00% Dentist 25.22% 19.61% Eye doctor 23.48% 11.76% *Please note, percentages do not add because up to 100% of the option to select multiple answers to the question. You: N = 115; Children: N = 51 Access to Health Providers When the survey participants ere w asked about how often they are able to see a doctor when needed, nearly 61% answered always, 19% answered 20% sometimes, and answered seldom or never. Those that answered seldom or never were then not asked why they were ble a to see a doctor when needed and those reasons are n shown i the table below. Over 91% of those respondents that are never or seldom able to see a doctor when needed is due to a lack of insurance.

Table 39: If you answered seldom or never, why? Couldn't get appointment 4.35% Lack of transportation 8.70% No insurance 91.30% Too expensive/cannot afford 47.83% *Please note, percentages do not add up he to 100% because of t option to select multiple answers to the question. N = 23 Seeking Care Outside the County When asked how often the survey travel participants outside of the county for health care, a considerable 70% answered never. The remaining broken 30% was out with 5% answering always, 17% answering sometimes, and 8% answering seldom. For those that did not answer “never”, follow up questions were asked about why they seek services outside what the county and for services they seek. Tables 40 and 41 below display that information. Nearly 71% of althcare those that seek he outside the county are looking for medical/doctor appointments and 29% are looking for dental appointments. The two greatest reasons for participants traveling outside the county for healthcare is because the services are not available in the county and because they feel can find better quality elsewhere.

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Table 40: What services do you seek outside the county? 31 Table 41: Why do you travel outside the county? Dental appointments 29.03% Better quality elsewhere 35.48% Hospitalization 12.90% Closer to work/home 9.68% Laboratory and other tests 9.68% Local doctors not covered by insurance 12.90% Medical/doctor appointments 70.97% Recently moved to this county 12.90% Outpatient treatment 16.13% Services not available in my county 41.94% Vision appointments 6.45% Too hard to get appointment with local doctor 6.45% X-‐rays 9.68% Other 25.81% Other 16.13% N/A 3.23% N/A 3.23% *Please note, percentages do not add up he to 100% because of t option to select multiple answers to the question. N = 31 Health Beliefs and Behaviors Health Status When survey participants were asked to rate their own ny health, nearly as ma rated their health as fair or poor (28.45%) as rated their health as very good or excellent (31.03%). Table 42 shows all health status percentages. Interestingly, exactly half rated of those who their health as fair or poor have an annual household income of less than $15,000 and another 18% are in the household income range of $15,000-‐$24,999.

Table 42: What is your current health status? Poor 4.31% Fair 24.14% Good 40.52% Very good 22.41% Excellent 8.62% N = 116 Survey participants were also asked how many days they have been too sick to work or carry out usual activities in the past 30 days. 19% were sick 1-‐2 days and only 7% were sick 3 or more days, leaving 74% that were not too sick in the past 30 days to work or carry out usual . activities Sources of Health Information “Doctors, nurses, and pharmacists” was the most frequent response a as source where the participants obtain health-‐related information, with nearly 76% of participants choosing that source. “ Friends or family” and the “ Internet” come in second and third, with 43% and 41% respectively. Again, “ doctors and nurses” are the person/place that the participants feel ble is most responsi for providing health-‐related information with 72% of participants choosing “ that answer. Yourself” and “hospitals” both tied in second at “ 29% and the Internet” came in third with 22%. Surprisingly, the “Health Department” came in after these other resources as a place that provides health information. Safety Exactly 80% of individual the respondents indicated that “ they almost always” wear their elt seatb , with an additional 17.39% indicating that they “sometimes” wear their seatbelt, leaving only 2.61%

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responding that “ they never” wear their seatbelt. Regarding children using a seatbelt, car seat, or booster seat as recommended, 92.45% answered “almost always”. No disparities were found across the different demographics. The “almost always” percentages for the individual respondents aren’t quite as high for driving the posted speed limit or wearing a helmet when ATV, riding a motorcycle, scooter as they were for wearing seatbelts. 66.35% of respondents said they “almost always” drive the posted speed limit with another 29.81% answe ring “sometimes” , leaving only 3.85% responding “ that they never” drive the posted speed limit. 65.12% of respondents said ways” they “almost al wear a helmet when riding a motorcycle, ATV, or scooter with another 20.93% answering ving “sometimes”, lea a gher hi 13.95% “ that never” wear a helmet. Regarding children wearing en a helmet wh riding a motorcycle, or ATV, scooter, 74% responded with “almost always”, leaving 26% wearing a helmet only “ sometimes” or “ never”. When riding a bicycle, rollerblading, or skateboarding, 69% responded with “almost always”, leaving 31% wearing a helmet only “sometimes” or “never”. No disparities were found across the different demographics.

Table 43: Safety Behavior Almost Always Sometimes Never Responses Individual Wear a helmet when riding a motorcycle, ATV, scooter 65.12% 20.93% 13.95% 43 Drive the posted speed limit 66.35% 29.81% 3.85% 115 Wear a seat belt 80.00% 17.39% 2.61% 115 Children Wear a helmet when riding a motorcycle, scooter ATV, or 74.07% 14.81% 11.11% 27 Wear a helmet when riding a bicycle/rollerblading/skateboarding 69.23% 20.51% 10.26% 39 Use seat belt, car seats, and booster seats as recommended 92.45% 5.66% 1.89% 53

Healthy Lifestyle For the individuals’ responses regarding healthy iors, lifestyle behav some positive findings are that nearly 98% “ never” chew tobacco, “never” 89% drive after drinking alcoholic drinks or using drugs, and nearly 92% “never” use illegal drugs. In addition, 70% “ almost always” or “ sometimes” apply sunscreen before planned time outside, “almost 86% always” or “sometimes” eat at least five servings of fruits and vegetables each day, “almost 80% always” or “sometimes” get enough sleep each night, and 70% “almost always” or “sometimes” exercise at a moderate pace at least 30 minutes per day, five days week. On the negative side, over “almost 47% are always” or “sometimes” exposed to secondhand smoke at home or work, “almost 78% always” or “sometimes” eat fast food more than once a week, and 37% “almost always” or “sometimes” smoke cigarettes.

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Almost Table 44: Healthy Lifestyle Behaviors Always Sometimes Never Responses Individual Apply sunscreen before planned time outside 18.81% 51.49% 29.70% 101 Are exposed to secondhand smoke in your home or work 18.27% 28.85% 52.88% 104 Chew tobacco 0.00% 2.02% 97.98% 99 Consume more than o 3 alc holic drinks/day (female), 5/day (male) 3.88% 19.42% 76.70% 103 Drive after drinking alcoholic drinks or using drugs 0.00% 10.89% 89.11% 101 Eat at least 5 servings of fruits and vegetables each day 13.79% 72.41% 13.79% 116 Eat fast food more than once a week 18.92% 59.46% 21.62% 111 Get enough sleep each -‐ night (7 9 hours) 28.95% 50.88% 20.18% 114 Smoke cigarettes 24.27% 12.62% 63.11% 103 Take vitamin pills or supplements daily 31.53% 32.43% 36.04% 111 Use illegal drugs (marijuana, cocaine, meth, etc) 2.04% 6.12% 91.84% 98 You exercise at a moderate pace at least k 30 min/day, 5 days/wee 20.87% 49.57% 29.57% 115

One disparity noticed was between household nd income a the percentage of those who smoke. Overall, for those that have a household income of less than $25,000, nearly 26% “almost always” smoke cigarettes compared to 14% of those with a household income greater than $50,000. Also, for those that “sometimes” smoke cigarettes, the less than $25,000 group is 14% compared to 5% for the greater than $50,000 group. For those that “never” smoke cigarettes, the less than $25,000 group is only 60% compared to 82% for the greater than $50,000 group. This disparity is also found with those exposed to secondhand smoke in the home or at work.

Table 45: Smoke Cigarettes Almost Always Sometimes Never Household Income Responses Number % Number % Number % Less than $5,000 2 22.22% 1 11.11% 6 66.67% 9 $5,000-‐$14,999 6 23.08% 3 11.54% 17 65.38% 26 $15,000-‐$24,999 7 30.43% 4 17.39% 12 52.17% 23 $25,000-‐$49,999 5 41.67% 2 16.67% 5 41.67% 12 $50,000-‐$74,999 1 9.09% 1 9.09% 9 81.82% 11 $75,000-‐$99,999 2 25.00% 0.00% 6 75.00% 8 $100,000 or higher 0.00% 0.00% 3 100.00% 3 Grand Total 23 11 58 92

For the individuals’ responses regarding their thy children’s heal lifestyle behaviors, some positive findings are that 87.5% “almost always” or “sometimes” apply sunscreen before planned time outside, 94% “almost always” or “sometimes” eat at least five servings of fruits and vegetables each day, 96% “almost always” or “sometimes” get enough sleep each “almost night, 96% always” or “sometimes” participate in at least one hour of physical and activity each day, 84% “almost always” or “sometimes” are limited to two hours or less per day of TV, computer, and video game time.

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On the negative side, over “almost 33% are always” or “sometimes” exposed to secondhand smoke in the home, “almost 73% always” or “sometimes” eat fast food more than once a week, and 85% “almost always” or “sometimes” drink soda and/or sugar sweetened drinks. Almost Table 46: Healthy Lifestyle Behaviors Always Sometimes Never Responses Children Apply sunscreen before planned time outside 39.58% 47.92% 12.50% 48 Are exposed to secondhand smoke in the home 8.89% 24.44% 66.67% 45 Are limited to 2 hours or less/day of TV, computer, video games 41.18% 43.14% 15.69% 51 Drink soda and/or sugar sweetened drinks 23.08% 61.54% 15.38% 52 Eat at least 5 servings of fruits and vegetables each day 33.33% 61.11% 5.56% 54 Eat fast food more than once a week 9.62% 63.46% 26.92% 52 Get enough sleep each -‐ night (7 9 hours) 73.21% 23.21% 3.57% 56 Participate in at least 1 hour of physical activity each day 69.81% 26.42% 3.77% 53 Take vitamin pills or supplements daily 34.88% 34.88% 30.23% 43

One disparity noticed was between household nd income a the percentage of children exposed to secondhand smoke in the Of home. the children exposed to secondhand always”, smoke “almost 2 out of 3 (67%) of those children are in a household than with income less $25,000 and of those children exposed to secondhand smoke “sometimes”, 80% (8 hose out of 10) t children are in a household with income less than $25,000. Hygiene/Communicable Disease Control Over 40% of the individual survey participants r” “neve t ge a flu shot each year and nearly 20% “never” practice safe sex using either a condom or other barrier method. Almost Table 47: Hygiene/Communicable Disease Control Always Sometimes Never Responses Individual Get a flu shot each year 34.82% 25.00% 40.18% 112 Practice safe sex (use condom or other barrier method) 48.28% 32.18% 19.54% 87 Wash hands with soap and water after oom using the restr 86.84% 10.53% 2.63% 114 Wash hands with soap and water before ng preparing/eati meals 81.74% 16.52% 1.74% 115

It appears as though lower household income plays a part in why some participants don’t get a flu shot each year. 50% of those participants with an annual income less than $25,000 “never” get a flu shot each year, while 50% of those participants with income greater than $50,000 “almost always” get a flu shot each year. It also appears that participants the percentage of that “almost always” get a flu shot each year increases with age as is shown in the following table.

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Table 48: Get a flu shot each year Age Almost Always Responses 18-‐24 13.51% 37 25-‐44 34.29% 35 45-‐64 47.83% 23 65+ 64.71% 17

It appears as though lower household income also plays a part in never practicing safe sex. Nearly 32% of participants with a household income $25,000 less than answered “never” when asked if they practice safe sex, compared to 18% of those with greater a household income than $50,000. Another disparity is shown for practicing safe sex % by race. Almost 23 of whites answered “never” when asked if they practice safe sex with an additional 35% only icing “sometimes” pract safe sex. Nearly 39% of the survey participants’ er” children “nev practice safe sex using either r a condom or othe barrier method and 25% eir of th children “never” get a flu shot each year. Almost Table 49: Hygiene/Communicable Disease Control Always Sometimes Never Responses Children Practice safe sex (use condom or other barrier method) 55.56% 5.56% 38.89% 18 Get a flu shot each year 51.02% 24.49% 24.49% 49 Wash hands with soap water and before eating meals 69.81% 24.53% 5.66% 53 Wash hands with soap and water after oom using the restr 70.00% 26.00% 4.00% 50

There appears to be a disparity between the children that are “never” practicing safe sex and their race. 62.5% of the children survey of a black participant “never” practice safe sex. Individual and Family Mental Health Issues and Behaviors Nearly 90% of survey participants feel stressed out either “almost always” or “sometimes,” yet in spite of that stress level, over 98% of participants their feel happy about life “almost always” or .” “sometimes Another 63% feel lonely "almost always” or “sometimes” and 43% worry about losing their job “almost always” or “sometimes.”

Table 50: Mental Health Issues and Behaviors Almost Always Sometimes Never Responses Individual Feel stressed out 17.39% 72.17% 10.43% 115 Feel lonely 9.73% 53.10% 37.17% 113 Worry about losing your job 4.04% 39.39% 56.57% 99 Feel safe in your community 67.86% 29.46% 2.68% 112 Feel happy about your life 56.03% 42.24% 1.72% 116

One disparity was found between those t who worry abou losing their job and household income. Nearly 53% of participants with a household ess income l than $25,000 worry about losing their job

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“almost always” or “sometimes”, while only 38% of those with an income greater than $50,000 worry about losing their job “sometimes.” 82.5% of the survey participants answered “almost always” for their children feeling safe in school and 0% answered “never”.

Table 51: Mental Health Issues and Behaviors Almost Always Sometimes Never Responses Children Feel safe in school 82.50% 17.50% 0.00% 40

Home Environmental Safety Regarding the environment and home safety, 82% of ving respondents reported ha more than one working smoke detector, yet only 51% nguisher, have a fire exti only 39% have a carbon monoxide detector, and only 3.54% reported having a radon eir test completed in th home. For emergencies, only 38% have a family fire safety/evacuation plan, 33% of children know how to dial 911 and know their home address and phone number, and only 14% of households r keep the poison control numbe by the phone. Most homes e (95%) hav their trash removed weekly, but only 35% ng. have curbside recycli

Table 52: Environmental/Home Safety Present in Home Absent in Home Trash removed weekly 94.69% 5.31% Food put back in fridge w/in 2 hrs 90.27% 9.73% More than one working detector smoke 82.30% 17.70% Internet access 61.95% 38.05% Have one or more fire extinguishers 51.33% 48.67% Carbon monoxide detector 38.94% 61.06% Family fire safety plan/evacuation plan 38.05% 61.95% Have one or more types of exercise equipment 36.28% 63.72% Curbside recycling 34.51% 65.49% Children know how to dial 911 for emergencies 32.74% 67.26% Children know home address and phone number 32.74% 67.26% Poison control number by phone 14.16% 85.84% Radon test been completed in home 3.54% 96.46% Pets 42.48% 57.52% Primary source of drinking water is well or cistern 23.89% 76.11% Septic tank 21.24% 78.76% Provide care for older adult 2.65% 97.35% Children under 13 unsupervised -‐ in non school hours 1.77% 98.23% N = 113 Health Issues The Health Issues section of the survey included a list of 27 diseases and health problems and the survey asked the participants if they have ever been diagnosed by a doctor with any of those diseases or health problems. If the participant ,” selected “Yes then they were to select “I am taking medications or getting

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treatment” if they are taking medications or getting feel treatment, “I the disease is well managed” if they feel as such, and/or “I see a see doctor” if they indeed a doctor for their condition. The results of that section are shown in High the table below. blood pressure was the most commonly diagnosed health problem at 26%; and of those that were diagnosed with high blood pressure, 72% are receiving medications or getting treatment, only s 34% feel it i well managed, and only 31% are seeing a doctor for the condition. The next most common sinus health conditions include problems, eye disorders, migraine headaches, and arthritis.

Table 53: Health Issues Receiving Medications Well Seeing a Disease/Health Problem No Yes or Treatment Managed Doctor Responses High Blood Pressure 73.87% 26.13% 72.41% 34.48% 31.03% 111 Sinus Problems 74.77% 25.23% 48.15% 29.63% 22.22% 107 Eye Disorders 78.70% 21.30% 30.43% 30.43% 39.13% 108 Migraine Headaches 81.48% 18.52% 40.00% 35.00% 15.00% 108 Arthritis 81.82% 18.18% 25.00% 15.00% 30.00% 110 Diabetes 82.14% 17.86% 55.00% 40.00% 65.00% 112 High Cholesterol 83.49% 16.51% 72.22% 50.00% 33.33% 109 Asthma 83.64% 16.36% 44.44% 38.89% 5.56% 110 Obesity 88.79% 11.21% 16.67% 0.00% 25.00% 107 Heart Disease 89.91% 10.09% 54.55% 27.27% 9.09% 109 Dental Health Problems 90.65% 9.35% 0.00% 10.00% 0.00% 107 Mental Disorders 90.83% 9.17% 30.00% 30.00% 20.00% 109 Hearing Disorders 91.59% 8.41% 11.11% 11.11% 22.22% 107 Kidney Disease 94.34% 5.66% 33.33% 33.33% 50.00% 106 Respiratory/Lung Disease 95.37% 4.63% 40.00% 40.00% 20.00% 108 Stroke 95.41% 4.59% 20.00% 40.00% 60.00% 109 Glaucoma 96.23% 3.77% 50.00% 25.00% 0.00% 106 Memory Loss 97.20% 2.80% 0.00% 0.00% 0.00% 107 Cancer 97.20% 2.80% 33.33% 33.33% 66.67% 107 Liver Disease 100.00% 0.00% 106 Hepatitis 100.00% 0.00% 106 Tuberculosis 100.00% 0.00% 106 Epilepsy 100.00% 0.00% 105 Lupus 100.00% 0.00% 106 Sickle Cell Anemia 100.00% 0.00% 106 Gonorrhea 100.00% 0.00% 106 HIV/AIDS 100.00% 0.00% 105

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Community Health Concerns A list of 56 health, safety, and environmental issues that might be found throughout the community was included in the Community Health Concerns section of the survey and the participants were asked to select whether they feel the issue is a serious problem, moderate problem, not a problem, or if they were not sure. 8 The 2 issues below are the of greatest concern as more than 50% of the survey participants felt the issue was a moderate to serious problem: 1. Allergies (87.88%) 2. Overweight Adults (81.82%) 3. Teen Pregnancy (78.48%) 4. Overweight Children (78.41%) 5. Unemployment (77.66%) 6. Mosquitos (77.53%) 7. Job Availability (77.32%) 8. Alcohol/Drug Use (77.23%) 9. Job Security (76.09%) 10. Crime (75.79%) 11. Health Care Affordability (73.26%) 12. Domestic Violence (72.09%) 13. Housing Affordability (68.60%) 14. Cancer (67.47%) 15. Smoking (65.91%) 16. Public Transportation (62.50%) 17. Child Abuse (62.16%) 18. High Blood Pressure/Strokes (61.19%) 19. Eating Disorders (59.52%) 20. Racism (57.30%) 21. Sexually Transmitted Infections (55.74%) 22. Heart Disease (55.71%) 23. Child Care/Day Care (54.22%) 24. Murder or Intentional Injury (52.63%) 25. Secondhand Smoke (51.16%) 26. Health Care Availability (51.16%) 27. Mental Illness (50.68%) 28. Asthma/Respiratory Disorders (50.67%) Each health, safety, and nmental enviro issue was divided into nine categories for purposes of analysis and discussion: 1. Public Services 2. Crime and Violence 3. Safety Behaviors 4. Health Behaviors 5. Health Care and Support Services 6. Environmental Protection 7. Health Condition/Disease 8. Mental Health 9. Social and Economic Issues

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Public Services Public transportation was the only concern from the Public ry Services catego that was included in the top concerns from the survey, ranked 16th. 62.5% of participants feel that transportation is a moderate to serious problem in Cape Girardeau County. Law enforcement, recreation opportunities, and school systems seem to only be moderate fire problems and protection seems satisfactory for vey the sur participants. Moderate to Not a Problem Table 54: Public Services Concerns Serious Problem Responses* Not Sure** Number % Number % Fire Protection 15 20.00% 60 80.00% 75 33 Law Enforcement 40 45.45% 48 54.55% 88 19 Recreation Opportunities 39 46.43% 45 53.57% 84 24 School Systems 39 45.35% 47 54.65% 86 22 Transportation (public) 55 62.50% 33 37.50% 88 22 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based on those only responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Crime and Violence The C rime and V iolence category has ive f concerns that are in the top issues. Crime overall ranked th 10 with nearly 76% participants feeling as a though it is moderate to serious Domestic problem. violence ranked 12th with 72% of participants feeling it serious is a moderate to problem. Child abuse ranked 17th and over 62% felt it is a moderate to serious problem. Racism ranked 20th on the top concerns list with 57% of participants feeling it is a moderate to serious problem. Lastly, murder or intentional injury made the top ich list, wh ranked 24th at 52.63%. The other three concerns, elder abuse, gang activity, and school violence seem to only be moderate problems, with s larger number of responses being “Not Sure.” Moderate to Not a Problem Table 55: Crime & Violence Concerns Serious Problem Responses* Not Sure** Number % Number % Child Abuse 46 62.16% 28 37.84% 74 36 Crime 72 75.79% 23 24.21% 95 14 Domestic Violence 62 72.09% 24 27.91% 86 22 Elder Abuse 27 40.30% 40 59.70% 67 41 Gang Activity 37 48.68% 39 51.32% 76 33 Murder or Intentional Injury 40 52.63% 36 47.37% 76 32 Racism 51 57.30% 38 42.70% 89 20 School Violence 32 41.03% 46 58.97% 78 30 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based on only those responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem

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Safety Behaviors None of S the afety B ehaviors below ranked in the top concerns cipants. of the survey parti Firearms and highway safety appear to be mild concerns, but did not fall towards the top of the concern list. Farming accidents had a high number of responses that e” were “Not Sur so there is not much awareness about this ssue i to know if it is a real concern. Moderate to Not a Problem Table 56: Safety Behaviors Serious Problem Responses* Not Sure** Number % Number % Farming Accidents 21 31.82% 45 68.18% 66 43 Firearms 36 45.00% 44 55.00% 80 29 Highway Safety 34 45.33% 41 54.67% 75 33 Pedestrian Safety 27 34.18% 52 65.82% 79 29 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based on only responses those where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Health Behaviors Four out of the H five ealth B ehaviors below made the list of top concerns. Overweight adults ranked in second place with nearly 82% of participants feeling it is a moderate to serious problem. Teen pregnancy came in third with 78.48% that felt to it is a moderate serious problem, and when just taking the serious problem percentage into consideration, teen pregnancy actually ranks the highest with nearly 46% f o the participants feeling it is a serious Overweight problem. children is ranked 4th on the list of concerns top with a moderate to serious problem percentage of 78.41%, which is almost equal to the teen pregnancy percentage. smoking Lastly, is ranked 15th on the top list with nearly 66% of participants feeling it is a moderate to serious problem. Many of the participants responded “Not as Sure” regarding smokeless tobacco, unsure if it is a concern. Moderate to Not a Problem Table 57: Health Behaviors Serious Problem Responses* Not Sure** Number % Number % Overweight Adults 72 81.82% 16 18.18% 88 21 Overweight Children 69 78.41% 19 21.59% 88 21 Smokeless Tobacco 30 44.78% 37 55.22% 67 42 Smoking 58 65.91% 30 34.09% 88 21 Teen Pregnancy 62 78.48% 17 21.52% 79 29 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based on only those responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Healthcare and Support Services Three of the Healthcare and Support Services concerns are on the top concern . list H ealth care affordability, which ranked 13th had 73.26% of participants that felt it was ious a moderate to ser problem. Child Care/Day Care is ranked 23rd and health care availability is ranked 26th on the list of top concerns. Most of the other concerns are mild e concerns, but th participants seem mostly satisfied with ambulance services.

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Moderate to Not a Problem Table 58: Health Care & Support Serious Problem Responses* Not Sure** Services Concerns Number % Number % Ambulance Services 23 28.40% 58 71.60% 81 29 Child Care/Day Care 45 54.22% 38 45.78% 83 28 Elder Day Care 24 38.71% 38 61.29% 62 46 Emergency Preparedness 24 31.58% 52 68.42% 76 33 Health Care Affordability 63 73.26% 23 26.74% 86 23 Health Care Availability 44 51.16% 42 48.84% 86 22 Nursing Home Care 31 45.59% 37 54.41% 68 40 Services for the Disabled 30 42.86% 40 57.14% 70 39 *Response numbers do not include surveys that are Not Sure; percentages of Moderate to Serious Problem and Not a Problem are based on only those responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Environmental Protection One Environmental P rotection concern that on is the top concern list mosquitos is , which is ranked quite high in th 6 place. Nearly % 78 of survey participants felt that mosquitos are a moderate to serious problem. Secondhand smoke is also on the top concern list where it ranked 25th with 51.16% of participants that felt it is a moderate to The serious problem. remaining five environmental concerns rank very low, within the bottom six on the list of 56 issues; however, radon gas and sewage treatment had a high number of responses that .” were “Not Sure Moderate to Not a Problem Table 59: Environmental Protection Serious Problem Responses* Not Sure** Concerns Number % Number % Animal Control 23 27.38% 61 72.62% 84 26 Clean Water/Water Pollution 22 26.51% 61 73.49% 83 26 Mosquitos 69 77.53% 20 22.47% 89 20 Radon Gas 14 25.93% 40 74.07% 54 53 Secondhand Smoke 44 51.16% 42 48.84% 86 23 Sewage Treatment 19 28.36% 48 71.64% 67 41 Trash/Solid Waste Management 20 26.67% 55 73.33% 75 33 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based on those only responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Health Conditions/Diseases Seven of the top concerns fall in the Health Conditions/Diseases category. Allergies ranked the highest on the top concern list with nearly 88% of participants s feeling it i a moderate to serious problem; however, when looking at the moderate and serious y, responses separatel participants classified it more as moderate, than serious. Cancer is ranked 14th on the top list with a combined moderate to serious percentage of 67.47%. High blood pressure/strokes and eating disorders are both ranked towards the bottom of the list, g rankin 19th at 61.19% and 20th at 59.52%, respectively. S exually transmitted infections and heart disease are moderate to serious problems, as they ranked ely, 21 and 22, respectiv on the list of Asthma concerns. and respiratory disorders round up the list ranking at the bottom in 28th place with 50.67% of participants that felt it is a moderate to serious problem. HIV/AIDS received the

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second highest number of responses that were “Not Sure” so participants are not certain how serious a problem it is. A large majority of participants feel infant that health and prenatal health are not problems. Moderate to Not a Problem Table 60: Health Conditions/ Serious Problem Responses* Not Sure** Diseases Concerns Number % Number % Allergies 87 87.88% 12 12.12% 99 12 Asthma/Respiratory Disorders 38 50.67% 37 49.33% 75 33 Cancer 56 67.47% 27 32.53% 83 25 Eating Disorders 50 59.52% 34 40.48% 84 27 Heart Disease 39 55.71% 31 44.29% 70 38 High Blood Pressure/Strokes 41 61.19% 26 38.81% 67 39 HIV/AIDS 29 49.15% 30 50.85% 59 49 Infant Health 25 36.76% 43 63.24% 68 38 Infectious Disease 22 36.67% 38 63.33% 60 47 Prenatal Health 24 32.88% 49 67.12% 73 34 Sexually Transmitted Infections 34 55.74% 27 44.26% 61 47 *Response numbers do not include surveys that are Not Sure; percentages of Moderate to Serious Problem and Not a Problem are based on only those responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Mental Health Two mental health concerns made the top . list Alcohol/drug use, ranked in 8th place with ver o 77% of survey participants that felt it is a moderate to serious problem. Mental Illness overall ranked 27th on the top concern list at 50.68%. Suicide seems to be a mild problem, but also received a high number of “Not Sure” responses. Moderate to Not a Problem Table 61: Mental Health Concerns Serious Problem Responses* Not Sure** Number % Number % Alcohol/Drug Use 78 77.23% 23 22.77% 101 9 Mental Illness 37 50.68% 36 49.32% 73 34 Suicide 30 47.62% 33 52.38% 63 44 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based only on those responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were alculating not used in c the percentages of Moderate to Serious and Not a Problem Social and Economic Issues Four of the top concerns fall in the Social and Economic Unemployment Issues category. is ranked 5th on the top concern list with nearly 78% of participants feeling s it i a moderate to serious problem. Job availability is ranked 7th with a combined moderate to serious 7 percentage of 7.32%. Job security and housing affordability are both ranked towards top the of the list, ranking th 9 at 76.09% and 13th at 68.60%, respectively. For this assessment, gambling did not rank very the high on list of concerns; however, a casino just opened in the fall of pe 2012 in the city of Ca Girardeau, so it may be interesting to see if this changes for the next assessment.

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Moderate to Not Problem a Table 62: Social & Economic Issues Serious Problem Responses* Not Sure** Concerns Number % Number % Gambling 30 37.97% 49 62.03% 79 29 Housing Affordability 59 68.60% 27 31.40% 86 23 Job Availability 75 77.32% 22 22.68% 97 12 Job Security 70 76.09% 22 23.91% 92 17 Unemployment 73 77.66% 21 22.34% 94 16 *Response numbers do not include surveys Sure; that are Not percentages of Moderate to Serious a Problem and Not Problem are based on only those responses where the participant chose Moderate, Serious, or Not a Problem **For reference only. These numbers were not used in calculating the percentages Serious of Moderate to and Not a Problem

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Chapter 7: Summary of Findings Using the Data to Determine Needs The secondary is data used to compare Cape Girardeau County to Missouri by examining quantitative data such as percentages, rates, and trends. If Cape Girardeau County ranks worse than the state or a negative trend is occurring, then a need is presented. The primary data is qualitative and takes in consideration the thoughts and opinions of people in the community. If a a consensus arises about concern, then a need is established. Secondary Data After a review of the secondary research found in chapters -‐ 2 5, it can be determined that Cape Girardeau County does remarkably well compared to the state of Missouri in many areas; however, there are some areas that should be of ng concern. The followi describes the findings from the secondary data. In the Education category, Cape Girardeau School District 63 in Cape Girardeau r County has a highe high school dropout rate than the state, 5.2% versus 3.4%. More specifically by race/ethnicity, 13.3% of Hispanics and 8.3% of blacks dropped rdeau out at Cape Gira School District 63 in 2011, compared to 3.8% of whites. Even though the Unemplo rate of yment in Cape Girardeau County is lower than the state rate, the rate has been continuously trending upwards since 2006. In the Public Assistance Participation category, there is a slightly higher percentage of people in Cape Girardeau County that Food are on Stamps (11.97%) when compared to the state (11.4%). Also, again when just looking at Cape Girardeau 63, School District there is a much higher percentage ts of studen enrolled in the Free/Reduced Lunch Program (61.5%) than t compared he state (47.8%) or any other school district in the . county Under Public Safety, the theft offense rate is higher for Cape Girardeau County than the state of Missouri, , 3 095 versus , 2 485 per 100,000 population. Also, for juvenile crime rates, truancy and those that are habitually absent from home are higher for Cape Girardeau ssouri. County than Mi In the Family and Domestic Violence category, the child abuse and neglect rate is higher in Cape Girardeau County than the state overall; e however, th rate has been wnward trending do 2004 – 2008. The child out of home placement rate gher is considerably hi in Cape Girardeau County than the state overall, at 5.2 versus 3.8 per 1,000 children. For Mental Health, the provider ratio in Cape Girardeau County is 12,203:1 which is considerably higher than the state’s ratio of 9,561:1. Also, mental the number of “poor health days” is higher in Cape Girardeau County at 4.3, compared to te. 3.7 for the sta The Leading Causes of Death in Cape Girardeau County are Heart Disease, ancers All c , stroke/other cerebrovascular disease, all injuries/poisonings, and ower chronic l respiratory disease, which accounted for 70% of all deaths 1999 – 2009. Of all leading causes of death, Cape Girardeau County has rates worse than the state iseas in heart d e, stroke/cerebrovascular disease, zheimer’s, Al and kidney disease. Cape Girardeau County has worse rates than Chronic the state in Disease category for colorectal cancer deaths, cervical cancer deaths, prostate cancer deaths and hospitalizations, and Arthritis/Lupus ER visits.

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Cape Girardeau County has a higher rate infectious of influenza in the disease category. The rate per 100,000 population was 1,090.2 for the county, compared 1 to a rate of 517. per 100,000 for Missouri. In the Unintentional Injuries category, the hospitalization rate for falls in Cape Girardeau County is slightly higher than Missouri. Also, the rate work injuries is considerably higher in the county than for the state; however, the rate has been trending downward – 2000 2009. Under the Health Status at Birth category, low birth weight has been increasing – 1997 2006 and was last equal to the state at 8.1%. Preterm births in Cape Girardeau County have also been trending upwards 1998 – 2009 and were last nearly equal the state at 12.6%. e The birth defects rat in Cape Girardeau County has almost always been y significantl higher than the – state 1999 2007 and was last at 823.6 per 10,000 live births versus 611.0 per 10,000 ate. live births for the st Overall in Preventable Hospitalizations , Cape Girardeau County does very well. There are only two diagnoses where the Cape Girardeau County rate bove just barely falls a the state rate: bacterial pneumonia and congenital syphilis. In the Maternal Health category, Cape Girardeau County has a slightly centage higher per of resident live births where no prenatal care was received, 8% 1.1%, compared to . for the state. Cape Girardeau County also has had a higher percentage of mothers gnancy that smoked during pre since -‐ 1998 2000 (moving average), and was at 19.2% of resident live births 2007-‐2009 (moving average), compared to 17.4% for Missouri. The residents of Cape Girardeau County do very well compared to the state Preventive in most Practices, except for women that are age 18 and older getting pap smears. 6% of women age 18 and older in Cape Girardeau County have never had a 4% pap smear compared to 3. in Missouri and 24.6% of women age 18 and older in Cape Girardeau County have not had a pap smear st in the la three years compared to 19.5% for the state. Specific to Child and A dolescent Health, the causes of d eath for c hildren and c auses of d eath for adolescents show Cape Girardeau County having of a higher rate death than the state ll in the a cancers (malignant n eoplasms) cause for both groups. Also, teen substance use in the last 30 days is higher in Cape Girardeau County for cigarettes, alcohol, binge uana, drinking, marij and -‐ over the-‐counter drugs than the state. The t een p regnancy rate is lower Girardeau in Cape County than for the state; however, the births to teens rate is trending upwards for Cape Girardeau County while trending downwards for the state. For Senior Health, safety is a greater concern in Cape Girardeau County as the property and violent crime rate per 1,000 persons was higher than the state at 37.6 compared to 35.4. Primary Data After a review of mary the pri research results found in Chapter 6, it can be determined that Cape Girardeau County has many areas of lowing concern. The fol lists the findings from the primary data, including the community surveys, focus groups, and checklist exercise completed at the focus groups. The issues were determined as a concern if the focus group participants eement were in agr about the issue and/or if more than 50% of survey participants classified the issue as a moderate to serious problem. Health Problems determined by the primary : research • Diabetes & re P -‐Diabetes • High Blood Pressure/Strokes • Heart Disease

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• Overweight Adults • Overweight Children • Cancer • High holesterol C • Dental H ealth • Autism • Chronic ain P • Mental ealth H – Anxiety and Depression • Asthma/Respiratory Disorders (especially in children) • Sexually Transmitted Infections (especially in adolescents) • Allergies (especially food allergies in children) Behavioral Problems determined by the primary research: • Smoking • Alcohol/Drug Use • Poor Diet & No Exercise • Poor Lifestyle • High-‐Risk P regnancies – because of no prenatal care, living an unhealthy lifestyle, and drug use • Drug Use with dolescents A • Eating Disorders Community P roblems determined by the primary research: • EMS called out for non-‐emergencies or repeat patients • Child A buse • Domestic iolence V • Health Care A ffordability • Health Care A vailability • Health F acilities • Teen Pregnancy • Transportation (public) • Unemployment • Mosquitos • Job Availability • Job Security • Crime • Housing Affordability • Racism • Child Care/Day Care • Murder or Intentional Injury • Secondhand Smoke • Lack of Communication and Resources Conclusion This Community Health Needs Assessment is the product of a completed ss proce of finding secondary data, performing primary research, and presenting those findings. This compiled information will allow the partnering hospitals to create an implementation strategy designed to meet some particular needs that e ar specific to the Cape Girardeau County community.

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Appendix A – Survey

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Appendix B - Focus Group Questions Community Health Needs Assessment Focus Group Questions

1. What do people in this community do to stay healthy? How do people get information about health?

2. In this group’s opinion, what are the serious health problems in your community? What are some of the causes of these problems?

3. What keeps people in your community from being healthy?

4. What could be done to solve these problems?

5. Is there any group not receiving enough health care? If so, why?

6. Of all the issues we have talked about today, are what issues do you think the most important for r you community to address?

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Appendix C – Focus Group Participant Information

Cape Girardeau City Fire Department Cross Trails Medical Center

• Battalion Chief: 29 years working in fire • Case Manager: 4 years working with service uninsured and underserved at a Federally Qualified Health Center Cape Girardeau County Public Health Center Department of Health & Senior Services • Assistant Director: 23 years working in public health • Adult Protective Community Supervisor: 15 ears y working with Cape Girardeau Police Department elderly/disabled/children

• Captain Family Support Division Cape Leaders Alliance • Eligibility Specialist Supervisor

• Board Members First Presbyterian Church • Director • Chairman/Pastor • Pastor

Chaffee Nursing Center Jackson Chamber of Commerce

• Outreach Coordinator/Social Work • Executive Director

City of Cape Girardeau Jackson Family Care

• Assistant City Manager • Physician: 34 years working in health care City of Jackson Jackson R-‐2 Public School District • Mayor: 20 years in government • Fire Chief: 13 years working as a • Director of Communications/Director of firefighter/EMT Foundation

Community Caring Council Jackson Senior Center

• Health Coordinator • President of the Board • Community Coordinator: 10 years Life Skills/Touch Point Autism Services working in community development • Autism Specialist

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Love in the Name of Christ of Southeast SoutheastHEALTH Missouri • Director, Emergency Services • Executive Director • Director, Case Management/Social Services: 25 years working in health MERS/Goodwill care • WIA Youth Case Management St. Vincent de Paul Catholic Church Oak Ridge -‐ R VI School District • Coordinator of Christian Service • School Nurse: 14 years working in Success by 6, United Way of Southeast MO nursing • SB6 Coordinator Saint Francis Medical Center The Bridge Community Outreach in South Cape • RN, Manager Emergency Services: 25 for La Croix United Methodist Church years working in nursing • Assistant Manager -‐ Social Services: 9 The Salvation Army years working hospital in social work • Major Samaritan Regional Health Clinic United Way of Southeast Missouri • CEO: 30 years working as a hospital ICU • Director of First Call for Help nurse • LIFE Initiative Coordinator SEMO Area Agency on Aging • Executive Director

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Appendix D – Survey Tracking Database

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