Community Health Assessment

DARE COUNTY

COMMUNITY HEALTH ASSESSMENT

Volume One: Demographic, Socioeconomic and Health Data Community Survey Stakeholder Interviews Issues Prioritization

November, 2010

Acknowledgements

This report is the culmination of a year’s effort by the members of Healthy Carolinians of the Outer Banks, whose dedicated focus on and support for the health and well-being of the citizens of Dare County is indeed remarkable:

Skeeter Sawyer (Chair), Dare County Emergency Medical Services Brandi Rheubottom (Vice-Chair), Dare County Older Adult Services Sheila Davies (Treasurer), Dare County Department of Public Health Anne Thomas, Dare County Department of Public Health Laura Willingham (Coordinator), Dare County Department of Public Health Amanda McDanel, Dare County Center, North Carolina Cooperative Extension Bonnie Drewry, Dare County Department of Social Services Chris Kelley, Outer Banks Relief Foundation Chuck Poe, Outer Banks Community Development Corporation Ellie Ward, Dare Home Health and Hospice Gail Hutchison, Outer Banks Hotline Gail Sonnesso, Gem Day Services Ginger Candeloria, Interfaith Community Outreach, Inc. Janet Jarrett, Albemarle Health Jay Burrus, Dare County Department of Social Services Jo Ann Hummers, Professional Counseling Services John Bone, Outer Banks Chamber of Commerce Katie Burgus, Outer Banks Family YMCA Loretta Michael, Children and Youth Partnership for Dare County Mandy Earnest, Dare County Department of Public Health Mary Betse Kelly, Outer Banks Hospital Sandy Brookshire, Dare County Department of Social Services Sue Burgess, Dare County Schools Van Smith, Outer Banks Hospital

2 Dare County Community Health Assessment – Volume One Table of Contents

Table of Contents

Acknowledgements ...... 2

Introduction ...... 8

Assessment Methodology ...... 9

Chapter One: Demographic and Socioeconomic Data ...... 11 Location and Geography ...... 12 History ...... 14 Population Characteristics ...... 19 General Population Characteristics ...... 19 Race and Ethnicity ...... 22 Age and Gender ...... 24 Households ...... 26 Older Adults ...... 27 Non-English Speaking Population ...... 32 Other Special Populations ...... 34 Government and Civic Participation ...... 36 Government ...... 36 Civic Engagement ...... 38 Electoral Process ...... 38 Religious Life ...... 39 Voluntary Participation in Community Organizations ...... 40 Economic Climate ...... 45 Income ...... 45 Dare County Revenue Indicators ...... 46 Tier Designation ...... 46 Employment ...... 47 Unemployment ...... 52 Seasonal Employment and Unemployment ...... 53 Business Closings and Layoffs ...... 54

3 Dare County Community Health Assessment – Volume One Table of Contents

Poverty ...... 55 Poverty and Race ...... 56 Poverty and Age ...... 57 Economic Services Utilization ...... 59 Housing ...... 60 Affordable Housing ...... 61 Children and Families ...... 62 Single-Parent Families ...... 63 Family Services Utilization ...... 64 Child Care ...... 65 Child Care Facilities ...... 65 Child Care Enrollment ...... 67 Subsidized Child Care ...... 67 Education ...... 68 Schools and School Enrollment ...... 68 Institutions of Higher Education ...... 68 Primary and Secondary Education ...... 68 Educational Attainment and Investment ...... 70 High School Dropout Rate ...... 71 Crime and Violence in Schools ...... 72 Crime and Safety ...... 76 Crime Rates ...... 76 Other Criminal Activity ...... 77 Juvenile Crime ...... 78 Sexual Assault and Domestic Violence ...... 80 Child Abuse, Neglect and Exploitation ...... 84 Adult Abuse, Neglect and Exploitation ...... 85

Chapter Two: Health Care and Health Promotion Resources ...... 87 Medical Insurance ...... 88 Medically Indigent Population ...... 88 Uninsured: Current Estimates ...... 89 North Carolina Health Choice ...... 90 Medicaid ...... 90 Health Check/Early and Periodic Screening, Diagnosis, and Treatment ...... 92 4 Dare County Community Health Assessment – Volume One Table of Contents

Medicaid Managed Care ...... 94 Carolina ACCESS ...... 94 Carolina ACCESS II/III ...... 95 Medicare ...... 96 Practitioners ...... 97 Hospitals ...... 99 Outer Banks Hospital ...... 99 Other Hospitals ...... 100 Emergency Services ...... 101 Dare County Department of Public Health ...... 102 Other Health Care Facilities ...... 106 School Health ...... 108 Long-Term Care Facilities ...... 110 Nursing Homes ...... 110 Adult Care Homes ...... 110 Adult Day Care/Adult Day Health Centers ...... 111 Alternatives to Institutional Care ...... 112 Mental Health Services and Facilities ...... 112 Recreational Facilities ...... 114

Chapter Three: Health Statistics ...... 116 Methodology ...... 117 Understanding Health Statistics ...... 117 Behavioral Risk Factor Surveillance System (BRFSS) Data ...... 120 Final Health Data Caveat ...... 120 Health Rankings ...... 121 America’s Health Rankings ...... 121 MATCH County Health Rankings ...... 121 Maternal and Infant Health ...... 124 Pregnancy ...... 124 Pregnancy, Fertility, Abortion and Birth Rates, Women Age 15-44 ...... 124 Pregnancy, Fertility, Abortion and Birth Rates, and Pregnancies, Women Age 15-19 ...... 125 Pregnancy, Adolescents Age 10-14 ...... 127 Sexual Behavior of Dare County High School Students ...... 127 Pregnancy Risk Factors ...... 128 5 Dare County Community Health Assessment – Volume One Table of Contents

High Parity and Short Interval Births ...... 128 Smoking During Pregnancy ...... 129 Late Prenatal Care ...... 130 Pregnancy Outcomes ...... 131 Low Birth-Weight and Very Low Birth Weight ...... 131 Caesarian Section Delivery ...... 132 Birth Complications ...... 133 Infant Mortality ...... 134 Other Pregnancy and Birth Data ...... 135 Leading Causes of Death ...... 136 County, State and National Mortality Rate Comparisons ...... 137 Gender Disparities in Mortality ...... 138 Racial Disparities in Mortality ...... 139 Age Disparities in Mortality ...... 139 Cancer (ranked by mortality rate) ...... 141 Total Cancer ...... 141 Lung Cancer (2003-2007 Incidence Rate Rank = 3) ...... 146 Breast Cancer (2003-2007 Incidence Rate Rank = 1) ...... 150 Prostate Cancer (2003-2007 Incidence Rate Rank = 2 ...... 153 Pancreas Cancer ...... 156 Colorectal Cancer (2003-2007 Incidence Rate Rank = 4) ...... 159 Dare County Cancer Outreach Program ...... 163 Diseases of the Heart ...... 164 Pneumonia and Influenza ...... 167 Cerebrovascular Disease ...... 171 Unintentional Non-Motor Vehicle Injury ...... 174 Chronic Lower Respiratory Disease ...... 177 Unintentional Motor Vehicle Injury ...... 180 Alzheimer’s Disease ...... 187 Diabetes Mellitus ...... 190 Suicide ...... 193 Septicemia ...... 196 Nephritis, Nephrotic Syndrome, Nephrosis (Kidney Disease) ...... 199 Chronic Liver Disease and Cirrhosis ...... 202 Homicide ...... 205 6 Dare County Community Health Assessment – Volume One Table of Contents

Acquired Immune Deficiency Syndrome (AIDS) ...... 208 Morbidity ...... 212 Communicable Disease ...... 212 Reportable Communicable Diseases ...... 212 Sexually Transmitted Infections ...... 213 Asthma ...... 215 Oral Health ...... 216 Adult Oral Health ...... 216 Child Oral Health ...... 216 Obesity ...... 219 Adult Obesity ...... 219 Childhood Obesity ...... 219 Mental Health and Substance Abuse ...... 222 Mental Health Service Utilization ...... 222 Developmental Disabilities Service Utilization ...... 224 Substance Abuse Service Utilization ...... 225

Chapter Four: Community Health Survey ...... 229 Survey Methodology ...... 230 Survey Participants ...... 231 Survey Results ...... 233

Chapter Five: Community Stakeholder Interviews ...... 258 Interview Methodology ...... 259 Interview Participants ...... 259 Interview Responses ...... 260

Chapter Six: Issues Prioritization ...... 284

References ...... 294

Appendices ...... 301 Appendix A: Community Health Survey Instrument ...... 302 Appendix B: Key Stakeholder Interview Protocol and Interview Guide ...... 314

7 Dare County Community Health Assessment – Volume One Introduction

Introduction

Local public health agencies in North Carolina (NC) are required to conduct a Comprehensive Community Health Assessment (CHA) once every four years. The community health assessment, which is both a process and a document, investigates and describes the current health status of the community, what has changed since the last assessment, and what still needs to change to improve the health of the community. The process involves the collection and analysis of a large range of data, including demographic, socioeconomic and health statistics, environmental data, and public and professional opinion. The document is a summary of all the available evidence and serves as a resource until the next assessment. Together they serve as the basis for prioritizing the community’s health needs, and culminate in planning to meet those needs.

In communities where there is an active Healthy Carolinians partnership, the coalition of partners usually coordinates the community assessment process with support from the local health department, which is a member of the partnership. Healthy Carolinians is “a network of public-private partnerships across North Carolina that shares the common goal of helping all North Carolinians to be healthy.” The members of local coalitions are representatives of the agencies and organizations that serve the health and human service needs of the local population, as well as representitives from businesses, communities of faith, schools and civic groups.

The Dare County Department of Public Health (DCDPH), on behalf of Healthy Carolinians of the Outer Banks (HCOB), contracted with Sheila S. Pfaender, Public Health Consultant, to assist in conducting the 2010 Community Health Assessment for Dare County, following the guidance provided by the Community Assessment Guidebook: North Carolina Community Health Assessment Process, published by the NC Office of Healthy Carolinians/Health Education and the NC State Center for Health Statistics (December 2008). The assessment also adheres to the 2010 standards for community assessment stipulated by the North Carolina Local Health Department Accreditation (NCLHDA) Program.

With the assistance of a coordinator from the DCDPH, the HCOB partners worked with the consultant to develop a multi-phase plan for conducting the assessment. The phases included: (1) a research phase to identify, collect and review demographic, socioeconomic, health and environmental data; (2) a survey phase to solicit information and opinion from the general public; (3) a stakeholder interview phase to gather information and opinion from local community leaders and health and human service agencies; (4) a data synthesis and analysis phase; (5) a period of reporting and discussion among the community stakeholders; and finally, (6) a prioritization and decision- making phase. Upon completion of this work HCOB and the DCDPH will have the tools they need to develop plans and activities that will improve the health and well-being of the people living in Dare County. The consultant provided direct technical assistance for phases 1, 2, and 4, and consulted on phases 3, 5, and 6.

8 Dare County Community Health Assessment – Volume One Assessment Methodology

Assessment Methodology

In order to learn about the specific factors affecting the health and quality of life of Dare County residents, the consultant tapped numerous readily available secondary data sources. For data on Dare County demographic, economic and social characteristics sources included: the US Census Bureau; Log Into North Carolina (LINC); NC Office of State Budget and Management; NC Department of Commerce; Employment Security Commission of NC; NC Division of Aging and Adult Services; NC Child Advocacy Institute; NC Department of Public Instruction; NC Department of Justice; NC Department of Juvenile Justice and Delinquency Prevention; NC Department of Administration; NC Division of Medical Assistance; NC Division of Child Development; NC State Board of Elections; NC Division of Health Services Regulation; the Cecil B. Sheps Center for Health Services Research; and the Annie E.Casey Foundation Kids Count Data Center. Local sources for socioeconomic data included: the Dare County Department of Social Services; the Outer Banks Chamber of Commerce; and the Outer Banks Visitors Bureau. The author has made every effort to obtain the most current data available at the time the report was prepared.

The primary source of health data for this report was the NC State Center for Health Statistics (NC-SCHS), including its Health Statistics Pocket Guides, County Health Data Books, Behavioral Risk Factor Surveillance System, Vital Statistics and Cancer Registry. Other health data sources included: the NC Comprehensive Assessment for Tracking Community Health (NC-CATCH) System; NC Division of Public Health (DPH) Epidemiology Section; NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services; National Center for Health Statistics; Healthy People 2020; NC Office of Healthy Carolinians; NC DPH Nutrition Services Branch; UNC Highway Safety Research Center; NC Department of Transportation; and the NC DPH Oral Health Section. Local (e.g., hospital, health department and department of social services) data has been included where appropriate.

Because in any community health assessment it is instructive to relate local data to similar data in other jurisdictions, Dare County data is compared to like data describing the state of North Carolina as a whole, as well as to data from a “peer” county. The NC-CATCH data system recommends that counties similar enough to Dare County in terms of certain selected population and economic indicators to be considered peer counties are Alexander, Davie, McDowell, and Stokes counties. However, all of these counties are in the western part of the state, and none shares with Dare the unique characteristics peculiar to a coastal county, particularly tourism-driven seasonal surges in population and economics, and coastal weather disturbances like “nor’-easters” and hurricanes. As a result, the assessment team selected Carteret County, another coastal county with a tourism industry, as the primary peer county for purposes of data comparison. Although the Carteret County population is twice the size of the population in Dare County, it is similar in many other respects. In fact, Carteret County is recommended by NC-CATCH as a peer to two of the Dare County peers (Alexander and McDowell counties). In some cases Dare County data is compared to US-level data, or to Healthy People 2020 goals or other standardized measures. Where appropriate, trend data has been used to show changes in indicators over time, at least since the previous assessment four years ago, but sometimes further back than that.

9 Dare County Community Health Assessment – Volume One Assessment Methodology

Environmental data were gathered from sources including: US Environmental Protection Agency; Sccorecard; NC Department of Environment and Natural Resources Divisions of Water Quality, Air Quality, Waste Management, and Environmental Health; NC State Laboratory of Public Health; and NC Department of Agriculture.

Primary data was collected via a community survey and interviews among community leaders. The survey was conducted via random sampling within census blocks to collect responses via door-to-door/face-to-face canvassing using paper-based surveys. Survey participants were asked to provide demographic information about themselves by selecting appropriate responses from lists describing categories of age, gender, race and ethnicity, education level, and household income level. This demographic information was collected in order to assess how well the survey participants represented the general population of the county. Other survey items sought participants’ opinions on health problems and behaviors. Participants also were asked questions about their personal health and health behaviors. All responses were kept in confidence and not linked directly to the respondents in any way. A complete description of the survey methodology and results appears in Chapter Four of this report. A copy of the survey instrument appears in the Appendix to this report.

In addition, the consultant collected primary data via telephone interviews conducted among community leaders in Dare County. Interview subjects, nominated by HCOB and DCDPH, represented agencies in key sectors of the community such as local health and human services, business, government, education, and law enforcement. Each interview was conducted according to a script of questions that asked each interviewee to describe the services their organization provided and to whom, how their clientele base and the problems with which these clients present has changed over the past five years, the barriers clients faced in accessing their services, and methods used to eliminate or reduce any barriers to service that exist. Respondents also were asked to describe the county’s general strengths and challenges, greatest health concerns, and possible causes and solutions for these shortcomings. Interviewees were all provided with assurance that no personally identifiable information, such as names or organizational affiliations, would be connected to their responses. A complete description of the interview methodology and results appears in Chapter Five of this report. A copy of the interview protocol and script appears in the Appendix.

The consultant and her assistants analyzed and synthesized all Dare County-specific secondary and primary data described above and prepared this Dare County Community Health Assessment in two volumes: Volume I contains demographic, socioeconomic and health data; Volume II contains environmental data.

10 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Chapter One

Demographic and Socioeconomic Data

11 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Chapter One: Demographic and Socioeconomic Data

Location and Geography

Dare County is located in northeastern North Carolina on the coast of the Atlantic Ocean. The county has a somewhat unusual geography: it includes a landmass bordered on the west by the Alligator River and Tyrrell County, and a thin strip of land “banks” running approximately north (from Currituck County) to south (to Hyde County) and separated from the mainland by the Albemarle Sound in the north and the Pamlico Sound in the south. The county also includes two inhabited islands: one, Roanoke Island, lies between the mainland and the “outer banks” separated from them respectively by the Croatan and Roanoke Sounds; the second, Hatteras Island, lies at the southern end of the land bank strip, surrounded by the Pamlico Sound and the Atlantic Ocean (Figure 1). Dare County encompasses a land area of approximately 384 square miles, and a water area of 1,178 square miles. The county’s unique geography – relatively small land areas separated by sounds and inlets – has been an important factor in the development of the county, and remains so today.

Dare County is a major tourist destination, the “Outer Banks” drawing tens of thousands of visitors annually, primarily in the summer months. However, tourists face considerable challenges in their travel, since the county is not served by Interstate highways, train service, or a major commercial airport. The nearest large commercial airport is Norfolk International Airport, located approximately 90 miles north of the Outer Banks. The county does support three general aviation airports, Dare County Regional Airport, First Flight Airstrip, and the Billy Mitchell Airstrip, the latter two of which are limited to daylight use (1). Only two major US highways traverse the county’s mainland: Highway 64, which runs west-to-east, and Highway 264, which runs north-to-south. Both of these trunk routes serve Roanoke Island. Only one major roadway, NC Highway 12, runs the course of the county along the Outer Banks, from Sanderling in the north to Hatters in the south. Traversing the entire county requires crossing several bridges, and in storm seasons may be limited by flooding along Highway 12.

The county is divided geopolitically into six townships. Atlantic Township includes the towns of Kill Devil Hills, Kitty Hawk and Southern Shores. Nags Head Township includes the towns of Manteo (the county seat) and Nags Head, and the Wanchese CPC. The remaining four townships are Hatteras Township, Kinnakeet Township, Croatan Township, and East Lake Township. The latter five of these townships have existed since 1870. The sixth township, Atlantic Township, was created in 1920, when the northern banks area around Kitty Hawk was removed from Currituck County and added to Dare.

12 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Figure 1. Map of Dare County

Source: NC Department of Transportation

13 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

History

Note: the following historical highlights were adapted from History Timeline of the Outer Banks (2).

The known history of the Dare County area dates to the earliest history of the United States. Amerigo Vespucci is said to have been the first European visitor, anchoring in the Bight of Hatteras in 1497. Between 1524 and 1588 French and Spanish explorers came to the area in search of gold. In 1584 Queen Elizabeth I of England issued a charter to Sir Walter Raleigh to establish a colony in North Carolina. Two attempts to settle on Roanoke Island were unsuccessful, with the settlers disappearing without a trace. Virginia Dare, the first English child born in the New World, was born on Roanoke Island, becoming part of the legend of the “lost colony”, and eventually giving the county its name.

The period from 1663 through 1729 was marked by the expansion of colonial North America under the aegis of eight Lords Proprietors (noblemen given charters for land in return for their support of King Charles II), and local rebellions focused on political and religious issues. The period from 1710-1718 was ruled by pirates, including the infamous Blackbeard, and confrontations with local native Americans. In 1729 the English Crown resumed direct rule of the colony from the Lords Proprietors. This area of colonial America grew and prospered but grew dissatisfied with British policies, and eventually participated in the War for Independence (1776-1783).

The century from 1800 to 1900 was generally “quiet” for the Dare County/Outer Banks area, except for numerous shipwrecks which ultimately gave the area the name, “graveyard of the Atlantic”. During the civil war (1861-1865) the Northern forces invaded the coast, and captured Fort Hatteras and Fort Clark on the Outer Banks. In February 1862 the Burnside Expedition captured Roanoke Island, the gateway to North Carolina’s eastern river system. In December 1862 a gale off Cape Hattreras sunk the USS Monitor, the Union ironclad noted for its battle with the Confederate ship, Virginia, in the first battle between ironclad ships. Today, study and recovery of the Monitor’s remains is a major marine archaeological project.

In the 20th century Dare County’s history was marked by the birth of aviation and the experience of two world wars. In December 1903 Wilbur and Orville Wright made the first successful power-driven airplane flight at Kill Devil Hills, near Kitty Hawk. From 1916-1919 the waters of the Outer Banks filled with German submarines. In August 1918 the Diamond Shoals Lightship was sunk by a German sub. The same month, a British tanker, the Mirlo, was sunk off Rodanthe by another German sub. The rescue of the Mirlo’s crew gave polish to the storied history of the Chicamacomico Lifesaving Station. During World War II German submarines again patrolled coastal North Carolina waters, sinking the British ship San Delfino north of Diamond Shoals.

Since World War II tourism largely supplanted fishing as the area’s major industry. The preservation of Fort Raleigh, the Pea Island National Wildlife Refuge, and the Cape Hatteras National Seashore have added to the area’s tourism draw and prevented run-away coastal development.

Following are historical highlights of some of the Dare County municipalities, adapted from sources available at Outerbanks.com as cited.

14 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Roanoke Island, Manteo and Wanchese (3)

Tiny Roanoke Island has been called “one of the most historic pieces of real estate in the country” (3). Roanoke Island can be reached from the mainland by crossing the Croatan Sound via either US Highway 64 and the Virginian Dare Memorial Bridge, or US Highway 264 and the William B. Umstead Memorial Bridge. Roanoke Island is best known as the site of the first attempted (and failed) settlements of English Colonies in the New World, and the birthplace of Virginia Dare, the first child born to English-speaking parents in the New World.

In 1584 England’s Queen Elizabeth I issued a charter to Sir Walter Raleigh to establish a colony on Roanoke Island. The expedition returned to England with two local Native Americans, Manteo and Wanchese, and “promising” reports of a new land. A second expedition arrived on Roanoke Island in 1585, but these colonists remained only a few months before returning to England. A third expedition arrived in the summer of 1586, leaving a party of 15 men who had disappeared by the time a fourth expedition of settlers arrived in 1587. These settlers, too, had vanished by 1590; among them was Virginia Dare. Although over the years many hypotheses to explain the disappearance of the “lost colony” have been proposed, the details of the settlers’ fate remain unknown.

Today Roanoke Island’s main attraction is the Fort Raleigh Historical Site, located on the northern end of the island, the grounds of which are believed to include part of the site of the first attempted settlement in the New World. Other attractions at the site include the Elizabethan Gardens and the Waterside Theatre, home to The Lost Colony, the country’s first and longest running outdoor drama. Fort Raleigh also honors the African Americans who lived in the Roanoke Island Freedman’s Colony, a National Underground Railroad Network to Freedom site. Slaves who had escaped the mainland to seek protection of the Federal troops that occupied Roanoke Island during the Civil War established the Freedman’s Colony in 1862, and by 1863 when Lincoln issued the Emancipation Proclamation, the population of the Freedman’s Colony exceeded 3,000.

Manteo, the county seat of Dare County, is a town of a little over 1,000 inhabitants (2000 Census) with a picturesque waterfront, interesting architecture, and numerous attractions such as art galleries and studios and antique shops. It is the home to Roanoke Island Festival Park, which includes the Elizabeth II, a replica of a 16th-century sailing ship, and a working settlement site. Manteo also is home to the NC Maritime Museum on Roanoke Island, and the NC Aquarium on Roanoke Island.

Wanchese, located at the southern end of Roanoke Island, has long been a fishing village: the Algonquin Indians traveled there to fish and gather shellfish well before the first European explorers landed on the island. Fishing is still the main enterprise in Wanchese, which is named for one of the Indian chiefs who traveled to England with Sir Walter Raleigh. Wanchese Seafood Industrial Park is homeport to Dare County commercial fishing vessels, several boatbuilding and repair shops, a marina, and other marine-oriented businesses. Products from the industrial park are shipped to points along the east coast, and around the world from Norfolk International Airport. Previously home to primarily fishermen, Wanchese is beginning to attract people seeking a refuge from the commercialism of the beaches of the Outer Banks.

15 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Nags Head (4)

Early maps of Nags Head, which may have been named for a similar location on the English coast, show the area as a promontory of land characterized by high sand dunes visible from miles away at sea. According to local lore, early history of the area was tied to an unusual breed of 18th century land-based pirates or “bankers” that developed their own unique method for tapping profits from the sea. Legend has it that these bankers and their minions walked horses with lanterns on their necks up and down the beach at night. Merchant captains offshore would mistakenly think the lights were from other ships closer to shore and be drawn in where they would run aground, then to be pillaged by the bankers.

Somewhat later, wealthy North Carolina plantation owners discovered the area as a comfortable escape from the long, hot summers on their plantations. Around 1830 the first of these plantation owners purchased 200 acres of land and built the first beach cottage. Within two decades, Nags Head had become a thriving resort area, which it remains to this day. For many years before and after the Civil War the Nags Head Hotel, located at the foot of Jockey’s Ridge, was the focal point of summer activity in Nags Head, until the shifting sand claimed it in the 1870s. Today, Jockey’s Ridge State Park contains the last vestige of the giant moving sand dunes that once towered over the Outer Banks beaches and greeted the first explorers.

Kill Devil Hills (5)

Kill Devil Hills is the largest incorporated municipality in Dare County, with a population of almost 6,000 (2000 US Census). Kill Devil Hills also is the oldest township in the county, officially established in 1953, although the landmark that gives the town its name has been around much longer. At one time the northern Outer Banks were characterized by a series of sand “mountains” over 100 feet high that stretched from Corolla in the north to Nags Head in the south. “Kill Devil Hill” was one of the larger of these dunes, its name perhaps deriving from a brand of rum popular during the colonial period. Although Kitty Hawk is noted as the location of the Wright Brother’s famous “first flight”, Kill Devil Hill (five miles south of the village of Kitty Hawk) is where the Wright brothers experimented and actually made their historic flights.

Prior to the “first flight”, the Kill Devil Hills area was sea-focused, and its residents were primarily fishermen and salvagers. The Kill Devil Hills Life Saving Station was built in 1878, one of 11 such stations erected along the Outer Banks to house special rescue workers trained to help with shipwrecks and maritime disasters. The rescue workers were called “surf men” because they retrieved shipwreck victims in lifeboats launched and beached through the surf. The Kill Devil Hills Life Saving Station employees were eyewitnesses and helpers for the Wright brothers’ flights.

Kitty Hawk (6)

Some say that Kitty Hawk is the closest-sounding English pronunciation of chickahauk, a native Indian term meaning “goose hunting grounds”. In 1900, Kitty Hawk was a remote fishing village, offering a perfect kind of privacy suitable for the Wright brothers as headquarters

16 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

for their “flying machine” experiments. Although they practiced their actual flights slightly further south, at the base of Kill Devil Hill, the 1903 telegraph announcing their eventual success was dispatched from Kitty Hawk, a “dateline” forever linking the village with their feat.

When the Wrights came to the Outer Banks, Kitty Hawk was the primary settlement on the northern end of the barrier island. Today Kitty Hawk is one of the largest townships on the Outer Banks, with a 2000 population of nearly 3,000 (2000 US Census). Oceanside the town resembles the rest of the highly developed and commercial Outer Banks, but along the Albemarle Sound, the village features quaint cottages along shaded lanes and canals, and a somewhat more leisurely pace.

Southern Shores (71)

The area encompassed by the town of Southern Shores -- approximately one mile by four miles, located north of US Route 158 and south of Duck, and between the Atlantic Ocean beaches and the Currituck Sound -- was a real estate development of the Kitty Hawk Land Company. A Southern Shores Civic Association, initially established by the developer, was instrumental in obtaining the Town's municipal incorporation in 1979. The first Town Council, appointed after its incorporation by the state legislature, drew its membership from the Civic Association.

Southern Shores describes itself as a town of volunteers, with volunteers often augmenting Town Staff. This tradition is said to date back to the early days when a volunteer pothole crew repaired the roads, now a task routinely maintained by the Public Works Department. Today, the town is composed of mostly single-family homes, with very little commercial development and a marvelous stretch of beach with low- density oceanfront homes behind a protective dune line.

Duck (7)

Located on the north end of the Outer Banks, Duck – named for the numbers of migratory waterfowl that flocked to the area – was undeveloped until the 1970s, and commercial development there remains limited. Prior to that time, the area was so desolate and difficult to travel that it was used as a bombing range for military aircraft. Before the Civil War, the main source of livelihood in Duck – as on most of the Outer Banks – was subsistence fishing and hunting. When the war ended, Northerners came to the area to work as commercial wildfowlers, or to operate fisheries. There were also private hunting estates and game clubs that attracted wealthy vacationers, and many locals worked as game or fishing guides. Duck has experienced tremendous residential growth over the past decade, and is becoming one of the most popular beach destinations in the country. In 2001, the almost 500 residents of Duck voted to incorporate; in 2002, Duck officially became a town.

Hatteras Island (8)

The southernmost portion of Dare County on the Outer Banks, Hatteras Island is home to seven villages, strung together like beads along the thread-like NC Highway 12, the “beach road”. Each of these communities – Rodanthe, Waves, Salvo, Avon, Buxton, Frisco, and 17 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Hatteras Village – is distinctly different in its own right, stemming from historical roots in isolation and the effort required traveling across the dunes or along the surf line in the days before the highway. Each village has developed its own culture, including “first families”, churches, interests, and in some cases, its own brogue. The total population of Hatteras Island in 2000 was 4001.

In 1953, the Federal government set aside a 72-mile stretch of the Outer Banks from Nags Head to Ocracoke Island as the Cape Hatteras National Seashore, the nation’s first National Seashore. Today, most of Hatteras Island remains protected by that designation and is one of the country’s most visited National Parks.

18 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Population Characteristics

The timing of the Dare County Community Health Assessment (CHA) process presents a unique problem in that the assessment was conducted at the same time as the 2010 US Census. That means that many of the census-based demographic and socioeconomic measures available are ten-years-old, and will not be replaced with updated figures until the results of the 2010 Census are tallied. Wherever feasible, the Dare County CHA uses recent US Census Bureau estimates or projections in lieu of 2000 Census counts to provide a more current description of important demographic parameters. Some measures, especially those cited as 2010 population data, are based on estimates from the NC Office of State Budget and Management, since these are figures the state uses to make budget and policy decisions.

General Population Characteristics

The following general population characteristics are based on 2010 population estimates presented in Table 1:

 Dare County has an estimated permanent population of 34,136 persons, essentially evenly divided by gender.  The median age of Dare County residents is 44.9 years, almost eight years older than the median age statewide, 37.2 years. The median age for Dare County males (43.6 years) is 2.5 younger than the median age for females (46.1 years). Statewide, the median age for males is 2.8 years younger than the median age for females.

Table 1. General Demographic Characteristics (2010 Estimate)

Median Total Number Number Median Age Median Age Location Age Population Males Fe m a le s Fe m a le s Overall Males

Dare County 34,136 17,077 43.6 17,059 46.1 44.9 Carteret County 65,388 39,944 46.2 33,444 48.9 47.6 State of NC 9,519,300 4,671,902 35.8 4,847,398 38.6 37.2 Source: a b b c c a

19 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

The population in Dare County has grown each decade between 1980 and 2000. The rate of increase from 2000 to 2010 is estimated at 15.0%, a rate expected to accelerate in the decade from 2010-2020 before decelerating the decade after that (Table 2).

Table 2. Decadal Population Growth (1980-2030 Projected)

Number of Persons and Percent Change Location % Change % Cha nge 2010 % Cha nge 2020 % Cha nge 2030 % Cha nge 1980 1990 2000 1980-1990 1990-2000 (Estimate) 2000-2010 (Projection) 2010-2020 (Projection) 2020-2030

Dare County 13,377 22,746 70.0 29,967 31.7 35,263 15.0 41,103 16.6 46,386 12.9 Carteret County 41,092 52,553 27.9 59,383 13.0 64,826 8.4 69,157 6.7 71,852 3.9 State of NC 5,880,095 6,632,448 12.8 8,046,485 21.3 9,502,904 15.3 10,966,956 15.4 12,465,481 13.7

Source: Log Into North Carolina (LINC) Database, Topic Group Population and Housing, Total Population, Population (Data Item 5001); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show

The Dare County population is growing in density, but it remains far less densely populated than the average NC county. In 2010, Dare County is estimated to be only about 52% as densely populated as the state as a whole. In 2030, after 20 additional years growth, Dare County still is predicted to be only about 67% as densely populated as the state as a whole (Table 3).

Table 3. Decadal Population Density (1980-2030 Projected)

Persons per Square Mile Location 2010 2020 2030 1980 1990 2000 (Estimate) (Projection) (Projection)

Dare County 34.2 59.6 78.1 100.3 121.1 140.4 Carteret County 78.2 98.9 114.2 126.7 135.2 140.6 State of NC 120.4 136.1 165.2 191.9 219.9 248.2

Source: Log Into North Carolina (LINC) Database, Topic Group Population and Housing, Total Population, Population Density (Data Item 5004); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show

20 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

The US Census Bureau defines “urban” populations as resident populations in urbanized areas and places of 2,500 or more inhabitants outside urbanized areas. An urbanized area contains a population concentration of at least 50,000 inhabitants, generally consisting of a central city and the surrounding, closely settled, contiguous territory (suburbs). A “rural" population is a resident population other than that classified as urban. The population of Dare County was categorized as predominately rural in the 1980, 1990 and 2000 Censuses, although the proportion of the county population considered “urban” increased by 30% over that period (Table 4). The results of the 2010 Census will be interesting in this regard.

Table 4. Decadal Rural/Urban Population Distribution (1980-2000)

Percent of Population Location 1980 1990 2000 Rural Urban Rural Urban Rural Urban

Dare County 100.0 0.0 81.4 18.6 69.6 30.4 Carteret County 80.1 19.9 76.4 23.6 38.0 62.0 State of NC 52.0 48.0 49.7 50.3 39.8 60.2

Log Into North Carolina (LINC) Database, Topic Group Population and Housing, Special Populations (Data Items 6002, 6003); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show

Dare County is divided into six townships: Atlantic Township (including the towns of Kill Devil Hills, Kitty Hawk, and Southern Shores); Nags Head Township (including the towns of Manteo and Nags Head and the Wanchese CDP (Census-designated place); Hatteras Township, Kinnakeet Township, Croatan Township, and East Lake Township. The following population information is derived from 2000 US Census data presented in Table 5. (Note that the relative placement of the towns and townships in this list are subject to change when the results of the 2010 Census are tallied).

 Atlantic Township is the largest township in Dare County, accounting for 51% of the county’s population. Kill Devil Hills is the largest town in Atlantic Township and Dare County, containing almost 20% of the county’s population.  Nags Head Township is the second-largest township in Dare County, with 31.5% of the county’s population. Nags Head is the largest town in the township, home to 9% of the county’s population.  East Lake Township is the smallest township in Dare County, and is home to only 0.5% of the overall county population.  East Lake Township is the youngest township in the county in terms of median age: 34.9 years.  Kinnakeet Township is the oldest township in the county, with a median age of 44.1 years.  Despite being only the third oldest township in the county in terms of median age, Atlantic Township is home to the oldest town, Southern Shores, with a median age of 51.4 years.

21 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 5. Dare County Population by Township (2000)

% of No. of Median Township County Persons Age Population

Atlantic Township1 15,342 51.2 40.4 Kill Devil Hills Town 2 5,897 19.7 36.7 Kitty Hawk Town 2,991 10.0 40.6 Southern Shores Town 2,201 7.3 51.4 Remainder of Township 4,253 14.2 n/a Nags Head Township 9,442 31.5 39.8 Manteo Town 1,052 3.5 41.2 Nags Head Town 2,700 9.0 42.7 Wanchese CDP 1,527 5.1 37.2 Remainder of Township 4,163 13.9 n/a Hatteras Township 2,642 8.8 42.4 Kinnakeet Township 1,359 4.5 44.1 Croatan Township 1,035 3.5 38.5 East Lake Township 147 0.5 34.9 Dare County Total 29,967 100.0 40.4

1 Township-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Quick Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov 2 Town-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Detailed Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov

Race and Ethnicity

The population of Dare County is not as racially or ethnically diverse as the state or as its peer county, Carteret County. For example, according to data in Table 6, the non-white population in Dare County is only about half as large as the non-white population in Carteret County, and only about one-fourth as large as the non-white population in North Carolina as a whole.

22 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 6. Population Distribution by Race/Ethnicity (2010 Estimate)

Number and Percent Black/African- Asian/Pacific Two or More Location Total White Non-White American Indian American Islander Races No. % No. % No. % No. % No. % No. %

Dare County 34,136 32,235 94.4 1,901 5.6 1,191 3.5 119 0.4 216 0.6 375 1.1 Carteret County 65,388 58,705 89.8 6,683 10.2 5,049 7.7 327 0.5 536 0.8 771 1.2 State of NC 9,519,300 7,018,700 73.7 2,500,600 26.3 2,058,084 21.6 119,935 1.3 199,051 2.1 123,530 1.3 Source a b h c h d h e h f h g h

a - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_2010.html b - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_white_2010.html c - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_nonwhite_2010.html d - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_black_2010.html e - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_aian_2010.html f - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_asian_2010.html g - NC Office of State Budget and Management, Facts and Figures, Socioeconomic Data, Population Estimates and Projections, County Estimates, County Projections; http://www.osbm.state.nc.us/demog/countytotals_agegroup_twoormore_2010.html h - Percentages are calculated

The following information about racial and ethnic population diversity at the township level in Dare County is derived from 2000 US Census data presented in Table 7.

 All townships (and towns) in Dare County are predominately white.  The largest number (703) of Blacks/African Americans in the county reside in Nags Head Township, where they compose 2.3% of the total county population. A large majority of these Black/African American residents (79%) live outside of the municipalities in the township.  The largest number (316) of Hispanics/Latinos in the county reside in Atlantic Township (predominately in Kill Devil Hills), where they compose 1.1% of the total county population. The second highest number (259) of Hispanics/Latinos reside in Nags Head Township, predominately outside of the municipalities.  No other racial or ethnic group composes as much as 1% of the population in Dare County.

23 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 7. Dare County Population by Race/Ethnicity, by Township (2000)

Persons Self-Identifying as of One Race American Native Hawaiian or Hispanic/Latino Black/African Township Total White Indian/Alaska Asian Other Pacific (of any race) American Population Native Islander No. % 1 No. % No. % No. % No. % No. % Atlantic Township2 15,342 14,914 49.8 80 0.3 36 0.1 64 0.2 10 <0.1 316 1.1 Kill Devil Hills Town 3 5,897 5,835 19.5 36 0.1 10 <0.1 35 0.1 7 <0.1 174 0.6 Kitty Hawk Town 2,991 2,976 9.9 19 <0.1 7 <0.1 8 <0.1 1 <0.1 28 <0.1 Southern Shores Town 2,201 2,162 7.2 2 <0.1 5 <0.1 5 <0.1 2 <0.1 34 0.1 Remainder of Township 4,253 3,941 13.2 23 <0.1 14 <0.1 16 <0.1 0 0.0 80 0.3 Nags Head Township 9,442 8,438 28.2 703 2.3 39 0.1 22 <0.1 1 <0.1 259 0.9 Manteo Town 1,052 908 3.0 106 0.4 6 <0.1 1 <0.1 0 0.0 27 <0.1 Nags Head Town 2,700 2,618 8.7 36 0.1 4 <0.1 12 <0.1 0 0.0 39 0.1 Wanchese CDP 1,527 1,498 5.0 5 <0.1 9 <0.1 2 <0.1 0 0.0 28 <0.1 Remainder of Township 4,163 3,414 11.4 556 1.9 20 0.1 7 <0.1 1 <0.1 165 0.6 Hatteras Township 2,642 2,605 8.7 4 <0.1 2 <0.1 1 <0.1 2 <0.1 27 <0.1 Kinnakeet Township 1,359 1,313 4.4 3 <0.1 4 <0.1 24 <0.1 0 0.0 4 <0.1 Croatan Township 1,035 980 3.3 7 <0.1 2 <0.1 0 0.0 0 0.0 56 0.2 East Lake Township 147 143 0.5 0 0.0 0 0.0 0 0.0 0 0.0 4 <0.1 Dare County Total 29,967 28,393 94.7 797 2.7 83 0.3 111 0.4 13 <0.1 666 2.2

1 Percentages are calculated from population figures. Percentage figures describe a population group as a proportion of the overall county population. Note that the population counts in the table do not include s who self-identify as being of more than one race or ethnicity. 2 Township-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Quick Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov 3 Town-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Detailed Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov

Age and Gender

The following information about the age and gender distribution of the Dare County population is derived from 2010 NC Office of State Budget and Management data presented in Table 8.

24 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 In terms of both numbers (5,531) and percent (16.2%), the largest segment of the population in Dare County is the 45-54 age group. This is slightly different from NC as a whole, where the segment composing the largest number and percent of the state’s population (14.6) is the next younger age group, age 35-44.  Persons 60 years of age or older compose 25.8% of the population in Dare County, but 18.3% of the population of NC.  Persons 17 years of age and younger compose 19.5% of the population in Dare County, but 23.6% of the population of NC.

Table 8. Population Distribution by Age and Gender, Number and Percent (2010 Estimate)

Dare CountyNorth Carolina North Carolina Age Group No. in Population % of Total PopulationNo. in Population % of Total Population Total Male Female Total Male Female Total Male Female Total Male Female All ages 34,136 17,077 17,059 100.0 100.0 100.0 9,519,300 4,671,902 4,847,398 100.0 100.0 100.0 0 to 2 1,167 571 596 3.4 3.3 3.5 388,430 199,078 189,352 4.1 4.3 3.9 3 to 4 894 465 429 2.6 2.7 2.5 256,118 131,144 124,974 2.7 2.8 2.6 5 470 234 227 1.4 1.4 1.3 123,444 62,979 60,465 1.3 1.3 1.2 6 to 9 1,541 794 747 4.5 4.6 4.4 495,088 252,720 242,368 5.2 5.4 5.0 10 to 13 1,215 589 626 3.6 3.4 3.7 483,961 246,415 237,546 5.1 5.3 4.9 14 347 184 163 1.0 1.1 1.0 120,663 61,393 59,270 1.3 1.3 1.2 15 324 165 159 0.9 1.0 0.9 121,785 62,036 59,749 1.3 1.3 1.2 16 to 17 722 381 341 2.1 2.2 2.0 248,176 126,128 122,048 2.6 2.7 2.5 18 to 19 841 444 397 2.5 2.6 2.3 285,978 144,956 141,022 3.0 3.1 2.9 20 to 24 2,213 1,164 1,049 6.5 6.8 6.1 696,518 363,205 333,313 7.3 7.8 6.9 25 to 34 3,000 1,609 1,391 8.8 9.4 8.2 1,242,025 631,120 610,905 13.0 13.5 12.6 35 to 44 4,402 2,270 2,132 12.9 13.3 12.5 1,385,245 693,201 692,044 14.6 14.8 14.3 45 to 54 5,531 2,684 2,847 16.2 15.7 16.7 1,360,925 663,216 697,709 14.3 14.2 14.4 55 to 59 2,640 1,307 1,333 7.7 7.7 7.8 581,213 276,371 304,842 6.1 5.9 6.3 60 to 64 2,335 1,130 1,205 6.8 6.6 7.1 511,206 241,496 269,710 5.4 5.2 5.6 65 to 74 3,625 1,706 1,919 10.6 10.0 11.2 672,130 307,687 364,443 7.1 6.6 7.5 75 to 84 2,244 1,073 1,171 6.6 6.3 6.9 390,299 159,993 230,306 4.1 3.4 4.8 85 to 94 583 281 302 1.7 1.6 1.8 141,500 45,190 96,310 1.5 1.0 2.0 95+ 42 17 25 0.1 0.1 0.1 14,596 3,574 11,022 0.2 0.1 0.2 Source a b c d d a b c d d d

25 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Figure 2, derived from the data in Table 8, is a graphic representation of the relative proportion of population, by age group, in Dare County and NC. From this comparison it is easily to discern all the ways in which these population distributions differ.

Figure 2. Population Distribution by Age Group, Percent (2000)

18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 Percent of Population of Percent 0.0

North Carolina Dare County

Households

Table 9 presents 2000 US Census data summarizing some of the characteristics of households in Dare County, Carteret County, and the state of NC as a whole.

 According to calculations made from the data in the table, the percentage of households that are one-person households is similar for Dare County (25%), Carteret County (26%) and the state of NC (25%).  According to similar calculations, the percentage of one person households inhabited by a person age 65 and older is 32% in Dare County, 39% in Carteret, and 34% in NC as a whole.

26 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 9. Household Characteristics (2000)

Persons in No. Persons No. One- No. One-person Location per Group person Age ≥65 Households1 Household Quarters2 Households Households

Dare County 12,690 2.34 232 3,176 1,005 Carteret County 25,204 2.31 1,084 6,582 2,551 State of NC 3,132,013 2.49 253,881 795,271 270,141

Source: Log Into North Carolina (LINC) Database, Topic Group Population and Housing, Living Arrangements/Marital Status (Data Items 221, 222, 6007, 6056, 6057); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show) 1 A household includes all the persons who occupy a housing unit. A housing unit is a house, an apartment, a mobile home, a group of rooms, or a single room that is occupied (or if vacant, is intended for occupancy) as separate living quarters. Separate living quarters are those in which the occupants live and eat separately from any other persons in the building and which have direct access from the outside of the building or through a common hall. The occupants may be a single family, one person living alone, two or more families living together, or any other group of related or unrelated persons who share living arrangements. (People not living in households are classified as living in group quarters. 2 Persons in group quarters are either under the custody or care of institutions (e.g., correctional institutions, mental hospitals, nursing homes, etc.) or those in group (10 or more persons) living arrangements such as convents, rooming houses, communes, etc.

Older Adults

Because the proportion of the Dare County population age 60 and older is larger than the proportion of that age group statewide, it merits closer examination. The population age 60 and older often requires more and different health and social services than the rest of the population, and understanding how that population will change in coming years will be an important consideration in community planning.

Growth of the Elderly Population

Figure 3 is a graphic representation of the growth of the Dare County elderly population, ages 60-85+, by decade from 1970 projected through 2030. This graph is based on US Census data, counted, estimated, or projected, depending on the year in question. The following information is derived from that graph.

 The proportion of every age group age 60 and older will grow through the year 2020.  By 2030, the rate of growth in the youngest age group (60-64) will have reversed to a decline, and the rate of growth in the next youngest age group (65-69) will have slowed. 27 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 Growth in the older age groups (age 70 and older) will continue to accelerate past 2020.  Though all segments of the elderly population will grow, the segment expected to grow by the largest percentage in the 20 years between 2010 and 2030 is the group aged 75-79, which is predicted to grow by 75% over that period, from 2.8% to 4.9% of the total county population.  The population segments aged 80-84 and 85+ are each predicted to increase by approximately 65% over the same period.

Figure 3. Decadal Growth of the Dare County Population Ages 60-85+ (1970-2030 Projected)

9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0

Age Group as Percent of Total Population Total of Percent as Group Age 1970 1980 1990 2000 2010 2020 2030

60-64 65-69 70-74 75-79 80-84 85+

Source: Log Into North Carolina (LINC) Database, Topic Group Population and Housing (Data Items 419-424); http://data.osbm.state.nc.us/pls/linc/dyn_linc_main.show. Note: Percentages are calculated from raw data.

Location of the Elderly Population

Table 10 shows the distribution of the Dare County population age 65 and older by township, according to the 2000 US Census. The following information derives from that table.

28 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 The largest percentage of the Dare County population age 65 and older (51.3%) resides in Atlantic Township, where the elderly population is almost evenly distributed among Kill Devil Hills, Southern Shores, and the non-incorporated parts of the township.  The next largest proportion of Dare County adults aged 65 and older (30.1%) resides in Nags Head Township, where the elderly population is almost evenly distributed in Nags Head Town and the non-incorporated parts of the township.

Table 10. Dare County Population Age 65 and Older, by Township1 (2000)

% of Count y % of County Township/Town No. Population Age Population 65 and Older Atlantic Township2 2,115 51.3 7.1 Kill Devil Hills Town 3 630 15.3 2.1 Kitty Hawk Town 388 9.4 1.3 Southern Shores Town 547 13.3 1.8 Remainder of Township 550 13.3 1.8 Nags Head Township 1,243 30.1 4.1 Manteo Town 181 4.4 0.6 Nags Head Town 459 11.1 1.5 Wanchese CDP 184 4.5 0.6 Remainder of Township 419 10.2 1.4 Hatteras Township 383 9.3 1.3 Kinnakeet Township 227 5.5 0.8 Croatan Township 141 3.4 0.5 East Lake Township 15 0.4 0.1 Total Dare County Population Age >65 4,124 100.0 13.8 Total Dare County Population 29,967 n/a 100.0

1 Percentages are calculated 2 Township-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Quick Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov 3 Town-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Detailed Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov 3 Town-Level Data Source: US Census Bureau, American Fact Finder, Data Sets, Census 2000 Summary File 1 (SF1), Detailed Tables, County Subdivision, NC, Dare, Table DP-1, Profile of General Demographic Characteristics 2000, http://factfinder.census.gov

29 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Sociodemographic Characteristics of the Elderly Population

Characteristics of the elderly persons in a county can help service providers understand how this population can or cannot access and utilize community services. Factors such as educational level, mobility and disability are all useful predictors of service access and utilization. The NC Division of Aging and Adult Services collects and catalogues information about factors like these on the county level (9). Some of the Division’s US Census Bureau-derived data for Dare County – and comparable data for Carteret County and the state as a whole – for persons age 65 and older are summarized below and in Tables 11 and 12.

Educational Attainment (Table 11)

 Elderly persons in Dare County tend to be more educated than their counterparts in Carteret County and NC. In Dare County 22% of persons age 65 and older lack a high school diploma, compared to a comparable figure of 29.7% for Carteret County and 41.6% for the state as a whole.  A larger proportion of Dare County residents than either Carteret County or NC residents age 65 and older have had a graduate school education (9.8% vs. 8.4% vs. 5.5%).  According to the source, in 2000 there were no persons age 65 and older in Dare County with limited or no English.

Living Conditions and Economics (Table 11)

 In 2000 approximately 111 persons in Dare County were classified as grandparents raising grandchildren under the age of 18. The comparable figure for Carteret County was 542, a proportionally larger figure than the two-fold population size difference might predict.  In both Dare and Carteret counties the proportion of the population age 65 and older still in the labor force is higher than the average for the state as a whole (4.3% and 4.9% respectively vs. 3.5%).  As might be expected from the relative difference in the size of their populations, the number of social security beneficiaries in Dare County is about half the number in Carteret County.  The average monthly social security benefit for persons age 65 and older is slightly higher in Dare County than in either Carteret County or NC as a whole.

Disability (Table 12)

 The US Census bureau definition of “disability” includes any long-lasting physical, mental or emotional condition that can make it difficult for persons to walk, climb stairs, dress, bathe, learn or remember. The elderly population in Dare County has a significantly lower proportion of persons with disabilities than in either Carteret County or NC as a whole. According to 2000 US Census figures, 33.2% of persons age 65 or older in Dare County reported having one or more disabilities, compared to 42.4% of persons this age in Carteret County and 45.7% statewide.

30 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Health and Health Care Access (Table 12)

 Persons age 65 and older would be expected to have medical care coverage through Medicare. Elderly persons living at certain levels of poverty would also be elibigle for Medicaid. The numbers of persons age 65 and older eligible for Medicaid and dually eligible for Medicaid and Medicare in Dare County are far smaller than in Carteret County, especially given the two-fold population difference between the counties.  A larger percentage of Medicare beneficiaries in Dare County take advantage of immunization for influenza than in either Carteret County of NC as a whole (53.9% vs. 41.0% vs. 43.5%).

Table 11. Sociodemographic Characteristics of the Population Age 65 and Older (Years as Noted)

No. Average % P e r s ons Age No. Social % P e r s ons Age % Persons Age Grandparents % P e r s ons Age Monthly Social 65+ with Security 65+ without HS 65+ with Raising 65+ in Labor Security Benefit Location Gr a dua te Beneficiaries Diploma Limited or No Grandchildren Force for Persons Education Age 65+ (2000) English (2000) Under Age 18 (2000) Age 65+ (2000) (2008) (2000) (2008)

Dare County 22.0 9.8 0.0 111 4.3 4,610 $1,141 Carteret County 29.7 8.4 0.7 542 4.9 10,850 $1,071 State of NC 41.6 5.5 0.5 79,810 3.5 1,090,908 $1,118

Source: NC DHHS Division of Aging and Adult Services, County Profiles; http://www.dhhs.state.nc.us/aging/cprofile/cprofile.htm

Table 12. Health and Health Care Access Characteristics of the Population Age 65 and Older (Years as Noted)

% of P e r s ons No. Medicare/ % M e dic a r e No. Medicaid- Age 65+ with Medicaid Dually Beneficiaries eligible Persons Location One or More Eligible Persons Immunized for Age 65+ Disabilities Age 65+ Influenza (SFY 2009) (2000) (SFY 2009) (2000)

Dare County 33.2 290 281 53.9 Carteret County 42.4 1,091 1,103 41.0 State of NC 45.7 179,051 176,608 43.5

Source: NC DHHS Division of Aging and Adult Services, County Profiles; http://www.dhhs.state.nc.us/aging/cprofile/cprofile.htm

31 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Non-English Speaking Population

North Carolina has seen continuous growth in the number of foreign-born residents, with this segment of the population increasing from 39,382 in 1969 to 430,000 in 2000, an almost 11-fold increase. According to demographers, this official count is likely an underestimate, since many in this population do not participate in the US Census. The foreign-born population in a community is one that potentially does not speak English, and so is of concern to service providers.

Statewide, the greatest proportion of the increase in foreign-born persons is represented by immigrants of Hispanic origin; however, statewide there has also been an influx of foreign-born immigrants from Southeast Asia.

According to US Census data summarized in Table 13:  As of the 2000 Census, there were 751 foreign-born residents in Dare County. Using a base 2000 population figure of 29,967, that means that foreign-born residents made up 2.5% of the total county population at that time.  The largest influx of the foreign-born population in Dare County – 280, or 37.3% of the total foreign-born populaiton in 2000 – arrived between 1995 and 2000.  The percent of increase in the foreign-born population in Dare County since 1994 was less than the percent of increase at the state level over the same period (59.4% vs. 76.2%).

Table 13. Foreign-Born Population, Number by Year of Entry (1965-2000)

Number of Persons Arriving per Five-Year Period % Increase Location <1965 1965-1969 1970-1974 1975-1979 1980-1984 1985-1989 1990-1994 1995-2000 Total thru 2000 1994-2000

Dare County 217 31 55 25 18 45 80 280 751 59.4 Carteret County 277 103 54 77 97 201 141 249 1,199 26.2 State of NC 28,217 11,165 14,099 21,721 35,480 50,961 82,454 185,903 430,000 76.2

Source: US Census Bureau, 2000 Census, American Fact Finder, Data Sets, Summary File 3, Detailed Tables, P22, Year of Entry for the Foreign-Born Population; http://www2.census.gov/census_2000/datasets/demographic_profile/North_Carolina/2kh37.pdf

“Linguistic isolation”, reflected as an inability to communicate because of a lack of language skills, can be a barrier preventing foreign-born residents from accessing needed services. The US Census Bureau tracks linguistically isolated households according to the following definition: A linguistically isolated household is one in which no member 14 years and over (1) speaks only English, or (2) speaks a non- English language and speaks English "very well". In other words, all members 14 years old and over have at least some difficulty with English.

32 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

The following information about linguistically isolated households is derived from the 2000 US Census data presented in Table 14.

 Of the 12,685 Dare County households canvassed in the 2000 US Census, 761, or 6%, reported speaking a language other than English. Of these, 89, or 11.7%, reported being linguistically isolated.  The largest group of linguistically isolated households in Dare County are Spanish-speaking households.

Table 14. Household Language by Linguistic Isolation (2000)

Number of Households Speaking Asian or Total Speaking Other Indo- Speaking Other Location English- Spanish-Speaking Pacific Island Households European Languages Languages Speaking Languages Isolated Not isolated Isolated Not isolated Isolated Not isolated Isolated Not isolated

Dare County 12,685 11,924 79 320 7 298 3 41 0 13 Carteret County 25,225 23,680 90 688 16 527 42 115 0 66 State of NC 3,133,282 2,841,028 43,698 125,899 6,804 69,246 8,730 25,143 1,607 11,127

Source: US Census Bureau, American Fact Finder, Data Sets, Summary File 3, Detailed Tables, P20, Household Language by Linguistic Isolation; http://factfinder.census.gov

Since the Hispanic/Latino population is the principal linguistically-isolated group in Dare County, further knowlegde of the characteristics of this group is helpful in anticipating service needs.

In Dare County, as in other counties in NC, a major impetus (at least until recently) for immigration is the prospect of employment opportunities. One would expect then that the age groups predominant in this population would be those in their “prime” for work, especially the physical labor-type jobs in construction, agricultural, and fishing industries that are available to them. Spouses of these workers would be in the midst of their childbearing years, so it might also be expected that this population would have children.

Figure 4 is a graphic depiction of the 2000 US Census population profile by age group of the total Dare County population compared to the same profile for the Hispanic/Latino population. These data would appear to corroborate the expectations cited above:

 In Dare County the age groups Under 14, 20-29 and 40-49 years represent higher proportions in the Hispanic/Latino population than in the overall county population. There is a lower proportion of Hispanics/Latinos than in the general population in all the other age groups.

33 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Figure 4. Distribution of the Total and Hispanic/Latino Populations in Dare County, by Age (2000)

16.00

14.00

12.00

10.00

8.00

6.00

4.00 Percent of of Population Percent

2.00

0.00

Total Population Latino/Hispanic Population

Source: US Census Bureau, American Fact Finder, Data sets, Summary File 3, Detailed Tables, By County, P145H: Sex by Age (Hispanic or Latino); http://factfinder.census.gov/

Recently, there have been reports in the media that immigrants are leaving the US due to a decrease in available employment and fears of new anti-immigration laws. It will be interesting to see the results of the 2010 Census with regard to changes in the immigrant population.

Other Special Populations

There are other population groups whose special needs are important considerations in health and social service planning, including military veterans, visually impaired persons, and developmentally disabled persons. Table 15 summarizes available Census data describing these special population groups in Dare County, Carteret County, and the state of NC.

34 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 15: Special Populations (Years as Noted)

Number of Persons Estimated with Estimated with Estimated Blind/Visually Developmental Developmental Location Military Impaired Disabilities, Disabilities, Veterans (2009) Ages 3-17 Age 18+ (2010) (2008) (2008)

Dare County 4,168 63 186 201 Carteret County 9,290 172 310 365 State of NC 765,942 21,543 59,559 55,200 Source a b c c

a - Log into North Carolina (LINC) Database, Topic Group Population and Housing (Data Item 302); http://data.osbm.state.nc.us/pls/linc/dyn_linc_main.show b - Log into North Carolina (LINC) Database, Topic Group Vital Statistics and Health (Data Item 520); http://data.osbm.state.nc.us/pls/linc/dyn_linc_main.show c - NC-CATCH, County Health Profiles, Health Profile, Disability; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Special Needs Registry

The challenges faced during emergencies and disasters by individuals with special needs must be addressed as a part of emergency preparedness. In response, local jurisdictions have developed voluntary special needs registries in order to apprise local emergency authorities of the presence and location of people with special needs. Some jurisdictions employ registries only as a means of pre- emergency outreach (e.g., to providing planning and other useful information, such as how to compile an emergency kit). Others use registries to alert registrants of impending emergencies, so individuals with special needs can make special preparations and/or evacuate. Still others rely on registries to assist in evacuations or to provide emergency services such as transportation, sheltering or health care during a disaster.

In Dare County, the Department of Social Services is responsible for maintaining the the local Special Medical Needs Voluntary Registry. The Dare County Emergency Management Department and the Dare County Department of Public Health partner in promoting the initiative. The program is targeted to any county resident with physical or mental health problems severe enough to require care and assistance to meet their basic needs. The public can access the registration form on the World Wide Web at http://www.co.dare.nc.us/Forms/SSMedNeeds.pdf .

35 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Government and Civic Participation

Government

Dare County is governed according to the County Manager/Board of Commissioners model. There is a seven-member Board of Commissioners all of whom are elected at-large in a county-wide election to serve four-year, staggered terms. Elections are held in November of even-numbered years, and new board members take office on the first Monday in December following the November election.

The Board’s primary duties include: adopting an annual budget; establishing the annual property tax rate; setting policies, goals and objectives to direct the County’s growth and development; adopting and providing for ordinances, rules and regulations as necessary for the general welfare of County citizens; entering into written contractual or legal obligations on behalf of the County; and carrying out other responsibilities as set forth by NC General Statutes (10).

The Commissioners value citizen involvement in the business of the county, and so the Board of Commissioners makes appointments to a number of advisory boards, committees and commissions from among a pool of interested and qualified citizen-applicants. The boards and commissions for which the commissioners accept applications include (11):

 ABC Board - Sets policy and adopts rules in conformity with ABC laws and Commission rules; hires and fires local board personnel.  Affordable Housing Committee - Addresses opportunities for affordable housing in unincorporated Dare County.  Aging Advisory Council for the Albemarle Commission - Assists the Division of Aging in planning and implementation of the Area Aging Plan. Assists with funding distribution of Home Community Care Block Grant funding and federal funding.  Airport Authority - Maintains and operates airports in Dare County. Provides air transportation services to the aviation traveling public and other aviation related services.  Albemarle Commission - Provides planning and economic development assistance to the region.  Albemarle Development - Creates more and better jobs and works to diversify the tax base of the region.  Albemarle Region Resource Conservation - Promotes and coordinates the long-term conservation of North Carolina’s threatened land and water resources.  Audit Committee - Provides oversight for the county’s finance department.  Board of Equalization and Review - Hears appeals of any taxpayer concerning the listing or appraisal of his property or the property of others.  College of the Albemarle Board of Trustees - Constitutes the local administrative board of the college.  Commission for Working Watermen - Addresses and advises the Board of Commissioners on issues involving Dare County’s commercial and recreational fishing industries.  Dare County Board of Health - Is responsible for the policy making, rule making and adjudicatory body for the County Health Department.

36 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 Dare County Scenic Byways Commission - Pursues national status for the Outer Banks Scenic Byway in cooperation with Hyde and Carteret counties.  Dare Day Committee - Promotes and produces the annual outdoor festival.  Department of Social Services Board - Establishes the county social services policy, selects director and advises the department. Board also helps along with the director on the planning of budget.  East Carolina Behavioral Health Board - Designs, develops, implements, and continuously improves the quality systems and services necessary to respond to the mental health, developmental disabilities and substance abuse healthcare needs of area consumers.  East Lake Community Center Board - Manages the community building. Conducts fundraisers to maintain the building.  Economic Improvement Council - Develops and implements programs for low income families.  Fessenden Center Advisory Board - Helps in establishing goals and policies to enhance Fessenden Center operation and community outreach consistent with goals, objectives, and policies of Dare County.  Game and Wildlife Commission -Issues and renews hunting blind licenses in all Dare County waters.  Hatteras Community Center Board - Is responsible for managing and upgrading the community building.  Industrial Bonding Authority - Issues and services revenue bond debt of private businesses for economic development purposes.  Joint Committee on Access at Cape Hatteras National Seashore Recreational Area - Addresses and advises the Board of Commissioners on issues involving access to Cape Hatteras National Seashore Recreation Area.  Jury Commission - Certifies jurors.  Land Transfer Tax Appeals Board - Conducts hearings when a person disputes the amount of tax due stated by the tax collector.  Library Board - Dare - Establishes local policies within those set by the Regional Library Board, oversees the Library Trust Fund budget, and serves on the Board of the Dare County Library Foundation.  Library Board - Regional East Albemarle Regional Library - Serves as the governing board and sets policy for the six libraries within the East Albemarle Regional Library System. Board is responsible for setting region-wide policies, and approving and reviewing the Regional budget.  Local Emergency Planning Committee - Develops an emergency response plan tailored to the needs of the community.  Manns Harbor Community Center Board - Is responsible for managing and upgrading the community building.  Nursing Home Community Advisory Committee - Monitors patient care and resolves grievances of nursing home patients or their families.  Older Adult Services Advisory Council - Advises Dare County Older Adult Services.  Oregon Inlet and Waterways Commission - Oversees county dredging projects and waterways related issues.  Parks and Recreation Advisory Council - Reviews programming and policies and advises Parks and Recreation in its efforts to promote, organize, plan, and coordinate activities and programs for youth and adults in Dare County.  Planning Board - Reviews and recommends action on development plans and issues.  Regional Emergency Medical Services Council - Facilitates exchange of information relative to each county Emergency Medical Services/Rescue division. Discusss grants, training, new technology, etc.  Roanoke Island Community Center Board - Is responsible for managing and upgrading the community building.

37 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 Rodanthe Waves Salvo Community Center Board - Is responsible for managing and upgrading the community building.  Shoreline Management Commission - Oversees and advocates for the preservation of and restoration of the shorelines of Dare County.  Special Motor Vehicle Valuation Review Board - Hears tax payer appeals related to vehicle appraisals.  Stumpy Point Community Center Board - Is responsible for managing and upgrading the community building.  Task Force on Higher Education - Discusses bringing higher education to Dare County.  Tourism Board - Promotes travel to and tourism in Dare County and its municipalities in order to increase visitation and revenue.  Town of Southern Shores Zoning Board of Adjustment - Hears appeals from the decisions of the Building Inspector or to consider recommending a variance from the Zoning Ordinance in special circumstances.  Transportation Advisory Board - Advises the county Transportation Department.  Wanchese Community Center Board - Is responsible for managing and upgrading the community building.  Workforce Development Board - Enhances the partnerships between private and public sectors  Youth Center - Oversees and facilitates ongoing programming of recreation with an emphasis on making opportunities available to all middle school and high school youth in Dare County.  Zoning Board of Adjustments - Hears and decides appeals from, and reviews any order, requirement, or decision of determination made by the Zoning Administrator, which includes interpretation of zoning maps, disputed questions of lot lines that may arise.

Civic Engagement

Electoral Process

One measure of a population’s engagement in community affairs is its participation in the electoral process. Tables 16 and 17 summarize current voter registration and historical voter turn-out data. It should be noted that turnout in any particular election is at least partially determined by the voters’ interest and investment in the particular issues on the table at that time. The turnout data presented represents turnout for general elections, some of which were contested in presidential election years.

 As of June 22, 2010, 85.4% of the voting age population in Dare County was registered to vote. This figure compares to overall voter registration percentages of 87.1% in Carteret County and 85.9% for NC as a whole (Table 16).  White voters make up 95.6% of the registered voters in Dare County (Table 16), while whites compose an estimated 94.4% of the total county population (Table 6, cited previously).  Voter turnout has been higher in Dare County than in NC as a whole for five of the past six general elections (Table 17)..  Voter turnout has been somewhat lower in Dare County than in Carteret County in all general election years except 2006 (Table 17)

38 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 16. Registered Voters, by Race/Ethnicity, Number and Percent (as of June 22, 2010)

Voting Age Number and Percent of Voting Age Population Registered to Vote Location Population Total White Black American Indian Other Hispanic (2010) No.1 % No. % No. % No. % No. % No. %

Dare County 30,742 26,246 85.4 25,085 95.6 506 1.9 37 0.1 242 0.9 117 0.4 Carteret County 54,199 47,197 87.1 43,448 92.1 2,558 5.4 89 0.2 330 0.7 204 0.4 State of NC 7,116,821 6,109,872 85.9 4,474,143 73.2 1,320,288 21.6 47,671 0.8 102,117 1.7 74,303 1.2 Source:a bcbcbcbcbcbc

1 The total number of registered voters reported by the NC State Board of Elections is based on the sum of registrations by party affiliation, and does not necessarily equal the sum of registrations by race, which is a smaller figure. Therefore, the sum of the percentages is less than 100%. a - Log Into North Carolina (LINC) Database, Topic Group Government, Voters and Elections, Voting Age Population (Data Item 1714); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show b - NC State Board of Elections, Voter Registration, Voter Statistics, Voter Registration Statistics, By County; http://www.sboe.state.nc.us/content.aspx?id=69 c - Percentages are calculated

Table 17. Voter Turnout in General Elections (1998-2008)

Percent of Registered Voters that Voted Location 1998 2000 2002 2004 2006 2008

Dare County 68 41 68 65 68 52 Carteret County 73 51 69 66 65 53 State of NC 70 37 64 47 59 43

Source: NC State Board of Elections, Election Central, Election Results, Voter Turnout; http://www.sboe.state.nc.us/content.aspx?id=69

Religious Life

The fabric of a community is often maintained and repaired through its citizens’ participation in organized religion. Increasingly, health and human service providers have come to realize that the faith community can be an important partner in assuring the health and well-being of at least its members if not greater segments of the population.

Table 18 lists the churches in Dare County, by town location. This data, gathered in June 2010, shows that there are options for exploring faith and religion in every community in the county.

39 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 18. Churches in Dare County, Number by Denomination by Location (June 2010)

Assembly Christian Church of Church of Non- Unitarian- Baptist Catholic Episcopal Jewish Lutheran M ethodist Presbyterian Total Location of God Science Christ God Denom Universalist

Avon 1 12 Buxton 1 1 11 4 Duc k 11 Eas t Lake 0 Frisco 1 1 13 Hatteras 1 12 Kill Devil Hills 2 11 1 5 Kitty Haw k 2 1 1 1 1 2 1 9 Manns Harbor 1 1 2 Manteo 1 4 1 1 1 8 Nags Head 2 1 1 1 1 6 Rodanthe 11 Salvo 1 1 Southern Shores 1 1 Stumpy Point 11 Wanchese 1 12 Waves 0

Source: Outer Banks Churches; http://outer-banks.com/churches/categorties.cfm

Voluntary Participation in Community Organizations

As noted previously in this report, people in Dare County have many opportunities to support their community through voluntary participation on governmental boards, commissions and committees. Another option for civic engagement is voluntary participation in non-governmental community organizations, and there are many options in this category for Dare County citizens.

Table 19 lists, by category, examples of the non-governmental community organizations in Dare County, with a brief description of the purpose of each organization. It is impossible to assure that such a list is current and complete at any moment in time; however, this table, to the extent that its sources are accurate, demonstrates the variety of community engagement opportunities available to the people of the county at the present time.

40 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 19. Non-Governmental Community Organizations in Dare County (July, 2010)

Organization Location Purpose/Service

Health Service Alcoholics Anonymous Var. Locations Provides an anonymous 12-step alcohol cessation program American Red Cross - Greater Albemarle Chapter Elizabeth City Facilitates services as a local affiliate of the national organization Dare County Home Health and Hospice Manteo Provides Medicare-certified home health and hospice services Dare County Substance Abuse Task Force Kill Devil Hills Works to alter the impact of substance abuse in the county Hatteras Island Cancer Foundation Hatteras Supports cancer patients (and their families) on Hatteras Island LeLeche League Var. Locations Promotes and supports breastfeeding Outer Banks Cancer Support Group Kitty Hawk Provides counseling for cancer patients, survivors, and their families Outer Banks Dare Challenge Kill Devil Hills Provides religion-themed drug and alcohol cessation programming

Social Service ADAP (Adult Developmental Activity Program) Manteo Provides daytime activities for developmentally disabled and mentally handicapped adults Beach Food Pantry Kill Devil Hills Provides food supplies to those in immediate need Children and Youth Partnership for Dare County Kill Devil Hills Provides programs and services to children and their families Dare County Friends of Youth Manteo Pairs at-risk youth with adult volunteer mentors Outer Banks Community Development Corp. Manteo Advocates, facilitates and develops housing for low- and moderate-income citizens Outer Banks Hotline, Inc. Manteo Operates a 24-hour telephone crisis intervention and prevention center Roanoke Island Food Pantry Manteo Provides food supplies to those in immediate need Thomas A. Baum Senior Center Manteo Provides/coordinates programs and services for adults age 55 and over Veterans Service Office Manteo Assists veterans in accessing state and federal entitlements

Business and Professional 1st Judicial District Bar Association Elizabeth City Provides membership services for area attorneys Dare County Marine Industry Association Wanchese Promotes the boat building industry in Dare County Dare County Restaurant Association Kill Devil Hills Provides legal consultation for restaurant operators Outer Banks Association of Realtors Nags Head Promotes professionalism of realtors Outer Banks Chamber of Commerce Kill Devil Hills Promotes the business community through referrals, programs, services, and education Outer Banks Homebuilders Association Kill Devil Hills Promotes homebuilders and homebuilding throughout the Outer Banks Outer Banks Visitors Bureau Manteo Promotes the tourism industry of Dare County SCORE (Service Corps of Retired Executives) Kill Devil Hills Provides advice to small businesses Virginia Dare Business & Professional Women Southern Shores Educates members on political and social issues important to women

41 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 19. Non-Governmental Community Organizations in Dare County (continued)

Culture, History and Education Chicamacomico Historical Association Rodanthe Restores and preserves the Chicamacomico Lifesaving Station and operates a museum Concert Chorale of the Outer Banks Kitty Hawk Provides live performances Dare County Arts Council Manteo Bring arts and arts performances to the community and schools Dare Education Foundation Kitty Hawk Promotes excellence in education in Dare County Schools Dare County Library Foundation Manteo Provides support and oversight for the county library system Dare Literacy Council Kill Devil Hills Provide reading skills to non-readers and low-level readers Frisco Native American Museum Frisco Acquires, preserves, and displays Native American artifacts Manteo High School Peer Helper Program Manteo Assists and tutors students who need assistance Outer Banks Forum Kitty Hawk Bring performing arts to the Outer Banks Outer Banks History Center Manteo Maintains regional archives/research library on the history and culture of coastal NC Roanoke Island Historical Association Manteo Produces The Lost Colony, America's longest-running outdoor drama Theater of Dare Kill Devil Hills Provides live theatrical performances

Nature and Conservation Alligator River National Wildlife Refuge Manteo US Fish and Wildlife Service facility Coastal Wildlife Refuge Society Manteo Provides volunteers for work at Pea Island and Alligator River Wildlife Refuges Ducks Unlimited Kitty Hawk Promotes wetlands conservation and responsible hunting behavior Dunes of Dare Garden Club Kitty Hawk Promotes conservation and environmental improvement and beautification Nags Head Woods Ecological Preserve Kill Devil Hills Nature Conservancy-sponsored facility Nags Head Woods Preserve Kill Devil Hills Provides education on the plants and animals found in Nags Head Woods NEST (Network for Endangered Sea Turtles) Kitty Hawk Preserves/protects the habitats/migration routes of Sea Turtle and other marine animals North Carolina Aquarium at Roanoke Island Manteo Provides marine education and information about coastal and ocean issues and concerns Pea Island National Wildlife Refuge Manteo US Fish and Wildlife Service facility Roanoke Island Gardening Club Manteo Maintains the Elizabethan Gardens; promotes gardening Soil and Water Conservation Kill Devil Hills Provides leadership and a voice for natural resource conservation

Sports and Recreation Babe Ruth Baseball for Boys Operates an organized baseball league for boys aged 7-15 Boy Scouts of America, Tidewater Council Var. locations Provides activities and programs for boys ages 11 through 17 Cape Hatteras Anglers Club Buxton Promotes interest and sportsmanship among fishing hobbyists Cape Hatteras Teen Association - Locomotion Buxton Provides activities (dance, dramatics, and family interaction) for children grades 4-12 Dare County 4-H Youth Var. locations Provides interest programs, camps, school enrichment and after school care to youth

42 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 19. Non-Governmental Community Organizations in Dare County (continued)

Category/Organization Name Location Purpose/Service

Sports and Recreation (continued) Dare County Youth Center Manteo Provides after-school and school holiday programming for youth Girl Scout Council of Colonial Coast Manteo Provides activities and programs for girls in grades K-12 in partnership with adults OBX Storm Soccer Club Kill Devil Hills Provides training and competition in Recreational- and Challenge-Level soccer Outer Banks Community Sailing Program Manteo Provides summer programming to children ages 8 through 16 and their families Outer Banks Family YMCA Nags Head Provides sports and recreation programs for members Outer Banks Paddler's Club Southern Shores Promotes kayak and canoe recreation for members and visitors Outer Banks Swim Club Nags Head Offers year-round swimming instruction, training and competition for ages 5-18 Outer Banks Youth Soccer Association Kill Devil Hills Provides soccer training and competition

Civic and Philanthropic American Legion & Auxiliary Kill Devil Hills Offers traditional war veteran post activities Blue Star Mothers of America Manteo Is an organization of mothers of children who are serving/have served in the US military Coastal Humane Society Kitty Hawk Operates an animal shelter Dare County Community Crime Line Kitty Hawk Provides awards for tips and information leading to criminal arrests and convictions Dare County Habitat for Humanity Kill Devil Hills Builds houses in partnership with families in need of housing Dare County Outer Banks Jaycees Kill Devil Hills Provides leadership/community service opportunities for men and women ages 21-39 Dare County Shrine and Shrinettes Clubs Manteo Supports Shriner's Hospitals for Children Dare County Youth Council Kill Devil Hills Provides programs/activities, civic projects and events for middle- and high schoolers Dare Voluntary Center Kill Devil Hills Promotes volunteerism and recruits and places volunteers with local agencies Feline Hope Kitty Hawk Provides food, medical care and homes for homeless cats Rotary International Var. locations Provides fellowship for members and conducts service projects for the community First Flight Society Kitty Hawk Promotes aviation and memorializes the roots of aviation in the Outer Banks Hatteras Village Civic Association Hatteras Sponsors community activities International Association of Lions Clubs Var. locations Provides fellowship for members and conducts service projects for the community Kiwanis International Var. locations Provides fellowship for members and conducts service projects for the community League of Women Voters of Dare County Kitty Hawk Promotes political responsibility and participation Outer Banks SPCA Kill Devil Hills Educates the public and provides shelter and care for abandoned companion animals Outer Banks Woman's Club Kill Devil Hills Provides members opportunities for community service Rodanthe-Waves-Salvo Civic Association Rodanthe Sponsors community activities

Sources (Accessed July 10, 2010): Outer Banks Chamber of Commerce, Outer Banks Community Directory, Dare County; http://www.outerbankschamber.com/daredirectory.cfm Children and Youth Partnership for Dare County, Family Resource Guide, Youth Programs - Clubs and Activities; http://www.darekids.org/guide.php?cat=36 TaxExemptWorld, Dare County NC Tax Exempt Organizations and Non-Profit Organizations; http://www.taxexemptworld.com/organizations/dare-county-nc-north-carolina.asp

43 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

A very special group of community volunteers are the citizens who serve as volunteer firemen and firewomen. In Dare County there are a number of all-volunteer fire departments as well as a number of “combination” fire departments, which have both permanent staff and volunteers. Table 20 lists the all-volunteer and combination fire departments in Dare County as of June, 2010.

Table 20. All-Volunteer and Combination Fire Departments in Dare County (June, 2010)

Department Name Status

Avon Volunteer Fire Department Volunteer Buxton Volunteer Fire Department Volunteer Chicamacomico Volunteer Fire Department Volunteer Collington Volunteer Fire Department Combination Duck Volunteer Fire Department Combination Frisco Volunteer Fire Department Volunteer Hatteras Island Rescue Squad, Inc. Volunteer Hatteras Volunteer Fire Department Volunteer Kill Devil Hills Fire Department Combination Kitty Hawk Fire Department Combination Manns Harbor Volunteer Fire Department Volunteer Nags Head Fire Rescue Combination Roanoke Island Volunteer Fire Department Volunteer Salvo Volunteer Fire Department Volunteer Southern Shores Volunteer Fire Department Combination Stumpy Point Volunteer Fire Department Volunteer

Source: Dare County Association of Fire Officers, Department Profiles (Accessed June 15, 2010); http://www.angelfire.com/nc2/darefire/preview.html

44 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Economic Climate

Income

There are several income measures that can be used to compare the economic well-being of communities, among them per capita personal income, median household income, and median family income. Table 21 summarizes recent (2009) income data for Dare County, Carteret County and the state of NC.

 The per capita personal income in Dare County ($29,204) is $2,703 higher than per capita personal income in Carteret County, and $3,215 higher than the comparable figure for NC as a whole.  Median household income in Dare County ($53,979) is $4,268 higher than median household income in Carteret County, and $2,561 higher than the comparable figure for NC as a whole. Note that median household income in Carteret County is $1,707 below the NC norm.  Median family income in Dare County ($61,480) is $2,540 higher than the median family income in Carteret County, and $1,046 higher than the comparable figure for NC as a whole.

Table 21. Income (2009)

Median Per Capita Median Family Per Capita Median Household Median Income Income Location Personal Household Income Fa m ily Difference Difference Income1 Income2 Difference Income 3 from State from State from State

Dare County $29,204 (+) $3,215 $53,979 (+) $2,561 $61,480 (+) $1,046 Carteret County $26,501 (+) $512 $49,711 (-) $1,707 $58,940 (-) $1,494 State of NC $25,989 n/a $51,418 n/a $60,434 n/a

Source: NC Dept of Commerce, Economic Intelligence Development System (EDIS), Community Demographics, County Report, County Profile, https://edis.commerce.state.nc.us/EDIS/demographics.html 1 Per capita personal income is the income earned per person 15 years of age or older in the reference population 2 Median household income is the incomes of all the people 15 years of age or older living in the same household (i.e., occupying the same housing unit) regardless of relationship. For example, two roommates sharing an apartment would be a household, but not a family. 3 Median family income is the income of all the people 15 years of age or older living in the same household who are related through either marriage or bloodline. For example, in the case of a married couple who rent out a room in their house to a non-relative, the household would include all three people, but the family would be just the couple.

45 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Dare County Revenue Indicators

The local Chamber of Commerce tracks certain revenue indicators (e.g., building permits, sales, and receipts) in order to assess changes in the economic well-being of the community. Table 22 presents an annual summary of several of these indicators for 2004-2010.

 The beginning of the current economic downturn is clearly evident from these data, as the number and value of building permits, land transfer collections and collections on retail sales all declined from 2006 to 2007 and have yet to recover; in fact, these revenue measures have continued to decline in recent years. Declines in the first three of these parameters can have long-term negative consequences, since normally they are indicators of economic development through investment in buildings and lands. The decline in gross revenue collections on retail sales likely reflects reduced spending by primarily the local population.  The increase in occupancy receipts and food and beverage receipts during the same 2006-2007 period may reflect spending by vacationers who opted for local, “stay-cations” in lieu of more expensive distant travel. Note that food and beverage receipts did decline between 2007 and 2008, but not to a value as low as any during the 2004-2006 period.

Table 22. Dare County Revenue Indicators (2004-2009)

Calendar Year Revenue Indicator 2004 2005 2006 2007 2008 2009 20102

Number of Building Permits 3,344 3,340 3,090 2,993 2,953 2,900 1,529 Value of Building Permits $342,152,578 $403,730,236 $254,278,317 $247,017,181 $141,482,617 $85,023,027 $34,509,656 Land transfer Collections $14,527,133 $13,584,752 $7,882,945 $6,637,595 $4,754,358 $3,961,956 $2,334,077 Gross Collections on Retail Sales $34,351,151 $48,962,289 $53,524,319 $51,373,088 $50,958,225 $46,778,8371 n/a Occupancy Receipts $259,606,340 $280,427,656 $310,145,298 $339,973,731 $349,894,493 $343,650,773 $41,865,433 Food and Beverage Receipts $166,047,308 $180,478,244 $180,647,134 $189,131,837 $185,121,476 $184,931,353 $48,260,843

Source: Economic Indicators for 2004-2008 sent as electronic files via personal communication from Sue Carrol (Outer Banks Chamber of Commerce) to Laura Willingham (Dare County Department of Public Health) on June 3, 2010. Economic indicators for 2009 and 2010 are from Outer Banks Chamber of Commerce, Economy, Economic Reports, Economic Indicators, 2009 and 2010; http://www.outerbankschamber.com/ 1 Figure represents total for January through October 2009 only. 2 2010 figures represent totals for January through May 2010.

Tier Designation

While personal, household and family income matter especially to individual citizens, the assignment of a Tier Designation matters especially to community planners. The NC Department of Commerce annually ranks the state’s 100 counties based on economic well-being and assigns a Tier Designation. The 40 most distressed counties are designated as Tier 1, the next 40 as Tier 2, and the 20 least

46 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

distressed as Tier 3. This Tier system is incorporated into various state programs, including a system of tax credits (Article 3J Tax Credits) that encourage economic activity and business investment in the less prosperous areas of the state. In 2009 Dare County was assigned a Tier 2 Designation. At the same time, Carteret County was assigned a Tier 3 Designation. The 2009 Tier Designation for each county was unchanged from 2008 (12).

Employment, unemployment and poverty are among the factors influencing the Tier Designation; each will be discussed subsequently.

Employment

The following definitions will be useful in understanding the data in this section.

 Labor force – includes all persons over the age of 16 who, during the week, are employed, unemployed or in the armed services.  Civilian labor force – excludes the Armed Forces from that equation.  Unemployed – civilians not currently employed but are available for work and have actively looked for a job within the four weeks prior to the date of analysis; also, laid-off civilians waiting to be called back to their jobs, as well as those who will be starting new jobs in the next 30 days.  Unemployment rate – calculated by dividing the number of unemployed persons by the number of people in the civilian labor force.

Table 23 details the various categories of industry by sector in Dare County, Carteret County and NC in 2009, showing the number employed in each sector, the percentage of all employment that that number represents, and the average annual wage for people employed in those sectors.

 The industry in Dare County that employes the largest percentage of the workforce (23.14%) is, not surprisingly, Accommodation & Food Services. Unfortunately, this is also the sector with the lowest average annual wage per employee ($17,449). Retail Trade accounts for the next largest percentage of the Dare County workforce, at 17.88%, followed by Real Estate & Rental & Leasing, at 12.68%. No other sector accounts for even 10% of the total workforce in Dare County, clearly illustrating the county’s economic roots in – and dependence upon – the travel and tourism industry.  In Carteret County, for comparison, the sector employing the largest percentage of the workforce (17.32%) is Retail Trade, followed by Accommodation & Food Service (15.74%) and, unlike Dare County, Health Care & Social Assistance (13.19%).  Statewide, the sector employing the largest percentage of the workforce is Health Care & Social Assistance (14.45%), followed by Manufacturing (11.70%) and Retail Trade (11.57%).  The highest average annual wages per employee in Dare County accrue to workers in the Utilities sector ($67,724); note however that this sector employes only a tiny fraction (0.50%) of the local workforce. The second and third highest average annual wages occur in the Finance & Insurance and Professional sector ($48,815), and Scientific & Technical Services sector ($42,661), respectively.

47 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 23. Insured Employment and Wages by Sector (Annual Summary, 2009)

Dare County Carteret County North Carolina Average Average Average % Tot a l % Tot a l % Tot a l Sector Avg. No. Annual Avg. No. Annual Avg. No. Annual Employment Employment Employment Employed Wage per Employed Wage per Employed Wage per in Sector in Sector in Sector Employee Employee Employee

Agriculture, Forestry, Fishing & Hunting 7 0.04 $27,042 88 0.39 $26,344 28,949 0.76 $27,257 Mining 0 0.00 n/a 0 0.00 n/a 3,424 0.09 $50,622 Utilities 93 0.50 $67,724 115 0.52 $49,899 13,889 0.36 $70,685 Construction 965 5.24 $35,280 1,462 6.55 $30,896 195,608 5.10 $38,837 Manufacturing 451 2.45 $36,616 951 4.26 $28,792 448,523 11.70 $48,763 Wholesale Trade 358 1.94 $32,564 588 2.63 $44,552 167,155 4.36 $56,667 Retail Trade 3,293 17.88 $23,460 3,867 17.32 $20,973 443,398 11.57 $24,061 Transportation & Warehousing 194 1.05 $34,179 351 1.57 $40,743 125,300 3.27 $41,624 Information 215 1.17 $34,678 355 1.59 $28,849 71,021 1.85 $58,200 Finance & Insurance 452 2.45 $48,815 521 2.33 $45,853 149,025 3.89 $66,228 Real Estate & Rental & Leasing 2,335 12.68 $22,311 528 2.37 $25,207 50,348 1.31 $34,733 Professional, Scientific & Technical Services 472 2.56 $42,661 871 3.90 $46,022 182,037 4.75 $61,998 Management of Companies & Enterprises 0 0.00 n/a 24 0.11 $37,136 72,800 1.90 $79,072 Administrataive & Waste Services 623 3.38 $22,963 1,299 5.82 $22,180 216,531 5.65 $28,563 Educational Services 955 5.18 $38,188 1,712 7.67 $35,428 370,810 9.68 $39,310 Health Care & Social Assistance 877 4.76 $40,944 2,944 13.19 $37,040 553,862 14.45 $40,744 Arts, Entertainment & Recreation 584 3.17 $24,335 687 3.08 $18,307 60,307 1.57 $27,754 Accommodation & Food Services 4,262 23.14 $17,449 3,513 15.74 $13,926 337,854 8.82 $14,130 Public Administration 1,672 9.08 $42,231 1,712 7.67 $35,105 238,629 6.23 $42,562 Other Services 561 3.05 $20,708 686 3.07 $21,481 93,877 2.45 $26,846 Unclassified 52 0.28 $31,334 51 0.23 $321,126 8,724 0.23 $48,413 TOTAL ALL SECTORS 18,421 100.00 n/a 22,325 100.00 n/a 3,832,071 100.00 n/a

Source: NC Employment Security Commission, Labor Market Information, Industry Information, Employment and Wages Data by Industry, 2009, Quarter 2, State (or County); http://eslmi23.ecs.state.nc.us/ew/EWResults.asp

Table 24 lists by name the top 25 employers in Dare County as the end of the 4th Quarter, 2009.

 None of the employers listed employs as many as 1,000 people.

48 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 The largest employer is Dare County Schools.

Table 24. Top 25 Employers in Dare County (4th Quarter 2009)

Rank Employer Industry No. Employed 1 Dare County Schools Education & Health Services 500-999 2 County of Dare Public Administration 500-999 3 Carolina Designs Realty, Inc. Financial Activities 250-499 4 East Carolina Health, Inc. Education & Health Services 250-499 5 Village Realty & Management Service Financial Activities 250-499 6 Food Lion, LLC Trade, Transportation & Utilities 250-499 7 NC Department of Transportation Public Administration 100-249 8 Wal-Mart Associates, Inc. Trade, Transportation & Utilities 100-249 9 Harris Teeter, Inc. Trade, Transportation & Utilities 100-249 10 Tandem, Inc; (dba MacDonalds) Leisure & Hospitality 100-249 11 National Park Service Leisure & Hospitality 100-249 12 Barrier Island Realty, Inc. Financial Activities 100-249 14 NC Department of Environment & Natural ResoucesPublic Administration 100-249 14 Home Depot USA, Inc. Trade, Transportation & Utilities 100-249 15 Town of Kill Devil Hills Public Administration 100-249 16 Town of Nags Head Public Administration 100-249 17 Sanderling Resort & Spa Leisure & Hospitality 100-249 18 Spencer Yachts, Inc. Manufacturing 100-249 19 Hatteras Realty Financial Activities 50-99 21 SPM Resorts, Inc. Financial Activities 50-99 21 Sun Realty Nags Head, Inc. Financial Activities 50-99 22 K Mart Corporation International Headquarters Trade, Transportation & Utilities 50-99 23 Young Men's Christian Association Other Services 50-99 24 The Dunes Restaurant, Inc. Leisure & Hospitality 50-99 25 Outer Banks Blue Realty Services Financial Activities 50-99

Source: NC Dept of Commerce, Economic Intelligence Development System (EDIS), Business Data, Top Employers, by County; https://edis.commerce.state.nc.us/EDIS/business.html

49 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Data gathered by the US Census Bureau on how many resident workers travel outside the county for employment can help demonstrate whether or not a county provides adequate employment opportunities for its own citizens. Table 25 summarizes these data for Dare County, Carteret County, and the state of NC. Note that these data are based on the 2000 US Census, and thus are due to be updated.

 The percentage of Dare County workers who work in the county is much higher than the comparable percentages for either Carteret County or NC as a whole. A total of 10% of Dare County workers leave the county for work (either in another county or out of the state), compared to 25.3% in Carteret County and 26.4% statewide. However, these data pre-date the current economic recession, and it might be expected that the 2010 US Census data will paint a different picture.

Table 25. Jurisdictional Place of Work for Resident Workers Age 18 and Older (2000)

Number and Percent of Residents # % # % Total # Total % Total # Location # Working % W or k ing # Working % W or k ing Working Working Working Working Leaving Leaving Workers in NC in NC in County in County out of out of out of out of County for County for Over 16 County County State State Work Work

Dare County 15,419 14,951 97.0 13,881 90.0 1,070 6.9 468 3.0 1,538 10.0 Carteret County 27,214 26,816 98.5 20,317 74.7 6,499 23.9 398 1.5 6,897 25.3 State of NC 3,837,773 3,762,169 98.0 2,826,122 73.6 936,047 24.4 75,604 2.0 1,011,651 26.4

Source: US Census Bureau, American Fact Finder, Summary File 3 for 1990 and 2000, Detailed Tables, Place of Work for Workers 16 Years and Over, State and County Level; http://factfinder.census.gov

Besides serving as an indicator of environmentalism, the mode of transportation workers use to get to their places of employment can also point to the relative convenience of local workplaces and the extent of the local public transportation system. Table 26 compares data on modes of transportation to work gathered in the 1990 and 2000 Censuses.

 Very small numbers of Dare County workers used public transpsortation to get to work, a direct reflection of the lack of a robust public transportation system in the county. Details behind the table (but not shown here) indicate in fact that the primary “public” mode of transportation used in Dare County was taxi service.  The number of Dare County workers who carpooled actually declined between 1990 and 2000.  The number of Dare County workers who walked to work increased by 150% between 1990 and 2000.  The number of Dare County workers who worked at home increased by almost 42% between 1990 and 2000.

50 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 26. Modes of Transportation to Work (2000)

Number of Persons Used Public Location Drove Alone Carpooled Walked Worked at Home Transportation 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000

Dare County 8,588 11,849 2,230 2,184 17 23 130 344 513 728 Carteret County 18,651 27,214 4,501 4,197 62 92 713 423 573 869 State of NC 2,527,980 3,046,666 529,828 538,264 33,902 34,803 96,614 74,147 70,959 102,951

Source: US Census Bureau, American Fact Finder, Data Sets, Summary File 3 for 2000 and 1990, Detailed Tables, Means of Transportation to Work for Workers 16 Years and Over; http://factfinder.census.gov

At the time this report was prepared, the only public transportation in Dare County was the Dare County Transportation System (DCTS), which operates vans with the support of grants from NC Department of Tranasportation Public Transportation Division and funds from the county. The system is intended to help patrons attend medical appointments in a short list of destinations within NC (Elizabeth City, Edenton, Greenville, Durham, and Chapel Hill) and VA (Chesapeake, Norfolk, Virginia Beach, Portsmouth, Newport News, Suffolk, and Hampton). The system provides curb-to-curb service with one-day’s notice. Riders are picked up according to pre-arrangement and must call the van when ready for a return trip. The service operates Monday through Friday; service is not provided on weekends or holidays. (This information was added to the report from the following source: http://www.co.dare.nc.us/General/Transportation.htm, accessed August, 2010.)

51 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Unemployment

Figure 5 plots the unemployment rate in Dare County, Carteret County and the state of NC from 2000 to 2010, and it is surprisingly easy to track the onset – and ongoing nature – of the current economic recession.

 From 2000 until 2007 the unemployment rate in all three of the cited jurisdictions fluctuated between approximately 4% and 6.5%.  Beginning with 2008 data, the unemployment rate trend increased sharply from a previous five-year low, and by 2009 had increased further, to a new 10-year high in all three jurisdictions.  By 2010 the rate of increase in unemployment in Carteret County and NC as a whole had begun to slow slightly, while in Dare County it continued its steep ascent. However, the 2010 data points represent the average monthly unemployment rate from January-April only, so given the seasonality of unemployment in Dare County, that final data point may be misleadingly high.

Figure 5. Annual Unemployment Rate Trend (2000-2010)

16.0

14.0

12.0

10.0

8.0 Unemployed

6.0

4.0 Percent 2.0

0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Dare County Carteret County State of NC

Source: NC Employment Security Commission, Labor Market Information, Workforce Information, Employed, Unemployed and Unemployment Rates, Labor Force Statistics, Single Areas for All Years; http://eslmi40.esc.state.nc.us/ThematicLAUS.clfasp/startCLFSAAY.asp Note: The unemployment rate is calculated by dividing the number of unemployed by the civilian labor force. The civilian labor force is the total employed plus the unemployed.

52 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Seasonal Employment and Unemployment

Due largely to its economic base in the tourism industry, employment (and attendant unemployment) data in Dare County display a strong seasonal component. Figure 6 plots the number of persons in the total labor force and the number employed for each of the 12 months of 2007. Figure 7 plots similar data for the state of NC.

 Figure 6 clearly shows the approximately 25% summer “surge” of employment in Dare County. Since the year represented by the graph – 2007 – was not yet a recession year, the close proximity of the “”labor force” and “employed” indicate very low unemployment. This graph might look very different when populated with more recent, mid-recession data.  Figure 7 shows a more moderate – approximately 2% -- summer surge in NC as a whole, but more notably, the gap between the “labor force” and “employed” lines indicates less than full employment. Note that the gap remains approximately constant throughout the entire year.

Figure 6. Seasonal Employment Trend in Dare County Figure 7. Seasonal Employment Trend in North Carolina (2007) (2007)

30,000 4,700,000

25,000 4,600,000 s n o rs 20,000 4,500,000 e Persons

P f of o 15,000 4,400,000 r e b m10,000 4,300,000 u N Number 5,000 4,200,000

0 4,100,000 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Labor Force Employed Labor Force Employed

Source: NC Employment Security Commission, Labor Market Information, Source: NC Employment Security Commission, Labor Market Information, Workforce Information, Employed, Unemployed and Unemployment Rates, Labor Workforce Information, Employed, Unemployed and Unemployment Rates, Labor Force Statistics, Single Areas for All Years; Force Statistics, Single Areas for All Years; http://eslmi40.esc.state.nc.us/ThematicLAUS.clfasp/startCLFSAAY.asp http://eslmi40.esc.state.nc.us/ThematicLAUS.clfasp/startCLFSAAY.asp

53 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 27 shows the number of active job applicants registered for work with the NC Employment Security Commission (NCESC) between July 2009 and June 2010. This data, which does represent a recessionary period, gives an estimate of the number of unemployed people who are actively seeking employment.

 This 12-month cycle of data again demonstrates the seasonality of employment in Dare County that surpasses similar fluctuations in Carteret County or the state as a whole. For example, in Dare County the number of job applicants fluctuated between 1,608 and 3,153 over the 12-month period cited, a variance of 96%. In Carteret County the number of job applicants fluctuated between 2,962 and 3,626, for a variance of 22% over the same period.  Recently, the media have identified a group of unemployed workers who have “given up” on their job search due to lack of success in finding employment; persons in that category may not appear in this data if they have let their NCESC registration status lapse.

Table 27. Active Job Applicants Registered to Work with the NC Employment Security Commission (2009-2010)

Number of Active Job Applicants Location 2009 2010 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Dare County 2,260 1,608 1,674 1,992 2,541 2,911 3,153 3,026 2,884 2,556 2,142 1,837 Carteret County 3,234 2,962 3,053 3,128 3,361 3,456 3,626 3,459 3,450 3,270 3,157 2,972 State of NC 586,608 453,608 456,160 453,453 449,762 449,520 467,156 456,074 470,240 456,636 448,253 454,491

Source: NC Employment Security Commission, Labor Market Information, Workforce Information, Active Job Applicants Registered for Work with ESC Offices; http://www.ncesc1/lmi/workForceStats/jobApplicantsregistered.asp

Business Closings and Layoffs

The NC Employment Security Commission monitors business closings and layoffs across the state by county. The data collection system is partially anecdotal and therefore imprecise, since it relies not only on data submitted to the commission, but also on newspaper reports. Sometimes the data notes a layoff or closing, but not re-hirings or re-openings. Table 28 lists the business closings and layoffs catalogued for Dare County for the period from 2000 to 2010.

 According to these data, from 2000 through May 2010 there were nine announced business closings in Dare County, involving a total of 127 workers.  The most common reason for a business closure was bankruptcy, which was the reported cause of five of the nine closings.  The NCESC did not record any layoffs in the county during the period cited.

54 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 28. Announced Business Closings and Layoffs in Dare County (2000-2010)

Effective No. Closing/ Company City Product Reason Date Affected Layoff

2007 Outer Banks Appliance, Inc. Kitty Hawk Appliance Store 5 Bankruptcy Closing 2007 Coastal Cactus Kitty Hawk Restaurant 26 Bankruptcy Closing 2007 Basnight's Lone Cedar Manteo Restaurant 77 Fire Closing 2007 Larry Sawyer Equipment Sales Manteo Equipment Sales 6 Bankruptcy Closing 2005 Outer Banks Home Health & Medical Supplies Nags Head Medical Equipment Rental n/a Bankruptcy Closing 2005 Lew's Golf & Tennis Outfitters Nags Head Sporting Goods n/a Bankruptcy Closing 2004 Fisherman's Oasis Seafood Restaurant Nags Head Restaurant 8 Fire Closing 2003 Wachovia, Inc. Southern Shores Branch Bank n/a Merger Closing 2000 The Carolinian Nags Head Hotel 5 Oceanfront Redevelopment Closing

Source: NC Employment Security Commission, Labor Market Information Division, Workforce Information, Business Closings and Permanent Layoffs; http://eslmi23.esc.state.nc.us/masslayoff/MLSData.asp?contentsFrame=5

Poverty

The poverty rate is the percent of the population (both individuals and families) whose money income (which includes job earnings, unemployment compensation, social security income, public assistance, pension/retirement, royalties, child support, etc.) is below the threshold established by the Census Bureau. (Note that the threshold changes over time, so old poverty rate data may not be comparable to more recent data.)

Table 29 shows the annual poverty rate at the time of each decennial US Census from 1970 to 2000. The table also includes a US Census Bureau poverty rate estimate for the year 2008. The data in this table describe an overall rate, representing the entire population of each jurisdiction. As subsequent data will show, poverty has strong racial and age components that are not detectable in these numbers.

 The poverty rate in Dare County has been consistently below the comparable state and Carteret County rates since 1970. The largest gap in poverty rate between Dare County and the state of NC occurred in 2008, when the difference was 5.4 percentage points, and the NC rate was 59% higher than the rate in Dare County.  The poverty rate in all three jurisdictions decreased each decade from 1970 through 2000 before increasing again in 2008.

55 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 29. Decadal Annual Poverty Rate (1970-2000 and 2008 Estimate)

Percent of All People in Poverty Location 1970 1980 1990 2000 2008

Dare County 16.4 11.3 8.3 8.0 9.2 Carteret County 18.0 14.0 11.6 10.7 11.2 State of NC 20.3 14.8 13.0 12.3 14.6 Source:aaaab

a - Log Into North Carolina (LINC) Database, Topic Group Employment and Income (Data Item 6094); http://data.osbm.state.nc.us/pls/linc/dyn_linc_main.show b - US Census Bureau, American Fact Finder, American Community Survey, 2006-2008 American Community Survey (ACS) 3-Year Estimates, Data Profiles, Detailed Tables, For Areas with Population > 20,000, Selected Economic Characteristics, by State or County; http://factfinder.census.gov

Poverty and Race

Table 30 shows the number and percent of persons in poverty, by race, as assessed by the decennial US Census in 1980, 1990 and 2000. These data are admittedly old, but the patterns are consistent throughout the period cited.

 In Dare County the percent of blacks in poverty decreased 29.2% (from 26.7% to 18.9%) between 1980 and 1990, and 2.1% (from 18.9% to 18.5%) between 1990 and 2000; the overall decrease for the entire period was 30.7%. The overall decrease of the percent of blacks in poverty in Carteret County over the same 20 year period was 41.8%.  The poverty rate among blacks in the state as a whole decreased over the same period by 24.7%.

Table 30. Persons in Poverty, Number and Percent, by Race by Decade (1980-2000)

1980 1990 2000 Location Total No. Total % in % W hit e in % Black in Total No. in Total % in % W hit e in % Black in Total No. Total % in % W hit e % Black in in Poverty Poverty Poverty Poverty Poverty Poverty Poverty Poverty in Poverty Poverty in Poverty Poverty

Dare County 1,499 11.3 10.2 26.7 1,861 8.3 7.7 18.9 2,381 8.0 7.3 18.5 Carteret County 5,618 14.0 11.9 34.0 5,977 11.6 9.7 31.8 6,268 10.7 9.9 19.8 State of NC 839,950 14.8 10.0 30.4 829,858 13.0 8.7 27.1 958,667 12.3 8.5 22.9

Source: Log Into North Carolina (LINC) Database, Topic Group Employment and Income (Data Items 6094, 6096, 6098); http://data.osbm.state.nc.us/pls/linc/dyn_linc_main.show

56 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Poverty and Age

Table 31 presents data on the number of persons in poverty by age. This is US Census data associated with the decennial census in 1980, 1990 and 2000. The table also includes estimated figures for 2008.

 While the percent of children under the age of 18 in poverty in Dare County decreased between 1980 and 1990, it increased between 1990 and 2000 and again between 2000 and 2008. The estimated 2008 poverty rate (11.9%) in this age group is 29.3% higher than the overall poverty rate in the county, and is the highest for the age group over the entire period.  The Dare County poverty rate pattern over the period cited was the same for children under the age of six as for children under the age of 18, except that the data are even more severe for the younger group. The estimated 2008 poverty rate (19.8%) in this younger age group is more than double the overall poverty rate in the county, and is the highest for the age group over the entire period.  The percentage of adults age 65 or older in poverty in Dare County was higher than the overall poverty rate for the county in 1980 and 1990, but was lower than the overall county poverty rate in 2000 and 2008. In 2008 the poverty rate among adults age 65 or older is 41% lower than the poverty rate for children under age 18, and 65% lower than the poverty rate for children under the age of six.

Table 31. Persons in Poverty by Age and Percent (2002-2005)

1980 1990 2000 2008 (Estimate) % Adults % Adults % Adult s % Adult s % Chldr e n % Children % Chldr e n % Children % Chldr e n % Children % Chldr e n % Childr e n Location Total % in 65 or Total % in 65 or Total % in 65 or Total % in 65 or Under 18 Under 6 in Under 18 Under 6 in Under 18 Under 6 in Under 18 Under 6 in Poverty Older in Poverty Older in Poverty Older in Poverty Older in in Poverty Poverty in Poverty Poverty in Poverty Poverty in Poverty Poverty Poverty Poverty Poverty Poverty

Dare County 11.3 11.7 12.9 15.0 8.3 8.3 7.9 10.5 8.0 10.0 12.8 5.3 9.2 11.9 19.8 7.0 Carteret County 14.0 16.6 18.3 22.9 11.6 15.7 18.9 11.9 10.7 15.4 16.0 9.4 11.2 16.6 23.6 7.5 State of NC 14.8 18.3 19.7 23.9 13.0 16.9 19.1 19.5 12.3 15.7 17.8 13.2 14.6 20.0 23.1 11.3 Source:aaaaaaaaaaaabbbb

a - Log Into North Carolina (LINC) Database, Topic Group Employment and Income (Data Items 6094, 6100, 6102, 6104); http://data.osbm.state.nc.us/pls/linc/dyn_linc_main.show b - US Census Bureau, American Fact Finder, American Community Survey, 2006-2008 American Community Survey (ACS) 3-Year Estimates, Data Profiles, Detailed Tables, For Areas with Population > 20,000, Selected Economic Characteristics, by State or County; http://factfinder.census.gov

Other data corroborate the impression that children, especially the very young, bear a disproportionate burden of poverty, and that their burden is increasing. One measure of poverty among children is the number and/or percent of school-age children who are eligible for and receive free or reduced-price school lunch. Table 32 shows the percent of students eligible for, and Table 33 the number of students receiving, free or reduced price school lunch in Dare County, Carteret County and NC as a whole over various periods of time.

While the date in Table 32 are somewhat dated, there are two important take-away messages relative to child poverty in Dare County:

57 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 The percent of students eligible for free and reduced-price school lunch in Dare County is much lower than the comparable percentages in either Carteret County or the state as a whole. The eligibility rate in Dare County averages approximately 59% of the Carteret County rate and approximately 44% of the NC rate.  The percentages of students eligible for free and reduced-price school lunch increased in Dare County as well as the other two jurisdictions between 2005 and 2006.

Table 32. Percent of Children Eligible for Free or Reduced-price School Lunch (Years as Noted)

Percent of Students Eligible Location Free Lunch Free & Reduced Lunch 2005 2006 2005 2006

Dare County 16.0 16.4 22.5 23.7 Carteret County 28.4 28.3 37.6 37.7 State of NC 40.3 40.1 48.4 48.5

Source: NC CATCH, County Health Profile, Economic Indicators; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Table 33 presents the number of students actually receiving free- or reduced-price school lunch, which perhaps is a more effective way to grasp the extent of the problem, especially at the county level. In Dare County, the number of children receiving these benefits in School Year (SY) 2007-08 was the highest over the period cited. In Carteret County and the state as a whole, the SY2007-08 figures represent the lowest over the period cited.

Table 33. Number of Students Receiving Free- or Reduced-Price Lunch (SY2003-04 through SY2007-08)

No. Students Receiving Free or Reduced-Price Lunch Location 2003-04 2004-05 2005-06 2006-07 2007-08

Dare County 940 1,058 990 981 1,167 Carteret County 3,323 3,177 3,050 3,031 2,949 State of NC 605,253 624,500 603,316 624,349 456,210

Source: US Department of Education, Institute of Education Sciences (IES), National Center for Educational Statistics, Common Core of Data, Build a Table Function, County Data (or State Data), Students in Special Programs, Total Free and Reduced Lunch Students; http://nces.ed.gov/ccd/bat/

58 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Economic Services Utilization

The Dare County Department of Social Services (DSS) has the responsibility for managing a number of programs that provide assistance to low-income people. These programs include general economic services, WorkFirst Family Assistance, and Nutrition Services (formerly known as Food Stamps). WorkFirst is North Carolina 's Temporary Assistance for Needy Families (TANF) program. It is based on the premise that parents have a responsibility to support themselves and their children. Through WorkFirst, parents can get short-term training and other services, including cash supports, to help them become employed and self-sufficient. Most families have two years to move off WorkFirst Family Assistance (12). Table 34 presents data on the economic services provided by Dare County DSS from 2004-2009.

 The Dare County DSS data demonstrate clearly that demand for the agency’s economic services has increased since 2007, in some cases dramatically. For example, the total number of economic services applications increased by 37% (from 3,862 to 5,291) between 2007 and 2009.  Over the same period the number of applications for nutrition services increased by 72%, from 1,015 to 1,747, and the agency’s average monthly expenditure on nutrition services increased by 152%, from $105,897 to $267,018.

Table 34. Economic Services Provided by Dare County Department of Social Services (2004-2009)

Service/Activity 2004 2005 2006 2007 2008 2009

Total No. Economic Services Applications 3,212 3,989 3,891 3,862 4,651 5,291

Work First Family Assistance No. Applications 222* 156* 174 177 192 218 Average Monthly No. Cases 49 41 50 44 44 51 No. Benefit Diversion Cases Approved 64* 20* 24 30 25 43

Nutrition Services (Formerly Food Stamps) No. Applications Received 902 1,050* 930 1,015 1,460 1,747 No. First-time Applications 254 390* 312* 319 367 595 Average Monthly No. Households Receiving Aid 370 414 486 551 686 1,020 Average Monthly No. Individuals Receiving Aid 745 834 989 1,152 1,425 2,154 Average Monthly Expenditures $57,009 $70,889 $86,520 $105,897 $143,206 $267,018

Special Assistance No. Requests/Applications 10 11 Not reported 36 41 24

Source: Source: Dare County Department of Social Services, State of the Department Annual Reports, 2005, 2006, 2007, 2008, 2009, 2010 * Value presented is an estimated created by doubling the reported 6-month total

59 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Housing

 In Dare County the number of housing units increased 21% (from 26,671 to 32,324) between 2000 and 2008. The percentage of owner-occupied housing units decreased 8% (from 74.5% to 68.5%) while overall occupancy rate remained about the same, so the observed 24% increase (from 25.5% to 31.5%) in the percentage of renter-occupied units during the same period is not surprising. A similar pattern was noted in both Carteret County and the state as a whole, although to a smaller degree.  The number and percentage of mobile home units decreased in all three jurisdictions over the period cited, and by the highest amount (30%) in Dare County.

Table 35. Housing by Type (2000 and 2008)

2000

Median Total Owner Median Mobile Occupied Monthly Cost, Renter Occupied Location Housing Occupied Monthly Home Housing Units Owner with Units Units Units Rent Units Mortgage

No. No. % No. % $ No. % $ No. %

Dare County 26,671 12,690 47.6 9,460 74.5 n/a 3,230 25.5 638 2,164 8.1 Carteret County 40,947 25,204 61.6 19,316 76.6 n/a 5,888 23.4 511 10,530 25.7 State of NC 3,523,944 3,132,013 88.6 2,172,355 69.4 n/a 959,658 30.6 548 577,323 16.4 Source: a a c a c a c a a c

2008 (Estimate) Median Total Owner Median Mobile Occupied Monthly Cost, Renter Location Housing Occupied Monthly Home Housing Units Owner with Occupied Units Units Units Rent Units Mortgage No. No. % No. % $No.% $No.%

Dare County 32,324 15,689 48.5 10,748 68.5 1,702 4,941 31.5 994 1,835 5.7 Carteret County 45,594 26,938 59.1 20,447 75.9 1,294 6,491 24.1 698 10,452 22.9 State of NC 4,120,257 3,533,366 85.8 2,407,681 68.1 1,222 1,125,685 31.9 698 600,845 14.6 Source: b b b b b b b b b b b a - Log Into North Carolina (LINC) Database, Topic Group Population and Housing (Data Items 6105, 6109, 6110, 6111, 6115, 6121); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show b - US Census Bureau, American Fact Finder, American Community Survey, 2006-2008 American Community Survey (ACS) 3-Year Estimates, Data Profiles, Detailed Tables, For Areas with Population > 20,000, Selected Housing Characteristics, by State or County; http://factfinder.census.gov c - Calculated

60 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Affordable Housing

An inescapable observation from Tables 35 (cited previously) is the high cost of housing in Dare County.

 In Dare County, the median monthly cost of a mortgage in 2008 was $1,702, a figure 31.5% higher than the median monthly mortgage cost in Carteret County and 39.3% higher than the median mortgage cost statewide.  Renters in Dare County in 2008 faced a similarly high cost: the median monthly rent was $994, a figure 42.4% higher than the median rent in both Carteret County and NC as a whole.  The high cost of housing in Dare County probably is a direct reflection its desirable proximity to the ocean and its many beach communities. Although there is considerable beachfront property in Carteret County, a higher proportion of the population there lives well inland. In addition, much of the housing in Dare County is newer, especially along the Cape Hatteras Seashore, and there are more miles of beachfront property in Dare than in Carteret County.

According to data from the NC Rural Economic Development Center based on the 2000 US Census, 26.3% of housing in Dare County was classified as “unaffordable”, compared to 19.0% in Carteret County and 20.7% statewide. This data represents the percent of the population living in households that pay more than 30% of the household income for housing costs (13).

The US Department of Housing and Urban Development maintains a system for tracking “affordable” housing for its low-income clients, to whom it provides housing subsidies. HUD services are delivered through Public and Indian Housing Authority (PHA) offices throughout NC. There is no PHA office located in Dare County to assist residents in accessing HUD services. The nearest offices are in Elizabeth City (Pasquotank County), Edenton (Chowan County), Hertford (Perquimans County), Plymouth (Washington County), and Ahoskie (Hertford County) (14). At the time this report was developed, there were no single-family HUD-subsidized homes available in Dare County (15) and only one affordable apartment (in Manteo, in an ARC facility for developmentally disabled persons) (16).

The US Department of Agriculture (USDA) catalogues information about rental properties available in rural areas. The agency’s Multi- Family Housing (MFH) Rental website provides an online guide to Government assisted rental projects. At the time this report was developed, the MFH website listed one qualifying rental property in Dare County: Harbourtowne Apartments in Manteo (17).

Homelessness

Enumerating the homeless population is as difficult in Dare County as elsewhere, but it is likely that homelessness is increasing in these difficult economic times. According to one estimate, the number of homeless persons in Dare County increased from six in 2006 to 17 in 2007. The county’s first homeless shelter initiative, Room in the Inn, opened in Kill Devil Hills in January 2009. The all-volunteer program was designed to provide temporary food and shelter for homeless people at area churches during the winter months (72).

61 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Children and Families

According to 2010 estimates of the Dare County population by age group, 19.5% of the county’s residents are under the age of 18 (calculated from Table 8, cited previously). Table 36 presents data describing the distribution of the Dare County population under the age of 18 by township from the 2000 Census (the most recent township-level data available).

 The township with the highest proportion of the county’s children under the age of 18 (50.6%) is Atlantic Township. Within this township, the highest percentage of minor children (19.2%) resides in Kill Devil Hills.  The township with the lowest percentage of the county’s minor children (0.6%) is East Lake Township.

Table 36. Dare County Population Under Age 18, by Township (2000)

% of County No. Persons Population % of County Township Under Age Under Age Population 18 18

Atlantic Township1 3,242 50.6 10.8 Kill Devil Hills Town 2 1,233 19.2 4.1 Kitty Hawk Town 644 10.0 2.1 Southern Shores Town 410 6.4 1.4 Remainder of Township 955 14.9 3.2 Nags Head Township 2,129 33.2 7.1 Manteo Town 208 3.2 0.7 Nags Head Town 519 8.1 1.7 Wanchese CDP 358 5.6 1.2 Remainder of Township 1,044 16.3 3.5 Hatteras Township 531 8.3 1.8 Kinnakeet Township 222 3.5 0.7 Croatan Township 248 3.9 0.8 East Lake Township 39 0.6 0.1 Total Dare County Population < Age 18 6,411 100.0 21.4 Total Dare County Population 29,967 n/a 100.0

62 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Single Parent Families

Table 37 (presented on this page and the next) presents data from the 1990 and 2000 US Census on family households with children (under age 18) headed by single parents; also included is a 2008 estimate of some of the same parameters.

 When compared to NC and Carteret County, Dare County had a lower percentage of single parent households headed by females throughout the period cited.  Compared to Carteret County, Dare County had a higher percentage of single parent households headed by males throughout the period cited. In 2000 and 2008 Dare County also had a higher percentage of single parent households headed by males than NC as a whole.  The number and percent of homes with a single parent head of household, female and male, increased over time throughout the period cited in both Dare County and NC as a whole.

Table 37. Single Parent Families (1990 and 2000; 2008 Estimate)

1990 Female Family Male Family Children <18 Children <18 Total Family Location Householders with Householders with Living with Not Living with Households Children < 18 Children < 18 Both Parents Both Parents Number Number % Number % Number Number

Dare County 6,469 407 6.3 95 1.5 4,103 1,074 Carteret County 15,351 1,028 6.7 145 0.9 9,063 2,726 State of NC 1,824,465 164,000 9.0 31,588 1.7 1,119,978 488,515 Source: a a b a b a a

2000 Female Family Male Family Children <18 Children < 18 Total Family Location Householders with Householders with Living with Not Living with Households Children < 18 Children <18 Both Parents Both Parents Number Number % Number % Number Number

Dare County 8,451 630 7.5 269 3.2 4,507 1,904 Carteret County 17,376 1,414 8.1 450 2.6 8,265 4,032 State of NC 2,158,869 227,351 10.5 60,791 2.8 1,266,526 697,521 Source: a a b a b a a

63 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

2008 (Estimate) Female Family Male Family Total Family Location Householders with Householders with Households Children < 18 Children <18 Number Number % Number %

Dare County 10,345 937 9.1 384 3.7 Carteret County 17,872 1,723 9.6 299 1.7 State of NC 2,355,509 278,599 11.8 76,289 3.2 Source: c c c c c

a - Log Into North Carolina (LINC) Database, Topic Group Population and Housing (Data Items 6044, 6048, 6049, 6050, 6051); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show b - Percentages are calculated c - US Census Bureau, American Fact Finder, American Community Survey, 2006-2008 American Community Survey (ACS) 3-Year Estimates, Data Profiles, Detailed Tables, For Areas with Population > 20,000, Selected Social Characteristics, by State or County; http://factfinder.census.gov

Family Services Utilization

At least some of the single-parent households discussed above qualify as low-income. The Dare County Department of Social Services (DSS) provides a range of services to low-income families; some of these were cited previously, in Table 34. Table 38 presents annual Dare County DSS data for two programs: WorkFirst Employment Services and Child Day Care Services (a subsidy program). While the data have been variable over time, the overall trend from 2004 seems to be increased demand for WorkFirst Employment Services.

Table 38. Family Services Provided by Dare County Department of Social Services (2004-2009)

Service/Activity 2004 2005 2006 2007 2008 2009

Work First Employment Services Registration Rate for All Families - Dare County 37.0% 45.8% 49.4% 59.7% 47.2% 56.0% Registration Rate for All Families - NC 34.5% 39.1% 41.0% 37.3% 36.3% 44.1% Average Monthly No. Families Receiving Services Not reported 14 16 16 14 16

Child Day Care Services No. Children Served b y Sub sidies 274 272 351 344 292 259

Source: Dare County Department of Social Services, State of the Department Annual Reports, 2005, 2006, 2007, 2008, 2009, 2010

64 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Child Care

Child Care Facilities

The NC Division of Child Development is the state agency charged with overseeing the child care industry in the state, including the regulation of child dare care programs. The Division licenses child care facilities that keep more than two unrelated children for more than four hours a day. In NC, regulated child day care facilities are divided into two categories – Child Care Centers and Family Child Care Homes – with the categories determined on the basis of enrollment. A child care center is a larger program providing care for three or more children, but not in a residential setting. The number of children in care is based upon the size of individual classrooms and having sufficient staff, equipment and materials. A family child care home is a smaller program offered in the provider's residence where three to five preschool children are in care. A family child care home may also provide care for three school age children (18).

In September 2000, the NC Division of Child Development began issuing “star rated” licenses to all eligible Child Care Centers and Family Child Care Homes. NC’s Star Rated License System gives stars to child care programs based on how well they are doing in providing quality child care. Child Care programs receive a rating of one to five stars. A rating of one star means that a child care program meets the state’s minimum licensing standards for child care. Programs that choose to voluntarily meet higher standards can apply for a two to five star license. (Note: Religious-sponsored child care programs can opt to continue to operate with a notice of compliance and not receive a star rating.)

Three areas of child care provider performance are assessed in the star system: program standards, staff education, and compliance history. Each area has a range of one through five points. The star rating is based on the total points earned for all three areas. A five-star facility has earned a total of from 14-15 points, a four-star facility from 11-13 points, a three-star facility from 8-10 points, a two-star facility from 5-7 points, and a one-star facility from 3-4 points. Table 39 lists the NC-regulated child care facilities in Dare County as of June, 2010. To summarize the contents of this table:

 There are 14 Licensed Child Care Centers in Dare County Five star - 5 Four star - 1 Three star - 6 Other – 2 (one temporary license; one exempt religious-sponsored)

 There are 23 Licensed Family Child Care Homes in Dare County Five star - 3 Four star - 4 Three star - 6 Two star - 6 One star - 4

65 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 39. NC-Regulated Child Care Facilities in Dare County (June, 2010)

Type/Name of Facility Location License Type

Child Care Centers (14) Cameron's Child Care and Learning Center Nags Head 4-Star Children's Workshop, Nags Head Nags Head 3-Star First Assembly of God Ministries Manteo 3-Star First Flight Elementary After School Enrichment Program Kill Devil Hills 5-Star Fun's Up Afterschool Enrichment Program Kill Devil Hills 3-Star Heron Pond Montessori School Kitty Hawk 3-Star Kitty Hawk Elementary After School Enrichment Program Kitty Hawk 5-Star Manteo Elementary After School Enrichment Program Manteo 5-Star Nags Head Elementary After School Enrichment Program Nags Head 5-Star Pledger Palace Child Development and Educational Center Kitty Hawk Temporary Roanoke Island Presbyterian Day Care Manteo 5-Star Sea Me Grow Child Care Kitty Hawk 3-Star Sonshine Children's Learning Center Kitty Hawk GS 110-106 The Munchkin Academy Buxton 3-Star

Family Child Care Homes (23) Angie's Wee Ones Wanchese 3-Star Babies, Bunnies and Bears Manteo 5-Star Carolyn Barnes Home Day Care Kill Devil Hills 3-Star Catherine's Kiddi-Land Day Care Home Manteo 3-Star Christie's Family Child Care Home Wanchese 2-Star Circle of Friends Child Care Home Kill Devil Hills 1-Star Cooper's Child Care and Learning Home Kill Devil Hills 5-Star First Friends Preschool Kill Devil Hills 5-Star First Step Child Care Manteo 3-Star Joanna's Kill Devil Hills 2-Star Katherine Tisch Day Care Home Wanchese 3-Star Kid's Care Family Child Care Home Kill Devil Hills 2-Star Kids Kountry Home Center Manns Harbor 4-Star Lisa Evans' Family Child Care Home Kill Devil Hills 1-Star Little Blessings Day Care Frisco 1-Star Miss Michelle's Family Child Care Home Manteo 4-Star Miss Winnie's Child Care Home Manteo 4-Star Patty Cake Daycare Wanchese 2-Star Small Wonders Buxton 1-Star The Giving Tree Kill Devil Hills 3-Star The Rainbow Connection Kill Devil Hills 4-Star Tic Tac Toes Day Care Home Wanchese 2-Star Tracy Walker's Family Child Care Home Wanchese 2-Star

Source: NC Department of Health and Human Services, Division of Child Development, Child Care Facility Search Site; http://ncchildcaresearch.dhhs.state.nc.us/search.asp

66 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Child Care Enrollment

Table 40 shows the number of children enrolled in NC-regulated child care over a period of time. Of interest is the fact that in both Dare and Carteret Counties enrollment has decreased recently. The downward trend began in 2006 in Dare County, and in 2007 in Carteret County. Enrollment continues to increase in the state as a whole.

Table 40. Children Enrolled in NC-Regulated Child Care (Years as Noted)

No. Children (0-5) Enrolled in Regulated Child No. Children (0-12) Enrolled in Regulated Child Location Care Care 2001 2005 2006 2007 2001 2005 2006 2007

Dare County 469 543 496 447 552 979 891 840 Carteret County 877 922 1,074 972 1,211 1,296 1,390 1,292 State of NC 161,103 184,500 188,466 193,600 211,553 260,252 265,943 276,099

Source: Annie E. Casey Foundation, Kids Count Data Center, Community Level Data, North Carolina Indicators; http://datacenter.kidscount.org/data/bystate/Default.aspx?state=NC

Subsidized Child Care

The WorkFirst Employment Program discusssed previously includes child care subsidies for families that qualify. Table 41 presents the number and percent of children in the jurisdictional population receiving WorkFirst Working Connections Child Care Subsidies; numbers and percents have declined in all three jurisdictions.

Table 41. Children Receiving WorkFirst Working Connections Child Care Subsidy (2000 and 2004-2007)

2000 2004 2005 2006 2007 Location No. % No. % No. % No. % No. %

Dare County 62 1.0 73 1.1 72 1.1 73 1.1 68 1.0 Carteret County 289 2.4 200 1.7 184 1.5 169 1.4 150 1.2 State of NC 77,755 3.9 63,398 3.1 53,872 2.7 46,616 2.4 41,075 2.1

Source: Annie E. Casey Foundation, Kids Count Data Center, Community Level Data, North Carolina Indicators; http://datacenter.kidscount.org/data/bystate/Default.aspx?state=NC

67 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Education

Schools and School Enrollment

Institutions of Higher Education

There are no four-year colleges in Dare County. There are two universities within a significant commuting distance of Dare County and the rest of the Outer Banks: Elizabeth City State University in Elizabeth City (Pasquotank County) and East Carolina University in Greenville (Pitt County).

The College of The Albemarle (COA) is a community college that serves the Outer Banks with locations throughout northeastern NC including a campus in Manteo, one in Elizabeth City, and a third in Edenton. A comprehensive community college, COA offers two-year degrees in college transfer and career programs, basic skills programs, continuing education classes for personal enrichment as well as credit, customized business and industry training, and cultural enrichment opportunities including an annual summer program called College for Kids. The COA is accredited by the Commission on Colleges of the Southern Association of Colleges and Schools to award associate degrees.

Credits earned at COA in curricula leading to the Associate in Arts degree and Associate in Science degree, and some of those leading to the Associate in Fine Arts degree, Associate in Applied Science degree and Associate in General Education degree are transferable to senior colleges and universities for a higher degree.

The college's main Dare County campus is located waterside in the town of Manteo on Roanoke Island. It is easily accessible from the North Beaches, Hatteras Island, the mainland, and nearby Currituck communities. A satellite facility, the Driftwood Center, houses English as a Second Language and the college's state-of-the-art pottery studio. The Driftwood Center is located on Manteo's Driftwood Drive. The 30,000 square foot Dare County campus features two buildings, 17 classrooms, six computer labs, and an 80-seat Information Highway Room in which programs can be offered via satellite or two-way video and audio conference from locations throughout the state (19).

Primary and Secondary Education

Tables 42 through 49 focus on data pertaining to primary and secondary (mostly public) schools in Dare County (and Carteret County and the state of NC where appropriate).

Tables 42, 43 and 44 focus on the numbers and kinds of schools and their enrollment.

 There are 11 public schools in the Dare County school district: 7 elementary schools, 2 high schools, 1 combined school, and 1 alternative school. There also are three private schools in the county (Table 42).

68 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 First Flight High School in Kill Devil Hills is the largest school in the district, with a 2010 enrollment of 819 (Table 43).  K-12 public school enrollment in Dare County and Carteret County has been declining steadily since the 2006-07 school year. K-12 public school enrollment is also declining statewide, but the trend started a year later at the state level, in SY2007-08 (Table 44).

Table 42. Number of K-12 Schools (SY2008-09)

Public Private Location Elementary Secondary CombinedOther K-12 K-9/8 9-12 Other (PK-8) (9-12)

Dare County 7 2 1 1 Alternative School 1 0 0 2 Carteret County 12 3 1 2 Charter Schools 4 0 0 3 State of NC 1,811 479 109 97 Charter Schools 39 8 21 11 Source: a a a a b b b b

a - NC Department of Public Instruction, Financial and Business Services, Data and Reports, Statistical Profile/Facts and Figures; http://www.ncpublicschools.org/fbs/resources/data/ b - Private School Review, North Carolina Private Schools, Search by Zip Code; http://www.privateschoolreview.com/zipsearch.php

Table 43. Public K-12 Schools in Dare County (June, 2010)

Enrollment School CitySchool Type/Calendar Grade Range SY2008-09

Cape Hatteras Elementary Buxton Regular School, Traditional Calendar PK-5 235 Cape Hatteras Secondary Buxton Regular School, Traditional Calendar 6-12 332 Dare County Alternative School Manteo Alternative Education, Traditional Calendar 7-12 34 First Flight Elementary Kill Devil Hills Regular School, Traditional Calendar PK-5 356 First Flight High Kill Devil Hills Regular School, Traditional Calendar 9-12 819 First Flight Middle Kill Devil Hills Regular School, Traditional Calendar 6-8 650 Kitty Hawk Elementary Kitty Hawk Regular School, Traditional Calendar K-5 468 Manteo Elementary Manteo Regular School, Traditional Calendar PK-5 585 Manteo High Manteo Regular School, Traditional Calendar 9-12 413 Manteo Middle Manteo Regular School, Traditional Calendar 6-8 345 Nags Head Elementary Nags Head Regular School, Traditional Calendar PK-5 529

Source: NC Department of Public Instruction, Data and Statistics, Education Data, NC School Report Cards; http://www.ncschoolreportcards.org/src

69 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 44. K-12 Public School Enrollment, Including Charter Schools (School Years as Noted)

Number of Students Location SY2004-05 SY2005-06 SY2006-07 SY2007-08 SY2008-09

Dare County 5,078 5,145 5,059 4,954 4,824 Carteret County 8,538 8,651 8,503 8,499 8,319 State of NC 1,421,335 1,456,895 1,481,981 1,491,142 1,460,868

Source: NC Department of Public Instruction, Financial and Business Services, Data and Reports, Statistical Profiles; http://www.ncpublicschools.org/fbs/resources/data/

Educational Attainment and Investment

Table 45 presents data on several measures of educational attainment and investment in public education.

 As of a 2008 US Census estimate, Dare County had higher percentages of both high school graduates and residents with a bachelor’s degree or higher than either Cartertet County or NC as a whole. The percentage of high school graduates in Dare County (93.4%) was 12.6% higher than in NC overall (82.9%). The percentage of the population with a bachelor’s degree or higher in Dare County (31.4%) was 22.6% greater than in NC overall (25.6%).  In the 2008-09 school year the total per pupil expenditure (the sum of Federal, state and local investments) in Dare County ($11,318) was 21.3% higher than the total in Carteret County ($9,330) and 30.8% higher than the average for the state as a whole ($8,656).  According to SY2008-09 End of Grade (EOG) Test results, a higher percentage of third graders in Dare County public schools demonstrated grade-appropriate proficiency in both reading and math than students statewide, but at rates similar to those in Carteret County. Eighth graders in Dare County public schools performed at lower levels of proficiency in both reading and math than students in either Carteret County or the state as a whole, although the difference in reading proficiency between Dare and Carteret eighth graders is probably not significant. Noteworthy is the observation that the percentage of eighth grade students performing at or above grade level in math in Dare County is 5.4 percentage points (or 6%) lower than the comparable result for third graders.  In SY2008-09 the average total SAT score for students in the Dare County schools (1032) was 20 points below the Carteret County average (1052), but 26 points above the average for NC as a whole (1006). Of significance may be the fact that a higher proportion of Dare County students (75%) participate in the SAT exam than in either Carteret County (56%) or statewide (63%).

70 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 45. Educational Attainment and Investment (Years as Noted)

% % % 3rd Graders % 3rd Graders % 8th Graders % 8th Graders Per Pupil Population Population At or Above At or Above At or Above At or Above SAT Expenditure Average Total High School Bachelor's Grade Level, Grade Level, Grade Le vel, Grade Level, Participation State, Federal SAT Scores Location Graduate or De gr e e or ABCs EOG ABCs EOG ABCs EOG ABCs EOG Rate and Local Highe r Highe r Reading Test Math Test Reading Test Math Test

2006-2008 2006-2008 SY2008-09 SY2008-09 SY2008-09 SY2008-09 SY2008-09 SY2008-09 SY2008-09

Dare County 93.4 31.4 $11,318 76.2 89.1 79.5 83.7 75% 1032 Carteret County 87.1 23.3 $9,330 76.1 89.7 79.7 89.5 56% 1052 State of NC 82.9 25.6 $8,656 65.5 81.3 84.8 88.9 63% 1006 Source:aabb b bbbb

a - US Census Bureau, American Fact Finder, American Community Survey, 2006-2008 American Community Survey (ACS) 3-Year Estimates, Data Profiles, Detailed Tables, For Areas with Population > 20,000, Selected Social Characteristics, by State or County; http://factfinder.census.gov b - NC Department of Public Instruction, Data and Statistics, Education Data, NC School Report Cards; http://www.ncschoolreportcatrds.org/src

High School Dropout Rate

Table 46 shows data on the high school (grades 9-12) dropout rate in Dare County, Carteret County, and NC as a whole. According to the NC Department of Public Instruction, a "dropout" is any student who leaves school for any reason before graduation or completion of a program of studies without transferring to another elementary or secondary school. For reporting purposes, a dropout is a student who was enrolled at some time during the previous school year, but who was not enrolled (and who does not meet reporting exclusions) on day 20 of the current school year.

 Although the high school dropout rate in Dare County fluctuated over the period cited, it was lower at every point than the comparable rates in either Carteret County or NC as a whole.  Of the three jurisdictions, Carteret County has made the greatest recent dropout rate improvement over the period cited: the most recent Carteret rate reported in the table (2.60) is 47% lower than the five-year high rate recorded two years earlier (4.93). At one point during the past five years (SY2007-08) Dare County had reported a similar level of improvement (48.8%), but the dropout rate in Dare has risen again since.  Noteworthy is the observation that the SY2008-09 overall NC dropout rate (4.27) was the lowest ever recorded for the state.

71 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 46. High School (Grades 9-12) Dropout Rate (School Years as Noted)

Drop-Out Rate Location SY2004-05 SY2005-06 SY2006-07 SY2007-08 SY2008-09

Dare County 2.81 3.28 2.07 1.68 2.03 Carteret County 3.48 4.46 4.93 3.86 2.60 State of NC 4.74 5.04 5.27 4.97 4.27*

Source: NC Dept of Public Instruction, Research and Evaluation, Annual Reports; http://www.ncpublicschools.org/research/dropout/reports/ * This is the lowest High School Dropout rate ever recorded in North Carolina

Crime and Violence in Schools

Along with test scores and dropout rates, schools now also track and report acts of crime and violence that occur on school property. The NC State Board of Education has defined 17 criminal acts that are to be monitored and reported, ten of which are considered dangerous and violent:  Homicide  Assault resulting in serious bodily injury  Assault involving the use of a weapon  Rape  Sexual offense  Sexual assault  Kidnapping  Robbery with a dangerous weapon  Robbery without a dangerous weapon  Taking indecent liberties with a minor

The other seven acts criminal acts are:  Assault on school personnel  Bomb threat  Burning of a school building  Possession of alcoholic beverage  Possession of controlled substance in violation of law  Possession of a firearm or powerful explosive  Possession of a weapon

72 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 47 summarizes crime and violence reported by schools in Dare County, Carteret County and for the state overall.

 The number and rate of acts of school crime and violence in Dare County fluctuated dramatically over the period cited. The most recent rate (12.3), in SY2008-09, equals the highest rate since SY2004-05, and is over 2½ times the rate (4.4) for SY2007-08. The Dare County rate in SY2008-09 is also 40% higher than the comparable rate in Carteret County and 62% higher than the comparable rate statewide.  Although the SY2009-10 crime and violence rate is not yet available from the source, the number of acts reported for that year was 50% less than the previous year, and should yield a lower rate.

Table 47. School Crime and Violence, All Grades (School Years as Noted)

SY2004-05 SY2005-06 SY2006-07 SY2007-08 SY2008-09 SY2009-10 Location No. No. No. No. No. Rate2 Rate Rate Rate Rate No. Acts Rate Acts1 Acts Acts Acts Acts

Dare County 59 12.3 29 6.0 25 5.2 21 4.4 59 12.3 28 n/a Carteret County 71 8.8 64 7.9 62 7.7 80 9.8 71 8.8 n/a n/a State of NC 10,107 7.5 10,959 7.9 11,013 7.8 11,276 7.9 11,116 7.6 n/a n/a Sourceaaaaaabbbbc

a - NC Department of Public Instruction, Research and Evaluation, Discipline Data, Annual Reports, Annual Reports of School Crime and Violence; http://www.ncpublicschools.org/research/discipline/reports/#consolidated b - NC Department of Public Instruction, Research and Evaluation, Discipline Data, Consolidated Data Reports; http://www.ncpublicschools.org/research/discipline/reports/#consolidated c - Final LEA280 Report, SY2009-10; personal communication from Nancy Griffin (Dare County Public Schools) to Laura Willingham (Dare County Department of Public Health), via email, July 30, 2010 1 For list of reportable acts see accompanying text 2 Rate is number of acts per 1,000 students

In SY2008-09, the most common reportable offenses in high schools statewide were (1) possession of controlled substance in violation of law, (2) possession of weapon excluding firearms, and (3) possession of alcoholic beverage. During the same period, the most common reportable offenses in high schools in Dare County were (1) possession of controlled substance in violation of law, (2) possession of alcoholic beverage, and (3) bomb threat (20).

In the spring of 2009, the Dare Health Alliance commissioned a comprehensive Youth Risk Behavior Survey among Dare County students in grades nine through 12 (21). The survey sample included 1,110 of the total 1,561 high school students in the county, a response rate of 71%. Among the questions included in the survey instrument were several that assessed the student’s exposure to and participation in violence-related behavior. Table 48 summarizes some of the relevant results from the survey.

73 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 Bullying appears to be among the most observed of the violence-related behaviors in Dare County High Schools. Almost two-thirds of students reported having seen other students being bullied on school property. Almost 24% of students reported themselves having been bullied on school property.  Just over 30% of students reported having had personal property stolen or damaged while they were at school.  Almost 13% of students reported having been threatened or injured by someone with a weapon on school property, and 8.4% reported that they had carried a weapon on school property.  With the exception of bullying, which is experienced equally by males and females, higher proportions of males than females report experiences with these violence-related behaviors.

Table 48. Violence-Related Behavior among Dare County High School Students (2009)

Percentage of Respondents Had Been Carried a Had Personal Did Not Attend Had Seen Other Threatened or Involved in a Had Been Bullied Weapon Such as Category Property Stolen School at Least Students Being Injured by Physical Fight on on School a Gun, Knife or or Damaged Once Beause Bullied on School Someone With a School Property Property Club on School While At School Fe lt Uns a fe Property Weapon on Property School Property

Females 9.2 27.5 7.6 22.7 66.3 8.1 3.4 Males 20.9 32.8 10.2 24.2 66.0 15.8 12.5 Overall 15.6 30.7 9.3 23.5 66.1 12.5 8.4

Source: 2009 Youth Risk Behavior Survey, Dare County High Schools

Acts of crime and violence detected on school property often result in disciplinary responses. The usual disciplinary action is either a short- term (up to 10-day) suspension, a long-term (11 or more days) suspension, or expulsion. Table 49 summarizes school disciplinary activity in high schools (grades 9-12) in Dare County, Carteret County and NC as a whole for three recent school years

 In Dare County, the most commonly employed disciplinary action is the short-term suspension. Dare County high schools issued only 10 long-term suspensions and no expulsions over the entire period cited.  High schools in Carteret County issued an average of 4.2 times as many short-term suspensions as high schools in Dare County, despite the fact that total school enrollment in Carteret County is only twice the comparable enrollment in Dare County.  The number of short-term suspensions in Dare County decreased from one year to the next throughout the period cited.

74 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 49. School Disciplinary Activity, Grades 9-12 (SY2006-07 through SY2008-09)

SY2006-07 SY2007-08 SY2008-09 SY2009-10

Location No. Short-Term No. Long-Term No. No. Short-Term No. Long-Term No. No. Short-Term No. Long-Term No. No. Short-Term No. Long-Term No. Suspensions1 Suspensions2 Expulsions Suspensions Suspensions Expulsions Suspensions Suspensions Expulsions Suspensions Suspensions Expulsions

Dare County 401 3 0 336 6 0 283 1 0 251 3 00 Carteret County 1,539 8 0 1,486 12 0 1,280 16 0 n/a n/a n/a State of NC 310,794 4,682 102 308,010 5,225 116 293,453 3,592 116 n/a n/a n/a Source:a aab bbb bbc cc

a - NC Department of Public Instruction, Research and Evaluation, Discipline Data, Annual Reports, Annual Study of Suspensions and Expulsions; http://www.ncpublicschools.org/research/discipline/reports/#consolidated b - NC Department of Public Instruction, Research and Evaluation, Discipline Data, Consolidated Data Reports; http://www.ncpublicschools.org/research/discipline/reports/#consolidated c - Final LEA280 Report, SY2009-10; personal communication from Nancy Griffin (Dare County Public Schools) to Laura Willingham (Dare County Department of Public Health), via email, July 30, 2010 1 A short-term suspension is up to 10 days 2 A long-term suspension is 11 or more days 3 Note: This figure includes all short-term suspensions for Cape Hatteras Secondary School (n=51) and the Dare County Alternative School (n=50), only some of which are attributable to students in grades 9-12. The total number of short-term suspensions for Manteo High School and First Flight High School combined is 150.

75 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Crime and Safety

Crime Rates

All crime statistics reported below were obtained from the NC Department of Justice, State Bureau of Investigation unless otherwise noted. Table 50 shows the rates for “index crime”, which consists of violent crime (murder, forcible rape, robbery, and aggravated assault) plus property crime (burglary, larceny, arson, and motor vehicle theft) for Dare County, Carteret County, and the state of NC from 2004 through 2008.

 The overall index crime rate in Dare County fluctuated between 2004 and 2008 but was higher than the index crime rate for either Carteret County or the state as a whole throughout the period.  The largest component of Dare County index crime is property crime, rates for which also were consistently higher than comparable rates in either Carteret County or NC as a whole. The Dare County index crime rate and property crime rate for 2008 were the highest of the comparable rates for any jurisdiction for the entire period cited.  The violent crime rate in Dare County also fluctuated between 2004 and 2008 but was lower than the violent crime rate for either Carteret County or NC as a whole throughout the period.

Table 50. Index Crime Rates (2004-2008)

Crimes per 100,000 Population 2004 2005 2006 2007 2008 Location Index Violent Property Index Violent Property Index Violent Property Index Violent Property Index Violent Property Crime Crime Crime Crime Crime Crime Crime Crime Crime Crime Crime Crime Crime Crime Crime

Dare County 4,944.8 264.0 4,680.7 5,395.9 318.3 5,077.7 5,010.1 304.7 4,705.4 4,686.5 233.6 4,452.9 6,194.6 335.6 5,859.0 Carteret County 3,397.5 265.8 3,131.7 3,158.2 326.5 2,831.7 3,338.1 307.5 3,030.6 3,744.6 332.0 3,412.6 3,995.6 372.9 3,622.8 State of NC 4,573.9 446.9 4,127.1 4,617.9 478.1 4,139.7 4,649.8 483.0 4,166.8 4,658.9 480.2 4,178.7 4,554.6 474.2 4,080.4

Source: NC Department of Justice, State Bureau of Investigation, Crime, View Crime Statistics, Crime Statistics (by Year); http://ncdoj.gov/Crime/View-Crime-Statistics.aspx

Table 51 shows the numbers of index crimes by type that occurred in Dare County from 2004 through 2008.

 The most common violent crime throughout the period cited was aggravated assault. The largest number of aggravated assaults committed during the period was 95, in 2008.  The most common property crime throughout the period cited was larceny. The largest number of larcenies committed during the period was 1,337, also in 2008.

76 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 51. Number of Index Crimes Reported in Dare County (2004-2008)

Number of Crimes Type of Crime 2004 2005 2006 2007 2008

Violent Crime Murder 11010 Rape 17 12 17 9 11 Robbery 710128 9 Aggravated Assault 63 86 77 65 95 Property Crime Burglary 455 509 435 415 591 Larceny 1,043 1,190 1,151 1,084 1,337 Motor VehicleTheft 62 43 51 46 80 Total Index Crimes 1,648 1,851 1,743 1,628 2,123

Source: NC State Bureau of Investigation, Crime in North Carolina, North Carolina Crime Statistics, Crime Statistics in Detailed Reports (By Year), Index Offenses in County Order; http://sbi2.jus.state.nc.us/crp/public/Default.htm

Other Criminal Activity

Table 52 summarizes some of the other types of criminal activity that are tracked: sex offenders, gangs, and methamphetamine lab busts.

 Of the 12,638 registered sex offenders living in NC as of August 20, 2010, 44 resided in Dare County and 69 in Carteret County.  There were no verified reports of gangs in Dare County in either 2007 or 2008.  There were no recorded methamphetamine lab busts in Dare County from 2005 through 2009.

77 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 52. Other Criminal Activity

No. Registered No. Gangs No. Methamphetamine Lab Busts Location Sex Offenders 2007 2008 2005 2006 2007 2008 2009 (2009)

Dare County440000000 Carteret County 69 1-9 0 1 2 0 4 0 State of NC 12,638 550 855 328 197 157 197 206 Source:a bcddddd

a - NC Department of Justice, Sex Offender Statistics, Offender Statistics; http://sexoffender.ncdoj.gov/stats.aspx b - Governor's Crime Commission, NC Criminal Justice Analysis Center, System Stats, Summer, 2008, Gangs in North Carolina: A Summary of the Law Enforcement Survey; http://www.ncgccd.org/pdfs/systemstats/summer08.pdf c - Governor's Crime Commission, NC Department of Crime Control and Public Safety, Gangs in North Carolina: A 2009 Report to the General Assembly; http://www.ncgccd.org/pdfs/2009/gangga.pdf d - NC Department of Justice, State Bureau of Investigation, Crime, Enforce Drug Laws, Meth Focus, Meth Lab Busts; http://sbi2.jus.state.nc.us/crp/public/Default.htmhttp://ncdoj.gov/getdoc/b1f6f30e-df89-4679-9889- 53a3f185c849/Meth-Lab-Busts.aspx

Juvenile Crime

The following definitions will be useful in understanding the subsequent data and discussion.

 Complaint – A formal allegation that a juvenile committed an offense, which will be reviewed by a counselor who decides whether to approve or not approve the complaint. If approved, it will be heard in juvenile court.  Undisciplined – Describes a juvenile between six and 16, who is unlawfully absent from school, or regularly disobedient and beyond disciplinary control of parent/guardian, or is regularly found where it is unlawful for juveniles to be, or has run away from home for more than 24 hours. It also includes 16-17 year olds who have done any of the above except being absent from school.  Delinquent – Describes a juvenile between six and not yet 16 who commits an offense that would be a crime under state or local law if committed by an adult.  Diversion – If a complaint is not approved, it may be diverted to a community resource or placed on a diversion contract or plan that lays out stipulations for the juvenile (like community service) to keep the juvenile out of court.

78 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

 Non-divertible – Non-divertible offenses include offenses like: murder, rape, sexual offense, arson, first degree burglary, crime against nature, willful infliction of serious bodily harm, assault with deadly weapon, etc.  Transfer to Superior Court – A juvenile who is 13, 14 or 15 who is alleged to have committed a felony may be transferred to Superior Court and tried and sentenced as an adult. If a juvenile is over 13 and charged with first degree murder, the judge must transfer the case to Superior Court if probable cause is found.  Rate – The number per 1,000 persons that are aged 6 to 17 in the county.

Table 53 presents a summary of juvenile justice complaints and outcomes for 2008 and 2009.

 The number and rate of complaints for undisciplined and delinquent youth in Dare County both increased from 2008 to 2009.  The rate of complaints for undisciplined and delinquent youth in Dare County dramatically exceeded the comparable rates for Carteret County and NC as a whole in both 2008 and 2009.  Despite the high rates of complaints against youth in Dare County, few are sent to secure detention, to youth development centers, or are transferred to Superior Court.

Table 53. Juvenile Justice Complaint and Outcomes (2008 and 2009)

Complaints Outcomes Rate Delinquent No. Se nt to Rate Undisciplined No. Se nt to No. Transferred No. (Complaints per Youth Location No. Delinquent (Complaints per Secure to Superior Undisciplined 1,000 Age 6 to De ve lopm e nt 1,000 Ages 6 to 17) De te ntion Court 15) Center 2008 2009 2008 2009 2008 2009 2008 2009 2008 2009 2008 2009 2008 2009

Dare County 23 34 202 224 5.14 8.22 54.29 67.09 13 7 0 1 0 0 Carteret County 11 3 204 230 1.39 0.38 31.18 35.47 17 26 2 1 0 0 State of NC 4,896 5,169 38,901 42,920 3.29 3.11 31.52 29.14 4,827 4,413 469 365 43 28

Source: NC Department of Juvenile Justice and Delinquency Prevention, Statistics and Legislative Reports, County Databooks (Search by Year); http://www.ncdjjdp.org/statistics/databook.html

79 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Sexual Assault and Domestic Violence

Table 54 summarizes the number of individuals who filed complaints of sexual assault in Dare County, Carteret County and the state of NC from FY2004-05 through FY2008-09.

 The annual number of complaints varies without a clear pattern in all three jurisdictions over the period covered.  Since the figures are counts and not rates, they are difficult to compare from one jurisdiction to another. However, the number of complaints in Dare County was generally between one-third to one-half the number in Carteret County. Since the Carteret County population is approximately twice the Date County population, these figures would be expected to yield approximately equivalent rates.

Table 54. Sexual Assault Trend (FY2004-05 through FY2008-09)

No. of Individuals Filing Complaints Location FY2004-05 FY2005-06 FY2006-07 FY2007-08 FY2008-09

Dare County 37 33 49 47 42 Carteret County 95 89 92 100 115 State of NC 8,564 8,721 7,444 6,527 8,494

Source: NC Department of Administration, Council for Women, Domestic Violence Commission, Statistics, County Statistics; http://www.doa.state.nc.us/cfw/stats.htm

Tables 55 and 56 offer details of sexual assault complaints in Dare County, Carteret County and NC in FY2008-09. Table 55 describes the types of assaults involved in the complaints. Table 56 describes the relationship of the offender to the complainant.

According to data in Table 55:

 The largest proportion of the 42 sexual assault complaints in Dare County for the period cited was 57.1%, for 24 complaints of date rape. The second highest proportion was 28.6% for 12 complaints of adult rape.  In Carteret County the highest proportion of the 115 sexual assault reports was 33.9%, for 39 complaints of child sexual assault lodged by adult survivors. The second highest proportion was 24.3%, for 28 complaints of child sexual offense.  Statewide the highest proportion (27.1%) of sexual assault reports was for child sexual offense; the second highest (24.1%) was for adult rape.

80 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Table 55. Sexual Assault Complaint Details: Types of Assault (FY2008-09)

Type of Assault Total Adult Survivor Child Sexual Location Assault Adult Rape Date Rape of Child Sexual Marital Rape Incest Other Offense Complaints Assault No. % No. % No. % No. % No. % No. % No. %

Dare County 42 12 28.6 24 57.1 2 4.8 1 2.4 0 0.0 0 0.0 3 7.1 Carteret County 115 17 14.8 13 11.5 39 33.9 3 2.6 28 24.3 7 6.1 8 6.9 State of NC 8,494 2,046 24.1 650 7.6 1,253 14.8 518 6.1 2,302 27.1 667 7.9 1,058 12.4

Source: NC Department of Administration, Council for Women, Domestic Violence Commission, Statistics, County Statistics; http://www.doa.state.nc.us/cfw/stats.htm

According to data in Table 56:

 In Dare County the most common type of sexual assault offender was an acquaintance, cited in 27 of the 42 complaints (64.3%). The second most common type of offender was a boy- or girl-friend, cited in 10 or 23.8% of the complaints during the period cited.  In Carteret County, the most common type of offender was a relative, cited in 56 of the 115 complaints (48.7%). The second most common type of offender was an acquaintance, cited in 49 or 42.6% of the complaints during the period.  Statewide, the offender pattern was the same as in Carteret County, with relatives being the most common offenders (35.0%) and acquaintances being the second most common offenders (32.4%)

Table 56. Sexual Assault Complaint Details: Offender Relationship (FY2008-09)

Type of Offender Total Location Relative Acquaintance Boy/Girl Friend Stranger Unknown Offenders No. % No. % No. % No. % No. %

Dare County 42 2 4.8 27 64.3 10 23.8 3 7.1 0 0.0 Carteret County 115 56 48.7 49 42.6 6 5.2 2 1.7 2 1.7 State of NC 8,280 2,899 35.0 2,684 32.4 921 11.1 500 6.0 1,276 15.4

Source: NC Department of Administration, Council for Women, Domestic Violence Commission, Statistics, County Statistics; http://www.doa.state.nc.us/cfw/stats.htm

81 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

The 2009 Youth Risk Behavior Survey of Dare County high school students (cited previously) asked a number of questions about sexual behavior. Results from that survey relative to sexual assault is presented in Table 57.

 Over 18% of high school students in Dare County reported having been hit, slapped or otherwise physically hurt by their boy- or girl- friend. Interestingly, boys gave this response at almost twice the percentage of girls.  Over 14% reported having been physically forced to have sexual intercourse. Boys reported having been physically forced to have intercourse at almost the same percentage as girls (13.1% vs. 15.2%, respectively).

Table 57. Sexual Violence among Dare County High School Students (2009)

Percent of Respondents Hit, Slapped Physically or Physically Category Force d to Hur t by Boy- Have Sexual or Girl- Intercourse Frie nd

Females 12.9 15.2 Males 23.2 13.1 Overall 18.3 14.1

Source: 2009 Youth Risk Behavior Survey, Dare County High Schools

Table 58 presents data on the number of complaints of domestic violence in Dare County, Carteret County and the state of NC for the period from FY2004-05 through FY2008-09. Table 59 presents services received in connection with domestic violence complaints in all three jurisdictions for FY2008-09.

 The number of individuals filing domestic violence complaints varied without pattern in all three jurisdictions throughout the period cited.  In Dare County the maximum number of domestic violence complaints over the period was lodged in FY2007-08. The maximum number in Carteret County was lodged in FY2004-05.  From FY2006-07 through FY2008-09 the numbers of complaints in Dare County and Carteret County were surprisingly similar, given that the population in Carteret County is approximately twice that of Dare County. Were the numbers rates instead, Dare County would probably would have had the higher rate of domestic violence complaints.  Statewide the maximum number of complaints was filed in FY2008-09.

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Table 58. Domestic Violence Trend (FY2004-05 through FY2008-09)

No. of Individuals Filing Complaints Location FY2004-05 FY2005-06 FY2006-07 FY2007-08 FY2008-09

Dare County 223 178 276 360 292 Carteret County 645 484 284 291 319 State of NC 50,726 48,173 47,305 41,787 51,873

Source: NC Department of Administration, Council for Women, Domestic Violence Commission, Statistics, County Statistics; http://www.doa.state.nc.us/cfw/stats.htm

Table 59 presents details about the domestic violence complaints lodged in FY2008-09 in terms of the services received by the complainants.

 The 292 complaints of domestic violence in Dare County were addressed by a total of 1,619 services.  The largest numbers of services received by domestic violence complainants in Dare County were for information (426) and referral (426), followed by advocacy (292). Dare County domestic violence complainants received services from the courts on 192 occasions.  The largest numbers of services received by domestic violence complainants in Carteret County were for information, referral, advocacy and counseling, in that order. Fewer complainants in Carteret received the services of the courts than in Dare County.  The local domestic violence shelter in Carteret County was full on 150 days the period from July 1, 2008 through June 30, 2009. The local shelter in Dare County was never full.

Figure 59. Domestic Violence Complaint Details, by Services Received (FY2008-09)

Total Services Received Days Local Domestic Location Shelter Violence Total Information Advocacy Referral Transport Counseling Hospital Court Other was Full Complaints

Dare County 292 1,619 426 292 426 83 86 2 192 112 0 Carteret County 319 3,297 1,518 391 605 189 364 13 88 129 150 State of NC 51,873 461,277 101,251 88,801 76,351 36,496 65,347 1,703 49,720 41,608 n/a

Source: NC Department of Administration, Council for Women, Domestic Violence Commission, Statistics, County Statistics; http://www.doa.state.nc.us/cfw/stats.htm

83 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

Child Abuse, Neglect and Exploitation

The responsibility for identifying and reporting cases of child abuse, neglect and exploitation falls to the child protective services program within a county’s department of social services. Generally speaking, such a unit will have sufficient staff to handle intake of all reports. However, an agency’s ability to investigate and monitor reported cases may vary from year to year, depending on the number of properly trained staff available to it; hence, follow-up on reports may vary independently of the number of reports. Table 60 presents child protective services data from the Dare County DSS State of the Department Annual Reports for the period from 2004-2009.

 The number of reports of abuse appear to fluctuate annually without a clear pattern. For the period cited, the highest number of reports was 283 in 2004, and the lowest was 251 in 2007. The average number of reports of child abuse, neglest or exploitation per year throughout the period cited was 265.  The number of children covered annually by those reports ranged from a low of 385 in 2006 to a high of 498 in 2004, and averaged 446 per year.

Table 60. Child Protective Services Provided by Dare County Department of Social Services (2004-2009)

Service/Activity 2004 2005 2006 2007 2008 2009

No. of Reports of Abuse, Neglect, Exploitation 283 257 260 251 281 261 No. of Children in Reports 498 455 385 485 425 428 % of Reports Substantiated1 NR* 52.3 40.4 NR* NR* NR* No. Children in Foster Care at End of Year 70 54 44 48 43 30 No.Licensed Foster Care Homes 12 15 15 14 14 19 2 No. of Children in Emergency/Long-term Care 13 16 14 17 11 10

Source: Dare County Department of Social Services, State of the Department Annual Reports, 2005, 2006, 2007, 2008, 2009, 2010 1 A "substantiated" report of child abuse, neglect or exploitation indicates that the investigation supports a conclusion that the subject child(ren) was/were abused, neglected, or exploited. 2 Dare County children in custody at the Methodist Home for Children * An asterisk (with NR) indicates data not reported in the associated State of the Department report

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The department of social services may remove children deemed in danger from their homes and place them under the custody of the agency and in foster care. The number of children who can be placed in foster care is dependent at least partially on the number of licensed foster homes in the county.

 The number of children in foster care listed in Table 60 (cited previously) is the number in care at the end of each reporting period. The number ranged from a high of 70 in 2004 to a low of 30 in 2009. The average over the period cited was 48.  The number of approved foster homes in Dare County had not varied much from year to year. For the period cited the number ranged from 12 in 2004 to 19 in 2009, and averaged 15.  From the data in Table 60 it would appear that the number of children in foster care in Dare County is not directly related to the number of foster homes available.  Sometimes it is difficult to find suitable foster care settings for children with special needs. In those cases the county must make alternate arrangements for care, usually as emergency care or long-term care. According to data in Table 60, the number of children in emergency care or long-term care in Dare County over the period cited ranged from a high of 17 in 2007 to a low of 10 in 2009.

Adult Abuse, Neglect and Exploitation

Adults who are elderly, frail, or mentally challenged are also subject to abuse, neglect and exploitation. The Dare County DSS maintains an Adult Protective Services unit with the responsibility to screen, investigate and evaluate reports of what may broadly be referred to as adult maltreatment. Table 61 presents adult protective services data from the Dare County DSS State of the Department Annual Reports for the period from 2004-2009.

 Although the number of reports of adult abuse, neglect and exploitation shown in Table 61 vary from year to year, the general trend appears to be toward increasing numbers of reports. The smallest number of reports over the period cited was 34 in 2004 and the largest number was 123 in 2009. The average for the entire period was 84.  As the number of reports has risen, so has the number of reports investigated. In 2009 the agency investigated 79% of reports.

The percentages of reports confirmed and substantiated are more realistic measures of adult maltreatment than are counts of reports. Confirmation of a report means the investigation demonstrated that the abuse did indeed occur. Substantiation of a report means that the investigation found maltreatment serious enough for the agency to provide the victim ongoing protection. According to data in Table 61:

 The Dare County DSS annually confirmed between 52% to 77% of reports of adult maltreatment. The average for the six-year period cited was 66%  The agency annually substantiated from 43% to 63% of reports of adult maltreatment. The average for the period was 48%.

85 Dare County Community Health Assessment – Volume One Demographic and Socioeconomic Data

As with children, adult victims of substantiated maltreatment sometimes must be removed from a dangerous living situation and placed under the guardianship of the DSS. Adult maltreatment victims sometimes are mentally unable to care for themselves and have no one else to care for them; in those cases DSS must petition the courts for a declaration of incompetency in order to seek proper care for the victim. According to data in Table 61:

 The number of guardianships assumed by Dare County DSS has increased over time. The annual number of guardianships for the period cited ranged from five in 2006 to 30 in 2009. The numbers were highest in the two most recent reporting periods.  The number of petitions for incompetency filed by Dare County DSS have varied considerably, ranging from a low of four in 2004 to a high of 16 in 2008. The annual average was 11.

Table 61. Adult Protective Services Provided by Dare County Department of Social Services (2004-2009)

Service/Activity 2004 2005 2006 2007 2008 2009

No. of Reports of Abuse, Neglect, Exploitation 34 58 84 105 99 123 No. of Reports Investigated NR* NR* 72 86 84 97 % Reports Confirmed1 52NR*60777367 % Reports Substantiated2 NR*6343474543 No. Guardianships Assumed by DSS 6 8 5 10 27 30 No. Petitions of Incompetency Filed 4 NR* 9 12 16 12

Source: Dare County Department of Social Services, State of the Department Annual Reports, 2005, 2006, 2007, 2008, 2009, 2010 1 A "confirmed" report of adult abuse, neglect or exploitation indicates that the investigation of the report determined that the allegations of mistreatment were true. 2 A "substantiated" report of adult abuse, neglect or exploitation indicates that the investigation of the report determined that the adult was in need of ongoing protection. * An asterisk (with NR) indicates data not reported in the associated State of the Department report

86 Dare County Community Health Assessment – Volume One Health Care and Health Promotion Resources

Chapter Two

Health Care and Health Promotion Resources

87 Dare County Community Health Assessment – Volume One Health Care and Health Promotion Resources

Chapter Two: Health Care and Health Promotion Resources

Medical Insurance

Access to and utilization of healthcare is affected by a range of variables including the availability of medical professionals in a county, insurance coverage, transportation, cultural expectations and other factors. Compilation of comprehensive health resources data was beyond the scope of this project; nevertheless, some overview-type data were collected and are presented here.

Medically Indigent Population

In most communities, citizens' utilization of health care services is related to their ability to pay for those services, either directly or through private or government health insurances plans/programs. People without these supports are called “medically indigent”, and theirs is often the segment of the population least likely to seek or to be able to access necessary health care.

Table 62 presents data on the proportion of the population (by age group) without health insurance of any kind. This data was selected partially on the basis of the reliability of the source. Unfortunately the data is somewhat dated, with 2005 being the most recent. The health insurance system in the US is built largely upon employer-based insurance coverage, so an increase in the number of unemployed people usually leads to an increase in the number of uninsured. Recent increases in unemployment, and the subsequent loss of insurance coverage by the unemployed, likely means that current figures for the percent of the population without health insurance would be higher. (See also the section of this report entitled, Uninsured: Current Estimates, below.)

 Although there is considerable variability in the annual rates presented in the table, it does appear that in Dare County there were higher proportions of the uninsured overall in 2004 and 2005 than in 2002 and 2003, mostly due to high proportions of the uninsured in the 18-64 age group.  In Dare County the percentage of uninsured children (ages 0-17) was lower in the two later periods than in the earlier two.

Table 62. Percent of Population without Health Insurance, by Age Group (2002-2005)

2002 2003 2004 2005 Location 0-64 0-17 18-64 0-64 0-17 18-64 0-64 0-17 18-64 0-64 0-17 18-64

Dare County 16.0 10.3 17.9 16.5 11.2 18.2 20.9 10.8 24.1 18.3 9.1 21.3 Carteret County 17.5 11.3 19.5 17.5 11.6 19.2 20.4 11.1 23.2 17.7 10.0 20.0 State of NC 20.2 14.0 22.6 17.3 11.7 19.6 16.6 10.0 19.2 18.6 12.4 21.1

Source: Sheps Center for Health Services Research, Publications, County-Level Estimates of the Uninsured: 2002-2004 and 2005 Updates; http://www.shepscenter.unc.edu/

88 Dare County Community Health Assessment – Volume One Health Care and Health Promotion Resources

Table 63 presents information on uninsured children that comes from another source and includes one additional year’s data.

 This data appears to corroborate the observation that in Dare County the percentage of children without health insurance had decreased from 2003 to 2005. Note, however, that while the 2007 figure (9.5%) is lower than the figures for 2003 (11.3%) and 2004 (10.8%), it was slightly higher than the figure for 2005 (9.1%).  In Carteret County the downward trend in the percentage of uninsured children over the period cited is more pronounced than in Dare County. At the state level, the percentage of uninsured children rose from 11.3% to 13.1% between 2005 and 2007.

Table 63. Percent of Children* without Health Insurance (2003-2005, 2007)

Location 2003 2004 2005 2007

Dare County 11.3 10.8 9.1 9.5 Carteret County 11.6 11.1 10.0 7.6 State of NC 11.9 11.9 11.3 13.1

Source: Annie E. Casey Foundation, Kids Count Data Center, Community Level Data, North Carolina Indicators; http://datacenter.kidscount.org/data/bystate/Default.aspx?state=NC

Uninsured: Current Estimates

Precise, current data on the proportion of population that is uninsured are not available. However, researchers at the Sheps Center for Health Services Research at UNC Chapel and the NC Institute for Medicine have developed up-to-date estimates describing the uninsured population in NC based on known unemployment rates, population estimates, and current economic indicators. Results from their report (22), which covers the period from 2007 to January 2009, are disheartening.

 From 2007 to January 2009, NC’s unemployment rate increased from 4.7% to 9.7%. This increase of five percentage points was the second largest in the country.  Based on this increase in unemployment the researchers estimated that the rate of uninsured climbed 3.1 percentage points.  The increase in the rate of uninsured translates into an increase in the number of NC uninsured by 322,000, the fourth largest increase in the country.  The estimated number of uninsured in NC increased by 22.5% over the period studied. This was the largest percentage increase in the US. As of January 2009, the total number of uninsured in NC was estimated at between 1.75 and 1.80 million.

89 Dare County Community Health Assessment – Volume One Health Care and Health Promotion Resources

North Carolina Health Choice

In 1997, the Federal government created the State Children’s Health Insurance Program (SCHIP) – later known more simply as the Children’s Health Insurance Program (CHIP) – that provides matching funds to states for health insurance for families with children. The program covers uninsured children in low-income families who nevertheless earn too much to qualify for Medicaid (23).

States are given flexibility in designing their CHIP eligibility requirements and policies within broad Federal guidelines. The NC CHIP program is called NC Health Choice for Children (NCHC). This plan, which took effect in October 1998, includes the same benefits as the State Health Plan, plus vision, hearing and dental benefits (following the same guidelines as Medicaid). Children enrolled in NCHC are eligible for benefits including sick visits, check-ups, hospital care, counseling, prescriptions, dental care, eye exams and glasses, hearing exams, hearing aids, and more (24). In NC, the maximum income limit for participation in the NCHC program is 200% of the Federal Poverty Guideline. Table 64 presents enrollment figures for NCHC for 2000, 2004 and 2007. It should be noted that enrollment is directly related to the funding available, which may change at either the Federal or state level.

 In Dare County, Carteret County and NC as a whole the number and percent of children enrolled in NCHC increased between 2000 and 2004 and decreased between 2004 and 2007.

Table 64. NC Health Choice (NCHC) Enrollment (2000, 2004, and 2007)

2000 2004 2007

Location # Children % Children # Children % Children # Children % Children Enrolled Enrolled Enrolled Enrolled Enrolled Enrolled

Dare County 340 5.3 510 7.4 408 5.8 Carteret County 791 6.5 1,018 8.9 876 7.6 State of NC 70,636 3.6 121,836 5.9 119,086 5.4

Source: Annie E. Casey Foundation, Kids Count Data Center, Community Level Data, North Carolina Indicators; http://datacenter.kidscount.org/data/bystate/Default.aspx?state=NC

Medicaid

Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. It serves low-income parents, children, seniors, and people with disabilities. The coverage is different for people with different kinds of needs, as are the eligibility requirements. Chief among these requirements is low income, which depending on service can range from 51% to 200% of the Federal Poverty Guideline.

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Table 65 summarizes data on Medicaid eligibility and expenditures from FY2001 through FY2008.

 The number of persons in Dare County eligible for Medicaid rose every year throughout the period cited. The number eligible in 2008 (3,985) was 28.4% higher than the number eligible in 2001 (3,103). This same trend can be noted at the state level; in Carteret County there was in increase in the number of Medicaid-eligible in every year except 2007.  The percent of Medicaid-eligible persons in Dare County and Carteret County varied up and down over the period cited, but increased overall between 2001 and 2008 in both jurisdictions. At the state level the percentage of eligible persons increased every year.  The percent eligible figures for Dare County were consistently and significantly lower than the comparable figures for both Carteret County and the state as a whole.  The dollar expenditure per eligible also fluctuated up and down from year to year in both Dare County and Carteret County, although in both jurisdictions the expenditure increased overall between 2001 and 2008. In Dare County the 2008 expenditure per eligible ($5,322) was 24% higher than the comparable figure in 2001 ($4,286). At the state level the expenditure increased every year throughout the period cited, and by 2008 was 34% higher than the expenditure in 2001.

Table 65. Medicaid Eligibility and Expenditures (FY2001-FY2008)

FY2001 FY2002 FY2003 FY2004

Location No. % Expenditure No. % Expenditure No. % Expenditure No. % Expenditure Eligible Eligible per Eligible Eligible Eligible per Eligible Eligible Eligible per Eligible Eligible Eligible per Eligible

Dare County 3,103 10.35 $4,286 3,130 10.03 $4,576 3,245 10.08 $5,049 3,457 10.37 $5,663 Carteret County 8,940 15.05 $4,478 8,710 14.61 $4,688 9,091 15.14 $4,730 9,398 15.51 $5,031 State of NC 1,354,593 16.83 $3,926 1,390,028 16.98 $4,267 1,447,283 17.39 $4,354 1,512,360 17.97 $4,567

FY2005 FY2006 FY2007 FY2008

Dare County 3,521 10.28 $5,799 3,778 10.86 $4,978 3,865 11.15 $4,844 3,985 11.63 $5,322 Carteret County 9,411 15.21 $5,284 9,789 15.60 $5,076 9,723 15.30 $5,365 9,919 15.67 $5,577 State of NC 1,563,751 18.31 $4,836 1,602,645 18.46 $4,934 1,682,028 18.98 $5,081 1,726,412 19.04 $5,262

Source: NC Division of Medical Assistance, Statistics and Reports, Medicaid Annual Reports (2001-2008), Medicaid Tables, NC Medicaid Eligibility and Program Expenditures for Which the County is Responsible for Its Computable Share; http://www.dhhs.state.nc.us/dma/pub/annualreports.htm

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As noted previously, children and youth under the age of 20 often suffer a disproportionate burden of poverty, and eligibility for Medicaid is another measure of poverty in a community. Medicaid programs can help this population overcome financial barriers to accessing health care. Table 66 presents data on the number and percent of children in Dare County, Carteret County and NC as a whole eligible for Medicaid during the period from 2003-2007.

 The number and percent of children and youth eligible for Medicaid in Dare County rose from one year to the next throughout the period cited. Between 2003 and 2007, the number of young people eligible had risen by 20%, and the percent eligible had risen by 13%. The patterns of increase were similar in the other two jurisdictions.

Table 66. Youth Age 0-20 Eligible for Medicaid (2003-2007)

2003 2004 2005 2006 2007 Location No. % No. % No. % No. % No. %

Dare County 1,995 26.8 2,097 27.6 2,113 27.1 2,331 29.5 2,394 30.3 Carteret County 4,864 36.8 5,037 38.7 5,055 39.0 5,275 40.9 5,196 39.9 State of NC 821,586 36.0 860,795 37.4 895,663 38.5 951,311 40.4 980,893 40.7

Source: NC-CATCH, County Health Profile, Economic Indicators, Medicaid Eligibles Age 0-20; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Health Check and Early Periodic Screening Diagnostic Treatment

Federal law requires that Medicaid-eligible children under the age of 21 receive any medically necessary health care service covered by the federal Medicaid law, even if the service is not normally included in the NC State Medicaid Plan. This requirement is called Early Periodic Screening, Diagnostic and Treatment (EPSDT). In NC, Health Check EPSDT covers complete medical and dental check-ups, provides vision and hearing screenings, and referrals for treatment (25).

Table 67 presents a three-year summary of the participation of elibigle children in the NC Health Check (NCHC) program.

 The number of Dare County children eligible for NCHC services increased from one fiscal year to the next over the period cited.  The NCHC participation ratio in Dare County was below the comparable ratios for Carteret County and for NC as a whole for all three fiscal years cited.

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Table 67. Participation in NC Health Check EPSDT (FY2006-07 through FY2008-09)

FY2006-07 FY2007-08 FY2008-09 No. Eligibles Due No. Eligibles Due No. Eligibles Due Location No. Participation No. Participation No. Participation Initial or Initial or Initial or Periodic Eligible Ratio 1 Eligible Ratio Eligible Ratio Periodic Service Periodic Servics Service

Dare County 2,402 1,472 74.0 2,442 1,526 75.2 2,683 1,605 72.6 Carteret County 5,186 2,863 83.9 5,232 2,870 88.7 5,577 3,054 87.7 State of NC 976,383 542,209 75.8 n/a 563,421 77.3 n/a 594,043 80.0

Source: NC Division of Medical Assistance, Statistics and Reports, Health Check Participation Data; http://www.ncdhhs.gov/dma/healthcheck/participationdata.htm 1 The participation ratio is calculated by dividing the number of eligibles receiving at least one initial screening service by the number of eligibles who should receive at least one initial or period screenings (not shown in the table).

The county department of social services is responsible for facilitating their clients’ access to the full range of Medicaid services for which they may qualify. Table 68 presents data about Medicaid services facilitated by Dare County DSS from that agency’s State of the Department Annual Reports for the period from 2004-2009.

 The agency’s data would seem to indicate increased demand for Medicaid services during the last two reporting periods.  The number of applications for Family Medicaid and the average monthly numbers of both households and individuals receiving Family Medicaid services in 2009 were the maxima for the entire period cited.  The number of applications for NC Health Choice, and the average monthly of numbers of both households and individuals receiving NCHC services, while on the rise over the three most recent reporting periods shown, have not yet attained their levels of 2004 and 2005.  The number of applications for adult Medicaid rose during the latest three reporting periods, and the current figure (690) is a six-year high.

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Table 68. Medicaid Services Facilitated by Dare County Department of Social Services (2004-2009)

Service/Activity 2004 2005 2006 2007 2008 2009

Family Medicaid No. Applications Received 2,216* 2,502* 2,418 2,234 2,437 2,612 Average Monthly Households 1,101 1,159 1,453 1,491 1,576 1,771 Average Monthly Individuals 1,522 1,535 1,864 1,907 2,041 2,331

North Carolina Health Choice No. Applications Approved 298* 300* 136 200 213 256 Average Monthly NCHC Households 335 342 261 262 313 327 Average Monthly NCHC Individuals 501 518 367 385 429 477

Adult Medicaid No. Applications Received 388* 388* 364 429 522 690

Source: Dare County Department of Social Services, State of the Department Annual Reports, 2005, 2006, 2007, 2008, 2009, 2010 * Value presented is an estimated created by doubling the reported 6-month total

Medicaid Managed Care: Community Care of North Carolina/Carolina ACCESS

The goal of Medicaid managed care is to create community health networks to achieve long-term quality, cost, access, and utilization objectives. North Carolina’s approach to Medicaid managed care is to create medical homes for eligible Medicaid recipients by enrolling them into Community Care of NC/Carolina ACCESS (CCNC/CA). Today CCNC/CA combines Carolina ACCCESS and ACCESS II/III, which are primary care case management health plans (26).

Carolina ACCESS

Carolina ACCESS, implemented in 1991, is NC’s Primary Care Case Management (PCCM) Program for Medicaid recipients. It serves as the foundation managed care program for Medicaid recipients and brings a system of coordinated care to the Medicaid program by linking each eligible recipient with a primary care provider (PCP) who has agreed to provide or arrange for healthcare services for each enrollee. Primary care providers bill fee-for-service and are reimbursed based on the Medicaid fee schedule; they also receive a small monetary incentive per member per month for coordinating the care of program participants enrolled with their practice. By improving access to primary care and encouraging a stable doctor-patient relationship, the program helps to promote continuity of care, while reducing inappropriate health service utilization and controlling costs. The program expanded statewide in 1998. Carolina ACCESS created the infrastructure for ACCESS II/III, an enhanced community-based primary care case management health plan (26).

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Carolina ACCESS II/III

ACCESS II and III are enhanced primary care programs initiated in 1998 to work with local providers and networks to manage the Medicaid population with processes that impact both the quality and cost of healthcare. ACCESS II/III includes local networks comprised of community providers such as primary care practices, hospitals, health departments, departments of social services, and othes who have agreed to work together in a public/private partnership to operate as a Carolina ACCESS PCP and provide the care management systems and supports that are needed to manage enrollee care. In addition to a primary care provider, ACCESS II and III enrollees have care managers who assist in developing, implementing, and evaluating enhanced managed care strategies for them. Providers in ACCESS II and III receive a small monetary incentive per member per month; the PCPs are paid a similar small per member per month care management fee. There are fourteen networks operating statewide. Dare County is a member of the Community Care Plan of Eastern Carolina, which also includes 26 other counties in the eastern part of the state (26).

Table 69 summarizes biennial CCNC/CA enrollment data for the period from 2002-2010.

 The percent of Medicaid eligibles enrolled in CCNC/CA fluctuated up and down from one biennial count to the next in all three jurisdictions.  The percent of Dare County Medicaid eligibles enrolled in CCNC/CA was lower than the percent enrolled in Carteret County for all five of the biennial periods cited in the table. The average percent enrolled in Dare County over the entire period was 73.9%; the comparable figure in Carteret County was 88.1%  The percent of Dare County Medicaid eligibles enrolled in CCNC/CA was lower than the percent enrolled in NC as a whole for three of the five biennial periods cited. The average percent enrolled statewide over the entire period was 77.7%.

Table 69. Community Care of NC/Carolina ACCESS Enrollment, Biennial Counts (2002-20101)

2002 2004 2006 2008 2010

% % % % % No. No. No. No. No. Location Medicaid Medicaid Medicaid Medicaid Medicaid Enrolled in Enrolled in Enrolled in Enrolled in Enrolled in Eligibles Eligibles Eligibles Eligibles Eligibles Medicaid Medicaid Medicaid Medicaid Medicaid Enrolled Enrolled Enrolled Enrolled Enrolled

Dare County 1,424 75.58 1,362 69.95 1,747 75.01 1,955 69.80 2,474 79.14 Carteret County 5,440 89.80 5,407 88.65 5,553 85.59 6,148 90.68 6,736 85.97 State of NC 724,819 74.84 782,437 75.13 826,833 73.91 944,667 81.47 1,113,717 82.90

NC Division of Medical Assistance, Statistics and Reports, CCNC/CA Medicaid Monthly Enrollment Reports (Selected Years); http://www.dhhs.state.nc.us/dma/ca/enroll/index.htm 1 Figures for 2002-2008 as of December 31; Figures for 2010 as of June

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Medicare

Medicare is the US government's health insurance program for senior citizens (people 65 years of age or older), certain younger people with specific disabilities, and people with end-stage renal disease. Medicare is an entitlement program and is not based on financial need. Medicare benefits are available to all Americans or their spouses who have paid Social Security taxes through their working years. The Medicare program is funded by the Social Security Administration with a budget equal to about 10% of the entire US budget (27). In 2008 there were 45.3 million persons enrolled in the program (28). In NC in 2009, there were approximately 1.4 million beneficiaries, representing 15.3% of the state’s population (29).

Table 70 summarizes Medicare enrollment data for the period from 2004-2007.

 The total number of aged persons enrolled in Part A and/or Part B Medicare in Dare County increased by 8.8% between 2004 and 2007. The number of disabled persons enrolled in Part A and/or Part B in the county increased by 8.2% over the same period.  The comparable increases in Carteret County were 10.5% among the aged, and 21.6% among the disabled.

Table 70. Medicare Enrollment, Number of Aged and Disabled Persons (2004 and 2007)

2004 2007 Location Aged Disabled Aged Disabled HI/SMI1 HI SMI HI/SMI HI SMI HI/SMI HI SMI HI/SMI HI SMI

Dare County 4,139 4,124 4,051 559 559 510 4,502 4,490 4,372 605 605 537 Carteret County 9,633 9,587 9,433 1,743 1,743 1,644 10,642 10,642 10,369 2,119 2,119 1,973

Source: US Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS); Research, Statistics, Data and Systems; Statistics, Trends and Reports; Medicare Enrollment Reports; http://www.cmslgov/MedicareEnrpts/ 1 Definition: HI = Hospital Insurance (Medicare Part A); SMI = Supplementary Medical Insurance (Medicare Part B), which covers physician and outpatient services.

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Practitioners

One way to judge the supply of health professionals in a jurisdiction is to calculate the ratio of the number of health care providers to the number of persons in the population of that jurisdiction. In NC, there is data on the ratio of active health professionals per 10,000 population calculated at the county level. Table 71 presents those data (which for simplicity’s sake will be referred to simply as the “ratio”) for Dare County, Carteret County and the state as a whole for five key categories of health care professionals: physicians, primary care physicians, registered nurses, dentists and pharmacists. The periods covered are 2004, 2006 and 2008.

 Compared to figures for 2004 and 2006, the 2008 Dare County ratios were the highest for all the categories of professionals except dentists. (However the ratio for dentists in 2006 and 2008 were only one-tenth point apart.)  In Dare County, the ratios for MDs, Primary Care MDs, and RNs were below the comparable NC ratios for all three years cited.  The Dare County ratio for DDSs was above the state ratio for all three years cited, as was the ratio for pharmacists for two of the three years cited.  Statewide, the lowest provider to population ratio historically has been for dentists. The 2008 dentist to population ratio in Dare County (6.2) was 44% higher than the ratio for the state as a whole (4.3).  Statewide, there is a dearth of dentists who accept Medicaid patients (in some counties there are none). At the time of this report, there were six Dare County dental practices (including an oral surgeon) that accepted Medicaid patients (30).

Table 71. Active Health Professionals per 10,000 Population (2004, 2006 and 2008)

2004 2006 2008

Location Primary Primary Primary MDs1 Care RNsDDSs Phar m s MDsCare RNsDDSs Pharms MDs Care RNs DDSs Pharm s MDs MDs MDs

Dare County 13.9 7.7 67.2 5.6 9.7 13.5 7.2 63.3 6.3 7.8 15.7 8.3 68.6 6.2 10.4 Carteret County 14.9 7.2 71.0 6.2 8.7 15.3 6.9 73.6 5.5 8.7 14.3 6.9 77.4 5.0 10.9 State of NC 20.3 8.6 90.7 4.2 8.5 20.8 9.0 92.9 4.4 8.9 21.2 9.0 95.1 4.3 9.3

Source: Cecil G. Sheps Center for Health Services Research, NC Health Professions Data System (HPDS), Publications, NC Health Professions Data Books (Years as noted); http://www.shepscenter.unc.edu/hp/publications.htm 1 Abbreviations used: MDs (Physicians), RNs (Registered Nurses), DDSs (Dentists), Pharms (Pharmacists)

Table 72 lists active health professionals in Dare County, by specialty, for 2008.

 The major medical specialties with the smallest representation are general practice, pediatrics, and psychology.

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Table 72. Active Health Professionals in Dare County, by Specialty (2008)

Category of Professional No.

Physicians Primary Care Physicians 28 Family Practice 17 General Practice 0 Internal Medicine 4 Obstetrics/Gynecology 6 Pediatrics 1 Other Specialties 25

Dentists and Dental Hygienists Dentists 21 Dental Hygienists 24

Nurses Registered Nurses 232 Nurse Practitioners 10 Certified Nurse Midwives 1 Licensed Practical Nurses 35

Other Health Professionals Chiropractors 8 Occupational Therapists 3 Occupational Therapy Assistants 2 Optometrists 3 Pharmacists 35 Physical Therapists 21 Physical Therapy Assistants 2 Physician Assistants 12 Podiatrists 2 Practicing Psychologists 1 Psychological Assistants 1 Respiratory Therapists 7

Source: Source: Cecil G. Sheps Center for Health Services Research, NC Health Professions Data System (HPDS), Publications, NC Health Professions Data Book (2008); http://www.shepscenter.unc.edu/hp/publications.htm

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Hospitals

Table 73, which lists the number of general hospital beds in the three jurisdictions being included in this report, reflects the fact that there is only one hospital in Dare County: Outer Banks Hospital.

Table 73. Number of General Hospital Beds1 (2004-2008)

Location 2004 2005 2006 2007 2008

Dare County 19 19 19 19 21 Carteret County 117 117 135 135 135 State of NC 20,590 20,338 20,329 20,322 20,443

Source: Log Into North Carolina (LINC) Database, Topic Group Vital Statistics and Health (Data Item 524); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show 1 Defined as "general acute care beds" in hospitals; that is, beds which are designated for short-stay use. Excluded are beds in service for dedicated clinical research, substance abuse, psychiatry, rehabilitation, hospice, and long-term care. Also excluded are beds in all federal hospitals and state hospitals.

Outer Banks Hospital

The Outer Banks Hospital (OBH), located in Nags Head, NC, is a full service critical access hospital offering a wide range of inpatient and outpatient services. OBH opened in March 2002 and is one of the newest hospitals in the eastern part if the state.

The hospital was designed especially to meet the health needs of a coastal community, whose year-round population of approximately 35,000 swells to about 250,000 in the summer season. OBH, which is fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JACHO), provides high quality care to all patients, regardless of their ability to pay, and has been nationally recognized for its outstanding patient care.

The hospital's 21 private rooms are furnished with built-in couches for family members and visitors. Two of the hospital's 21 beds are designed as labor/delivery/recovery/postpartum rooms, and one is a Level 1 nursery bed. More than 400 babies are born at OBH every year.

The Emergency Department employs physicians who are board certified in emergency medicine, and trauma-trained RNs who are supported by unit secretaries and nursing assistants. During the summer, a Minor Care section helps accommodate the increased volume of patients seen during the tourist season. Dare County Emergency Medical Services provides medical air transports out of the community utilizing the helipad adjacent to the Emergency Department, weather permitting.

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The hospital has two operating rooms used for general surgery and a third designated for Cesaerean-sections. The Outer Banks Hospital is a partnership between University Health Systems of Eastern Carolina and Chesapeake Regional Medical Center (31).

Other Hospitals

Table 74 lists eight NC hospitals in counties within commuting distance of Dare County. Of these, only Pitt County Memorial Hospital in Greenville offers a Trauma Center (rated for Level I care).

Table 74. North Carolina Hospitals in the Vicinity of Dare County

Operating County/Facility Name Location No. Beds Rooms

Beaufort County Beaufort County Medical Center Washington General - 120 7 Psychiatric - 22 Pungo District Hospital CorporationBelhaven General - 39 2 Nursing Home - 10 Washington Washington County Hospital Plymouth General - 49 2 Pasquotank Albemarle Hospital Elizabeth City General - 182 13 Chowan Chowan Hospital Edenton General - 49 4 Nursing Home - 40 Bertie Bertie Memorial Hospital Windsor General - 6 2 Martin Martin General Hospital Williamston General - 49 3 Pitt Pitt County Memorial Hospital Greenville General - 734 35 Rehabilitation - 75 Psychiatric - 52

Source - NC Department of Health and Human Services, Division of Health Services Regulation (DHSR), Licensed Facilities, Hospitals (by County); http://www.ncdhhs.gov/dhsr/reports.htm

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Because of its location in northeastern NC, residents of Dare County may seek medical services in southeastern VA, primarily in the area referred to as Tidewater. There are 15 hospitals in the Tidewater VA area: 2 in Chesapeake, 7 in Norfolk, 4 in Virginia Beach, and 2 in Portsmouth (32).

Emergency Services

Dare County Emergency Medical Services operates a system of eight stations that extend throughout the county, in Kill Devil Hills, Manteo, Frisco, Southern Shores, Nags Head, Rodanthe, Dare County Airport (Manteo), and Manns Harbor.

Dare County EMS operates Type III “box” ambulances capable of transporting two patients and EMS crew members. Dare County also operates an EMS-configured MMB BK117 helicopter, capable of transporting two patients and air crew members. EMS staff function at three certification levels: Paramedic, EMT-Intermediate, and EMT-Basic. The Dare County EMS system provides Advanced Life Support (ALS) to every emergency call. All staff hold certifications issued by the State of NC, and paramedics also maintain current certifications in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Basic Trauma Life Support (BTLS) (33).

Table 75 lists a summary of the Dare County EMS calls for 2009.

Table 75. Emergency Calls to Dare County EMS (2009)

Call Type No. Calls Call Type No. Calls

Patient refusals 1,057 Hemorrhage - GI 110 Calls cancelled, EMS not needed 937 Fire standbys 87 Trauma 911 Phychiatric/behavioral/anxiety 84 Cardiac symptoms 803 Hypertension 82 Respiratory 481 Diabetic 70 Sick, flu, dehydration 477 Overdose 65 Falls 421 Allergic reaction 50 Abdominal pain, nausea, vomiting 397 Water-related 50 Syncopal episodes 321 Alcohol-related 48 Convalescent transports 319 Event standbys 48 Patient assistance 232 Pregnancy/childbirth 42 Well person checks 152 Environmental 26 Altered level of consciousness 146 Choking 19 Stroke 137 Animal bite 14 Seizures 130 Epistaxis 11 Back pain 118

Source: Dare County EMS Annual Report, 2009

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The Outer Banks Hospital Emergency Department treats many of the patients involved in Dare County EMS calls, as well as patients who self-refer and travel there by other means. Table 76 describes emergency department (ED) utilization statistics for Outer Banks Hospital for 2009. In 2009, 655 (2.8%) of all ED visits resulted in admission. The vast majority of the ED patients (21,416 or 88.8%) were treated and released.

Table 76. Emergency Department Utilization, Outer Banks Hospital (2009)

Parameter No. Patients

Total Patients 24,104 Volum e by Age 0-18 5,713 19-54 12,625 55+ 5,766 Volume by Disposition Admitted 665 Transferred 1,337 Sent home 21,416 Other disposition 686

Source: Emergency Department Demographics, Outer Banks Hospital, Patients Arriving 01/01/09 to 12/31/09; personal communication from Ed Heise, OBH to Laura Willingham, DCDPH, June 8, 2010.

Dare County Department of Public Health

The mission of the Dare County Department of Public Health (DCDPH) is to promote healthy living and optimize the quality of life for all residents of Dare County through prevention education, outreach, clinical care services, and environmental protection. The DCDPH operates facilities in Manteo, Frisco, Nags Head and Kill Devil Hills. The agency’s primary services are listed below.

Clinical Services Division

 Adult Health – Adult Health program provides preventive services such as physicals, immunizations and some laboratory testing. Identifying and providing education in minimizing health risks is an important component of this program.

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 Maternal Health – The Maternal Health program targets uninsured and underinsured pregnant women to prevent maternal and infant morbidity and mortality through early and consistent access to prenatal and postpartum care to ensure healthy outcomes for women and babies.  Maternity Care Coordination (MCC) – Maternity Care Coordination focuses on the care of pregnant women including their personal and family needs. The primary goal is early access to health care, social services, and community based support systems that contribute to the physical and emotional wellness of the pregnant woman and her baby.  Baby LINKS (BL) – The Baby LINKS program provides skilled nursing assessments for postpartum mothers and newborns and ‘Links’ new mothers in Dare County to available support services. The BL nurse provides follow-up visits as needed and referrals for services offered at the DCDPH.  Child Health – The Child Health program provides preventive health services and physical and developmental assessments to identify and minimize potential health risks for infants and children. Childhood immunizations including flu vaccines are available through DCDPH Child Health services. The program also includes school health, dental health, and health education components.  Health Check Coordination (HCC) – The Health Check Coordinator improves access and removes barriers to health care for Medicaid eligible children by assisting families with children through age 19, in obtaining health insurance coverage, periodic well child checkups, specialized medical services, dental care, age appropriate immunizations and transportation. In addition the HCC offers assistance in obtaining other Medicaid coverage including Medicaid for Pregnant Women and Presumptive Medicaid.  Child Service Coordination (CSC) – Child Service Coordination provides services to children from birth to age three at risk for developmental delays or disabilities, or up to age five for those diagnosed delay or disability.  Family Planning – The Family Planning program provides information and the means to clients so they can exercise personal choice in determining the number and spacing of their children and to improve health practices that will reduce long term health risks. This program provides education, counseling and clinical services to clients.  Immunization Program – The Immunization program promotes public health through the identification and elimination of vaccine- preventable diseases like polio, hepatitis B, measles, chickenpox, whooping cough, tetanus, rubella (German measles), and mumps. Education to raise awareness of the importance of immunizations across the ages is a vital component of the services offered.  Medical Nutrition Therapy Program – The Medical Nutrition Therapy (MNT) program provides nutrition assessment and counseling to improve individual and community health through nutrition education and health provider/staff education.  Diabetes Education and Management Program – The ADA recognized Diabetes Education and Management Program provides diabetes assessment and education for people with Type 2 Diabetes Mellitus, Type 1 Diabetes Mellitus, Gestational Diabetes Mellitus and Juvenile Diabetes.  Breast and Cervical Cancer Control – The DCDPH provides free or low cost breast and cervical cancer screening and follow up diagnostic testing.  Sexually Transmitted Infections (STI) – All individuals seeking STI services receive on-site screening and treatment regardless of their county of residence. Those requesting HIV testing services receive laboratory testing and referral for treatment of HIV/ AIDS symptoms.

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Dental Services

Miles of Smiles is a school based dental program operating from a mobile dental clinic. The program van has two dental chairs and is staffed by a dentist and dental assistant. The van has a rotating schedule through Dare and Hyde counties.

Women-Infants-Children (WIC)

WIC is a food supplement and nutrition education program for pregnant and post-partum women, infants, and children under age five. Qualified participants receive food and infant formula. WIC also provides breastfeeding education and support, and loans breast pumps.

Communicable Disease Control and Surveillance Services (CD)

The Communicable Disease Program provides surveillance and tracking of all CDC reportable diseases and emerging health threats. Disease outbreak investigations are conducted and appropriate control measures are implemented. Staff work together utilizing the multidisciplinary EPI Team model to assess data and information, address what actions need to be taken and how to assure the community is receiving information to meet its needs.

Public Health Preparedness

Preparedness is charged with insuring that the public’s health is protected in the case of intentional disasters (e.g., terrorism) or unintentional crises such as pandemics and weather related events (e.g., hurricanes and floods).

School Health

School Health Nurses provide screening, evaluation, treatment, health education, and case management for chronic illnesses for children in Dare County Schools. In addition, the nurses provide counseling services as necessary, and sponsor small group discussions with students on peer pressure, decision making skills, and goal setting. They track school-required immunizations and provide vaccines as needed to assure that children are protected.

Health Education Division

 Peer Power Program – Peer Power is a program provided in collaboration with Dare County Schools that teaches students about healthy behaviors including nutrition, physical activity, and the harmful effects of tobacco use.  Touch No Tobacco (TNT) program – The purpose of the TNT program is to prevent tobacco use initiation, eliminate exposure to secondhand smoke, promote tobacco cessation and reduce health disparities attributable to tobacco use.  Healthy Carolinians of the Outer Banks – Healthy Carolinians of the Outer Banks (HCOB) is a collaborative, community based network of individuals, businesses, government and non-profit organizations dedicated to improving the quality of life for all county

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residents by evaluating and addressing community issues, supporting health education and awareness, and promoting resource accessibility. Healthy Carolinians aids the DCDPH in completing the Community Health Assessment (CHA) every four years.  Public Awareness Activities – The Health Education Division works closely with all Health Department Staff to increase public awareness of services offered.  Community Health Education and Health Promotion – Health Promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health. The primary means of health promotion occur through developing healthy public policy that addresses the prerequisites of health such as income, housing, food security, employment, and quality working conditions.

Dare Home Health and Hospice Division

 Home Health – The Home Health program provides skilled care in the home in compliance with the Medicare Conditions of Participation, in order to assist patients to return to their maximum level of functioning as quickly as possible. Services include Skilled Nursing, Rehabilitative Supports (Physical, Occupation and Speech Therapy), Nutrition Therapy, Certified Nursing Assistants, and Social Work support. Medicare, Medicaid, Private Insurance and Self Pay are accepted for payment of services.  Hospice – The Hospice program provides palliative care, symptom management and holistic support for individuals at the end of life, and their families. Services are provided with a team centered focus and address physical, emotional, relational and spiritual needs. Services include Skilled Nursing, Social Work support, Bereavement support, Rehabilitative Supports (Physical, Occupation and Speech Therapy), Nutrition Therapy, Chaplain, Medical Director, Certified Nursing Assistants, and trained Hospice Volunteers. Medicare, Medicaid, Private Insurance and Self Pay are accepted for payment of services. Additionally, community funds and memorial donations may be utilized for under/un-insured patients.  Respite Care – The Respite Care program provides trained volunteers to offer a brief break or “respite” to family caregivers. Volunteers go into the home to provide psychosocial support to the care recipient, thereby allowing the family caregiver time to engage in restorative activities in order to return to their care giving role renewed, refreshed and better able to respond to the demands of full-time care giving. These services are made available without charge.

Environmental Health Division

 On-Site Water Protection Program – This program is responsible for activities associated with subsurface sewage collection, treatment and disposal and for activities associated with private drinking water wells.  Recreational Water Quality Program – This program works closely with the N.C. Recreational Water Quality Program to protect the public health. Coastal waters are monitored by the state. Public notices are issued when bacteriological standards for safe bodily contact, established by the EPA, are exceeded.  Food and Lodging Program – This programs include the inspection of all food handling facilities, lodging facilities, childcare and residential care facilities, institutions, tattoo artists/establishments, and public swimming pools and spas to ensure that they comply with the sanitation standards established within the state rules.

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Substance Abuse Division

The goal of Dare County Substance Abuse programming is to build an effective prevention, intervention and treatment system for Dare County by providing a continuum of substance abuse services including:

 Prevention Services – School-based substance abuse prevention programs are delivered in collaboration with Dare County Schools. A children’s program at the outpatient clinic is available to help children in grades K-5 in coping with a loved one with a substance use disorder. Community awareness and education is an important component of prevention services.  Intervention Services/New Horizons - Alcohol and drug assessment services are available to adults and adolescents. An after- hours helpline is available to community members. School based intervention services are available to adolescents.  Treatment Services/New Horizons - Outpatient, individual, and group services are available for adolescents and adults with a substance use disorder.

Other Health Care Facilities (in alphabetical order)

Albemarle Health Regional Health Center

Albemarle Health Regional Health Center, an affiliate of Albemarle Hospital in Elizabeth City, NC, is located in Kitty Hawk. The facility houses an outpatient surgery center, laboratory, diagnostic imaging services, and offices for nearly 50 physicians. Its services include Urgent Care and Family Medicine (provided by Beach Medical Care, Ltd.), Same Day Surgery, and Radiology which features MRI, Mammography, and CT (35, 36).

Community Care Clinic of Dare

The Community Care Clinic of Dare provides basic healthcare, medication assistance, and wellness education for financially challenged, uninsured persons living or working in Dare County. It was founded in 2005 by a partnership of the Albemarle Hospital Foundation, Dare County Department of Public Health, and The Outer Banks Hospital. The Clinic currently operates facilities in Kitty Hawk, Frisco, and Manteo. Although open primarily in the daytime, each site offers some evening hours. Visits are scheduled by appointment. To be eligible to receive services from the Community Care Clinic of Dare the patient must:

 be between 18 and 65 years of age,  live or work in Dare County,  have no health insurance, Medicare, or Medicaid OR have non-comprehensive health insurance,  have income at or below 250% of the federal poverty level if living in Dare County,  have income at or below 225% of the federal poverty level if working in Dare County and living elsewhere,

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 have less than $3,000 cash on hand or in a bank, and  have household income less than the limits set forth in the Patient Eligibility guidelines.

The Community Care Clinic of Dare provides: basic (non-emergency) medical care; specialty care referrals when possible; prescription drug access (excluding pain medication) through voucher and Prescription Assistance Programs; health education; and interagency referrals. It does not provide: emergency or urgent care services, access to narcotics or other controlled medications including those for pain management, mental health care, or obstetrical and gynecological care (37).

Dare County Dialysis Center

Dare County Dialysis Center is a small, for-profit dialysis clinic located in Manteo; it is managed by Fresenius Medical Care, which operates other dialysis facilities throughout the country. The Center has nine stations offering hemodialysis services. It is Medicare certified (38).

Dare Home Health and Hospice

Dare Home Health, a program of the Dare County Departmenf of Public Health, has provided home health services to Dare County residents since 1976. Dare Hospice, Inc., a volunteer non-profit organization, joined with the home health agency in June 1997. Dare Home Health and Hospice is Medicare certified for both home health and hospice, and is accredited by the Accreditation Commission for Health Care, Inc. (39) (See also Dare County Department of Public Health).

HealthEast Family Care

HealthEast Family Care is a network of three facilities (in Avon, Hatteras and Nags Head) offering comprehensive primary medical care for children and adults. Specialties vary with site, but include Family Medicine, Internal Medicine, and Pediatrics (35).

Outer Banks Cancer Center

The Outer Banks Cancer Center, located in Nags Head, offers radiation treatment for cancer patients (35).

Outer Banks Urgent Care Center

Outer Banks Urgent Care in Nags Head offers early- through late-day urgent and emergency care, and regular family medical care by appointment (35). 107 Dare County Community Health Assessment – Volume One Health Care and Health Promotion Resources

School Health

According to the Dare County Schools website (http://www.darecountyschoolsonline.com/moxie/admin/health/index.shtml), Dare County is one of the few counties in NC to have a school health nurse in each of its county schools. The majority of the school health nursing staff is employed the the Dare County Department of Public Health, which offers other services to Dare County Schools, including the Peer Power and other school-based programs.

Table 77 presents the Student-to-School-Nurse Ratio for the three jurisdictions covered in this report.

 The Student-to-School Nurse ratio in Dare County decreased in each of the periods cited.

Table 77. Student to School Nurse Ratio (2000,2003 and 2006)

School Nurse to Student Ratio Location 2000 2003 2006

Dare County 650.0 589.8 485.8 Carteret County 1344.0 1161.1 1368.2 State of NC 2075.0 1897.1 1340.7

Source: NC-CATCH, County Health Profiles, Health Profile, Health Care Access, School Nurse to Student Ratio; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Dare County school health nurses offer a variety of services to its educational facilities, including (but not limited to) immunization audits, vision screenings, educational programs, and communicable disease prevention. Table 78 presents a summary of the services provided by all nurses in Dare County schools for SY2009-10.

 The public is sometimes surprised by the variety of services provided by school nurses. Student’s needs range from first aid for cuts, acute illness nursing and hygiene counseling to chronic disease management, grief counseling and suicide prevention.

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Table 78. School Nurse Activity Summary (SY2009-10)

No. Services Provided/ Nature of Activity Clients Served

Screening Vision 2,058 Dental 207 Immunization Audit 2,920 Pediculosis 405 Counseling - Individual Session Depression/Psychological Problem/Suicide 971 Pregnancy 125 Tobacco Use 50 Substance Abuse 61 Hygiene/Puberty 1,402 Child Abuse/Neglect 7 Grief/Loss 38 Bullying/Violence 174 Chronic Illness - Individual Interventions Asthma 476 Peak Flow 42 Nebulizer 16 Diabetes 625 Blood Sugar 330 Other Chronic Illness 857 Services - Individual Interventions First Aid At home 6,210 Major injury 86 Major illness 27 Minor injury at school 4,012 Minor illness at school 18,460 Communicable Disease 1 Individual Education Plan (IEP) 83 Conferences Parents 6,828 Teachers 6,243 Students 2,295 Other Professionals 2,969 Presentations Students 236 Parents 5 Staff 49

Source: Annual School Health Report 2009-2010; personal communication from Laura Willingham (Dare County Department of Public Health) transmitted via email to S. Pfaender

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Long-Term Care Facilities

The NC Division of Aging and Adult Services is the state agency responsible for planning, monitoring and regulating services, benefits and protections to support older adults, persons with disabilities, and their families. That agency is the source for the following information on categories of long- and short-term adult care (43). Among the facilities under the agency’s regulatory jurisdiction are the long-term care facilities described below.

Nursing Homes

Nursing homes are facilities that provide skilled nursing or convalescent care for three or more persons unrelated to the licensee. A nursing home provides long-term care of chronic conditions, or short-term convalescent or rehabilitative care of remedial ailments for which medical and nursing care are indicated. All nursing homes must be licensed in accordance with state law by the NC Division of Facility Services, Licensure Section (43).

Table 79 shows the number of nursing facility beds in Dare County, Carteret County, and the state of NC.

 The number of nursing facility beds in both Dare County and Carteret County have been static from 2005 through 2009. At the state level the number of nursing facility beds grew by only 0.7% over that period.

Table 79. Number of Nursing Facility Beds1 (2005-2009)

Location 2005 2006 2007 2008 2009

Dare County 126 126 126 126 126 Carteret County 424 424 424 424 424 State of NC 43,987 44,248 44,210 44,234 44,315

Source: Log Into North Carolina (LINC) Database, Topic Group Vital Statistics and Health (Data Item 513); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show 1 This count includes beds licensed as nursing facility beds, meaning those offering a level of care less than that offered in an acute care hospital, but providing licensed nursing coverage 24 hours a day, seven days a week.

Adult Care Homes

Adult care homes are residences for aged and disabled adults who may require 24-hour supervision and assistance with personal care needs. People in adult care homes typically need a place to live, some help with personal care (such as dressing, grooming and keeping up

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with medications), and some limited supervision. Medical care may be provided on occasion but is not routinely needed. These facilities, which are also sometimes called domiciliary homes, rest homes, or family care homes, vary in capacity from 2 to 100. Adult care homes differ from nursing homes in that the former provide a less sophisticated level of care and require lesser qualifications for staff. The 1,400 adult care homes in NC are licensed by the Division of Facility Services, Group Care Section, and are monitored by Adult Home Specialists within county departments of social services. Facilities that violate licensure rules are subject to sanctions, including fines (43).

Adult Day Care/Adult Day Health Centers

Adult day care provides an organized program of services during the day in a community group setting for the purpose of supporting the personal independence of older adults and promoting their social, physical and emotional well-being. Also included in the service, when supported by funding from the Division of Aging and Adult Services (NCDAAS), are no-cost medical examinations required for admission to the program. Nutritional meals and snacks, as appropriate, are also expected. Providers of adult day care must meet State Standards for Certification, which are administrative rules set by the state Social Services Commission. These standards are enforced by the office of the Adult Day Care Consultant within the NCDAAS. Routine monitoring of compliance is performed by Adult Day Care Coordinators located at county departments of social services. Costs to consumers vary, and there is limited funding for adult day care from state and federal sources (43). The NCDAAS did not list any adult day care/adult day health centers for Dare County at the time this report was developed.

Table 80 lists all the NC-licensed adult care facilities in Dare County as of 2009.

 There were only three licensed adult care facilities in Dare County at the time of this summary – one nursing home, one adult care home, and one family care home – offering a total of 201 beds.

Table 80. NC-Licensed Adult Care Facilities in Dare County (2009)

Star Rating Facility Type/Name Location # Beds (If applicable)

Adult Care Homes/Homes for the Aged Spring Arbor of the Outer Banks Kill Devil Hills 72 4

Family Care Homes Canine Cabana Nags Head 3 n/a

Nursing Homes/Homes for the Aged Britthaven of the Outer Banks Nags Head 126 n/a

Source - NC Department of Health and Human Services, Division of Health Services Regulation (DHSR), Licensed Facilities, Adult Care Homes, Family Care Homes, Nursing Facilities (by County); http://www.ncdhhs.gov/dhsr/reports.htm

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 According to the Medicare Nursing Home Compare system, the one nursing home in Dare County – Britthaven of the Outer Banks – participates in Medicare and Medicaid (41).

Alternatives to Institutional Care

An alternative to institutional care preferred by many disabled and senior citizens is to remain at home and use community in-home health and/or home aide services. As noted previously, Dare Home Health and Hospice is the home health services provider in the county. In addition, Dare County DSS facilitates access to in-home aide services for their clients. Aide services typically include help with bathing, dressing, walking, meal preparation, essential errands, housekeeping and home management (42). Table 81 presents in-home aide service utilization data for the period from 2004-2009.

 There was a net increase in the annual number of clients who received Dare County DSS in-home aide services between 2004 and 2009. The annual average number of clients over the period cited was 153.  For the period cited the number of hours of in-home aide services provided by Dare County DSS peaked in 2006 (34,665) and has declined since. The annual average number of hours of services provided throughout this period was 31,624.

Table 81. In-home Aide Services Provided by Dare County Department of Social Services (2004-2009)

Activity 2004 2005 2006 2007 2008 2009

No. of Clients Served 147 153 144 153 156 162 No. Hours of Service Provided 31,004 31,365 34,665 31,515 30,195 31,001

Source: Dare County Department of Social Services, State of the Department Annual Reports, 2005, 2006, 2007, 2008, 2009, 2010

Mental Health Services and Facilities

The unit of NC government responsible for overseeing mental health services is the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS). In NC, the mental health system is built on a system of Local Management Entities (LMEs). LMEs are agencies of local government – area authorities or county programs – that are responsible for managing, coordinating, facilitating and monitoring the provision of mental health, developmental disabilities and substance abuse services in the catchment area served. LME responsibilities include offering consumers 24/7/365 access to services, developing and overseeing providers, and handling consumer complaints and grievances (43).

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At the time this report was prepared, the LME for Dare County was East Carolina Behavioral Health (ECBH). In July 2009 NC DMH/DD/SAS contracted with ECBH to “stabilize” the operations of the county’s previous LME, Albemarle Mental Health (AMH), and develop a network of services (44).

ECBH serves a total of 19 counties in eastern NC, facilitating mental health services for both children and adults. Services offered include: diagnostic assessment, outpatient therapy, multi-systemic therapy, psychosocial rehabilitation, developmental therapy, intensive in-home services, medication management, substance abuse residential care, day treatment, community respite, group living, supportive living, supportive employment, substance abuse treatment (outpatient and residential), day activity and vocational program for the developmentally disabled, personal assistance, and targeted case management.

It should be noted, however, that the list of ECBH services relates to providers throughout the 19-county service area; at the present time very few system providers and services are located in Dare County itself. A gap analysis commissioned by ECBH and released in March, 2010 identified many services in the former 10-county AMH LME that would need to improve dramatically in order to meet present needs. For example, the gap analysis revealed that disabled populations were “dramatically underserved”, substance abuse services were “almost non-existent”, and that people living in the area had “no expectations” for local services (44). Gap analysis findings specific to Dare County included the following:

 Lack of substance abuse services  Lack of short- and long-term inpatient treatment beds  Lack of psychiatrists  Lack of crisis care  Lack of collaboration among mental health care providers

Anecdotal reports indicate that people in Dare County appear to be satisfied with changes and improvements in MH/DD/SAS service management that ECBH has been able to accomplish thus far. A follow-up study will be necessary to demonstrate measurable improved outcomes.

Table 82 lists the NC-licensed mental health facilities in Dare County as of June, 2010.

Table 82. NC-Licensed Mental Health Facilities in Dare County (June, 2010)

Name of Facility Location Category Capacity

Dare Activity Center Manteo Day Activity 6 Roanoke Trail Facility Manteo Supervised Living, Developmentally Disabled 6

Source - NC Department of Health and Human Services, Division of Health Services Regulation (DHSR), Licensed Facilities, Mental Health Facilities (G.S. 122C) (by County); http://www.ncdhhs.gov/dhsr/reports.htm

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Recreational Facilities

Physical activity can support individual and community health and wellbeing. Dare County offers many opportunities for outdoor physical recreation associated with its temperate climate and its proximity to the ocean: swimming, boating, fishing and hunting, hiking and cycling, to name a few. Those who prefer organized team and/or indoor activities are also well-served by the many recreational facilities, both public and private, located throughout the county. Table 83 lists many of the public parks and recreational centers in the county; Table 84 lists some of the private gyms and sports clubs.

Important note: neither Table 83 nor Table 84 is intended to be all-inclusive.

Table 83. Public Parks and Recreational Centers in Dare County (July, 2010)

Name Location Facilities

Public Parks and Recreation Centers Avon Kinnakeet Village Playground Avon Playground Fessenden Center Buxton Playground, tennis courts, basketball court, skate park Youth Ball Field Buxton Lighted ball field Dare County Family Recreation Park Kill Devil Hills Playground, covered picnic pavillion, softball field Mann's Harbor Field Mann's Harbor Ball field Westcott Park Manteo Indoor recreation center Old Swimming Hole Manteo Playground Airport Pavillion Manteo Indoor recreation center Roanoke Island Skate Park Manteo Skate park Nags Head Soccer Complex Nags Head Lighted soccer fields Rodanthe, Waves, Salvo Community Center Rodanthe Playground Pointer's Field Stumpy Point Lighted ball field Stumpy Point Playground Stumpy Point Playground Pigum Walker Park Wanchese Playground, tennis courts, ball field

Source: County of Dare, Dare County Parks and Recreation, Parks and Facilities; http://www.co.dare.nc.us/depts/Parks_Rec/facilities.php

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Table 84. Private Gyms and Clubs in Dare County (July, 2010)

Name Location Facilities

Private Gyms and Clubs Astanga Yoga Center Nags Head Yoga lessons Barrier Island Fitness Center Kitty Hawk Weight room, swimming pool, hot tub, steam and sauna Bushin Kan Karate Kitty Hawk Karate classes CrossFit Outer Banks Kill Devil Hills Weights, cardio equipment, conditioning training programs Curves for Women Kill Devil Hills Weight loss consultant and equipment Home Bodies Personal Training Nags Head Personal training, classes Island Fitness Club Buxton Cardiovascular and weight training equipment Island Wellness Health Club Manteo Weights, pool, sauna, kickboxing, yoga, personal training Kilmarlic Health and Racquet Club Harbinger Tennis courts, fitness and swimming KnuckleUp Fitness and Mixed Martial Arts Kitty Hawk Gym, personal training, boxing, health club, lessons OBX Triathlon Club n/a Facilitates fellowship and competitions for triathletes Nautics Hall Health and Fitness Center Manteo Weights, pool, treadmills, resistance equipment, lessons OBX Adult Fitness Center Southern Shores Cardio equipment, circuit training system Outer Banks Family YMCA Nags Head Indoor/outdoor pools, water park, fitness center, classes Outer Banks Karate Nags Head Karate classes Outer Banks Running Club Nags Head Facilitates fellowship and competitions for runners Outer Banks Sports Club Nags Head Gym, sauna, cardio equipment, classes Outer Banks Yoga and Pilates Var. locations Yoga and pilates classes Pine Island Racquet and Fitness Center Pine Island Weights, cardio equipment, tennis courts and tennis instruction Pirate's Cove Realty, Rentals and Fitness Center Manteo Fitness center, swimming pools, tennis courts Resuslts Personal Training Southern Shores Personal training equipment and programs Sanderling Inn Resort, Spa and Fitness Center Duck Fitness center, spa, pool,golf, tennis Spa Koru Avon Spa, salon, and fitness center; residential facilities Why Weight? Women's Total Fitness Southern Shores Weight loss consultation and programming

Sources: Outer Banks Realty, Outer Banks, Services, Outer Banks Fitness Centers; http://outerbeaches.com/ Health Promotion Facilities in Dare County, North Carolina; http://www.hcobx.org/publications/health_promotion_resources.pdf Outer Banks Yellow Pages, Outer Banks Health Clubs; http://outerbanksyellowpages.net/Outer_Banks_Helath_Clubs_and_Centers.html

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Chapter Three

Health Statistics

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Chapter Three: Health Statistics

Methodology

Routinely collected mortality and morbidity surveillance data and behavior survey data can be used to describe the health status of Dare County residents. These data, which are readily available in the public domain, typically use standardized definitions, thus allowing comparisons among county, state and national figures. There is, however, some error associated with each of these data sources. Surveillance systems for communicable diseases and cancer diagnoses, for instance, rely on reports submitted by health care facilities across the state and are likely to miss a small number of cases, and mortality statistics are dependent on the primary cause of death listed on death certificates without consideration of co-occurring conditions.

Understanding Health Statistics

Age-adjustment

Mortality rates, or death rates, are often used as measures of the health status of a community. Many factors can affect the risk of death, including race, gender, occupation, education and income. The most significant factor is age, because the risk of death inevitably increases with age. Thus, as a population ages, its collective risk of death increases. Therefore, an older population will automatically have a higher overall death rate just because of its age distribution. At any one time some communities have higher proportions of “young” people, and other populations have a higher proportion of “old” people. In order to compare mortality data from one community with the same kind of data from another, it is necessary first to control for differences in the age composition of the communities being compared. This is accomplished by “age-adjusting” the data. Age-adjustment is a complicated statistical manipulation usually performed by the professionals responsible for collecting and cataloging health data, such as the staff of the NC State Center for Health Statistics (NCSCHS). It is not necessary to understand the nuances of age-adjustment to use this report. Suffice it to know that age-adjusted data are preferred for comparing health data from one population or community to another and have been used in this report whenever available.

Aggregate Data

Another convention typically used in the presentation of health statistics is aggregate data combining data gathered over a multi-year period, usually three or five years. The practice of presenting data that are aggregated avoids the instability typically associated with using highly variable year-by-year data consisting of relatively few cases or deaths. It is particularly important to aggregate data for smaller jurisdictions like Dare County. The calculation is performed by dividing the number of cases or deaths due to a particular disease over a period of years by the sum of the population size for each of the years in the same period.

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Incidence

Incidence is the population-based rate at which new cases of a disease occur and are diagnosed. It is calculated by dividing the number of newly diagnosed cases of a disease or condition during a given period by the population size during that period. Typically, the resultant value is multiplied by 100,000 and is expressed as cases per 100,000; sometimes the multiplier is a smaller number, usually 10,000.

Incidence

Incidence is calculated according to the following formula:

Incidence = number of new cases of disease X 100,000 = cases per 100,000 people population size

The incidence rates for certain diseases, such as cancer, are simple to obtain, since data are routinely collected by the NC Central Cancer Registry. However, other conditions, such as diabetes or heart disease, are not normally reported to central data-collecting agencies. It is therefore difficult to measure the new burden of certain diseases within a community.

Mortality

Mortality is calculated by dividing the number of deaths due to a specific disease in a given period by the population size in the same period. Like incidence, mortality is a rate, usually presented as number of deaths per 100,000 residents. Mortality rates are easier to obtain than incidence rates since the underlying (or primary) cause of death is routinely reported on death certificates. However, some error can be associated with cause-of-death classification, since it is sometimes difficult to choose a single underlying cause of death from potentially many co-occurring conditions.

Mortality

Mortality is calculated according to the following formula:

Mortality Rate = number of deaths from disease X 100,000 = deaths per 100,000 people population size

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Morbidity

Morbidity as used in this report refers generally to the presence of injury, sickness or disease (and sometimes the symptoms and/or disability resulting from those conditions) in the population.

Prevalence

Prevalence, which describes the extent of a problem, refers to the number of existing cases of a disease or health condition in a population at a defined point in time or during a period. Prevalence expresses a proportion, not a rate. Prevalence is often estimated by consulting hospital records. Hospital discharge records show the number of residents within a county who use hospital in-patient services for given diseases during a specific period. Typically, these data underestimate the true prevalence of the given disease in the population, since individuals who do not seek medical care or who are diagnosed outside of the hospital in-patient setting are not captured by the measure. Note also that decreasing hospital discharge rates do not necessarily indicate decreasing prevalence; rather they may be a result of a lack of access to hospital care.

Trends

Data for multiple years is included in this report wherever possible. Since comparing data on a year-by-year basis can yield very unstable trends due to the often small number of cases and deaths per year, the preferred method for reporting incidence and mortality trend data is long-term trends using the age-adjusted, multi-year aggregate format. Most trend data used in this report are of that type, and are standardized (by the statisticians) to the population at the time of the 2000 US Census.

Small Numbers

Year-to-year variance in small numbers of events can make dramatic differences in rates that can be misleading. For instance, an increase from two events one year to four the next could be statistically insignificant but result in a calculated rate increase 100% larger. Aggregating annual counts over a five year period before calculating a rate is one method used to ameliorate the effect of small numbers. Sometimes even aggregating data is not sufficient, so the NC State Center for Health Statistics recommends that all rates based on fewer than 20 events – whether covering an aggregate period or not – be considered “unstable”. To be sure that unstable data do not become the basis for local decision-making, this report will highlight and discuss primarily rates based on 20 or more events. Where exceptions occur, the narrative will highlight the potential instablilty of the rate being discussed.

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Behavioral Risk Factor Surveillance System (BRFSS)

Dare County residents participate in the state’s annual Behavioral Risk Factor Surveillance System (BRFSS) Survey, as part of an aggregate 41 county sample that encompasses the entire eastern third of NC. It is not possible to isolate survey responses from Dare County BRFSS participants, and since the aggregate regional data covers such a diverse area, the results are not especially useful in describing health in Dare County. As a result, BRFSS data will not be used in this document.

Final Health Data Caveat

Some data that is used in this report may have inherent limitations, due to sample size, or its age, for example, but it is used nevertheless because there is no better alternative. Whenever this kind of data is used, it will be accompanied by a warning about its limitations.

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Health Rankings

America’s Health Rankings

Each year for 20 years, America’s Health RankingsTM, a project of United Health Foundation, has tracked the health of the nation and provided a comprehensive perspective on how the nation – and each state – measures up. America’s Health Rankings is the longest running state-by-state analysis of health in the US (45).

America’s Health Rankings are based on several kinds of measures, including determinants (socioeconomic and behavioral factors and standards of care that underly health and well-being) and outcomes (measures of morbitiy, mortality, and other health conditions). Together the determinates and outcomes help calculate an overall rank.

Table 85 shows where NC stood in the 2009 rankings relative to the “best” and “worst” states.

Table 85. State Rank of North Carolina in America’s Health Rankings (2009)

National Rank (Out of 50)1 Location Overall Determinants Outcomes

Verm ont 1 1 9 2 North Carolina 37 36 38 Mississippi 50 50 50

Source: United Health Foundation, 2009. America's Health Rankings, A Call to Action for Individuals & Their Communities; http://www.americashealthrankings.org/2009/report/AHR2009%20Final%20Report.pdrf 1 Rank of 1 equals "best" 2 State ranked first in Outcomes is Minnesota

MATCH County Health Rankings

Building on the work of America's Health Rankings, the Robert Wood Johnson Foundation, collaborating with the University of Wisconsin Population Health Institute, undertook a project to develop health rankings for the counties in all 50 states. The 2010 County Health Rankings are a key component of the partners’ Mobilizing Action Toward Community Health (MATCH) project (46).

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Each state’s counties are ranked according to health outcomes and the multiple health factors that determine a county’s health. Each county receives a summary rank for its health outcomes and health factors and also for the four different types of health factors: health behaviors, clinical care, social and economic factors, and the physical environment.

Table 86 presents the county rankings for Dare County and Carteret County in terms of health outcomes and health factors.

 Dare County ranks 13th best in NC in terms of mortality; Carteret County ranks 39th.  Dare County ranks 7th best in NC in terms of morbidity; Carteret County ranks 18th.  Among health factors ranked, Dare County ranks higher (i.e., “better”) than Carteret County in social and economic factors and physical environment. Carteret County ranks higher than Dare County in health behaviors and clinical care.

Table 86. MATCH Rankings for Dare County and Carteret County among NC Counties (2010)

County Rank (Out of 100)1 Health Outcomes Health Factors Location Social & Health Clinical Physical Mortality Morbidity Economic Behaviors Care Environment Fa c tor s

Dare County137 48871024 Carteret County 39 18 33 62 14 50

Source: County Health Rankings. Mobilizing Action Toward Community Health (MATCH). 2010. University of Wisconsin Population Health Institute; http://www.countyhealthrankings.org/print/north-carolina 1 Rank of 1 equals "best".

Table 87 presents some of detailed information included in the rankings in Table 86. From this table it is clear what contributes to a “higher” or “lower” ranking.

 Smoking and binge drinking negatively affect Dare County’s health behaviors ranking. (Note that the use of controlled substances and misuse of prescription drugs are not part of the ranking system.)  A higher proportion of uninsured adults negatively affects Dare County’s clinical care ranking.  High educational attainment and a lower percentage of children in poverty are among the factors positively affecting Dare County’s social and economic factors ranking.  Access to healthy foods positively affects Dare County’s physical environment ranking.

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Table 87. MATCH County Health Rankings Detail (2010)

Dare Carteret NC County Health Factor Target County County Average Mortality Premature death 7,512 8,526 8,174 7,420 Morbidity Poor or fair health 12% 15% 19% 15% Poor physical health days 3.8 3.7 3.6 3.1 Poor mental health days 3.1 3.6 3.2 2.7 Low birthweight 7.5% 7.7% 9.0% 7.7% Health Factors Health Behaviors Adult smoking 29% 26% 23% 20% Adult obesity 24% 27% 29% 24% Binge drinking 25% 14% 11% 5% Motor vehicle crash death rate 23 19 20 15 Chlamydia rate 127 211 346 89 Teen birth rate 41 43 51 39 Clinical Care Uninsured adults 26% 18% 17% 14% Primary care provider rate 100 110 115 154 Preventable hospital stays 72 87 73 55 Diabetic screening 83% 83% 84% 88% Hospice use 19% 17% 28% 37% Social & Economic Factors High school graduation 90% 72% 74% 82% College degrees 32% 24% 25% 31% Unemployment 7% 6% 6% 5% Children in poverty 14% 18% 20% 15% Income inequality 45 42 46 40 Inadequate social support 16% 20% 20% 16% Single-parent households 12% 9% 10% 6% Homicide rate n/a n/a 7 4 Physical Environment Air pollution-particulate matter days 0 0 1 0 Air pollution-ozone days 0 0 4 0 Access to healthy foods 50% 35% 45% 69% Liquor store density 1.2 1.3 0.6 n/a

County Health Rankings. Mobilizing Action Toward Community Health (MATCH). 2010. University of Wisconsin Population Health Institute; http://www.countyhealthrankings.org/print/north-carolina

123 Dare County Community Health Assessment – Volume One Health Statistics

Maternal and Infant Health

Pregnancy

The following definitions and statistical conventions will be helpful in understanding the data on pregnancy:

 Reproductive age = 15-44  Total pregnancies = live births + induced abortions + fetal death at 20+ weeks gestation  Pregnancy rate = number of pregnancies per 1,000 women of reproductive age  Fertility rate = number of live births per 1,000 women of reproductive age  Abortion rate = number of induced abortions per 1,000 women of reproductive age  Birth rate = number of live births per 1,000 population (Note that in the birth rate calculation the denomenator includes the entire population, both men and women, not just women of reproductive age.)

Pregnancy, Fertility, Abortion and Birth Rates, Women Age 15-44

Table 88 presents annual pregnancy, fertility and abortion rates for women age 15-44, stratified by race, for the period from 2004-2008.

 The total pregnancy rate in Dare County was higher than the total pregnancy rate for Carteret County and for NC througout the period cited. In Dare County the pregnancy rate among minorities was higher than the pregnancy rate among whites in 2005, 2006, and 2008; it was lower than ther rate among whites in 2007. The number of minority pregnancies in Dare County in 2004 was below the threshold of 20 and resulted in an unstable rate that should not be used for purposes of comparison.  The total fertility rate in Dare County was above the total fertility rate for Carteret County throughout the period cited, and above the total fertility rate for NC in all years cited except 2007. In Dare County the fertility rate among minorities was higher than the fertility rate among whites in 2005, and 2008; it was lower in 2006. Minority fertility rates in Dare County in other years were unstable.  The total abortion rate in Dare County was above the total abortion rate for Carteret County and NC throughout the period cited. The abortion rate among minorities in Dare County was unstable throughout the period cited.

The total birth rate for women ages 15-44 for the five-year aggregate period 2004-2008 in the three jurisdictions are as follows (47):

 Dare County: 13.0 live births per 1,000 population  Carteret County: 10.3 live births per 1,000 population  State of NC: 14.2 live births per 1,000 population

124 Dare County Community Health Assessment – Volume One Health Statistics

Table 88. Pregnancy, Fertility and Abortion Rate per 1,000 Women Age 15-44, by Race (2004-2008)

Females Ages 15-44 2004 2005 2006 2007 2008 Location Pregnancy Fertility Abortion Pregnancy Fertility Abortion Pregnancy Fertility Abortion Pregnancy Fertility Abortion Pregnancy Fertility Abortion Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate

Dare County Total 97.3 76.3 20.8 105.6 72.3 32.5 101.8 75.9 25.8 91.9 67.9 23.6 91.5 72.2 18.4 White 98.9 78.0 20.7 103.0 71.7 30.6 99.1 76.0 23.0 90.2 68.6 21.2 89.5 71.5 17.3 Minority 50.0 39.3 10.7 153.8 83.9 66.4 115.8 73.7 42.1 75.0 53.6 21.4 95.2 87.3 4.0 Carteret County Total 72.6 59.9 12.5 76.6 63.2 12.8 77.4 62.2 15.1 76.1 62.5 13.0 66.0 54.4 11.3 White 70.7 59.2 11.2 74.7 62.5 11.7 75.5 61.3 14.2 73.8 61.2 12.2 64.7 54.7 9.7 Minority 81.8 66.6 15.2 88.9 70.3 16.6 90.3 71.2 19.1 92.3 74.5 14.7 74.6 51.7 22.9 State of NC Total 82.0 65.5 16.0 82.2 66.8 15.0 84.8 68.5 15.8 84.7 69.1 15.1 83.9 69.1 14.4 White 76.5 66.6 9.6 77.2 67.8 9.0 79.1 69.3 9.5 79.3 69.8 9.1 78.6 69.9 8.4 Minority 91.1 62.9 27.5 89.9 64.1 25.0 93.2 66.7 25.8 92.4 67.5 24.2 91.2 67.1 23.3

Source: NC Center for Health Statistics, County-level Data, County Health Data Books (2006-2010). Pregnancy and Live Births. Pregnancy, Fertility, & Abortion Rates per 1,000 Population, by Race, by Age; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates an unstable rate based on a small number (fewer than 20 cases)

Pregnancy, Fertility, Abortion and Birth Rates, and Pregnancies, Women Age 15-19

Table 89 presents annual pregnancy, fertility and abortion rates for women age 15-19 (“teens”), stratified by race, for the years from 2004- 2008. Note that the state does not calculate a birth rate for this age group.

 The total “teen” (women age 15-19) pregnancy rate in Dare County was higher than the total teen pregnancy rate for Carteret County in 2004 and 2005 and lower than the rate for Carteret County in 2006-2008. The Dare County teen pregnancy rate was higher than the NC teen pregnancy rate in 2005, but lower in 2004 and 2006-2008. The 2008 teen pregnancy rate in Dare County (39.0) was the lowest pregnancy rate during the entire period cited. The teen pregnancy rate among minorities in Dare County was unstable throughout the period due to small numbers of events.  The total teen fertility rate in Dare County followed the same pattern as the pregnancy rate relative to Carteret County and the state: higher than the total teen fertility rate for Carteret County in 2004 and 2005 and lower than the rate for Carteret County in 2006-2008 and higher than the NC teen fertility rate in 2005, but lower in 2004 and 2006-2008. The 2008 teen fertility rate in Dare County (24.4) was the lowest fertility rate during the entire period cited. The teen fertility rate among minorities in Dare County was unstable throughout the period due to small numbers of events.  The total teen abortion rate in Dare County was unstable in 2004, 2006 and 2008; in 2005 and 2007 the total teen abortion rate was above the comparable rates in Carteret County and NC. The teen abortion rate among minorities in Dare County was unstable throughout the period cited.

125 Dare County Community Health Assessment – Volume One Health Statistics

Table 89. Pregnancy, Fertility and Abortion Rate, per 1,000 Women Age 15-19, by Race (2004-2008)

Females Ages 15-19 2004 2005 2006 2007 2008 Location Pregnancy Fertility Abortion Pregnancy Fertility Abortion Pregnancy Fertility Abortion Pregnancy Fertility Abortion Pregnancy Fertility Abortion Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate Rate

Dare County Total 56.2 39.8 16.3 67.7 33.9 33.9 58.3 37.8 20.5 51.1 25.0 26.1 39.0 24.4 14.6 White 54.5 39.6 15.0 58.6 32.1 26.5 61.0 39.5 21.5 49.0 22.7 26.3 36.7 23.4 13.3 Minority 68.2 45.5 22.7 243.9 73.2 170.7 0.0 0.0 0.0 88.9 66.7 22.2 45.5 45.5 0.0 Carteret County Total 51.8 38.0 13.8 63.9 49.5 14.5 62.3 46.4 15.9 65.1 48.5 16.6 42.9 32.3 10.1 White 48.0 34.6 13.5 61.3 46.0 15.3 59.3 43.6 15.6 58.5 41.5 17.0 38.6 31.0 7.0 Minority 80.0 68.6 11.4 82.8 82.8 0.0 89.8 71.9 18.0 120.3 113.9 6.3 83.8 44.7 39.1 State of NC Total 62.4 46.6 15.4 61.7 47.0 14.3 63.1 48.3 14.5 63.0 48.4 14.3 58.6 45.7 12.5 White 51.7 41.0 10.5 50.9 40.9 9.8 52.9 42.8 9.8 52.3 42.3 9.8 47.8 39.6 8.0 Minority 83.4 59.3 23.5 82.3 60.6 21.0 82.1 60.0 21.3 82.5 61.5 20.3 77.7 58.3 18.7

Table 90 presents figures on the annual number of teen (ages 15-19) pregnancies in Dare County and Carteret County for the years from 2004-2008.

 The number of teen pregnancies in Dare County has decreased every year between 2005 and 2008. The number of teen pregnancies (40) in 2008 was 27% lower than the number (55) in 2004.  In Carteret County the number of teen pregnancies increased between 2004 and 2005 and stayed at that level until decreasing in 2008. The number of teen pregnancies (81) in 2008 in Carteret County was 10% lower than the number (90) in 2004.

Table 90. Number of Teen (Age 15-19) Pregnancies, 2004-2008

Location 2004 2005 2006 2007 2008

Dare County 55 64 54 45 40 Carteret County 90 106 106 106 81

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010). Pregnancy and Live Births, Total Pregnancies by County of Residence; http://www.schs.state.nc.us/SCHS/data/databook/

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Pregnancy, Adolescents Age 10-14

Table 91 shows the annual number of adolescent (ages 10-14) pregnancies for the years from 2004-2008.

 During the five-year period from 2004 through 2008 there were 7 reported pregnancies among 10-14 year-olds in Dare County and 6 in Carteret County. Due to the small numbers, a pregnancy rate for this age group has not been calculated for either county.

Table 91. Number of Adolescent (Ages 10-14) Pregnancies (2004-2008)

Location 2004 2005 2006 2007 2008

Dare County 32002 Carteret County 02112

Sexual Behavior of Dare County High School Students

 According to survey results, 54.7% of females and 61.0% of males in Dare County High Schools reported that they had had sexual intercourse.  The average age of first intercourse was 14.6 years for females and 13.9 years for males.  Almost 30 percent (29.9%) of females and 45.9% of males reported having consumed alcohol or drugs the last time they had sexual intercourse.  A little over half of all students (54.4% of females and 53.3% of males) reported having used a condom the last time they had sexual intercourse.  Female students reported having had 2.9 sexual partners in their lifetime at the time of the survey; the comparable figure for males was 3.5 partners.

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Table 92. Sexual Behaviors of Dare County High School Students (2009)

Consumed Percent Used a Age in Years Average No. Alcohol or Prevalence Condom at Category at First of Lifetime Drugs at of Last Intercourse Partners Last Intercourse Intercourse Intercourse

Females 54.7 14.6 2.9 29.9 54.4 Males 61.0 13.9 3.5 45.9 53.3 Overall 57.9 14.2 3.2 38.8 53.8

Source: 2009 Youth Risk Behavior Survey, Dare County High Schools

Pregnancy Risk Factors

High Parity and Short Interval Births

According to the NCSCHS, a birth is high parity if the mother is younger than 18 when she has had one or more births, or aged 18 or 19 and has had two or more births, or is 20-24 and has had four or more births, etc. A short-interval birth means a pregnancy occurring less than six months since the last birth. High-parity and short-interval pregnancies can be a physical strain on the mother and sometimes contributes to complicated pregnancies and/or poor birth outcomes.

Table 93 presents aggregate data on high-parity and short interval births for the period from 2004 through 2008.

 In Dare County the percentage of high parity births among mothers under 30 (11.0%) was lower than the comparable percentage in either Carteret County (14.4%) or the state as a whole (18.0%).  The percentage of high parity births among Dare County mothers age 30 and older (20.0%) was higher than the percentage in Carteret County (18.2%) and equal to the percentage for NC.  The percentage of short interval births in Dare County (10.7%) was slightly lower than in Carteret County (12.9%) or the state as a whole (12.7%).

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Table 93. High-Parity and Short-Interval Births (Five-Year Aggregate Data, 2004-2008)

High Parity Births Short Interval Births Location Mothers < 30 Mothers > 30 No.1 %2 No.1 %2 No.3 %4

Dare County 148 11.0 178 20.0 153 10.7 Carteret County 314 14.4 192 18.2 257 12.9 State of NC 74,440 18.0 43,711 20.0 53,431 12.7 Source: a a a a b b

a - NC State Center for Health Statistics, County-level Data, County Health Data Book (2010), Pregnancy and Births, 2004-2008 Number At Risk NC Live Births due to High Parity by County of Residence; http://www.schs.state.nc.us/SCHS/data/databook/ b - NC State Center for Health Statistics, County-level Data, County Health Data Book (2010), Pregnancy and Births, 2004-2008 NC Live Births by County of Residence, Number with Interval from Last Delivery to Conception of Six Months or Less; http://www.schs.state.nc.us/SCHS/data/databook/ 1 Number at risk due to due to high parity 2 Percent of all births with age of mother in category indicated 3 Number with interval from last delivery to conception of six months or less 4 Percent of all births excluding first pregnancies

Smoking During Pregnancy

Smoking during pregnancy is an unhealthy behavior that may have negative effects on both the mother and the fetus. Smoking can lead to fetal and newborn death, and contribute to low birth weight and pre-term delivery. In pregnant women, smoking can increase the rate of placental problems, and contribute to premature rupture of membranes and heavy bleeding during delivery (48).

Table 94 presents data on smoking during pregnancy for Dare County, Carteret County and NC for several five-year aggregate periods.

 For every aggregate period, the percentage of women in Dare County who smoked during pregnancy was greater than the comparable percentage for the state as a whole, but lower than the percentage for Carteret County.  The percentage of women in Dare County and NC who smoked during pregnancy decreased from one period to the next over the entire span cited in the table. In Dare County, the percentage for 2004-2008 (13.6%) was 12.8% lower than the percentage in 2000- 2004 (15.6%). In Carteret County, the percentage who smoked during pregnancy was more variable, but decreased 5.5% from the first period (20.0%) to the last (18.9%).

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Table 94. Smoking During Pregnancy (Five-Year Aggregate Data, Intervals as Noted)

Number and Percent of Births to Mothers Who Smoked Prenatally Location2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 No. % No. % No. % No. % No. %

Dare County 308 15.6 316 15.1 329 15.0 315 14.0 306 13.6 Carteret County 605 20.0 627 20.4 609 19.3 597 18.5 611 18.9 State of NC 78,659 13.2 76,712 12.9 74,901 12.4 73,887 11.9 72,513 11.5

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Pregnancy and Births, Births to Mothers Who Smoke; http://www.schs.state.nc.us/SCHS/data/databook/

Late Prenatal Care

Good pre-conception health and early prenatal care can help assure women the healthiest pregnancies possible.

Table 95 presents five-year aggregate data on the percent of all women and of black women receiving prenatal care in the first trimester for the three jurisdictions included in this report.

 For every aggregate period presented, a higher percentage of pregnant women in Dare County than in Carteret County or NC received prenatal care during the first trimester. The difference between the percentages in Dare and Carteret County were very slight and probably insignificant; the difference between the percentages in those counties and NC was larger.  In Dare County the percentage of black women receiving prenatal care in the first trimester was lower than the percentage for women overall, and the percentage for black women appears to have fallen 16.1% since 2000-2004.

Table 62. Prenatal Care, Total Women and Black Women (Five-Year Aggregate Data, Years as Noted)

Percent of Women Receiving Prenatal Care in the First Trimester Location 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 Total Black Total Black Total Black Total Black Total Black

Dare County 90.0 88.0 90.8 81.0 90.4 73.7 89.9 74.1 88.8 73.8 Carteret County 89.7 79.1 90.4 84.9 90.1 85.5 89.1 83.8 88.7 81.7 State of NC 83.7 75.4 83.5 75.5 83.0 75.4 82.5 75.2 82.1 75.0

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Pregnancy and Births, Women Receiving Prenatal Care in the First Trimester; http://www.schs.state.nc.us/SCHS/data/databook/

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Pregnancy Outcomes

Low Birth Weight and Very Low Birth Weight

Low birth weight can result in serious health problems in newborns (e.g., respiratory distress, bleeding in the brain, and heart, intestinal and eye problems), and cause lasting disabilities (mental retardation, cerebral palsy, and vision and hearing loss) or even death (48).

Table 96 presents five-year aggregate data on low birth weight births: infants weighing 2,500 grams (5.5 pounds) or less.

 The percentages of total low birth weight births were similar in Dare and Carteret Counties and varied little over time. However, in every period over the entire span cited in the table, the percent of total low birth weight births in Dare County was lower than the comparable percentage statewide.  In Dare County the percentages of low birth weigtht births among blacks were based on small numbers of events and thus were unstable. In Carteret County and NC as a whole, where the percentages are based on larger numbers, the average percentage of low birth weight births among black women is 50% higher than the percentage among all women.  No jurisdiction cited in the table demonstrated much improvement in the percentage of low birth weight births over time.

Table 96. Low (< 2,500 Grams) Birth Weight Births (Five-Year Aggregate Data, Intervals as Noted)

Percent of Low Birth Weight (< 2,500 Gram) Births Location 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 Total Black Total Black Total Black Total Black Total Black

Dare County 7.4 18.0 7.8 15.5 7.6 19.3 7.3 17.2 7.4 12.3 Carteret County 8.1 12.6 7.8 12.7 7.5 14.9 7.3 14.7 7.2 13.4 State of NC 9.0 14.0 9.0 14.2 9.1 14.3 9.1 14.4 9.1 14.4

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Pregnancy and Births, Low and Very Low Weight Births, Black Births; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates an unstable rate based on a small number (fewer than 20 cases)

Table 97 presents data on very low birth-weight births: infants weighing 1,500 grams (3.3 pounds) or less.

 The percentage of very low birth weight births in Dare County was lower than the percentage as the state as a whole in every aggregate period, and was lower than the comparable percentage in Carteret County in two of the five periods.

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 The percentages of very low birth weight births among black women in both Dare and Carteret Counties tended to be unstable and are not suitable for comparison. At the state level, however, the percentage of very low birth weight births among blacks was consistently about twice the percentage among all women.  There has been almost no change in the total percentage of very low birth weight births in any of the three jurisdictions.

Table 97. Very Low (< 1,500 Grams) Birth Weight Births (Five-Year Aggregate Data, Intervals as Noted)

Percent of Very Low Birth Weight (< 1,500 Gram) Births Location 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 Total Black Total Black Total Black Total Black Total Black

Dare County 1.2 4.0 1.3 1.7 1.4 5.3 1.2 5.2 1.3 4.6 Carteret County 1.5 3.4 1.5 3.5 1.3 3.4 1.1 3.4 1.1 3.4 State of NC 1.9 3.6 1.9 3.6 1.9 3.6 1.9 3.6 1.8 3.5

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Pregnancy and Births, Low and Very Low Weight Births, Black Births; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Caesarian Section Delivery

Table 98 presents data on the percent of births delivered by a primary (first-time) Caesarian section.

 As elsewhere in the US, the percentage of Casearian section delivery in all three jurisdictions has risen over time: 10% in Dare County, 16% in Carteret County, and 9% statewide.

Table 98. Caesarian Section Deliveries (Five-Year Aggregate Data, Intervals as Noted)

Percent of Resident Births Delivered by Caesarian Section (Primary) Location 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008

Dare County 22.1 23.7 24.1 24.2 24.3 Carteret County 18.3 19.4 20.1 21.0 21.2 State of NC 16.8 17.4 17.8 18.1 18.3

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Pregnancy and Births, Births Delivered by Primary Caesarian Section; http://www.schs.state.nc.us/SCHS/data/databook/

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Birth Complications

Table 99 presents data reflective of birth complications and negative birth outcomes.

 Dare County rates for hospital discharges due to perinatal complications and congenital malformations are unstable and unsuitable for comparison.  The NC Child Service Coordination Program is a program of state-sponsored services for children birth to age three who are at risk for developmental delay or disability, long term illness and/or social and emotional disorders, and children ages birth to five who have been diagnosed with developmental delay or disability, long term illness and/or social, emotional disorder (49). In 2007 the percentage of births where the infant was referred for child services coordination was 28% lower in Dare County (16.5%) than in Carteret County (23.0%), and 81% higher than in NC as a whole (9.1%).

Table 99. Birth Complications (Years as Noted)

Perinatal Congenital Births Where Complications Malformation Child Was Location Discharges Discharges Referred to CSC (2006) (2006) (2007)

No. Rate1 No. Rate1 No. %

Dare County 6 1.7 2 0.6 67 16.5 Carteret County 60 9.5 23 3.6 148 23.0 State of NC 4,694 5.4 3,225 3.7 11,853 9.1 Source: a a b b c c

a - NC-CATCH, County Health Profiles, Health Profile, Reproductive Health, Perinatal Complications Discharges per 10,000 Population; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx b - NC-CATCH, County Health Profiles, Health Profile, Infants/Children, Congenital Malformation Discharges per 10,000 Population; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx c - NC-CATCH, County Health Profiles, Health Profile, Infants/Children, % Births Where Child Was Referred to CSC; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx 1 Number of discharges per 10,000 population Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Infant Mortality

Infant mortality is the number of infant (under one year of age) deaths per 1,000 live births.

Table 100 presents infant mortality data for Dare County, Carteret County and the state of NC.

 Most of the Dare County and many of the Carteret County infant death rates cited in the table are based on small numbers of events and likely unstable, so comparisons are not valid.  Statewide the total and white infant death rates were stable and essentially unchanged throughout the period cited. According to America’s Health Rankings (50), the 2009 infant mortality rate in NC was 8.4 deaths per 1,000 live births and ranked 44th out of 50.  Statewide the average minority infant death rate (14.5) was 138% higher than the average white infant death rate (6.1).

Table 100. Infant (<1 year) Mortality Rate per 1,000 Live Births (2000-2006)

Infant Deaths Location 2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 No. Rate No. Rate No. Rate No. Rate No. Rate

Dare County Total 17 8.6 20 9.6 14 6.4 16 7.1 14 6.2 White 16 8.4 19 9.5 13 6.2 14 6.5 12 5.6 Minority 1 13.2 1 12.2 1 11.4 2 22.7 2 21.5 Carteret County Total 28 9.2 23 7.5 22 7.0 20 6.2 18 5.6 White 22 8.1 19 6.9 15 5.3 13 4.5 12 4.1 Minority 6 9.3 4 12.4 7 21.3 7 20.8 6 17.9 State of NC Total 5,013 8.4 5,056 8.5 5,084 8.4 5,234 8.4 5,333 8.4 White 2,618 6.1 2,648 6.1 2,680 6.1 2,773 6.2 2,818 6.2 Minority 2,391 14.6 2,404 14.7 2,400 14.5 2,457 14.4 2,515 14.3

Source: NC Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Mortality, Infant Death Rates per 1,000 Live Births; http://www.schs.state.nc.us/SCHS/data/databook/

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Other Pregnancy and Birth Data

Table 101 presents data on Medicaid births as a percent of all births. By 2007, more than half of all births in all three jurisdictions were to Medicaid families.

Table 101. Medicaid Births (2003-2007)

Medicaid Births as a Percent of All Births Location 2003 2004 2005 2006 2007

Dare County 43.6 50.7 45.0 50.9 53.7 Carteret County 48.6 61.0 55.7 63.5 59.4 State of NC 42.8 48.8 47.8 51.8 51.7

Source: NC-CATCH, County Health Profiles, Health Profile, Reproductive Health, % Medicaid Births; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Table 102 summarizes a number of other pregnancy and birth indicators.

 The proportion of births to mothers receiving prenatal care from the local health department in Dare County was three times the percentage in Carteret County and 61% higher than the percentage statewide.  The proportion of births to mothers participating in WIC is lower in Dare County than in the other two jurisdictions; the proportion of Dare County births involving maternity care coordination is higher than comparable percentages in Carteret County and NC.

Table 102. Other Pregnancy and Birth Indicators (2007)

% Bir t hs % Live % Live Births % Bir t hs % Bir t hs where Mom Births to to Location where Mom to WIC Received Mother Unmarried Visited LHD Mothers MCC < Age 18 Mothers

Dare County 34.2 36.0 19.7 1.7 40.9 Carteret County 12.0 42.3 9.8 4.4 36.2 State of NC 21.2 40.2 14.9 3.8 41.1

Source: NC-CATCH, County Health Profiles, Health Profile, Reproductive Health, Parameters as Noted; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

135 Dare County Community Health Assessment – Volume One Health Statistics

Leading Causes of Death

Table 103 lists age-adjusted mortality rates for the fifteen leading causes of death for the five-year aggregate period from 2004 through 2008. While the table also shows the comparable rates for Carteret County and the US (where available), the causes are listed in the descending order of the Dare County mortality rates. Figures in italic type indicate causes of death for which the Dare County rate exceeds the comparable rate for the state as a whole. Figures in bold type are likely unstable rates based on fewer than 20 events. Each cause of death will be discussed in a subsequent section, in the order in which each appears in this table.

Table 103. Age-Adjusted Mortality Rates1 for the 15 Leading Causes of Death (Five-Year Aggregate Period 2004-2008)

United Carteret North Dare County States Cause of Death County Carolina (2006) Number Rate Rate Rate Rate 1. Total Cancer 351 171.1 191.6 192.5 180.7 2. Diseases of the Heart 304 162.4 198.7 202.2 200.2 3. Pneumonia and Influenza 79 49.8 16.0 20.3 17.8 4. Cerebrovascular Disease 62 37.1 48.3 54.4 43.6 5. Unintentional Non-Motor Vehicle Injury 62 35.5 38.0 28.4 39.8 6. Chronic Lower Respiratory Disease 62 33.4 41.1 47.8 40.5 7. Unintentional Motor Vehicle Injury 34 19.4 20.8 18.6 15.0 8. Alzheimer's Disease 24 13.7 26.0 28.7 22.6 9. Diabetes Mellitus 26 13.3 16.2 25.2 23.3 10. Suicide 24 12.6 15.1 11.9 10.9 11. Septicemia 22 11.6 10.0 14.2 n/a 12. Nephritis, Nephrotic Syndrome, Nephrosis 18 10.3 13.1 18.8 14.5 13. Chronic Liver Disease and Cirrhosis 19 8.5 12.8 9.1 8.8 14. Homicide 5 3.1 3.4 7.2 6.2 15. Acquired Immune Deficiency Syndrome 3 1.3 0.7 4.4 4.0 Total Deaths All Causes (Some causes are not listed above) 1,302 699.8 800.2 861.4 776.5 Source: a a a a b

a - NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ b - National Center for Health Statistics, National Vital Statistics Reports, Volume 57, Number 14 (April 17, 2009), Deaths: Final Data for 2006, Table 29: Age-adjusted death rates for selected causes of death; http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf 1 Rate = Number of events per 100,000 population, where the Standard = Year 2000 US Population

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County, State and National Mortality Rate Comparisons

The following comparisons are based on data in Table 103.

Compared to Carteret County, Dare County has higher age-adjusted mortality rates for:

 Pneumonia/Influenza – by 211.3%  Septicemia – by 16.0%

Compared to North Carolina, Dare County has higher age-adjusted mortality rates for:

 Pneumonia/Influenza – by 145.3%  Unintentional Non-Motor Vehicle Injury – by 25.0%  Unintentional Motor Vehicle Injury – by 4.3%  Suicide – by 5.9%

Compared to the United States, Dare County has higher age-adjusted mortality rates for:

 Pneumonia/Influenza – by 179.8%  Unintentional Motor Vehicle Injury – by 29.3%  Suicide – by 15.6%

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Gender Disparities in Mortality

Table 104 compares numbers of deaths and death rates for males and females in Dare County and NC for the 15 leading causes of death. The mortality data cited in this section were obtained from the NC State Center for Health Statistics and represent the five-year aggregate period from 2004-2008. The causes of death are listed in the same order as in Table 103. Italic type indicates the higher rate in each gender pair; bold type indicates a likely unstable rate based on fewer than 20 events.

Table 104. Sex-Specific Age-Adjusted Death Rates1 for the 15 Leading Causes of Death (Five-Year Aggregate Data, 2004-2008)

Dare County State of NC Cause of Death Males FemalesMales Females Number Rate Number Rate Number Rate Number Rate 1. Total Cancer 197 204.8 154 141.8 44,987 243.4 40,219 158.7 2. Diseases of the Heart 177 193.1 127 130.3 44,413 256.6 42,919 161.2 3. Pneumonia and Influenza 22 30.0 57 61.3 3,710 23.9 4,889 18.1 4. Cerebrovascular Disease 27 38.2 35 36.1 9,195 55.9 13,963 52.4 5. Unintentional Non-Motor Vehicle Injury 44 50.4 18 19.9 7,423 37.8 5,012 20.2 6. Chronic Lower Respiratory Disease 28 33.6 34 33.4 9,942 58.9 10,580 41.3 7. Unintentional Motor Vehicle Injury 25 27.3 9 11.6 5,830 26.7 2,478 10.8 8. Alzheimer's Disease 3 3.6 21 21.2 3,142 22.2 8,784 31.8 9. Diabetes Mellitus 14 15.3 12 11.8 5,359 28.9 5,690 22.2 10. Suicide 18 18.4 6 6.7 4,103 19.1 1,240 5.4 11. Septicemia 5 4.5 17 17.0 2,709 15.6 3,421 13.2 12. Nephritis, Nephrotic Syndrome, Nephrosis 9 10.7 9 9.3 3,749 22.3 4,340 16.6 13. Chronic Liver Disease and Cirrhosis 15 13.3 4 3.8 2,764 12.9 1,435 5.8 14. Homicide 4 4.7 1 1.3 2,481 11.0 727 3.3 15. Acquired Immune Deficiency Syndrome 3 2.6 0 0.0 1,370 6.1 612 2.7 Total Deaths All Causes (Some causes are not listed 700 777.1 602 607.2 184,468 1,034.1 189,378 728.7

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ 1 Rate = Number of events per 100,000 population, where the Standard = Year 2000 US Population

For all deaths combined, Dare County males have a 28% higher mortality rate than Dare County females.

138 Dare County Community Health Assessment – Volume One Health Statistics

As noted before, when comparing rates – including mortality rates – it is important to consider the base number of events for which each rate was calculated. When the number of events is small, the rate calculated from that number may be unstable and neither a reliable measure nor a valid predictor. Because the population of Dare County is small, the numbers of specific events in a particular population group are often small. This report will not analyze disparities in any cause of death for which there were fewer than 20 aggregate deaths during the period in question for any of the stratified groups (e.g., gender or race) examined.

Following the protocol discussed above there are nevertheless apparent valid gender differences in mortality in Dare County.

Compared to the mortality rates for Dare County females, the mortality rates among Dare County males are higher for:

 Total Cancer – by 44.4%  Diseases of the Heart – by 48.2%  Cerebrovascular Disease – by 5.8%  Chronic Lower Respiratory Disease – by 0.6%

Compared to the mortality rates for Dare County males, the mortality rate among Dare County females is higher for:

 Pneumonia/Influenza – by 104.3%

Racial Disparities in Mortality

The overall 2004-2008 age-adjusted mortality rate among Dare County minorities was 928.6, 34% higher than the overall age-adjusted mortality rate for whites (693.2) (51). Because the minority population in Dare County is small, the numbers of Dare County minority deaths for most individual diseases and health conditions covered in this report also are too small (<20) per five-year aggregate period for valid rate comparison.

Age Disparities in Mortality

Each age group tends to have its own leading causes of death. Table 105 lists the three leading causes of death by age group for five-year aggregate data from 2004-2008. Note that for this purpose it is important to use non-age adjusted rates.

139 Dare County Community Health Assessment – Volume One Health Statistics

The leading cause of death in each of the age groups in Dare County is summarized below:

 Age group 0-19 – Perinatal conditions/unintentional motor vehicle injury/unintentional non-motor vehicle injury (tie)  Age group 20-39 – Unintentional non-motor vehicle injury  Age group 40-64 – Cancer (all sites)  Age group 65-84 – Cancer (all sites)  Age group 85+ - Diseases of the heart

Table 105. Three Leading Causes of Death by Age Group, Number of Deaths and Unadjusted Death Rates (Five-Year Aggregate Data, 2004-2008)

Cause of Death Age Group Rank Dare County Carteret County State of NC

00-19 1 Perinatal conditions Motor vehicle injuries Perinatal conditions Motor vehicle injuries Non-motor vehicle injuries 2 Congenital anomalies Perinatal conditions Motor vehicle injuries 3 Cerebrovascular disease Non-motor vehicle injuries Congenital anomalies Homicide SIDS 20-39 1 Non-motor vehicle injuries Non-motor vehicle injuries Motor vehicle injuries 2 Motor vehicle injuries Motor vehicle injuries Non motor vehicle injuries 3 Suicide Diseases of the heart Suicide 40-64 1 Cancer - All Sites Cancer - All Sites Cancer - All Sites 2 Diseases of the heart Diseases of the heart Diseases of the heart 3 Non-motor vehicle injuries Non-motor vehicle injuries Non motor vehicle injuries 65-84 1 Cancer - All Sites Cancer - All Sites Cancer - All Sites 2 Diseases of the heart Diseases of the heart Diseases of the heart 3 Chronic lower respiratory disease Chronic lower respiratory disease Chronic lower respiratory disease 85+ 1 Diseases of the heart Diseases of the heart Diseases of the heart 2 Pneumonia and influenza Cancer - All Sites Cancer - All Sites 3 Cancer - All Sites Cerebrovascular disease Cerebrovascular disease

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, Death Counts and Crude Death Rates per 100,000 for Leading Causes of Death, by Age Groups, NC, 2004-2008; http://www.schs.state.nc.us/SCHS/data/databook/

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Cancer

Total Cancer

Cancer is a term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. If the disease remains unchecked, it can result in death (52). Cancers of all kinds are sometimes grouped together statistically in a parameter called total cancer. Total cancer was the leading cause of death in Dare County for the aggregate period from 2004-2008. The site-specific cancer with the highest mortality in Dare County over the same aggregate period was lung cancer, followed by breast cancer, prostate cancer, pancreatic cancer, and colon/rectal cancer. (Each of these site-specific cancers will be discussed subsequently, in that order.) In 2008, inpatient hospital charges associated with cancer diagnoses in Dare County residents totaled $3,589,081 (53).

Cancer incidence and mortality data for Dare County were obtained from the NC Cancer Registry, which collects data on newly diagnosed cases from NC clinics and hospitals, as well as on NC residents whose cancers were diagnosed at medical facilities in bordering states.

Total Cancer Incidence

Table 106 presents the number of new cases (and associated rates) for total cancer and the four major site-specific cancers for Dare County, Carteret County and the state of NC for the five-year aggregate period 2003-2007.

 There were 840 newly diagnosed cases of all cancers combined in Dare County between 2003 and 2007. The incidence rate for total cancer in Dare County during the period (433.0) was lower than the total cancer incidence rates for either Carteret County (538.0) or NC as a whole (487.0).  Among the site-specific cancers, breast cancer had the highest incidence, followed by prostate cancer, lunger cancer, and colon cancer, in that order.

Table 106. Incidence of Total Cancer and the Five Major Site-Specific Cancers, Cases and Rate1 (Five Year Aggregate Data, 2003-2007)

Total Cancer Breast Cancer Prostate Cancer Lung Cancer Colon Cancer Location Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate

Dare County 840 433.0 163 156.5 120 126.6 129 66.9 88 44.1 Carteret County 2,263 538.0 349 160.2 346 167.0 343 77.7 205 48.4 State of NC 216,944 487.0 36,562 149.6 30,578 153.8 33,559 75.8 21,000 47.4

Source: NC State Center for Health Statistics, Health Data, Cancer, Cancer Data Available from SCHS, Annual Reports, NC Cancer Incidence Rates, 1999-2007, Cancer Incidence Rates for All Counties; http://www.schs.state.us.nc/SCHS/CCR/reports.html 1 Rate = New cases per 100,000 Population, Age-Adjusted to the 2000 US Census

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Total Cancer Incidence Rate Trend

As shown in Figure 8, the total cancer incidence rate in Dare County was below the total cancer incidence rates for both Carteret County and the state of NC from 1995-2007. The total cancer incidence rate in Dare County was not much different at the end of the period cited than at the beginning.

Figure 8. Total Cancer Incidence Rate Trend (Five-Year Aggregate Periods, 1995-2007)

600.0

500.0

400.0

300.0

200.0

100.0

0.0 New Cases per 100,000 Population 100,000 per New Cases

Dare County Carteret County State of NC

NC State Center for Health Statistics, Health Data, Cancer, Cancer Data Available from SCHS, Annual Reports, NC Cancer Incidence Rates for All Counties by Specified Site (Years as Noted); http://www.schs.state.us.nc/SCHS/CCR/reports.html

Total Cancer Hospital Discharges

As noted previously, community prevalence of a disease can be approximated for comparison purposes by hospital discharge rates. Table 107 presents data on the annual rate of hospital discharge for treatment of malignant neoplasms for the period from 2004-2008. The rate is expressed as the number of discharges per 1,000 population.

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 The hospital discharge rate for all malignant neoplasms in Dare County was lower than the comparable rate for Carteret County and NC as a whole for the entire period cited. The Dare County rate declined from 2004 to 2006, then rose again the following two years.  In both Carteret County and the state as a whole, the malignant neoplasms discharge rate decreased overall from 2004 to 2008, by 24% and 10%, respectively.

Table 107. Hospital Discharges for Malignant Neoplasms, per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 2.7 2.5 2.1 2.7 2.9 Carteret County 7.0 5.8 5.2 5.8 5.3 State of NC 4.0 3.9 3.9 3.9 3.6

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006-2010), Morbidity, Inpatient Hospital Utilization and Charges by Principal Diagnosis and County of Residence; http://www.schs.state.nc.us/SCHS/data/databook/

Total Cancer Mortality

Total cancer was the leading cause of death in Dare County in the five-year aggregate period from 2004 through 2008, resulting in 351 deaths and a total cancer mortality rate of 171.2 deaths per 100,000. This rate was 11% below the state rate of 192.5 (Table 108).

Table 108. Total Cancer Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 344 171.6 7 137.2 197 204.8 154 141.8 351 171.2 Carteret County 819 189.3 56 217.6 497 246.0 378 150.0 875 191.6 State of NC 66,879 186.5 18,327 215.6 44,987 243.2 40,219 158.7 85,206 192.5

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Total Cancer Mortality Rate Trend

Figure 9 plots the total cancer mortality rate trend for the period from 1999-2008.

Since 1999, the total cancer mortality rate in Dare County decreased from higher than the state rate to lower than the state rate, and the total cancer mortality rate in Carteret County decreased from above the state rate to equal to the state rate. The state rate itself decreased only slightly over the entire period cited.

Figure 9. Total Cancer Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

250.0

200.0 opulation 150.0

100.0

50.0

Deaths per 100,000 P 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Total Cancer Mortality

The numbers of deaths attributable to total cancer among both minority males (n=4) and minority females (n=3) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

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Figure 10 plots total cancer mortality rates valid for comparison. Among whites alone, the total cancer death rate for Dare County males (205.5) was 45% higher than the total cancer death rate for females (141.9)

Measured against the comparable total cancer mortality rates statewide, the rates for both white males and white females in Dare County are lower. Note that statewide the total cancer death rates for both minority males and females exceed the comparable rates for whites.

Figure 10. Gender and Racial Disparities in Total Cancer Mortality (Five-Year Aggregate Data 2004-2008)

350.0 300.0 250.0 Population

200.0 150.0 100,000

100.0 per

50.0 0.0 Deaths White Minority White Minority

Males Females

Dare County State of NC

Source: NC State Center for Health Statistics, County-level Data, County Health Data Book (2010), Mortality, 2004-2008 NC Resident Race and Sex-Specific Age Adjusted Death Rates, by County; http://www.schs.state.nc.us/SCHS/data/databook/

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Lung Cancer

In the aggregate period from 2004-2008 lung cancer was the site-specific cancer in Dare County with the highest mortality rate (52.5 deaths per 100,000 population) (56). This category of cancer includes cancer of the trachea, bronchus and lung.

Lung Cancer Incidence

For the aggregate period from 2003 through 2007, 129 new cases of lung cancer were diagnosed in Dare County, making it the third most commonly diagnosed site-specific cancer, with an incidence rate of 66.9 new cases per 100,000 population (Table 106, cited previously). In 2008, hospital charges for the treatment of lung cancer in Dare County residents totaled $417,240 (53).

The incidence rate for lung cancer in Dare County has fluctuated up and down since 1995, and in 2007 was approximately the same as in 1995. Meanwhile, in the lung cancer incidence rate in Carteret County fell slightly overall; in NC it rose slightly (Figure 11).

Figure 11. Lung Cancer Incidence Rate Trend (Five-Year Aggregate Periods, 1995-2007)

100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 New Cases per 100,000 Population 100,000 Newper Cases

Dare County Carteret County State of NC

Source: NC State Center for Health Statistics, Health Data, Cancer, Cancer Data Available from SCHS, Annual Reports, NC Cancer Incidence Rates for All Counties by Specified Site (Years as noted); http://www.schs.state.us.nc/SCHS/CCR/reports.html

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Lung Cancer Hospital Discharges

Table 109 presents data on hospital discharges related to the treatment of lung/bronchus/trachea cancer. All the discharge rates for Dare County residents for the period cited were likely unstable due to small numbers of events. Noteworthy is that in none of the three jurisdictions was there much change in the discharge rate over time.

Table 109. Hospsital Discharges for Malignant Neoplasms of theTrachea, Bronchus and Lung, per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.50.30.50.40.5 Carteret County 0.9 0.8 0.8 1.0 0.8 State of NC 0.6 0.6 0.6 0.6 0.5

Lung Cancer Mortality

In the aggregate period 2004-2008 lung cancer claimed the lives of 110 Dare County residents, for a mortality rate of 52.5. This rate was 11% lower than the comparable rate in either Carteret County or NC as a whole.

Table 110. Lung Cancer Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 108 52.7 2 36.8 66 64.0 44 40.7 110 52.5 Carteret County 265 59.9 11 43.8 151 72.5 125 48.5 276 59.1 State of NC 21,615 59.8 4,710 54.9 15,542 81.9 10,783 42.7 26,325 59.1

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Lung Cancer Mortality Rate Trend

For the majority of the five-year aggregate periods cited, the lung cancer mortality rate in Dare County, while decreasing, was higher than the comparable rates in Carteret County or NC as a whole (Figure 12). From the beginning to the end of the time span represented by the table, the lung cancer mortality rate in Dare County decreased by approximately 28%. During the same time the rate in NC remained essentially unchanged.

Figure 12. Lung Cancer Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0

Deaths per 100,000 Population 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Lung Cancer Mortality

The numbers of deaths attributable to lung cancer among both minority males (n=2) and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 13 plots lung cancer mortality rates valid for comparison. Among whites alone, the lung cancer death rate for Dare County males (63.7) was 53% higher than the lung cancer death rate for Dare County females (41.5)

148 Dare County Community Health Assessment – Volume One Health Statistics

Measured against the lung cancer mortality rates statewide, the rates for both white males and white females in Dare County are lower. Note that statewide the lung cancer death rate for minority males exceeds the comparable rates for white males, and that the lung cancer death rate for white females exceeds the rate for minority females.

Figure 13. Gender and Racial Disparities in Lung Cancer Mortality (Five-Year Aggregate Data, 2004-2008)

100.0 90.0 80.0 70.0 Population 60.0 50.0 40.0 100,000 30.0 per 20.0 10.0 0.0 Deaths White Minority White Minority

Males Females

Dare County State of NC

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Breast Cancer

In the aggregate period from 2004-2008 female breast cancer was the site-specific cancer in Dare County with the second-highest mortality rate (30.4 deaths per 100,000 population). Note that although rare, breast cancer does occur in males, and during the period cited one Dare County male died of breast cancer (56).

Breast Cancer Incidence

For the aggregate period between 2003 and 2007, breast cancer was the most commonly diagnosed site-specific cancer in Dare County, with 163 new cases diagnosed during that period for an incidence rate of 156.5 (Table 106, cited previously). In 2008, hospital charges associated with the treatment of breast cancer in Dare County residents totaled $58,672 (53).

The breast cancer incidence rate in Dare County fell overall from 1997-2004, but increased after that to a current high (Figure 14). Statewide, the breast cancer incidence rate has shown little overall change. Throughout most of the period cited the Dare County breast cancer incidence rate had been below the state incidence rate, but recently has exceeded the state incidence rate.

Figure 14. Female Breast Cancer Incidence Rate Trend (Five-Year Aggregate Periods, 1995-2007)

200.0 180.0 160.0 opulation 140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 New Cases per 100,000 P 100,000 New per Cases

Dare County Carteret County State of NC

Source: NC State Center for Health Statistics, Health Data, Cancer, Cancer Data Available from SCHS, Annual Reports, NC Cancer Incidence Rates for All Counties by Specified Site (Years as Noted); http://www.schs.state.us.nc/SCHS/CCR/reports.html

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Breast Cancer Hospital Discharges

Table 111 presents data on hospital discharges related to the treatment of female breast cancer. All the discharge rates for Dare County residents for the period cited were likely unstable due to small numbers of events. Noteworthy is that in none of the three jurisdictions was there much change in the discharge rate over time.

Table 111. Hospital Discharges for Malignant Neoplasms of the Female Breast, per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.1 0.2 0.2 <0.1 0.1 Carteret County 0.5 0.7 0.6 0.6 0.6 State of NC 0.2 0.2 0.2 0.2 0.2

Source: NC State Center for Health Statistics, County-level Data, County Health Data Books (2006- 2010), Morbidity, Inpatient Hospital Utilization and Charges by Principal Diagnosis and County of Residence; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Breast Cancer Mortality

During the aggregate period 2004-2008, 34 women in Dare County died of breast cancer, representing a mortality rate of 30.4 per 100,000. During this time, the comparable state breast cancer mortality rate was 25.0 (Table 112).

Table 112. Female Breast Cancer Mortality, by Race (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Total Number Rate Number Rate Number Rate

Dare County 33 30.2 1 28.2 34 30.4 Carteret County 51 22.1 4 25.6 55 22.4 State of NC 4,629 23.0 1,827 31.6 6,301 25.0

NC State Center for Health Statistics, County Health Databook (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ Note: During this period, there was one male death in Dare County and 54 statewide, due to breast cancer.

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Breast Cancer Mortality Rate Trend

The Dare County breast cancer mortality rate fluctuated up and down between 1999 and 2008, but the overall trend has been toward an increasing rate. The Dare County rate exceeded the state rate (which has remained flat) for the entire span of dates cited in Figure 15, and exceeded the Carteret County rate (which has been falling steadily) for all aggregate periods cited except the first.

Figure 15. Female Breast Cancer Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

35.0

30.0

25.0

20.0

15.0

10.0

5.0

Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Racial Disparities in Breast Cancer Mortality

The numbers of deaths attributable to breast cancer among minority women (n=1) in the 2004-2008 aggregate period (56) was below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Statewide, the breast cancer mortality rate among minority women (31.1) is 36% higher than the rate among white women (22.8) (56).

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Prostate Cancer

In the aggregate period from 2004-2008 prostate cancer was the site-specific cancer in Dare County with the third-highest mortality rate (15.5 deaths per 100,000 population) (56).

Prostate Cancer Incidence

For the aggregate period between 2003 and 2007, prostate cancer was the second most commonly diagnosed site-specific cancer in Dare County, with 120 new cases diagnosed during that period for an incidence rate of 126.6 (Table 106, cited previously). In 2008, hospital charges associated with the treatment of prostate cancer in Dare County residents totaled $175,421 (53).

The prostate cancer incidence rate in Dare County fell overall from the 1996-2000 aggregate through the 2000-2004 aggregate, after which it began to increase again (Figure 16). However, the Dare County prostate cancer incidence rate has been and remains well below the comparable rates for Carteret County and NC as a whole.

Figure 16. Prostate Cancer Incidence Rate Trend (Five-Year Aggregate Periods, 1995-2007)

200.0 180.0 160.0 opulation 140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 New Cases per 100,000 P 100,000 Newper Cases

Dare County Carteret County State of NC

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Prostate Cancer Hospital Discharges

Table 113 presents data on hospital discharges related to the treatment of prostate cancer. All the discharge rates for Dare County residents for the period cited were likely unstable due to small numbers of events. Noteworthy is that only in Carteret County was there significant improvement in the discharge rate over time.

Table 113. Hospital Discharges for Malignant Neoplasms of the Prostate, per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.20.20.30.30.2 Carteret County 0.7 0.6 0.6 0.5 0.3 State of NC 0.3 0.3 0.3 0.4 0.3

Prostate Cancer Mortality

For the aggregate period from 2004 through 2008, 12 Dare County men died of prostate cancer, representing a mortality rate of 15.5; this rate was much lower than the state rate (27.3), but was based on so few cases it likely was unstable.

Table 114. Prostate Cancer Mortality, by Race (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Total Number Rate Number Rate Number Rate

Dare County 12 15.7 0 0.0 12 15.5 Carteret County 41 23.7 3 23.8 44 23.9 State of NC 2,855 21.8 1,459 56.3 4,314 27.3

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Prostate Cancer Mortality Rate Trend

Since 1999, the Dare County prostate cancer mortality rate decreased overall, despite some fluctuation (Figure 17). Comparable rates in Carteret County and NC as a whole also decreased. The rate in Dare County was consistently below the rates in both the other jurisdictions.

Figure 17. Prostate Cancer Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

Prostate Cancer Mortality Rate Trend 35.0 30.0 25.0 opulation 20.0 15.0 10.0 5.0

Deatls per 100,000 P 100,000 per Deatls 0.0

Dare County Carteret County State of NC

Racial Disparities in Prostate Cancer Mortality

Because the 2004-2008 aggregate age-adjusted prostate cancer mortality rates for white males and minority males in Dare County are based on small numbers of events (n=12 and n=0, respectively) they are unstable, and comparison is not recommended. At the state level, the prostate cancer mortality rate for minority men (56.3) is over 2½ times the rate for white men (21.8) (56).

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Pancreas Cancer

In the aggregate period from 2004-2008 pancreas cancer was the site-specific cancer in Dare County with the fourth-highest mortality rate (12.0 deaths per 100,000 population) (56). The NC State Center for Health Statistics now includes it among the cancers for which mortality rates are routinely published, but there is not similarly accessible data on the incidence of pancreas cancer; consequently only pancreas cancer mortality will be discussed.

Pancreas Cancer Mortality

From Table 115 it is apparent that the total number of deaths on which the 2004-2008 pancreas cancer mortality rate is based is barely over the threshold for stability, and of the stratified rates, only the rate for whites is stable.

Table 115. Pancreas Cancer Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 21 11.7 1 41.1 9 11.5 13 12.7 22 12.0 Carteret County 52 11.7 7 25.9 39 17.9 20 7.9 59 12.6 State of NC 3,729 10.4 1,180 14.2 2,380 12.6 2,529 9.9 4,909 11.1

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Pancreas Cancer Mortality Rate Trend

Rather than examine one year, it may be more instructive to examine the pancreas cancer mortality rate trend over time. Figure 18 presents this data for the three jurisdictions for five-year aggregate periods from 1999 through 2008.

From the data in Figure 18 it appears that while the pancreas cancer mortality rate in NC as a whole remained stable throughout the span of years cited, the comparable rate in Dare County decreased then steadied during the two most recent aggregate periods. In Carteret County, the pancreas cancer mortality rate increased over the three most recent aggregate periods. Both the Dare County and Carteret County pancreas cancer mortality rates were above the comparable NC rate in the 2004-2008 aggregate.

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Figure 18. Pancreas Cancer Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

16.0 14.0 12.0 opulation 10.0 8.0 6.0 4.0 2.0 Deatls per 100,000 P 100,000 per Deatls 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Pancreas Cancer Mortality

In Dare County, the numbers of deaths attributable to pancreas cancer among white males (n=9), white females (n=12), minority males (n=0) and minority females (n=1) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so local rate data is not presented here.

Figure 19 plots the valid stratified NC pancreas cancer mortality rates for a point of reference. Statewide the pancreas cancer death rates for both white males and females exceed the comparable rates for minorities, and the rates for both white and minority females exceed the rates for males.

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Figure 19. Gender and Racial Disparities in Pancreas Cancer Mortality (Five-Year Aggregate Data, 2004-2008)

16.0 14.0 12.0 Population 10.0 8.0 100,000

6.0

per 4.0

2.0 0.0 Deaths White Minority White Minority

Males Females

Dare County State of NC

NC State Center for Health Statistics, County-level Data, County Health Data Book (2010), Mortality, 2004-2008 NC Resident Race and Sex-Specific Age Adjusted Death Rates, by County; http://www.schs.state.nc.us/SCHS/data/databook/

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Colon, Rectum and Anus Cancer (Colorectal Cancer)

In the aggregate period from 2004-2008 colon/rectum/anus cancer (subsequently referred to as “colorectal” cancer) was the site-specific cancer in Dare County with the fifth-highest mortality rate (11.2 deaths per 100,000 population) (56).

Colorectal Cancer Incidence

For the aggregate period from 2003 through 2007, 88 new cases of colorectal cancer were diagnosed in Dare County, making it the fourth most commonly diagnosed site-specific cancer, with an incidence rate of 44.1 new cases per 100,000 population (Table 106, cited previously). In 2008, hospital charges for the treatment of colorectal cancer in Dare County residents totaled $740,314 (53).

The incidence rates for colorectal cancer in all three jurisdictions have fluctuated up and down since 1995. In the 2003-2007 aggregate the Dare County colorectal cancer incidence rate was slightly higher than in the 1995-1999 aggregate period (Figure 20).

Figure 20. Colorectal Cancer Incidence Rate Trend (Five-Year Aggregate Periods, 1995-2007)

70.0

60.0

opulation 50.0

40.0

30.0

20.0

10.0

0.0 New Cases per 100,000 P 100,000 New Cases per

Dare County Carteret County State of NC

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Colorectal Cancer Hospital Discharges

Table 116 presents data on hospital discharges related to the treatment of colorectal cancer. All the discharge rates for Dare County residents for the period cited were likely unstable due to small numbers of events. Noteworthy is that in none of the three jurisdictions was there much stable change in the discharge rate over time.

Table 116. Colon, Rectum, Anus Malignant Neoplasm Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.40.30.20.50.6 Carteret County 0.8 0.4 0.6 0.6 0.7 State of NC 0.5 0.5 0.5 0.5 0.4

Colorectal Cancer Mortality

In the aggregate period 2004-2008 colorectal cancer claimed the lives of 24 Dare County residents, for a mortality rate of 11.2. This rate was 35% lower than the comparable rate in either Carteret County or NC as a whole.

Table 117. Colon, Rectum, Anus Cancer Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 22 10.5 2 29.6 16 16.5 8 6.9 24 11.2 Carteret County 67 15.7 8 30.9 42 21.4 33 13.3 75 17.0 State of NC 5,730 16.0 1,897 22.5 3,849 20.7 3,778 14.7 7,627 17.3

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County, http://www.schs.state.nc.us/SCHS/data/databook/ Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Colorectal Cancer Mortality Rate Trend

The colorectal cancer mortality rate in Dare County decreased for the first four aggregate periods cited, then increased for the last two. Meanwhile, the colorectal cancer mortality rate in Carteret County remained approximately stable, and the NC rate decreased slightly. For all of the aggregate periods cited, the colorectal cancer mortality rate in Dare County was lower than the comparable rates in Carteret County or NC as a whole (Figure 21).

Figure 21. Colorectal Cancer Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

25.0

20.0

15.0

10.0

5.0

Deatlsper 100,000 Population 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Colorectal Cancer Mortality

In Dare County, the numbers of deaths attributable to colorectal cancer among white males (n=15), white females (n=7), minority males (n=1) and minority females (n=1) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate stable rates, so local rate data is not presented here.

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Figure 22 plots the valid stratified NC colorectal cancer mortality rates for a point of reference. Statewide the colorectal cancer death rates for both minority males and females exceed the comparable rates for whites, and the rates for both white and minority males exceed the rates for females.

Figure 22. Gender and Racial Disparities in Colorectal Cancer Mortality (Five-Year Aggregate Data, 2004-2008)

30.0

25.0 Population

20.0

15.0 100,000 10.0 per 5.0

0.0 Deaths White Minority White Minority

Males Females

Dare County State of NC

Source: North Carolina State Center for Health Statistics, County-level Data, County Health Data Books, 2008 County Health Data Book, Mortality, 2002-2006 Race-Sex Specific Age-Adjusted Rates by County, http://www.schs.state.nc.us/SCHS/data/databook

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Dare County Cancer Outreach Program

Dare County is one of the original sites for the UNC Cancer Network, an outreach effort of UNC Lineberger Comprehensive Cancer Center and the NC Cancer Hospital in partnership with the County of Dare (57).

The UNC Cancer Network seeks to improve cancer care and support across the state by reaching out with comprehensive cancer support programming in Dare County, including:

 Second Opinion Oncology Specialty Clinics in Dare County;  Telemedicine consultations and videoconferencing of multidisciplinary team meetings with UNC’s patient care teams as they review individual treatment plans;  Patient Navigation Programs that connect oncology nurses with patients, families and care givers to help overcome health system barriers and facilitate timely access to quality care through all phases of the cancer experience;  Community-based support such as Hands of Hope Community Care Team; and  Community presentations including Lunch and Learns and the Coping with Cancer Symposium.

Dare County organizations playing an active or supporting role in the program include:

 Dare County Department of Public Health  Outer Banks Hospital  Hatteras Island Cancer Foundation  Dare County Online Community Resource Directory  Dare County Community Care Clinic  Interfaith Community Outreach  Outer Banks Relief Foundation  The Outer Banks Hospital Cancer Resource Center  The Outer Banks Cancer Support Group

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Diseases of the Heart

Diseases of the heart include any disease that diminishes or interrupts blood supply to the heart. The most common cause of both of heart disease is a narrowing or blockage of arteries that supply the heart (52). Heart disease was the second leading cause of death in Dare County for the five-year aggregate period from 2004-2008 (Table 103, cited previously).

Heart Disease Hospital Discharges

Heart disease accounts for more hospitalizations than any other health condition. Consequently, the hospital charges associated with its treatment are greater than for any other disease, accounting for over $4,567,831 in hospital charges to Dare County residents in 2008 (53).

Hospital discharge data summarized Table 118 give some indication of the extent of heart disease in Dare County. Hospital discharge rates for heart disease declined overall between 2004 and 2008 in both Dare County and NC as a whole.

Table 118. Heart Disease Hospital Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 6.8 5.0 4.7 5.0 5.0 Carteret County 20.0 18.5 16.9 18.5 19.5 State of NC 13.6 13.1 12.7 12.2 11.8

Heart Disease Mortality

Table 119 presents heart disease mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 304 people died from heart disease over the period 2004-2008, for an overall mortality rate of 162.4, 19.7% lower than the rate for NC as a whole, and 18.3% lower than the rate in Carteret County.

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Table 119. Heart Disease Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 294 160.2 10 244.6 177 193.1 127 130.3 304 162.4 Carteret County 810 197.5 52 215.2 461 249.2 401 158.8 862 198.7 State of NC 68,625 195.0 18,707 228.4 44,413 256.6 42,919 161.2 87,332 202.2

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 23 presents mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The heart disease mortality rates in all three jurisdictions have decreased overall between 1999 and 2008.  The heart disease mortality rate in Dare County was significantly lower than the comparable rate in either Carteret County or NC as a whole over the entire period covered by this data.  The rate of decrease in the Dare County heart disease mortality rate appears to have slowed during the last three reporting periods, and may in fact have begun to reverse.

Figure 23. Heart Disease Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

300.0

250.0

200.0

150.0

100.0

50.0

Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

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Gender and Racial Disparities in Heart Disease Mortality

The numbers of deaths attributable to heart disease among both minority males (n=4) and minority females (n=6) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 24 plots heart disease mortality rates valid for comparison. Among whites alone, the heart disease death rate for Dare County males (192.0) was 51% higher than the heart disease death rate for females (127.1)

Measured against the heart mortality rates statewide, the rates for both white males and white females in Dare County are lower. Note that statewide the heart disease death rate for minority males exceeds the comparable rates for white males, and that the heart disease death rate for minority females exceeds the rate for white females.

Figure 24. Gender Disparities in Heart Disease Mortality (Five-Year Aggregate Data, 2004-2008)

350.0 300.0 250.0 200.0 150.0 100.0 50.0 0.0 Deaths per 100,000 Population 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

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Pneumonia and Influenza

Pneumonia and influenza are diseases of the lungs. Pneumonia is an inflammation of the lungs caused by either bacteria or viruses. Bacterial pneumonia is the most common and serious form of pneumonia, and among individuals with suppressed immune systems it may follow influenza or the common cold. Influenza (the “flu”) is a contagious infection of the throat, mouth and lungs caused by an airborne virus (52).

Pneumonia/influenza was the third leading cause of death in Dare County for the five-year aggregate period from 2004-2008 (Table 103, cited previously).

Pneumonia and Influenza Hospital Discharges

Treatment of pneumonia and influenza accounted for $952,363 in hospital charges to Dare County residents in 2008 (53).

Hospital discharge data summarized Table 120 give some indication of the burden of pneumonia and influenza in Dare County. Hospital discharge rates for pneumonia and influenza declined overall between 2004 and 2008 in all three jurisdictions: by 32% in Dare County, by 19% in Carteret County, and by 11% statewide.

Table 120. Pneumonia/Influenza Hospital Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 3.1 2.4 2.2 2.2 2.1 Carteret County 4.7 6.0 4.9 4.3 3.8 State of NC 3.7 4.1 3.7 3.4 3.3

It should be noted that hospital discharge data of this type is limited in that it does not include people who may have cardiovascular conditions but have not sought medical care or been hospitalized.

Pneumonia/Influenza Mortality

Table 121 presents heart disease mortality data for the aggregate period 2004-2008, stratified by race and sex.

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In Dare County, 79 people died from pneumonia or influenza over the period 2004-2008, for an overall mortality rate of 49.8, 1½ times the rate for NC as a whole, and more than twice the rate in Carteret County.

Table 121. Pneumonia/Influenza Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 76 48.7 3 114.8 22 30.0 57 61.3 79 49.8 Carteret County 63 15.7 5 22.2 33 20.2 35 13.3 68 16.0 State of NC 7,144 20.6 1,455 18.5 3,710 23.9 4,889 18.1 8,599 20.3

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases

Figure 25 presents mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The pneumonia/influenza mortality rates in all Carteret County and NC as a whole decreased slightly overall between 1999 and 2008.  The pneumonia/influenza mortality rate in Dare County was significantly higher than the comparable rate in either Carteret County or NC as a whole over the entire period covered by this data.  The Dare County pneumonia/influenza mortality rate appears to have increased over the first three of the aggregate periods cited; only recently has it begun to decrease.

It is somewhat surprising that pneumonia and influenza cause such a high rate of death in Dare County. Although the Dare County population is “older” than the median for NC as a whole, these data are age-adjusted and should have accounted for that fact. Furthermore, the Dare County Department of Public Health employs an aggressive influenza immunization strategy. In FY2009-10 alone the health department administered 3,383 immunizations for seasonal influenza, and 3,861 for H1N1 influenza (58).

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Figure 25. Pneumonia/Influenza Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

70.0

60.0

opulation 50.0

40.0

30.0

20.0

10.0

Deaths per 100,000 P 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Pneumonia/Influenza Mortality

The numbers of deaths attributable to pneumonia and influenza among both minority males (n=1) and minority females (n=2) in the 2004- 2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 26 plots total pneumonia/influenza mortality rates valid for comparison. Among whites alone, the pneumonia/influenza death rate for Dare County females (60.5) was more than double the rate for males (28.3).

Measured against comparable pneumonia/influenza mortality rates statewide, the rates for both white males and, especially, white females in Dare County are higher. Note that statewide the pneumonia/influenza death rates for minority males and females are slightly lower than the comparable rate for white males and females, respectively.

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Figure 26. Gender Disparities in Pneumonia/Influenza Mortality (Five-Year Aggregate Data, 2004-2008)

70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Deatlh per Population per 100,000 Deatlh White Minority White Minority

Males Females

Dare County State of NC

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Cerebrovascular Disease

Cerebrovascular disease, (“stroke”) includes any disease that diminishes or interrupts blood supply to the brain. Stroke also includes the condition when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells (52). Cerebrovascular disease was the fourth leading cause of death in Dare County for the five-year aggregate period from 2004-2008 (Table 103, cited previously).

Cerebrovascular Disease Hospital Discharges

Cerebrovascular disease accounted for $448,946 in hospital charges to Dare County residents in 2008 (53).

Hospital discharge data summarized Table 122 give some indication of the prevalence of stroke in Dare County. Hospital discharge rates for stroke declined overall between 2004 and 2008 in all three jurisdictions, but most (39%) in Dare County.

Table 122. Cerebrovascular Disease Hospital Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 1.8 2.0 1.2 1.4 1.1 Carteret County 4.2 4.5 3.4 3.7 4.1 State of NC 3.3 3.2 3.1 3.1 3.0

It should be noted that hospital discharge data of this type is limited in that it does not include people who may have cerebrovascular conditions but have not sought medical care or been hospitalized.

Cerebrovascular Disease Mortality

Table 123 presents stroke mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 62 people died from cerebrovascular disease over the period 2004-2008, for an overall mortality rate of 37.1, 31.8% lower than the rate for NC as a whole, and 23.2% lower than the rate in Carteret County.

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Table 123. Cerebrovascular Disease Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 61 37.2 1 41.1 27 38.2 35 36.1 62 37.1 Carteret County 195 47.5 13 57.0 92 52.8 116 45.0 208 48.3 State of NC 17,451 50.1 5,707 71.5 9,195 55.9 13,963 52.4 23,158 54.4

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 27 presents stroke mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The cerebrovascular disease mortality rates in all three jurisdictions decreased overall between 1999 and 2008.  The cerebrovascular disease mortality rate in Dare County was significantly lower than the comparable rate in either Carteret County or NC as a whole over the entire period covered by this data.

Figure 27. Cerebrovascular Disease Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0

Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

172 Dare County Community Health Assessment – Volume One Health Statistics

Gender and Racial Disparities in Cerebrovascular Disease Mortality

The numbers of deaths attributable to cerebrovascular disease among both minority males (n=0) and minority females (n=1) in the 2004- 2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 28 plots stroke mortality rates valid for comparison. Among whites alone, the cerebrovascular disease death rate for Dare County males (192.0) was 51% higher than the heart disease death rate for females (127.1).

Measured against comparable stroke mortality rates statewide, the rates for both white males and white females in Dare County are lower. Note that statewide the stroke death rate for minority males much exceeds the comparable rates for white males, and that the stroke death rate for minority females exceeds the rate for white females, but by a smaller margin. Statewide, the stroke mortality rates for white males and white females are similar.

Figure 28. Gender Disparities in Cerebrovascular Disease Mortality (Five-Year Aggregate Data, 2004-2008)

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Deaths per 100,000 Population 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

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Unintentional Non-Motor Vehicle Injury

The NC State Center for Health Statistics distinguishes unintentional non-motor vehicle injuries from motor vehicle injuries when calculating mortality rates and ranking leading causes of death. Unintentional non-motor vehicle injuries are those without purposeful intent, including poisoning, falls, burns, choking, animal bites, drowning, and occupational or recreational injuries. Unintentional non-motor vehicle injuries are the fifth leading cause of death in Dare County (Table 103, cited previously).

Unintentional Non-Motor Vehicle Injury Hospital Discharges

No specific measure of hospital utilization for this cause of death exists in the public domain; however as an approximate measure, injuries (of all kinds) and poisonings accounted for $2,908,887 in hospital charges to Dare County residents in 2008 (53).

Hospital discharge data for injuries and poisonings summarized Table 124 give some indication of the extent of these problems in Dare County. Hospital discharge rates in this category declined by 7.5% in Dare County between 2004 and 2008.

Table 124. Injuries and Poisoning Hospital Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 4.0 4.1 3.9 3.4 3.7 Carteret County 10.2 9.4 10.2 10.5 10.4 State of NC 8.5 8.5 8.6 8.6 8.5

Unintentional Non-Motor Vehicle Injury Mortality

Table 125 presents unintentional non-motor vehicle injury mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 62 people died from unintentional non-motor vehicle injury over the period 2004-2008, for an overall mortality rate of 35.5, 25% higher than the rate for NC as a whole, but 6.6% lower than the rate in Carteret County.

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Table 125. Unintentional Non-Motor Vehicle Injury Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 58 33.8 4 52.0 44 50.4 18 19.9 62 35.5 Carteret County 125 38.5 9 34.1 79 48.1 55 28.1 134 38.0 State of NC 10,358 30.5 2,077 21.3 7,423 37.8 5,012 20.2 12,435 28.4

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 29 presents unintentional non-motor vehicle injury mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The unintentional non-motor vehicle injury mortality rates in Dare County and Carteret County were higher than the state rate across the span of dates included in the figure.  The unintentional non-motor vehicle injury mortality rate in Dare County was significantly higher than the comparable rate in Carteret County for the first three periods cited; after that, the Dare County rate declined to where in the last period it was lower than the comparable rate in Carteret County.

Figure 29. Unintentional Non-Motor Vehicle Injury Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0

Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Source: NC State Center for Health Statistics, County Health Data Book (Years as noted), Mortality, Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ 175 Dare County Community Health Assessment – Volume One Health Statistics

Gender and Racial Disparities in Unintentional Non-Motor Vehicle Injury Mortality

The numbers of deaths attributable to unintentional non-motor vehicle injury among white females (n=16), minority males (n=2), and minority females (n=2) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 30 plots rates valid for comparison. Measured against the unintentional non-motor vehicle injury mortality rate for white males statewide, the rate for white males in Dare County was 24.5% higher. Note that statewide the death rate for minority male is much lower than the comparable rates for white males, and that the rates for minority females and white females are lower than the comparable rated for males.

Figure 30. Gender and Racial Disparities in Unintentional Non-Motor Vehicle Injury Mortality (Five-Year Aggregate Data, 2004-2008)

60.0

50.0

40.0

30.0

20.0

10.0

0.0

Deaths per 100,000 100,000 per Population Deaths White Minority White Minority

Males Females

Dare County State of NC

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Chronic Lower Respiratory Disease

Chronic obstructive pulmonary disease (COPD) is a group of lung diseases involving limited airflow, airway inflammation and the destruction of lung tissue (52). Around 1999 the NC State Center for Health Statistics started classifying COPD within the broader heading of Chronic Lower Respiratory Disease (CLRD) when computing mortality rates. (Other data, such as hospital discharge data, remains in the COPD category.) CLRD/COPD was the fifth leading cause of death in Dare County for the period 2004-2008 (Table 103, cited previously).

COPD Hospital Discharges

COPD accounted for $893,959 in hospital charges to Dare County residents in 2008 (53).

Hospital discharge data summarized Table 126 give some indication of the burden of chronic lung disease in Dare County. Hospital discharge rates for COPD declined 31% overall in Dare County between 2004 and 2008, while increasing slightly in both Carteret County (7%) and NC (6%).

Table 126. Chronic Obstructive Pulmonary Disease Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 3.2 3.0 2.9 2.4 2.2 Carteret County 4.2 4.6 4.3 4.5 4.5 State of NC 3.2 3.5 3.2 3.1 3.4

CLRD Mortality

Table 127 presents CLRD mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 62 people died from CLRD/COPD over the period 2004-2008, for an overall mortality rate of 33.4, 30% lower than the rate for NC as a whole, and 18.7% lower than the rate in Carteret County.

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Table 127. Chronic Lower Respiratory Disease Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 62 33.9 0 0.0 28 33.6 34 33.4 62 33.4 Carteret County 177 41.7 7 30.8 99 52.7 85 33.5 184 41.1 State of NC 18,167 51.6 2,355 29.5 9,942 58.9 10,580 41.3 20,522 47.8

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 31 presents CLRD/COPD mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The CLRD/COPD mortality rates in Dare County and Carteret County were lower than the state rate across the span of dates included in the figure.  The CLRD/COPD mortality for NC changed little over the period cited. In the same time frame the comparable rate in Carteret County decreased slighly, and the rate in Dare County decreased more significantly.

 Figure 31. CLRD/COPD Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

60.0

50.0

40.0

30.0

20.0

10.0 Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Source: NC State Center for Health Statistics, County Health Data Book (Years as noted), Mortality, Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/ 178 Dare County Community Health Assessment – Volume One Health Statistics

Gender and Racial Disparities in CLRD/COPD Mortality

The numbers of deaths attributable CLRD/COPD among minority males (n=0), and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 32 plots rates valid for comparison. Measured against comparable CLRD/COPD mortality rate statewide, the rate for white males in Dare County was 44.4% lower, and the rate for white females in Dare County was 26.1% lower. Note that statewide the death rate for minority males and females is much lower than the comparable rates for white males and white females, respectively.

Figure 32. Gender and Racial Disparities in CLRD/COPD Mortality (Five-Year Aggregate Data, 2004-2008)

70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Deaths per 100,000 Population 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

179 Dare County Community Health Assessment – Volume One Health Statistics

Unintentional Motor Vehicle Injury

The NC State Center for Health Statistics distinguishes unintentional motor vehicle injuries from all other injuries when calculating mortality rates and ranking leading causes of death. Injury mortality attributable to motor vehicle crashes is the seventh leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

Unintentional Motor Vehicle Injury Hospital Discharges

The NC State Center for Health Statistics does not record hospital discharges separately for this cause of death.

Unintentional Motor Vehicle Injury Mortality

Table 128 presents unintentional motor vehicle injury mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 34 people died from unintentional motor vehicle injury over the period 2004-2008, for an overall mortality rate of 19.4, 4.3% higher than the rate for NC as a whole, and 6.7% lower than the rate in Carteret County.

Table 128. Unintentional Motor Vehicle Injury Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 34 20.2 0 0.0 25 27.3 9 11.6 34 19.4 Carteret County 59 20.6 5 21.1 44 31.0 20 10.7 64 20.8 State of NC 6,292 18.7 2,016 18.1 5,830 26.7 2,478 10.8 8,308 18.6

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 33 presents unintentional motor vehicle injury mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The unintentional motor vehicle injury mortality rates in Dare County and Carteret County were higher than the state rate across most of the span of dates included in the figure.  The unintentional motor vehicle injury mortality rate for NC changed little over the period cited. In the same time frame the comparable rate in Carteret County rose slighly, and the rate in Dare County rose more significantly. However, there is an indication that the unintentional motor vehicle injury mortality rate in Dare County and Carteret County may be on the decrease.

180 Dare County Community Health Assessment – Volume One Health Statistics

Figure 33. Unintentional Motor Vehicle Injury Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

30.0

25.0

20.0

15.0

10.0

5.0

Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Unintentional Motor Vehicle Injury Mortality

The numbers of deaths attributable to unintentional motor vehicle injury among white females (n=9), minority males (n=0), and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 34 plots rates valid for comparison. Measured against the unintentional motor vehicle injury mortality rate statewide, the rate for white males in Dare County was 7.6% higher. Note that statewide the death rate for minority males is higher than the comparable rate for white males, and the rate for minority females is lower than the rate for white females. Statewide the unintentional motor vehicle injury mortality rate for males is significantly higher than the rate for females regardless of race.

181 Dare County Community Health Assessment – Volume One Health Statistics

Figure 34. Gender and Racial Disparities Unintentional Motor Vehicle Injury Mortality (Five-Year Aggregate Data, 2004-2008)

30.0

25.0

opulation 20.0

15.0

10.0

5.0

0.0 Deaths per 100,000 P 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

The unintentional motor vehicle injury death rate has a strong age component.

Table 129 presents unintentional motor vehicle injury mortality data for the five-year aggregate period 2004-2008, stratified by age. The numbers of deaths in all age groups in Dare County were under the threshold to calculate stable rates for comparison; the same was true for two of the age groups in Carteret County. At the state level, however, the pattern emerges: the highest unintentional motor vehicle injury mortality rate occurs in the 20-39 age group (24.8), followed by the 40-64 age group. The youngest age group (0-19) has the lowest rate, although there is a perception that the youngest drivers are involved in a higher proportion of motor vehicle crashes.

182 Dare County Community Health Assessment – Volume One Health Statistics

Table 129. Motor Vehicle Injury Mortality, Numbers and Rates, by Age (Five-Year Aggregate Data, 2004-2008)

Number of Deaths and Unadjusted Death Rates per 100,000 Population Location All Ages 0-19 20-39 40-64 Number Rate Number Rate Number Rate Number Rate

Dare County 34 19.8 6 15.3 9 22.4 12 17.9 Carteret County 64 20.3 8 12.3 21 31.0 19 15.4 State of NC 8,308 18.7 1,302 10.8 3,108 24.8 2,593 18.0

Source: NC State Center for Health Statistics, 2010 County Health Databook, Death Counts and Crude Death Rates per 100,000 Population for Leading Causes of Death, by Age Groups, NC 2004-2008; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

According to data collected in the 2009 Youth Risk Behavior Survey, significant proportions of Dare County High School students tempt fate and invite injury by demonstrating unhealthy behaviors when riding in a car or on a bicycle.

Table 130. Youth Automobile and Bicycle Behaviors (2009)

Percentage of Respondents Dr ove a Car Bicycle Alw ays Wear Rode in a Car Rode in a Car Dr ove a Car Unde r the Riders Who a Seat Belt Where Driver Where Driver Category After Influence of Wore a When a Had Be e n Had Be e n Dr ink ing Dr ugs Othe r Helmet Most Passenger Recklessly Dr ink ing Alcohol Than of the Time in a Car Speeding Alcohol Tobacco or Always

Females 49.053.126.613.320.32.8 Males 45.056.827.018.626.44.0 Overall 46.8 55.1 27.1 16.4 23.9 3.8

Source: 2009 Youth Behavior Risk Survey, Dare County High School Students

Table 131 presents detailed data on motor vehicle crashes in 2008.

 In 2008 there were 667 motor vehicle crashes in Dare County, resulting in 341 nonfatal injuries and four fatalities.  In 2008 in Dare County 63 of the 667 crashes (9.5%) were alcohol-related. This percentage was above the comparable percentages for both Carteret County and NC. 183 Dare County Community Health Assessment – Volume One Health Statistics

 Alcohol was involved in 22.6% of non-fatal injuries, but 75% of the fatal injuries in Dare County in 2008. Both of these percentages are significantly above the comparable percentages for Carteret County and NC.  Just over 61% of driving while intoxicated (DWI) charges in Dare County in 2008 resulted in DWI convictions. This is approximately the same as the statewide DWI conviction percentage, but 18.5% higher than the conviction rate in Carteret County.

Table 131. Motor Vehicle Crash Details (2008)

Crashes Number of Crash Injuries Alcohol Related Injuries DWI Charges As Num be r Percent Alcohol Alcohol As As Total Percent Location Crashes Crashes Non-Fatal Related Re late d Percent Percent No. DWI No. DWI % DWI Num be r Fatal of Non- Alcohol Alcohol- Injuries Non-Fatal Fatal of Total of Fatal Charges Convictions Convictions1 Crashes Fatal Re late d Re late d Injuries Injuries Injuries Injuries Injuries

Dare County 667 63 9.5 341 4 77 3 23.2 22.6 75.0 645 394 61.1 Carteret County 1,029 81 7.9 681 4 54 2 8.2 7.9 50.0 1,341 730 54.4 State of NC 218,857 11,712 5.4 112,387 1,450 9,267 431 8.5 8.3 29.7 72,660 44,804 61.7 Source: a a a b b b b b b b c c c

a - UNC Highway Safety Research Center, Safety Information, Alcohol Studies, NC Alcohol Facts (NCAF), Data by County, Crash Data, Overview (2008); http://www.hsrc/unc.edu/ncaf b - UNC Highway Safety Research Center, Safety Information, Alcohol Studies, NC Alcohol Facts (NCAF), Data by County, Crash Data, Crash Injuries (2008); http://www.hsrc/unc.edu/ncaf c - UNC Highway Safety Research Center, Safety Information, Alcohol Studies, NC Alcohol Facts (NCAF), Impaired Driving Court Cases, County Data (2008); http://www.hsrc/unc.edu/ncaf

Table 132 presents data on the incidence of bicycle crashes in both the towns and rural areas of Dare County for the years from 1997-2004.

 There was a total of 103 bicycle crashes in Dare County during the period cited.  The highest number of bicycle crashes (47) occurred in the rural areas of the county.  The towns with the highest number of bicycle crashes were Kill Devil Hills (20) and Nags Head (18).

184 Dare County Community Health Assessment – Volume One Health Statistics

Table 132. Dare County City and Rural Bicycle Crashes (1997-2004)

Number of Crashes City Name 1997 1998 1999 2000 2001 2002 2003 2004 Total

Duck 0 0 0 0 0 0 7 0 7 Kill Devil Hills 1 1 4 1 1 3 7 2 20 Kitty Hawk 2 1 0 1 2 0 2 1 9 Manteo 1 0 0 1 0 0 0 0 2 Nags Head 0 2 3 3 0 4 5 1 18 Non-City (Rural) 3 8 10 6 9 6 2 3 47 Southern Shores 0 0 0 0 0 0 0 0 0 Total 71217121213237103

Source: NC Department of Transportation, Division of Bicycle and Pedestrian Transportation, Data Query, Bicycle Crash Data, Crash Facts; http://www.pedbikeinfo.org/pbcat/about_bike.htm

Table 133 presents data on the incidence of crashes involving pedestrians in both the towns and rural areas of Dare County for the years from 1997-2004.

 There was a total of 102 pedestrian crashes in Dare County during the period cited.  The highest number of pedestrian crashes (34) occurred in the rural areas of the county.  The towns with the highest number of pedestrian crashes were Kill Devil Hills (23) and Kitty Hawk (20).

Table 133. Dare County City and Rural Pedestrian Crashes (1997-2004)

Number of Crashes City Name 1997 1998 1999 2000 2001 2002 2003 2004 Total

Duck 0 0 0 0 0 0 0 0 0 Kill Devil Hills 4 3 0 5 5 1 3 2 23 Kitty Hawk 2 1 4 2 0 4 5 2 20 Manteo 1 1 0 0 1 0 1 1 5 Nags Head 3 3 3 1 1 4 2 1 18 Non-City (Rural) 4 4 2 8 3 5 3 5 34 Southern Shores 0 1 0 0 0 0 0 1 2 Total 14 13 9 16 10 14 14 12 102

NC Department of Transportation, Division of Bicycle and Pedestrian Transportation, Data Query, Pedestrian Crash Data, Crash Facts; http://www.pedbikeinfo.org/pbcat/about_ped.htm 185 Dare County Community Health Assessment – Volume One Health Statistics

Table 134 lists the number of motor vehicle crashes involving deer for 2008.

Table 134. Deer-Motor Vehicle Crash Data (2008)

No. Location Crashes

Dare County 17 Carteret County 54 State of NC 19,693

Source: UNC Highway Research Center, Safety Information, Animal- Vehicle Crash Information, 2008 Deer-Motor Vehicle; http://www.hsrc.unc.edu/safety_info/animal_vehicle/nc_deer2008.cfm

186 Dare County Community Health Assessment – Volume One Health Statistics

Alzheimer’s Disease

Alzheimer’s disease is a progressive neurodegenerative disease affecting mental abilities including memory, cognition and language. Alzheimer’s disease is characterized by memory loss and dementia. The risk of developing Alzheimer’s disease increases with age (e.g., almost half of those 85 years and older suffer from Alzheimer’s disease). Early-onset Alzheimer’s has been shown to be genetic in origin, but a relationship between genetics and the late-onset form of the disease has not been demonstrated. No other definitive causes have been identified (52). Alzheimer’s disease was the eighth leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

Alzheimer’s Disease Hospital Discharges

The NC State Center for Health Statistics does not record hospital discharges separately for this cause of death.

Alzheimer’s Disease Mortality

Table 135 presents Alzheimer’s disease mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 24 people died from Alzheimer’s disease over the period 2004-2008, for an overall mortality rate of 13.7, 47.3% lower than the rate for Carteret County and 52.2% lower than the rate for NC as a whole.

Table 135. Alzheimer's Disease Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 24 13.9 0 0.0 3 3.6 21 21.2 24 13.7 Carteret County 107 26.7 3 14.0 32 20.0 78 29.6 110 26.0 State of NC 10,272 29.8 1,654 23.3 3,142 22.2 8,784 31.8 11,926 28.7

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/, Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Alzheimer’s disease data has been recorded only in recent years, so trend data has some gaps in the early years of county data presented in Figure 35. 187 Dare County Community Health Assessment – Volume One Health Statistics

For the span of years for which county and state data on Alzheimer’s disease mortality exist, the Alzheimer’s mortality rate in Dare County is significantly lower than the corresponding rates in Carteret County or NC as a whole. Furthermore, the rate in Dare County appears to be decreasing, while it is rising slightly at the state level.

Figure 35. Alzheimer's Disease Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

Alzheimer's Disease Mortality Rate Trend

35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Deaths per 100,000 Population 100,000 per Deaths

Dare County Carteret County State of NC

Source: NC State Center for Health Statistics, County Health Data Book (Years as noted), Mortality, Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: the steep incline for the county measures between the 1999-2003 and 2000-2004 data points reflects a lack of data for the earlier period.

Gender and Racial Disparities in Alzheimer’s Disease Mortality

The numbers of deaths attributable to Alzheimer’s disease among white males (n=3), minority males (n=0), and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 36 plots rates valid for comparison. Measured against the Alzheimer’s mortality rate for white females statewide, the rate for white females in Dare County was 34.9% lower (56). Note that statewide the death rate for white females is higher than the comparable rate for white males, and minority males and females.

188 Dare County Community Health Assessment – Volume One Health Statistics

Figure 36. Gender and Racial Disparities for Alzheimer’s Diseases Mortality (Five-Year Aggregate Data, 2004-2008)

35.0 30.0

opulation 25.0 20.0 15.0 10.0 5.0 0.0 Deaths per 100,000 P 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

189 Dare County Community Health Assessment – Volume One Health Statistics

Diabetes Mellitus

Diabetes mellitus (hereafter “diabetes”) is a disorder of the metabolic system resulting from a shortage of insulin, a hormone that allows sugar to enter body cells and convert into energy. If diabetes is uncontrolled, sugar and fats remain in the blood, over time damaging vital organs (52). Diabetes was the ninth leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

Diabetes Hospital Discharges

Diabetes accounted for $255,502 in hospital charges to Dare County residents in 2008 (53).

Hospital discharge data summarized Table 136 give some indication of the burden of diabetes in Dare County. Hospital discharge rates for diabetes declined 50% overall in Dare County between 2004 and 2008, while decreasing 30% in Carteret County and increasing slightly in NC as a whole.

Table 136. Diabetes Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.8 0.6 0.3 0.3 0.4 Carteret County 2.0 1.8 1.5 1.4 1.4 State of NC 1.7 1.8 1.8 1.9 1.8

Diabetes Mortality

Table 137 presents diabetes mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 26 people died from diabetes over the period 2004-2008, for an overall mortality rate of 13.3, 47% lower than the rate for NC as a whole, and 18% lower than the rate in Carteret County.

190 Dare County Community Health Assessment – Volume One Health Statistics

Table 137. Diabetes Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 24 12.7 2 41.7 14 15.3 12 11.8 26 13.3 Carteret County 65 15.4 7 29.2 38 19.8 34 13.5 72 16.2 State of NC 7,004 19.7 4,045 49.2 5,359 28.9 5,690 22.2 11,049 25.2

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 37 presents diabetes mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The diabetes mortality rates in Dare County and Carteret County were lower than the state rate across the span of dates cited.  The diabetes mortality rate for NC decreased slightly over the period cited. In the same time frame the comparable rate in Carteret County decreased significantly, and the rate in Dare County rose slightly before decreasing in the last period to the same level as in the first period cited.

Figure 37. Diabetes Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

30.0

25.0

opulation 20.0

15.0

10.0

5.0

0.0 Deaths per 100,000 P 100,000 per Deaths

Dare County Carteret County State of NC

191 Dare County Community Health Assessment – Volume One Health Statistics

Gender and Racial Disparities in Diabetes Mortality

The numbers of deaths attributable to diabetes among white males (n=13), white females (n=11), minority males (n=1) and minority females (n=1) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 38 plots rates valid for comparison. Statewide, the rate for white males was 48.8% higher than the rate for white females. Note that statewide the death rate for minority males and females are much higher than the comparable rates for whites. The diabetes mortality rate for minority males is more than twice the rate for white males, and the rate for minority females is almost three times the rate for white females.

Figure 38. Gender and Racial Disparities in Diabetes Mortality (Five-Year Aggregate Data, 2004-2008)

60.0

50.0

opulation 40.0

30.0

20.0

10.0

0.0 Deaths per 100,000 P 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

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Suicide

Suicide was the tenth leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

Suicide Hospital Discharges

The NC State Center for Health Statistics does not release hospitalization data for attempted suicide.

Suicide Mortality

Table 138 presents suicide mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 24 people took their own lives over the period 2004-2008, for an overall mortality rate of 12.6, 5.9% higher than the rate for NC as a whole, and 16.6% lower than the rate in Carteret County.

Table 138. Suicide Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 24 13.1 0 0.0 18 18.4 6 6.7 24 12.6 Carteret County 51 16.3 1 3.2 41 25.3 11 5.9 52 15.1 State of NC 4,754 13.9 589 5.2 4,103 19.1 1,240 5.4 5,343 11.9

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 39 presents suicide mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The suicide mortality rates in Dare County fluctuated up and down around the state rate across the span of dates included in the figure, and was approximately the same at the end of the span as at the beginning.  The suicide mortality rate for the NC as a whole remained approximately the same through all the periods cited.  The suicide mortality rate in Carteret County was significantly higher than the rate for NC through all the periods cited, although it appears to be on a downward trend most recently.

193 Dare County Community Health Assessment – Volume One Health Statistics

Figure 39. Suicide Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

25.0

20.0

opulation 15.0

10.0

5.0

0.0 Deaths per 100,000 P 100,000 per Deaths

Dare County Carteret County State of NC

Gender and Racial Disparities in Suicide Mortality

The numbers of deaths attributable to suicide among white males (n=18), white females (n=6), minority males (n=0) and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 40 plots rates valid for comparison. Statewide, the suicide rate for white males is the highest of all the stratified groups and is almost 3½ times the rate for white females. Statewide the suicide death rate for minority males is almost 60% lower than the rate for white males, but is still 4½ times the rate for minority females.

194 Dare County Community Health Assessment – Volume One Health Statistics

Figure 40. Gender and Racial Disparities in Suicide Mortality (Five-Year Aggregate Data, 2004-2008)

25.0

20.0 Population 15.0

10.0 100,000

per 5.0

0.0 Deaths White Minority White Minority

Males Females

Dare County State of NC

The 2009 Youth Risk Behavior Survey of Dare County High School students asked several questions relative to mental health that are pertinent to a discussion of suicide. Those results are presented in Table 139.

 Over 30% of Dare County high school students reported feeling sad or hopeless for two or more weeks in a row.  Almost 16% reported having contemplated suicide, and almost 14% reported having developed a suicide plan.  Just over 12% of Dare County high school students reported having attempted suicide.

Table 139. Suicide-Related Feelings and Behaviors Among Dare County High School Students (2009)

Percent of Respondents Felt Sad or Hopeless Made a Category Seriously Considered Attempted for Two or More Weeks Suicide Attempting Suicide Suicide in a Row Plan

Females33.3 15.3 12.6 10.4 Males28.0 16.2 14.7 13.7 Overall30.7 15.9 13.8 12.4

Source: 2009 Youth Risk Behavior Survey, Dare County High Schools

195 Dare County Community Health Assessment – Volume One Health Statistics

Septicemia

Septicemia is a rapidly progressing infection resulting from the presence of bacteria in the blood. The disease often arises from other infections throughout the body, such as meningitis, burns and wound infections. Septicemia can lead to septic shock wherein low blood pressure and low blood flow cause organ failure (52). While septicemia can be community-acquired, ironically some cases are acquired by patients hospitalized initially for other conditions; these are referred to as nosocomial infections. Sepsis is now a preferred term for septicemia, but the NC State Center for Health Statistics persists in using the older term. Septicemia was the eleventh leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

Septicemia Hospital Discharges

Hospital charges associated with the treatment of septicemia totaled $551,073 for Dare County residents in 2008. Septicemia is not as well known a health condition as heart disease, for example, but it costs even more to treat. In 2008, the per-case hospital charge associated with heart disease in Dare County averaged $27,029; the comparable cost for a septicemia case was $34,442 (53).

Hospital discharge data on septicemia is summarized Table 140. Hospital discharge rates for septicemia rose in all three jurisdictions between 2004 and 2008. Note, however, that the rates for Dare County are likely unstable, and the rates in Carteret County fluctuated considerably. The NC rates, likely the most reliable, increased every year over the span of years cited, to a 2008 rate that was 77% higher than the state rate in 2004.

Table 140. Septicemia Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.30.30.40.40.5 Carteret County 1.6 2.0 1.6 1.5 2.1 State of NC 1.3 1.6 1.8 2.0 2.3

Table 141 presents septicemia mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 22 people died of septicemia over the period 2004-2008, for an overall mortality rate of 11.6, 18.3% lower than the rate for NC as a whole, but 16% higher than the rate in Carteret County. 196 Dare County Community Health Assessment – Volume One Health Statistics

Table 141. Septicemia Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 21 11.2 1 41.1 5 4.5 17 17.0 22 11.6 Carteret County 42 10.1 2 8.9 25 12.2 19 8.1 44 10.0 State of NC 4,379 12.5 1,751 21.4 2,709 15.6 3,421 13.2 6,130 14.2

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 41 presents septicemia mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The septicemia mortality rate in Dare County was significantly higher than the rates for Carteret County and the state for the first three aggregate periods cited in Figure 41, even though falling significantly over the first five aggregate periods to a current rate below that of NC as a whole.  The septicemia mortality rate in Carteret County was fairly stable and below the state rate for the entire span of years cited.  The septicemia mortality rate in NC as a whole was stable and steady for the entire span cited.

Figure 41. Septicemia Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

25.0

20.0

opulation 15.0

10.0

5.0

0.0 Deaths per 100,000 P 100,000 per Deaths

Dare County Carteret County State of NC

197 Dare County Community Health Assessment – Volume One Health Statistics

Gender and Racial Disparities in Septicemia Mortality

The numbers of deaths attributable to septicemia among white males (n=5), white females (n=16), minority males (n=) and minority females (n=1) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 42 plots rates valid for comparison. Statewide, the septicemia mortality rate for white males was 18.1% higher than the rate for white females, and the rate for minority males was 26.3% higher than the rate for minority females. Likewise, the septicemia mortality rate for minority males was 78.8% higher than the rate for white males, and the rate for minority females was 67.2% higher than the rate for white females.

Figure 42. Gender and Racial Disparities in Septicemia Mortality (Five-Year Aggregate Data, 2004-2008)

30.0

25.0

20.0

15.0

10.0

5.0

Deaths per 100,000 Population 100,000 per Deaths 0.0 White Minority White Minority

Males Females

Dare County State of NC

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Nephritis, Nephrosis and Nephrotic Syndrome (Kidney Disease)

Nephritis, nephrosis, and nephrotic syndrome are renal (kidney) diseases. Nephritis is any inflammation of the kidneys, while nephrotic syndrome (also known as nephrosis) is a kidney disease resulting from damage to the blood vessels that filter waste from the blood. These conditions can result from infections, drug exposure, malignancy, hereditary disorders, immune disorders, or diseases that affect multiple body systems (e.g., diabetes and lupus) (52). This complex of kidney disorders represented the twelfth leading cause of death in Dare County for the aggregate period from 2004 to 2008 (Table 103, cited previously).

Kidney Disease Hospital Discharges

Hospital charges associated with the treatment of kidney diseases totaled $201,670 for Dare County residents in 2008 (53).

Hospital discharge data on kidney disease is summarized Table 142. Hospital discharge rates for kidney disease fell overall in Dare County between 2004 and 2008. (Note, however, that the rates for Dare County are likely unstable.) The kidney disease discharge rate in both Carteret County and NC as a whole increased over the same period, by 100% in Carteret County and by 60% in the state.

Table 142. Nephritis, Nephrosis, Nephrotic Syndrome Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.8 1.1 0.5 0.5 0.3 Carteret County 0.5 0.7 0.6 0.6 1.0 State of NC 1.0 1.2 1.3 1.7 1.6

Kidney Disease Mortality

Table 143 presents kidney disease mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 18 people died of kidney diseases over the period 2004-2008, for an overall mortality rate of 10.3, 45.2% lower than the rate for NC as a whole, and 21.4% lower than the rate in Carteret County. Note, however, that the rate in Dare County is based on fewer than 20 deaths, and may therefore be unstable.

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Table 143. Nephritis, Nephrosis and Nephrotic Syndrome Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 17 10.1 1 16.0 9 10.7 9 9.3 18 10.3 Carteret County 51 12.2 7 30.1 31 16.5 27 10.9 58 13.1 State of NC 5,271 15.1 2,818 35.0 3,749 22.3 4,340 16.6 8,089 18.8

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 43 presents kidney disease mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The kidney disease mortality rates in both Dare County and Carteret County were significantly lower than the rates for the state as a whole for the entire span of dates cited.  The kidney disease mortality rate in Dare County fluctuated over the span cited, but in the end was approximately the same as in the beginning; the same appears so in Carteret County. Statewide, the kidney disease mortality rate rose slightly over the span cited.

Figure 43. Kidney Disease Mortality, by Race and Sex (Five-Year Aggregate Data, 1999-2008)

20.0 18.0 16.0

opulation 14.0 12.0 10.0 8.0 6.0 4.0 2.0

Deaths per 100,000 P 100,000 per Deaths 0.0

Dare County Carteret County State of NC

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Gender and Racial Disparities in Kidney Disease Mortality

The numbers of deaths attributable to kidney disease among white males (n=8), white females (n=9), minority males (n=1) and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 44 plots rates valid for comparison. Statewide, the kidney disease mortality rate for white males was 50% higher than the rate for white females, and the rate for minority males was 16.1% higher than the rate for minority females. Minorities clearly suffer a disproportionate burden of death from kidney diseases: the mortality rate for minority males was over twice the rate for white males, and the rate for minority females was over 2½ times the rate for white females.

Figure 44. Racial and Gender Disparities in Kidney Disease Mortality (Five-Year Aggregate Data, 2004-2008)

45.0 40.0 35.0 opulation 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Deaths per 100,000 P 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

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Chronic Liver Disease and Cirrhosis

Chronic liver disease is marked by the gradual destruction of liver tissue over time. Cirrhosis is a group of chronic liver diseases in which normal liver cells are damaged and replaced by scar tissue, progressively diminishing blood flow through the liver. Risk factors for chronic liver disease include: exposure to hepatitis and other viruses; use of certain drugs; alcohol abuse; chemical exposure; autoimmune diseases; diabetes; malnutrition; and hereditary diseases (52). Chronic liver disease and cirrhosis together were the thirteenth leading cause of death in Dare County for the aggregate period from 2004 to 2008 (Table 103, cited previously).

Chronic Liver Disease Hospital Discharges

Hospital charges associated with the treatment of liver diseases totaled $69,298 for Dare County residents in 2008 (53).

Hospital discharge data on chronic liver disease and cirrhosis is summarized Table 144. Hospital discharge rates for liver disease rose overall in Dare County between 2004 and 2008. (Note, however, that the rates for Dare County are likely unstable.) The liver disease discharge rates in both Carteret County and NC as a whole remained stable over the same period.

Table 144. Chronic Liver Disease/Cirrhosis Discharges per 1,000 Population (2004-2008)

Discharges per 1,000 Population Location 2004 2005 2006 2007 2008

Dare County 0.10.20.30.40.2 Carteret County 0.5 0.5 0.5 0.3 0.5 State of NC 0.3 0.3 0.3 0.3 0.3

Chronic Liver Disease Mortality

Table 145 presents liver disease mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, 19 people died of chronic liver diseases over the period 2004-2008, for an overall mortality rate of 8.5, 6.6% lower than the rate for NC as a whole, and 33.6% lower than the rate in Carteret County. Note, however, that the rate in Dare County is based on fewer than 20 deaths, and may therefore be unstable.

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Table 145. Chronic Liver Disease/Cirrhosis Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 19 8.7 0 0.0 15 13.3 4 3.8 19 8.5 Carteret County 55 13.3 1 4.3 39 18.6 17 7.9 56 12.8 State of NC 3,380 9.3 819 8.2 2,764 12.9 1,435 5.8 4,199 9.1

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 45 presents chronic liver disease mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The chronic liver disease mortality rate in Dare County approximated the rate for the state as a whole for the entire span of dates cited, finally falling below the state rate in the final period.  The chronic liver disease mortality rate in Carteret County exceeded the rates for Dare County and NC for every period across the span of dates cited. The mortality rate in Carteret County also appears to be increasing.

Figure 45. Chronic Liver Disease/Cirrhosis Mortality, by Race and Sex (Five-Year Aggregate Data, 1999-2008)

14.0

12.0

10.0

8.0

6.0

4.0

2.0

0.0 Deaths per 100,000Population

Dare County Carteret County State of NC

Source: NC State Center for Health Statistics, County Health Databook (Years as Noted), Mortality, Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/

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Gender and Racial Disparities in Chronic Liver Disease/Cirrhosis Mortality

The numbers of deaths attributable to kidney disease among white males (n=15), white females (n=4), minority males (n=0) and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 46 plots rates valid for comparison. Statewide, a disproportionate burden of liver disease is borne by males. The chronic liver disease mortality rate for white males was twice the rate for white females, and the rate for minority males was almost 2½ times the rate for minority females. The rates for white males and minority males are similar: 13.0 and 12.2, respectively.

Figure 46. Racial and Gender Disparities in Chronic Liver Disease/Cirrhosis Mortality (Five-Year Aggregate Data, 2004-2008)

14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Deaths per 100,000 Population 100,000 per Deaths White Minority White Minority

Males Females

Dare County State of NC

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Homicide

Homicide was the fourteenth leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

Homicide Hospital Discharges

The NC State Center for Health Statistics does not release hospitalization data for attempted homicide.

Homicide Mortality

Table 146 presents homicide mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, five people died at the hand of others from 2004-2008, for an overall mortality rate of 3.1, 56.9% lower than the rate for NC as a whole, and 8.8% lower than the rate in Carteret County.

Table 146. Homicide Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 4 2.6 1 16.6 4 4.7 1 1.3 5 3.1 Carteret County 7 2.6 3 11.5 7 4.7 3 1.9 10 3.4 State of NC 1,414 4.3 1,794 15.2 2,481 11.0 727 3.3 3,208 7.2

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

Figure 47 presents homicide mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The homicide rates in Dare County and Carteret County were significantly lower than the rate for NC as a whole across the entire span of years covered in the figure.  The homicide mortality rate in Dare County fluctuated up and down around the Carteret County rate throughout the period cited, probably becauses the rate in each five-year aggregate period is based on a small number of events and is therefore unstable.  The homicide mortality rate for the NC as a whole remained approximately the same through all the periods cited.

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Figure 47. Homicide Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0

Deaths per 100,000 Population 100,000 per Deaths 0.0

Dare County Carteret County State of NC

Gender and Racial Disparities in Homicide Mortality

The numbers of deaths attributable to homicide among white males (n=4), white females (n=0), minority males (n=0) and minority females (n=1) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 48 plots rates valid for comparison. Statewide, the homicide mortality rate for minority males is the highest for all the stratified groups and is almost 4.4 times the rate for white males and 4.9 times the rate for minority females. White females have the lowest homicide mortality rate of all the stratified groups.

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Figure 48. Gender and Racial Disparities in Homicide Mortality (Five-Year Aggregate Data, 2004-2008)

30.0

25.0

Population 20.0

15.0 100,000 10.0 per 5.0

0.0 Deaths White Minority White Minority

Males Females

Dare County State of NC

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Acquired Immune Deficiency Syndrome (AIDS)

The human immunodeficiency virus (HIV) is the virus that causes AIDS. HIV attacks the immune system by destroying CD4 positive (CD4+) T cells, a type of white blood cell that is vital to fighting off infection. The destruction of these cells leaves people infected with HIV vulnerable to other infections, diseases and other complications. The acquired immunodeficiency syndrome (AIDS) is the final stage of HIV infection. A person infected with HIV is diagnosed with AIDS when he or she has one or more opportunistic infections, such as pneumonia or tuberculosis, and has a dangerously low number of CD4+ T cells (less than 200 cells per cubic millimeter of blood) (52). AIDS was the fifteenth leading cause of death in Dare County for the aggregate period 2004-2008 (Table 103, cited previously).

HIV Incidence

Figure 49 presents the HIV incidence rate trend for the years 2003-2007. The HIV incidence rates for Dare County and Carteret County, while lower than the rate for NC as a whole, demonstrate significant instability, the result of being based on small numbers of events. According to the NC State Center for Health Statistics, the higher statewide rates for 2003 and 2006 were the result of “enhanced surveillance activities”.

Figure 49. HIV Disease Rate (2003-2007)

30.0

25.0

20.0

15.0

10.0

5.0

0.0

New Population 100,000 Cases per 2003 2004 2005 2006 2007

Dare County Carteret County State of NC

NC-CATCH, County Health Profiles, Health Profile, Communicable/STD; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

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AIDS Hospital Discharges

The NC State Center for Health Statistics does not publish hospital charges related to the treatment of HIV/AIDS.

Hospital discharge data for AIDS is summarized Table 147. The AIDS discharge rates in Dare County and Carteret County are unstable. The AIDS discharge rate in NC fluctuated over the period cited, but was slightly lower at the end of the period than at the beginning.

Table 147. AIDS Discharges per 1,000 Population (2002-2008)

Discharges per 1,000 Population Location 2002 2003 2004 2005 2006

Dare County 1.3 0.6 0.6 n/a n/a Carteret County 1.50.51.31.10.8 State of NC 2.4 2.7 2.4 2.3 2.3

Source: NC-CATCH, County Health Profiles, Health Profile, Communicable/STD; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

AIDS Mortality

Table 148 presents AIDS mortality data for the aggregate period 2004-2008, stratified by race and sex.

In Dare County, three people died of AIDS over the period 2004-2008, for an overall mortality rate of 1.3, 70% lower than the rate for NC as a whole, but almost twice the rate in Carteret County. Note, however, that the rates in Dare County and Carteret County are unstable due to the small number of cases.

Table 148. AIDS Mortality, by Race and Sex (Five-Year Aggregate Data, 2004-2008)

Deaths, Number and Rate (per 100,000 Population) Location Whites Minorities Males Females Total Number Rate Number Rate Number Rate Number Rate Number Rate

Dare County 3 1.3 0 0.0 3 2.6 0 0.0 3 1.3 Carteret County 1 0.3 1 4.2 1 0.5 1 0.9 2 0.7 State of NC 431 1.3 1,551 14.3 1,370 6.1 612 2.7 1,982 4.4

Source: NC State Center for Health Statistics, County Health Data Book (2010), Mortality, 2004-2008 Race-Specific and Sex-Specific Age-Adjusted Death Rates by County; http://www.schs.state.nc.us/SCHS/data/databook/. Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Figure 50 presents AIDS mortality rate trend data for five-year aggregate periods between 1999 and 2008.

 The AIDS mortality rate in Dare County and Carteret County varied due to instability, but nevertheless were lower than the rate for the state as a whole for the entire span of dates cited; both appear to have decreased overall.  Statewide, the AIDS mortality rate fell 21.4% from the beginning of the period cited to the end.

Figure 50. AIDS Mortality Rate Trend (Five-Year Aggregate Periods, 1999-2008)

6.0

5.0

4.0

3.0

2.0

1.0

0.0 Deaths per 100,000 Population 100,000 per Deaths

Dare County Carteret County State of NC

Gender and Racial Disparities in AIDS Mortality

The numbers of deaths attributable to AIDS among white males (n=3), white females (n=0), minority males (n=0) and minority females (n=0) in the 2004-2008 aggregate period (56) were below the threshold sufficient to calculate a stable rate, so that data is not presented here.

Figure 51 plots rates valid for comparison. Statewide, a disproportionate burden of AIDS mortality is borne by minorities, especially males. The AIDS mortality rate for minority males was almost 10 times the rate for white males, and almost 2.2 times the rate for minority females. The AIDS mortality rate for minority females was 18.6 times the rate for white females.

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Figure 51. Racial and Gender Disparities in AIDS Mortality (Five-Year Aggregate Data, 2004-2008)

25.0

20.0 Population 15.0

10.0 100,000

per 5.0

0.0

Deaths White Minority White Minority

Males Females

Dare County State of NC

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Morbidity

Communicable Disease

A communicable disease is a disease transmitted through direct contact with an infected individual or indirectly through a vector (59). (Food-, water- and vector-borne communicable diseases are discussed in greater detail in Volume II, Environmental Data, of this assessment.) The topic of communicable diseases includes sexually transmitted infections (STIs). HIV/AIDS, the fifteenth leading cause of death in Dare County, is sometimes grouped with STIs, but was covered instead in the previous section on the Leading Causes of Death.

Reportable Communicable Diseases

Health professionals are required to report cases of certain communicable diseases to the NC Department of Health and Human Services through their local health department. Table 149 presents data for several important infectious diseases subject to this requirement for the period 2000-2005.

Over the period cited, the incidence of most communicable diseases in Dare County was very low, with the exception of Campylobacter and Salmonella infections, which are often food-borne and likely to infect multiple people at the same time. Note that these diseases are also among the most common at the state level as well.

Table 149. Communicable Disease Incidence (2000-2005)

Total Number of Cases Reported for the Period 2000-2005

Location E Coli Er lic En ce p h F-B F-B He p He p He p B Mening Vibrio Whoop Campy H Flu Legion Lyme Mumps RMSF Salmon Shigell Strep A V Vulni VRE O157 Mono WNV Staph Othe r A B (Carr) Pneu Other Cough

Dare County131212142472512470321223 Carteret County65121017321127014111592108316121 State of NC 3,825 211 127 25 182 1,256 283 920 1,222 4,807 158 552 225 36 2,048 8,985 3,577 717 30 67 2,808 622

Source: NC DHHS, Epidemiology, Communicable Disease, NC Communicable Disease Information, Statistics, County Tables: Reported Cases, North Carolina, 2000-2005, County of Residence by Disease and by Year of Report; http://www.epi.state.nc.us/epi/gcdc/pdf/CDbyDiseasebyYear2000-2005.pdf

Disease Abbreviations: Campy = Camplyobacter; Erlich Mono = Erlichia monocytosis; Enceph WNV=Encephalitis-West Nile Virus; F-B Staph= Food-borne Staphylococcus; H Flu = Haemophillus influenzae; Hep = Hepatitis; Legion = Legionella; Mening Pneu = Pneumonococcal meningitis; RMSF = Rocky Mountain Spotted Fever; Salmon = Salmonellosis; Shigell = Shigellosis; V Vulni = Vibrio vulnificus ; VRE = Vancomycin-resistant Enterococci

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Sexually Transmitted Infections

Tables 150 and 151 present data for the most prevalent sexually transmitted infections (STIs) for which data are routinely reported:

Chlamydia is the most frequently reported bacterial STI in the United States. It is estimated that there are approximately 2.8 million new cases of chlamydia in the United States each year. Chlamydia cases frequently go undiagnosed and can cause serious problems in men and women, such as penile discharge and infertility respectively, as well as infections in newborn babies of infected mothers (52).

Gonorrhea is the second most commonly reported bacterial STI in the United States following chlamydia. The highest rates of gonorrhea have been found in African Americans, 20 to 24 years of age, and women, respectively. Gonorrhea can spread into the uterus and fallopian tubes, resulting in pelvic inflammatory disease (PID). PID affects more than 1 million women in this country every year and can cause tubal (ectopic) pregnancy and infertility in as many as 10 percent of infected women. In addition to gonorrhea playing a major role in PID, some health researchers think it adds to the risk of getting HIV infection (52).

Syphilis is a sexually transmitted, bacterial infection that initially causes genital ulcers (sores). If untreated, the disease will progress to more serious stages of infection, including blindness and nerve damage. Primary and secondary syphilis are the communicable stages of the disease and as such are the cases reported. An ancient disease, syphilis is still of major importance today. Although syphilis rates in the United States declined by almost 90 percent from 1990 to 2000, the number of cases rose from 5,979 in 2000 to 9,756 in 2006. In a single year, from 2005 to 2006, the rate of syphilis jumped 12 percent. HIV infection and syphilis are linked. Syphilis increases the risk of transmitting as well as getting infected with HIV (52).

At the present time other STIs growing in prevalence – for example, human papillomavirus (HPV), genital warts, and trichomoniasis – are not routinely reported, but may be in the future.

Table 150 shows the incidence of chlamydia and gonorrhea for the years 2003-2007.

 The incidence of chlamydia infections in Dare County has been decreasing since 2005, and in 2007 was at the lowest level of the entire period cited. The incidence of gonorrhea in Dare County decreased from year to year and in 2007 was at the lowest level of the period cited.  In Dare County the incidence rates for both chlamydia and gonorrhea were well below the comparable state incidence rates every year cited. In 2007 the chlamydia incidence rate in NC as a whole was 2.7 times the rate in Dare County, and the gonorrhea incidence rate in NC was 4.3 times the rate in Dare County.

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Table 150. Chlamydia and Gonorrhea Incidence (2003-2007)

New Cases per 100,000 Population Location Chlamydia Gonorrhea 2003 2004 2005 2006 2007 2003 2004 2005 2006 2007

Dare County 142.3 187.7 195.7 159.1 126.7 112.0 95.3 53.4 50.1 44.2 Carteret County 150.6 211.0 194.1 210.7 210.7 65.5 109.5 136.8 110.1 78.6 State of NC 309.7 339.9 359.6 379.6 345.6 179.2 178.1 173.8 195.5 188.2

Source: NC-CATCH, County Health Profiles, Health Profile, Communicable/STDs; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

For a more current perspective, Table 151 presents both numbers of cases and current rates for gonorrhea and syphilis, stratified by race, for the 2004-2008 aggregate period.

 Syphilis is practically non-existent in Dare County. The syphillis incidence rate in Carteret County is one-third the NC incidence rate.  The 2004-2008 five-year aggregate rates for gonorrhea in Dare County and Carteret County shown in Table 151 are higher than the comparable one-year rates shown in Table 150 (above). The aggregate state rate is lower than the one-year rate.  There is a significantly higher incidence of gonorrhea among minorities than among the population overall. The gonorrhea rate among minorities in Dare County is 8.9 times the overall county rate; at the state level the rate among minorities is 3.1 times the overall state rate. The difference in Carteret County is smaller: the gonorrhea rate among minorities there is 2.4 times the overall county rate.

Table 151. Gonorrhea and Syphilis, Number of Cases and Rates per 100,000 Population (Five-Year Aggregate Data, 2004-2008)

Gonorrhea Primary & Secondary Syphilis Location Total Cases Minority Cases Total Cases Minority Cases Number Rate Number Rate Number Rate Number Total

Dare County 92 53.5 31 474.5 0 0.0 0 0.0 Carteret County 306 97.1 147 558.8 3 1.0 1 2.4 State of NC 79,172 178.4 62,494 552.9 1,384 3.1 934 8.3

Source: NC State Center for Health Statistics, County-Level Data, County Health Data Book (2010), Morbidity, Gonorrhea Cases and Rates per 100,000 Population, 2004-2008, and Primary and Secondary Syphilis Cases and Rates per 100,000 Population, 2004-2008; http://www.schs.state.nc.us/SCHS/healthstats/databook/

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Asthma

One way the burden of asthma in a community can be assessed is by reviewing hospital discharge records. Table 152 presents hospital discharge data from 2008 that tally information about asthma patients who reside in Dare County regardless of the location of their hospitalization (Table 152):

 The total hospitalization rate due to asthma (including children and adults) in 2008 among Dare County residents (32.4) was 28% of the state rate. Note, however, that this rate was based on fewer than 20 events and likely is unstable. The Dare County asthma discharge rate for children is based on an even smaller number of cases.  Statewide, the asthma hospital discharge rate for children is 32% higher than the comparable overall rate.

Table 152. NC Hospital Discharges with a Primary Diagnosis of Asthma, Numbers and Rates per 100,000 (2008)

Number and Rate of Discharges Location All Ages Age 0-14 No. Rate No. Rate

Dare County 11 32.4 2 35.5 Carteret County 67 105.5 15 155.9 State of NC 10,644 115.4 2,778 151.9

Source: NC State Center for Health Statistics, County-level Data, County Health Data Book (2010), Morbidity, Asthma Hospital Discharges (Total and Age 10-14) per 100,000 Population, 2008; http://www.schs.state.nc.us/SCHS/data/databook Note: Bold type indicates a likely unstable rate based on a small (fewer than 20) number of cases.

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Oral Health

Adult Oral Health

Dare County residents are surveyed about their dental health status and dental health behaviors in the state’s annual Behavioral Risk Factor Surveillance System (BRFSS) Survey, as part of an aggregate 41-county sample. As noted previously, since the aggregate data covers such a diverse area, the results are not especially useful in describing health in Dare County specifically and so are not discussed in this report.

The Dare County Community Health Survey, to be described in a subsequent section, contains limited data on adult access to dental care.

Child Oral Health

The Oral Health Section of the NC Division of Public Health periodically coordinates a dental assessment screening for kindergarten and fifth-grade schoolchildren. Dental hygienists use a standardized technique to measure the prevalence of decayed and filled teeth among these children. Table 153 presents the percent of untreated decay results of the child dental screenings for the period covering 2003-2007.

 After falling between 2003 and 2004, the percent of kindergarteners in Dare County with untreated decay rose between 2004 and 2006.  The percentage of Dare County kindergarteners with untreated decay averaged 18.6 over the entire period cited; the percentage of fifth graders with untreated decay averaged 2.2% annually. The comparable averages were 16.2 and 3.8 in Carteret County and 20.6 and 4.6 for NC as a whole.

Table 153. Child Dental Screening Summary (2003-2007)

Percent Children with Untreated Decay Location 2003 2004 2005 2006 2007 K-garten 5th Grade K-garten 5th Grade K-garten 5th Grade K-garten 5th Grade K-garten 5th Grade

Dare County 19.0 2.0 14.0 3.0 18.0 1.0 21.0 3.0 21.0 2.0 Carteret County 17.0 4.0 20.0 4.0 13.0 4.0 16.0 3.0 15.0 4.0 State of NC 23.0 5.0 22.0 5.0 21.0 5.0 19.0 4.0 18.0 4.0

Source: NC-CATCH, County Health Profile, Health Profile, Dental Health, % of Kindergarteners/5th Graders with Untreated Tooth Decay; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

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Table 154 presents detailed results for the child dental screening conducted in SY2008-09.

 A higher percentage of kindergarteners were screened in Dare County (94%) than in either Carteret County (89%) or NC as a whole (83%).  A higher percentage of fifth-graders were screened in Dare County (94%) than in either Carteret County (90%) or NC as a whole (77%).  The percentage of kindergarteners with untreated decay was similar in all three jurisdictions; at the fifth grade level, the percentage of children with untreated decay in Dare County was half the percentage in Carteret County and NC.

Table 154. Child Dental Screening Details (SY2008-09)

% % Children w ith Children Children Screened Untreated Tooth Average DMFT/Child Average DT/Child with Decay Location Sealants K-garten 5th Grade K-garten 5th Grade 5th Grade K-garten 5th Grade K-garten 5th Grade No. % No. %

Dare County 341 94 318 94 16 2 56 1.07 0.46 0.42 0.03 Carteret County 508 89 580 90 16 4 41 1.58 0.63 0.48 0.07 State of NC 96,303 83 85,988 77 17 4 44 1.50 0.56 0.47 0.05

Source: NC Division of Public Health, Oral Health Section, County Level Oral Health Status Data, 2008-2009; http://www.communityhealth.dhhs.state.nc.us/dental/Assessment_Data/2008-2009%20County%20Level%20Oral%20Health%20Status%20Data.pdf NC Division of Public Health, Oral Health Section, County Level Oral Health Status Data, 2008-2009; http://www.communityhealth.dhhs.state.nc.us/dental/Assessment_Data/2008-2009%20County%20Level%20Oral%20Health%20Status%20Data.pdf Definitions used in table: DMFT = decayed, missing and filled teeth; DT = teeth with untreated decay

Across NC, there now are more than 75 dental clinics dedicated to serving low-income patients who have limited access to dental care. Typically, these clinics are operated by local public health departments, community health centers, or other non-profit organizations. Most of these clinics accept patients enrolled in Medicaid or Health Choice. Many of these clinics also provide services on a sliding-fee scale to low- income patients who have no dental insurance. These Safety Net Dental Clinics are located in most counties in the state. In Dare County, the Safety Net Dental Clinic contact listed is the Mobile Dental Clinic operated by the Dare County Department of Public Health (60).

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Table 155 presents data on the percentage of Medicaid-eligible children and youth who actually receive dental services.

 Lower percentages of Medicaid-eligible children and youth in all age categories received dental services in Dare County than in either Carteret County or NC as a whole for both years cited (44% and 33% lower, respectively)

Table 155. Medicaid Eligible Youth Receiving Dental Services (2005-2006)

% Eligibles Receiving Services Location 2005 2006 Age 0-5 Age 6-14 Age 15-20 Age 0-5 Age 6-14 Age 15-20

Dare County 19.0 41.0 27.0 8.0 31.0 22.0 Carteret County 28.0 51.0 39.0 21.0 55.0 39.0 State of NC 28.0 45.0 32.0 24.0 48.0 33.0

Source: NC-CATCH, County Health Profile, Health Profile, Dental Health, % Medicaid Eligibles Receiving Dental Services; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

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Obesity

Adult Obesity

As noted previously, Dare County residents participate in the state’s annual Behavioral Risk Factor Surveillance System (BRFSS) Survey, as part of an aggregate 41-county sample too broad to be of use for this report. Although adult obesity is a topic covered in the BRFSS, the data are not specific to Dare County and are not useful to the present discussion.

The Dare County Community Health Survey, to be described in a subsequent section, contains limited data on adult obesity.

Childhood Obesity

The NC Healthy Weight Initiative, using the NC Nutrition and Physical Activity Surveillance System (NC-NPASS), collects height and weight measurements from children seen in NC Division of Public Health-sponsored WIC and Child Health Clinics, as well as some school-based Health Centers (61). (Note that this data is not necessarily representative of the entire county population of children.) This data is used to calculate Body Mass Indices (BMIs) in order to gain some insight into the prevalence of childhood obesity.

BMI is a calculation relating weight to height by the following formula:

BMI = (weight in kilograms) / (height in meters)

By definition, for adults, Underweight = BMI less than 18.5, Recommended Range = BMI 18.5-24.9, Overweight = BMI 25.0-29.9, and Obese = BMI 30.0 or greater.

For children, a BMI in the 95th percentile or above is considered “obese” (formerly defined as “overweight”), while BMIs that are between the 85th and 94th percentiles are considered “overweight” (formerly defined as “at risk for overweight”).

Tables 156-159 present annual data on overweight and obesity in children for single years from 2004 through 2008. Note that caution should be exercised when using these data, since the survey sample is relatively small, especially in some age groups, and may not be representative of the countywide population of children. Unstable percentages based on small numbers of cases are noted in bold type in the following tables.

According to data on all screened children, ages 2-18, presented in Table 156:

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 Dare County had higher percentages of overweight children and youth than Carteret County in all years except 2006, and higher percentages of overweight children and youth than NC as a whole in all years except 2007.  Dare County had higher percentages of obese children and youth than Carteret County and NC as a whole in 2005, 2006 and 2007.  The annual percentage of overweight children and youth in Dare County decreased every year from 2004 to 2007 before increasing in 2008.  The annual percentage of obese children and youth in Dare County decreased between 2004 and 2005 before increasing again.

Table 156. Prevalence of Overweight and Obesity in Children and Youth, Ages 2-18 (2004-2008)

Prevalence of Overweight and Obesity in Children Ages 2-18, by Percent Location 2004 2005 2006 2007 2008 Overweight Obese Overweight Obese Overweight Obese Overweight Obese Overweight Obese

Dare County 20.6 15.7 18.8 17.6 16.8 21.8 15.9 18.8 16.8 16.8 Carteret County 16.3 19.0 16.0 16.9 19.4 14.2 14.4 17.1 15.8 16.9 State of NC 15.9 17.0 15.7 16.7 15.9 17.4 16.0 17.3 16.4 17.5

Source for Tables 156-159: NC Division of Public Health, Nutrition Services Branch, Surveillance Data and Statistics, North Carolina Nutrition and Physical Activity Surveillance System (NC-NPASS), Physical Activity and Nutrition Data Resources, Data on Children and Youth, NC-NPASS Data on Childhood Overweight (Years as Noted), County-Specific Data; http://www.eatsmartmovemorenc.com/Data/ChildAndYouthData.html

According to data in Table 157 specific for children ages 2-4:

 Dare County had a higher percentage of overweight children ages 2-4 than Carteret County every year except 2006, and than NC every year except 2007 and 2008.  Dare County had higher percentages of obese children ages 2-4 than Carteret County every year except 2006, and than NC every year except 2004.

Figure 157. Prevalence of Overweight and Obesity in Children and Youth, Ages 2-4 (2004-2008)

Prevalence of Overweight and Obesity in Children Ages 2-4, by Percent1 Location 2004 2005 2006 2007 2008 Overweight Obese Overweight Obese Overweight Obese Overweight Obese Overweight Obese

Dare County 19.9 12.8 18.3 16.2 17.4 20.1 15.2 17.9 16.0 16.0 Carteret County 16.2 18.8 15.9 16.6 19.6 13.9 14.3 17.1 15.8 16.2 State of NC 15.6 14.9 15.4 14.6 15.7 15.2 15.7 15.3 16.3 15.4

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According to data in Table 158 specific for children ages 5-11:

 Dare County appears to have had a higher percentage of overweight children ages 5-11 than NC in every year cited as well as a higher percentage of obese children ages 5-11 than NC every year except 2007 and 2008. (Note, however, that most of the Dare County percentages were based on a small number of cases and are likely unstable.)  Carteret County data for this age group is either unstable or missing, so will not be used for comparison.

Figure 158. Prevalence of Overweight and Obesity in Children and Youth, Ages 5-11 (2004-2008)

Prevalence of Overweight and Obesity in Children Ages 5-11, by Percent Location 2004 2005 2006 2007 2008 Overweight Obese Overweight Obese Overweight Obese Overweight Obese Overweight Obese

Dare County 20.0 25.0 25.0 31.3 17.1 34.1 19.4 20.9 21.3 17.0 Carteret County 22.2 16.7 33.3 16.7 n/a 25.0 n/a n/a n/a n/a State of NC 16.0 23.8 16.2 24.5 16.8 25.2 16.9 24.9 17.0 25.7

Note: Figures denoted in bold type indicate percentages based on fewer than 10 cases

According to data in Table 159 specific for children ages 12-18:

 Dare County appears to have had a higher percentage of overweight children ages 12-18 than NC in every year except 2007 and 2008, as well as a higher percentage of obese children ages 12-18 than NC every year except 2006 and 2008. (Note, however, that all of the Dare County percentages were based on a small number of cases and are likely unstable.)  Carteret County data for this age group is either unstable or missing, so will not be used for comparison.

Figure 159. Prevalence of Overweight and Obesity in Children and Youth, Ages 12-18 (2004-2008)

Prevalence of Overweight and Obesity in Children Ages 12-18, by Percent Location 2004 2005 2006 2007 2008 Overweight Obese Overweight Obese Overweight Obese Overweight Obese Overweight Obese

Dare County 29.4 41.2 25.0 50.0 6.3 18.8 15.4 30.8 18.2 27.3 Carteret County 12.5 25.0 n/a 50.0 25.0 25.0 n/a n/a 9.1 45.5 State of NC 18.3 27.2 18.1 27.3 17.3 29.5 17.7 29.9 17.2 28.5

Note: Figures denoted in bold type indicate percentages based on fewer than 10 cases

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Mental Health and Substance Abuse

With the mental health system in the state – and Dare County – still in post-reform disarray, and with substance abuse an ongoing issue of considerable community concern in Dare County, these topics merit a closer look.

As noted in the Mental Health Services and Facilities section of this report (cited previously), as of 2009 Dare County had a new local management entity (LME) that currently is working to improve mental health services and supports throughout the county. Some of the data that is discussed in this section pre-dates the current LME, and is not necessarily reflective of present operations or efforts.

Mental Health Service Utilization

Table 160 presents data on persons served by the Dare County Area Mental Health Program from 2005-2009. (Note that this data reflects persons who were served, and says nothing of those who needed services but who could not or did not access them.)

 The number of persons served by the Dare County Area Program decreased every year from 2005-2009.

Table 160. Persons Served by Area Mental Health Programs (2005-2009)1

Number of Persons Served Location 2005 2006 2007 2008 2009

Dare County 1,631 1,605 1,583 1,514 1,439 Carteret County 1,545 1,076 2,037 2,252 2,183 State of NC 337,676 322,397 315,338 306,907 309,155

Log Into North Carolina (LINC) Database, Topic Group Vital Statistics and Health (Data Item 519); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show 1 All clients of a community-based Area Program for mental health, developmental disabilities, and drug and alcohol abuse active at the beginning of the state fiscal year plus all admissions during the year. Also included are persons served in three regional mental health facilities. Multiple admissions of the same client are counted multiple times. County of residence is reported at the time of admission. North Carolina data include clients reported to reside out-of-state and sometimes contains individuals of unknown county of residence.

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Table 161 presents estimates of the number of persons with severe emotional disturbances, by age group, for the period 2007-2008. This group presumably is in greatest need of mental health services.

 The number of estimated persons with severe emotional disturbance in Dare County and Carteret County did not vary by more than a few individuals over the two years cited.

Table 161. Estimated Persons with Severe Emotional Disturbance, By Age Group (2007-2008)

Estimated Number of Persons Location 2007 2008 Age 0-17 Age 18+ Age 0-17 Age 18+

Dare County 694 1,504 692 1,483 Carteret County 1,169 2,839 1,162 2,822 State of NC 219,149 370,202 222,906 378,594

Source: NC-CATCH, County Health Profiles, Health Profile, Mental Health, Estimated Persons with Severe Emotional Disturbance; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Table 162 shows the number of persons served in NC state psychiatric hospitals.

 The number of persons served in NC state psychiatric hospitals decreased significantly in all jurisdictions over the years cited.

Table 162. Persons Served in NC State Psychiatric Hospitals (2005-2009)1

Number of Persons Served Location 2005 2006 2007 2008 2009

Dare County 89 69 66 30 22 Carteret County 133 116 121 83 40 State of NC 18,435 18,292 18,498 14,643 9,643

Source: Log Into North Carolina (LINC) Database, Topic Group Vital Statistics and Health (Data Item 519); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show 1 Sometimes referred to as "episodes of care", these counts reflect the total number of persons who were active (or the resident population) at the start of the state fiscal year plus the total of first admissions, readmissions, and transfers-in which occurred during the fiscal year at the four state psychiatric hospitals. Excluded are visiting patients and outpatients. Multiple admissions of the same client are counted multiple times. County of residence is reported at the time of admission.

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Developmental Disabilities Service Utilization

Table 163 shows the estimated number of persons with developmental disabilities in each jurisdiction, by age group, in 2008.

Table 163. Estimated Number of Persons with Developmental Disabilities

Number of Persons

Estimated with Estimated with Developmental Developmental Location Disabilities, Disabilities, Ages 3-17 Age 18+ (2008) (2008)

Dare County 186 201 Carteret County 310 365 State of NC 59,559 55,200

Source: NC-CATCH, County Health Profiles, Health Profile, Disability; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

Table 164 shows the number of persons served in NC State Developmental Centers during the period 2005-2009.

 The number of persons served in NC State Developmental Centers changed little over time in all jurisdictions.

Table 164. Persons Served in NC State Developmental Centers (2005-2009)

Number of Persons Served Location 2005 2006 2007 2008 2009

Dare County76116 Carteret County 19 17 7 14 15 State of NC 2,172 1,690 1,409 1,409 1,404

Source: NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Statistics and Publications, Reports and Publications, Statistical Reports, Developmental Centers (FY2005-FY2009); http://www.ncdhhs.gov/mhddsas/statspublications/reports/index.htm#statisticalreports

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Substance Abuse Service Utilization

According to the Dare County Community Health Assessments (CHAs) from 2002 and 2006, substance abuse in Dare County was an area of considerable community concern (62, 63). Findings from the Community Health Survey undertaken in connection with 2010 Dare County CHA indicate that this concern continues (see Chapter Four of this report). Data presented below substantiate this concern.

Table 165 presents data on the number of persons served in NC State Alcohol and Drug Treatment Centers for the period 2005-2009.

 The number of Dare County residents served in NC State Alcohol and Drug Treatment Centers was much higher than the comparable figures for Carteret County for every year cited. In some years, the figure for Dare County was approximately twice the figure for Carteret County; in 2009, the figure for Dare County was 50% higher.  The number of Dare County residents utilizing these services climbed from 2007 to 2008, and again from 2008 to 2009; a similar pattern was noted in Carteret County and in NC as a whole.

Table 165. Persons Served in NC State Alcohol and Drug Treatment Centers (2005-2009)1

Number of Persons Served Location 2005 2006 2007 2008 2009

Dare County 61 62 61 78 86 Carteret County534324657 State of NC 3,732 4,003 3,733 4,284 4,812

Source: Log Into North Carolina (LINC) Database, Topic Group Vital Statistics and Health (Data Item 518); http://data.osbm.state.nc/pls/linc/dyn_linc_main.show 1 Sometimes referred to as "episodes of care", these counts reflect the total number of persons who were active (or the resident population) at the start of the state fiscal year plus the total of first admissions, readmissions, and transfers-in which occurred during the fiscal year at the three state alcohol and drug treatment centers. Excluded are visiting patients and outpatients. Multiple admissions of the same client are counted multiple times. County of residence is reported at the time of admission. North Carolina data include clients reported to reside out-of-state.

Table 166 presents data on the estimated number of youth with substance abuse for 2007 and 2008.

 According to the figures in Table 166, the numbers of youth with substance abuse in Dare County range from 52% to 58% of the comparable figures in Carteret County. This would seem to approximate the proportionality of the size of the population in each county, since the population in Carteret County is approximately twice that in Dare County.

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Table 166. Estimated Youth with Substance Abuse, by Age Group (2007-2008)

Estimated Number of Persons Location 2007 2008 Age 12-17 Age 18-25 Age 26+ Age 12-17 Age 18-25 Age 26+

Dare County 184 580 1,753 174 586 1,666 Carteret County 341 1,008 3,345 328 1,001 3,212 State of NC 58,970 192,391 412,273 57,885 204,759 405,331

Source: NC-CATCH, County Health Profiles, Health Profile, Mental Health, Estimated Youth with Substance Abuse; http://www.ncpublichealthcatch.com/ReportPortal/design/view.aspx

The 2009 Youth Risk Behavior Survey of Dare County High School Students (21) asked a number of questions about the students’ use of alcohol, tobacco and “other drugs” (ATOD). Results for some of the key ATOD queries are presented below in Tables 167 and 168.

Table 167 summarizes survey data on the age of onset of alcohol, cigarette and marijuana use by Dare County high school students.

 The average age on onset of use of all three substances listed is approximately the same: in the fourteenth year. Youth of this age are usually in the final two years of middle school or sometimes the first year of high school (grades 7-9)

Table 167. Age of Onset of ATOD Use by Dare County High School Students (2009)

Substance/Behavior Avg. Age at First Use

Alcohol Us e 13.5 years Cigarette Use 13.2 years Marijuana Use 13.6 years

Source: 2009 Youth Risk Behavior Survey, Dare County High Schools

Table 168 summarized survey data on the lifetime use of ATOD by the Dare County high school students.

 Almost 75% of high school students reported use of alcohol, females and males at approximately the same prevalence rate.  Almost 50% of high school students reported use of marijuana, males with a 15% higher prevalence of use than females.

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 Slightly less than 45% of students reported use of cigarettes, males with a 23% higher prevalence of use than females.  Just over 28% of students reported misusing prescription drugs, females with a 9% higher prevalence of misuse than males.  Note that from 6% to ~13% of Dare County high school students report using various “hard core” drugs (e.g., cocaine, methamphetamine and heroin), and almost 10% report having injected illegal drugs.

Table 168. Lifetime Use of Alcohol, Tobacco and Other Drugs (ATOD) Among Dare County High School Students (2009)

Prevalence Rate of Lifetime Use Substance as Percent of Survey FemalesRdt Males Overall

Alcohol 72.2 74.0 73.2 Cigarettes 39.6 48.6 44.4 Inhalants 10.9 14.5 13.0 Marijuana 44.2 50.9 47.9 Ecstasy 8.7 15.6 12.8 Cocaine 9.4 15.4 12.8 Methamphetamine 3.3 11.6 8.0 Heroin 3.1 8.9 6.6 Steroids 3.7 7.4 5.9

Rx Drugs (no MD order) 29.4 27.0 28.4 Inject illegal drugs 3.8 13.3 9.3

Source: 2009 Youth Risk Behavior Survey, Dare County High Schools

Dare County Schools contract with a vendor to conduct random drug testing among students in grades 7-12 who participate in “privileged activities.” Privileged activities are extracurricular activities, interscholastic athletics, and campus parking. Also included are students whose parents “opt in” to the program (64).

The program has clear consequences for initial and subsequent positive tests. All positive tests result in notification of the student and his/her parent or guardian; school officials are notified only upon the second and third offenses. Other consequences relate to participation in privileged activities and school attendance:

 First Positive Test: Student may continue privileged activity if parent/guardian secures a physician’s note; student is subject to mandatory retest.  Second Positive Test: Student is ineligible to participate in privileged activity for 365 calendar days unless he/she complies with substance abuse assessment/counseling requirement.

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 Third Positive Test: Student is ineligible to participate in privileged activity for at least 365 calendar days, but may regain eligibility after 365 days by satisfying substance abuse assessment/counseling plan, mandatory negative drug test, and providing a physician’s note.

Table 169 presents outcomes of the random drug testing program for SY2005-06 through SY2009-10.

 The percentage of students in grades 7-12 participating in the program increased through the third year of the program, and then leveled off.  There were approximately 100 initial positive tests every year for the past three school years, as well as from 50-70 refusals each year.  There has been a substantial increase over time in the total rate for positives/refusals.

Table 169. Dare County Schools Random Drug Testing Program Results (School Years as Noted)

Outcome SY2005-06 SY2006-07 SY2007-08 SY2008-09 SY2009-10

Participation Rate, Grade 7-12 65% 78% 86% 82% 83% Total No. Tests 325 1,175 1,817 1,641 992 No. Positive Tests 146110111794 No. Refusals 823707351 Total Positives + Refusals 22 84 171 190 145 Positive/Refusal Rate 6.8% 7.1% 9.4% 11.6% 14.6% 2nd Positive Rate 0.96% 0.34% 0.77% 1.6% 2.2% 3rd Positive Rate 0.00% 0.17% 0.44% 1.2% 1.2%

Source: Random Drug Testing Annual Program Report, 2009-2010; personal communication from Nancy Griffin (Dare County Public Schools) to Laura Willingham (Dare County Department of Public Health), via email, July 30, 2010

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Chapter Four

Community Health Survey

229 Dare County Community Health Assessment – Volume One Community Health Survey

Chapter Four: Community Health Survey

Survey Methodology

The Dare County Department of Public Health (DCDPH) partnered with Healthy Carolinians of the Outer Banks (HCOB) to assemble the 2010 Community Health Assessment Survey Team. The Survey Team was made up of Dare County Employees, HCOB members, and community volunteers. Targeted survey participants included randomly selected Dare County residents, at least 18 years of age.

The survey was designed based on a template provided by Healthy Carolinians and then modified by the DCDPH to be more specific to Dare County. The survey was reviewed and finalized by the DCDPH and the HCOB Partnership Board. The survey included demographic questions and questions about the health concerns, unhealthy behaviors, community issues, personal health, economy, education, environment, housing, leisure activities, safety, social issues, transportation, elder issues, and emergency preparedness issues. (The survey instrument appears in the Appendix to this report.)

Survey sample sites were chosen using a two stage, cluster sampling technique developed by the World Health Organization for assessing vaccine prevalence in children. Specialized software randomly selects 30 population weighted census blocks from throughout the county. From those census blocks, seven random samples are then selected for a total of 210 randomly chosen sample sites. Survey teams then go in to the field and administer the surveys at those sites. All of the members of the Survey Team participated in a half-day training at the DCDPH. The training was conducted on March 23, 2010 by Rick Scott, Industrial Hygiene Consultant, Public Health Regional Surveillance Team 1, and Laura Willingham, DCDPH Health Education Supervisor and HCOB Coordinator.

Ten smaller teams made up of two members of the Survey Team covered designated areas throughout the county to administer the survey. The surveys were collect from March 23-31, 2010. All team members wore uniform vests and identification badges so the public could recognize them. The Team members read the paragraph below to the residents at the selected addresses:

Hello, I am ______and this is ______representing Healthy Carolinians of the Outer Banks (HCOB), a partnership facilitated by the Dare County Department of Public Health. [Show badges.] We are here to ask you to participate in a health opinion survey for our county. You were one of the addresses selected at random. The purpose of this survey is to learn more about the health and quality of life in DARE County, North Carolina. The Dare County Department of Public Health and Healthy Carolinians of the Outer Banks will use the results of this survey to develop plans for addressing the major health and community issues in Dare County. All the information you give us will be completely confidential and will not be linked to you in any way. The survey is completely voluntary. It should take no longer than 20 minutes to complete. If you have already completed this survey, or if you don’t live in Dare County 6 months out of the year, please tell me now. You will be given a $10 gift card for your participation.

The members of the door-to-door survey team recorded the survey subjects’ responses directly on the paper surveys. The survey responses were later entered by contract staff into EpiInfo 2002, a CDC-developed survey database and data analysis program.

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Survey Participants

The survey sought demographic information in order to assess how well the survey participants represented the general population of Dare County. Table compares the demographic profile of the survey respondents to that of the overall Dare County population.

Table 170. Demographic Comparison of Survey Respondents with the Overall Dare County Population

Survey Participants County1 Population Category No. % %

Gender (n=213) Males - White 78 36.6 47.2 Males - Minority 62.82.8 Females - White 121 56.8 47.2 Female - Minority 83.82.8 Race/Ethnicity (Race n=213)2 White 199 93.4 94.4 African-American 83.83.5 Asian 00.00.6 Native American 20.90.4 Other 41.91.1 Hispanic/Latino 52.33.83 Age (n=214) 18-24 13 6.1 9.0 25-54 100 46.7 37.9 55-64 53 24.8 14.5 65+ 48 22.4 19.0 Other (n=various) Unemployed 14 6.5 14.64 Retired 68 31.8 n/a Household income < $25,000 44 21.6 n/a Less than HS Diploma or GED 11 5.2 6.65 5 Bachelors degree or higher 76 35.7 31.4

1 County data are 2010 NC Office of State Budget and Management estimates unless otherwise noted. 2 The total number of response (218) exceeds 213 because the five Hispanics responded with both race (white) and ethnicity. 3 2009 US Census Bureau estimate 4 NC Employment Security Commission average, Jan-Apr 2010 5 2006-2008 US Census Bureau estimate 231 Dare County Community Health Assessment – Volume One Community Health Survey

From the data in Table 170 it is apparent that white females were significantly over-represented in the survey sample, while white males were significantly under-represented. In terms of its racial/ethnic composition, the survey is relatively balanced, except that it included no Asians and under-represented the Hispanic/Latino segment of the population by approximately 40%. The survey sample also skewed significantly toward being older than the general population, with the age group 55-64 being the most significantly over-represented. The proportion of survey respondents who reported being unemployed was only about half of the official county unemployment rate at the time of the survey. As to education level, a slightly lower percentage of respondents had less than a high school diploma or GED than the general population, and a slightly higher percentage had a Bachelor’s degree or higher.

Table 171, below, shows the number of surveys conducted on each day of the exercise. A total of 214 surveys were conducted. Note that some of the surveys were undated.

Table 171. Dates of Survey Implementation

Date Number Percent 03-23-2010 10 4.8% 03-24-2010 26 12.5% 03-25-2010 23 11.1% 03-26-2010 28 13.5% 03-27-2010 32 15.4% 03-28-2010 27 13.0% 03-30-2010 19 9.1% 03-31-2010 17 8.2% 04-01-2010 8 3.8%

04-02-2010 8 3.8%

04-03-2010 2 1.0% 04-05-2010 3 1.4% 04-06-2010 1 0.5% 04-07-2010 4 1.9% Total 208 100.0%

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Survey Results

Survey responses were analyzed for frequency of response using the EpiInfo software package. It should be noted that not every respondent answered every question. The number and corresponding percentage of individuals who chose each response category are presented in the analysis below. Note: The order of some of the questions in the analysis may differ from their order in the actual survey, having been rearranged for clarity.

Demographic Questions

1. What is your age? (n=214)

Number Percent 15-19 3 1.4% 20-24 10 4.7% 25-34 30 14.0% 35-44 25 11.7% 45-54 45 21.0% 55-64 53 24.8% 65-74 39 18.2% 75 or older 9 4.2%

 20.1% of the survey respondents were under the age of 35.  68.2% of the respondents were age 45 or older, and 47.2% were age 55 or older.  Around 47% of those surveyed were over the age of 55.

2. What is your gender? (n=214)

Number Percent Female 130 60.7% Male 84 39.3%

 The majority (60.7%) of survey respondents were female; 39.3% were male.

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3. What is your race? (n=213)

Number Percent American Indian 2 0.9% Black 8 3.8% Other 4 1.9% White 199 93.4% Other races included: American, Peruvian, Mexican, Hispanic

 The vast majority (93.4%) of the survey respondents were white.

4. Are you of Hispanic origin? (n=213)

Number Percent Yes 5 2.3% No 208 97.7%

 2.3% of the survey respondents were of Hispanic origin.

5. Do you speak a language other than English at home? (n=214) If yes (n=15), what language?

Number Percent Yes 15 7.0% No 199 93.0%

Number Percent German 2 13.3% Romanian 1 6.7% Sign 1 6.7% Spanish 11 73.3%

 7.0% of the respondents spoke a language other than English at home, with Spanish being the most common language, followed by German.

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6. What is your marital status? (n=213)

Number Percent Divorced 26 12.2% Domestic partner 1 0.5% Married 133 62.4% Never married/single 33 15.5% Other 1 0.5% Separated 8 3.8% Widowed 11 5.2%

 62.4% of the participants were married; 16.0% were separated or divorced.

7. What is the highest level of school, college or vocational training that you have finished? (n=213)

Number Percent Some high school, no diploma 11 5.2% High school or GED 50 23.5% Associates degree or Vocational Training 18 8.5% Some college (no degree) 57 26.8% Bachelors degree 40 18.8% Graduate or professional degree 36 16.9% Other 1 0.5%

 35.7% of the respondents had a bachelors degree or higher; 62.1% of had attended at least some college or higher.  28.7% of the respondents had a high school education or less.

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8. What was your total household income last year, before taxes? (n=204) Note: respondents often misinterpret this question, and answer with their personal income, rather than total household income. The following responses may reflect that misinterpretation.

Number Percent Less than $14,999 20 9.8% $15,000-24,999 24 11.8% $25,000-34,999 26 12.7% $35,000-49,999 23 11.3% $50,000-74,999 45 22.0% $75,000+ 66 32.4%

 54.4% of the respondents reported a total household income of $50,000 or more.  21.6% of the respondents reported a total household income of less than $25,000.

9. How many people does this income support? (n=210)

Number Percent 1 34 16.2% 2 90 42.9% 3 36 17.1% 4 37 17.6% 5 11 5.2% 6 2 1.0%

 59.1% of the respondents supported two people or fewer on their reported total household income.  6.2% of the respondents supported families of five or more on their reported total household income.

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10. What is your employment status? (n=214) Note: respondents could choose more than one answer to this question, so the total number of responses exceeds 214, and the total percent of responses exceeds 100%.

Number Percent Full Time 77 36.0% Part Time 35 16.4% Retired 68 31.8% Disabled 10 4.7% Unemployed 14 6.5% Student 5 2.3% Homemaker 13 6.1% Military 1 0.5% Self-employed 20 9.3%

 6.5% of the respondents were unemployed; 4.7% identified themselves as disabled.  31.8% of the respondents were retired (but that answer did not preclude some other response in addition.)  52.4% of the respondents were employed, either part- or full-time.

11. Do you have access to the Internet? (n=214)

Number Percent Yes 194 90.7% No 20 9.3%

 Almost 91% of the participants had access to the Internet.

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12. What is your zip code? (n=214)

Number Percent 27912 10.5% 27915 (Avon) 20.9% 27920 (Buxton) 10 4.7% 27936 (Frisco) 52.3% 27943 (Hatteras) 52.3% 27948 (Kill Devil Hills) 48 22.4% 27949 (Duck, Kitty Hawk, Southern Shores) 59 27.6% 27951 (Not a valid zip code) 10.5% 27953 (East Lake, Manns Harbor) 22 10.3% 27954 (Manteo) 35 16.4% 27959 (Nags Head) 15 7.0% 27972 (Salvo) 10.5% 27978 (Stumpy Point) 31.4% 27981 (Wanchese) 52.3% 27982 (Waves) 10.5% 29155 (Out-of-state) 10.5%

 The largest percentage of survey participants (27.6%) lived in the 27949 zip code (Kitty Hawk)  22.4% of the participants lived in the 27948 zip code (Kill Devil Hills).  16.4% of the respondents lived in the 27954 zip code (Manteo)  Just over 10% lived in the 27953 zip code (Mann’s Harbor).  Around 16% lived in the 27954 zip code (Manteo).

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Quality of Life Questions

1. There is a good health care system in Dare County. (Consider the cost and quality, number of options, and availability.)

Number Percent Strongly Disagree 6 2.8% Disagree 26 12.3% Agree 154 73.0% Strongly Agree 25 11.8% Total 211 100.0%

 A large majority (84.8%) of survey respondents agreed or strongly agreed with this statement.

2. Dare County is a good place to raise children. (Consider the quality and safety of schools and child care programs, after school programs, and places to play.)

Number Percent Strongly Disagree 5 2.4% Disagree 20 9.6% Agree 113 54.1% Strongly Agree 71 34.0% Total 209 100.0%

 A large majority (88.1%) of survey respondents agreed or strongly agreed with this statement.

3. Dare County is a good place to grow old. (Think about elder-friendly housing, transportation to medical services, recreation and services for the elderly.)

Number Percent Strongly Disagree 7 3.3% Disagree 28 13.2% Agree 119 56.1% Strongly Agree 58 27.4% Total 212 100.0%

 A large majority (83.5%) of survey respondents agreed or strongly agreed with this statement.

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4. There is plenty of economic opportunity in Dare County. (Consider the number and quality of jobs, job training/higher education opportunities, and availability of affordable housing.)

Number Percent Strongly Disagree 35 16.5% Disagree 111 52.4% Agree 62 29.2% Strongly Agree 4 1.9% Total 212 100.0%

 Nearly 70% of survey respondents disagreed (52.4%) or strongly disagreed (16.5%) with this statement.

5. Dare County is a safe place to live. (Consider how safe you feel at home, in the workplace, in schools, at playgrounds, parks, shopping centers.)

Number Percent Strongly Disagree 0 0% Disagree 9 4.2% Agree 133 62.4% Strongly Agree 71 33.3% Total 213 100.0%

 A vast majority (95.7%) of the survey respondents agreed or strongly agreed with this statement.

6. There is plenty of support and help for individuals and families during times need in Dare County. (Consider social support: neighbors, support groups, faith community outreach, community organizations and emergency monetary assistance.)

Number Percent Strongly Disagree 3 1.4% Disagree 27 13.0% Agree 142 68.3% Strongly Agree 36 17.3% Total 208 100.0%

 A large majority (85.6%) of the survey respondents agreed or strongly agreed with this statement.

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Health Problems

Survey participants were asked to consider an alphabetical list of health problems and select, in no particular order, the five they thought had the greatest overall impact on health in Dare County. They also had the option of “writing-in” a topic of their choice. The list of responses below is arranged in descending order of the frequency with which a named health problem was chosen.

Most Important Health Problems (n=214)

Number Percent

1. Cancer 136 63.6% 2. Heart disease/heart attacks 132 61.7% 3. Obesity/overweight 103 48.1% 4. Aging Problems 102 47.7% 5. Mental Health 94 43.9% 6. Diabetes 77 36.0% 7. Motor vehicle accidents 71 33.2% 8. Other injuries 45 21.0%

9. Teen Pregnancy 41 19.2%

10. Stroke 40 18.7% 11. Lung disease 37 17.3% 12. Dental Health 33 15.4% 13. Infectious/Contagious diseases 24 11.2% 14. STDs 20 9.3% 15. Asthma 15 7.0% 16.(T) HIV/AIDS 12 5.6% 16.(T) Other 12 5.6%

18.(T) Kidney Disease 11 5.1%

18.(T) Liver Disease 11 5.1% 20. Neurological disorders 9 4.2% 21.(T) Birth Defects 5 2.3% 21.(T) Infant Death 5 2.3% 23. Autism 3 1.4% 24. Gun-related injuries 2 0.9%

“Other” responses included: alcohol/drug use (7), drowning, falls, hypertension,orthodontics, theft Types of cancer: all (48), breast (14), lung (2), prostate (2), skin (4)

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 Cancer and heart disease were the first and second most commonly identified health problems in Dare County; each was selected by more than 61% of the survey respondents.  Obesity, selected by 48.1% of the survey respondents, was the third most frequently chosen health problem.  Aging problems was the fourth most commonly identified health problem (47.7%), followed by mental health (43.9%).

Unhealthy Behaviors

Survey participants were asked to consider an alphabetical list of unhealthy behaviors and select, in no particular order, the five they thought had the greatest overall impact on health in Dare County. They also had the option of “writing-in” a topic of their choice. The list of responses below is arranged in descending order of the frequency with which a named unhealthy behavior was chosen.

Most Important Unhealthy Behaviors (n=214) Number Percent 1. Alcohol abuse 198 92.5% 2. Drug Abuse 192 89.7% 3. Smoking/tobacco use 128 59.8% 4. Reckless/drunk driving 112 52.3% 5. Poor eating habits 90 42.1% 6. Lack of exercise 68 31.8% 7. Not going to the doctor 66 30.8% 8. Having unsafe sex 52 24.3% 9. Not going to the dentist 40 18.7% 10. Not using seat belts 31 14.5% 11. Violent behavior 23 10.7% 12. Suicide 16 7.5% 13. Not using child safety seats 14 6.5% 14. Not getting prenatal care 12 5.6% 15. Not getting immunizations 9 4.2% 16. Other 3 1.4%

 Alcohol abuse and drug abuse were the two most commonly identified unhealthy behaviors; each was selected by at least 89% of the respondents.  The third most commonly identified unhealthy behavior was smoking/tobacco use, chosen by 59.8% of the respondents.  Reckless/drunk driving was selected by 52.3% of the respondents, placing it fourth on the list of unhealthy behaviors.

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Community Social Issues

Survey participants were asked to consider an alphabetical list of community social issues and select, in no particular order, the five they thought had the greatest overall impact on health in Dare County. They also had the option of “writing-in” a topic of their choice. The list of responses below is arranged in descending order of the frequency with which a named issue was chosen.

Most Important Community Social Issues (n=214) Number Percent 1. Unemployment 132 61.7% 2. Inadequate/unaffordable housing 123 57.5% 3. Availability of positive teen activities 86 40.2% 4. Affordability of health services 82 38.3% 5. Low income/poverty 80 37.4% 6. Lack of/inadequate health insurance 74 34.6% 7. Lack of transportation options 67 31.3% 8.(T) Availability of child care 45 21.0% 8.(T) Dropping out of school 45 21.0% 10. Animal control issues 39 18.2% 11. Domestic violence 37 17.3% 12. Lack of health care providers1 35 16.4% 13. Lack of recreational facilities 28 13.1% 14. Homelessness 27 12.6% 15.(T) Lack of healthy family activities 23 10.7% 15.(T) Pollution 23 10.7% 17. Neglect and abuse 2 20 9.3% 18. Racism 12 5.6% 19.(T) Lack of culturally appropriate health services 11 5.1% 19.(T) Unsafe, unmaintained roads 11 5.1% 21. Availability of healthy food choices 10 4.7% 22. Rape/sexual assault 9 4.2% 23. Other3 8 3.7% 24.(T) Bioterrorism; Violent crime 0 0.0%

1 Lacking providers named: pediatricians (4), primary care/family practice (5), all (3), ENT, specialists, trauma, neurologist (2), rheumatologist 2 Types of abuse indicated: Elder (5), Child (6), Both (6) 3 “Other” responses include: beach closures (2), breaking and entering (2), swimming pools, lack of services for the disabled, clear cutting of trees for the airport 243 Dare County Community Health Assessment – Volume One Community Health Survey

 Unemployment was the most frequently identified community social issue; it was selected by 61.7% of the survey respondents.  Inadequate/unaffordable housing was the second most commonly chosen social issue; it was selected by 57.5% of respondents.  The availability of positive teen activities (40.2%) and affordability of health services (38.3%) ranked 3rd and 4th, respectively.  Low income/poverty was the fifth most frequently identified community social issue, chosen by 37.4% of respondents.

Personal Health Questions

1. How would rate your own personal health?

Personal Health Number Percent Very Healthy 41 19.2% Healthy 104 48.6% Somewhat healthy 60 28.0% Unhealthy 7 3.3% Very unhealthy 2 0.9% Total 214 100.0%

 Just over two-thirds (67.8%) of survey respondents rated themselves as healthy or very healthy.  Only 4.2% of respondents rated themselves unhealthy or very unhealthy.

2. Where do you get most of your health-related information?

Primary Information Provider Number Percent Friends and Family 28 13.1% Doctor/nurse/pharmacist 121 56.5% Internet 33 15.4% TV 6 2.8% Hospital 3 1.4% Help Lines 0 0.0% Books/Magazines 13 6.1% Radio 1 0.5% School 1 0.5% Church 0 0.0% Other 8 3.7% Total 214 100.0% “Other” responses included: wife (2), BCBS, Dare County EMS, personal trainer, health department, VA Medical Center

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 56.5% of survey respondents get their health-related information from a doctor, nurse or pharmacist.  The internet was the second most popular source (15.4%), followed by friends and family members (13.1%).

3. Where do you go most often when you are sick or need advice about your health?

Primary Care Provider Number Percent Doctor's Office 136 63.6% Health Department 7 3.3% Hospital 9 4.2% Medical Clinic 8 3.7% Urgent Care Center 39 18.2% Community Care Clinic 2 0.9% Other 13 6.1% Total 214 100.0% “Other” responses included: books, church, internet (2), Healtharama, VA Medical Center (2), Virginia, infirmary, natural/homeopathic (2)

 A majority of survey respondents (63.6%) to go a doctor’s office when they are sick or need advice about their health.  The second most commonly cited health care provider was Urgent Care centers (18.2%).  Less than 1% of survey respondents used the Community Care Clinic.

4. What city or town is this in?

Provider Location Number Percent Dare County 178 83.2% Other city in NC 10 4.7% Elizabeth City 5 2.3% Out of state 21 9.8% Total 214 100.0%

 A significant majority of the survey respondents (83.6%) receive health care services in Dare County.  Nearly 10% of respondents, however, get their medical care out of state.

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5. During the past 12 months, did you ever have a problem getting the health care you needed from any type of health care provider or facility?

Problem Getting Health Care Number Percent Yes 24 11.2% No 190 88.8% Total 214 100.0%

 Approximatel 11% (n=24) of the survey respondents had a problem getting needed health care at some point in the past year.

6. If yes, which of these problems did you have? Note that respondents could select more than one answer.

Reasons for Problems Getting Care (Percent of those who said yes to #5; n=24) Number Percent I didn’t have health insurance 6 25.0% My insurance didn’t cover what I needed 4 16.6% My share of the cost (deductible/co-pay) was too high 3 12.5% Doctor would not take my insurance or Medicaid 2 8.0% Hospital would not take my insurance 2 8.0% I didn’t have a way to get there 1 4.1% I didn’t know where to go 0 0.0% I couldn’t get an appointment 4 16.7 Other 8 33.3% “Other” responses included: didn't have money (2), doctor didn't appear to be concerned, higher level of care needed, No ENT specialist , not the right doctor, services not available in Dare County, “wouldn't listen”

 The most common reasons for not getting health care were lack of insurance and insurance not covering what was needed.  A doctor or hospital not taking insurance, lack of transportation, and not knowing where to go were seldom identified as barriers to accessing needed health care.

7. During the past 12 months, did you have problem filling a medically necessary prescription?

Problem Filling Prescription Number Percent Yes 13 6.1% No 201 93.9% Total 214 100.0%

 6.1% (n=13) of the survey respondents had a problem filling a medically necessary prescription in the past year.

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8. If yes, which of these problems did you have? Note that respondents could select more than one answer.

Reasons for Problems Filling Prescription (Percent of those who said yes to #7; n=13) Number Percent I didn’t have health insurance 4 30.8% My insurance didn’t cover what I needed 3 23.1% My share of the cost (deductible/co-pay) was too high 4 30.8% Pharmacy would not take my insurance or Medicaid 1 7.7% I didn’t have a way to get there 1 7.7% I didn’t know where to go 0 0.0% Other 4 30.8% “Other” responses included: not available at pharmacy (3), couldn’t afford

 The most common reasons for not filling a needed prescription were lack of insurance and high cost.  A pharmacy that wouldn’t take insurance, lack of transportation, and not knowing where to go were seldom identified as barriers for not filling a necessary prescription.

9. Was there a time during the past 12 months when you needed to get dental care, but could not?

Problem Getting Dental Care Number Percent Yes 34 15.9% No 180 84.1% Total 214 100.0%

 Nearly 16% (n=34) of survey respondents had a problem getting needed dental care at some point in the last year.

10. If yes, why could you not get dental care?

Reasons for Problems Getting Dental Care (Percent of those who said yes to #9; n=34) Number Percent I didn’t have dental insurance 18 52.9% My insurance didn’t cover what I needed 3 8.8% I couldn’t afford the cost 22 64.7% Dentist would not take my insurance or Medicaid 0 0.0% I didn’t have a way to get there 1 2.9% I didn’t know where to go 1 2.9% I couldn’t get an appointment 2 5.9% Other 5 14.7% Other responses: cost, distance, no time, quality of care, wanted to make payments but wasn’t allowed.

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 Among the respondents who had a problem getting dental care, the most common reason was being unable to afford the cost (64.7%); the next most common reason was not having dental insurance (52.9%).  Not knowing where to go and not having transportation were seldom cited as barriers to dental care.  No one cited non-acceptance of insurance or Medicaid as a barrier to dental care.

11. If a friend or family member needed counseling for a mental health, or a drug/alcohol abuse problem, who would you tell them to contact?

Referral for MH/SA Counseling Number Percent Private counselor or therapist 80 37.4% Support group (e.g. AA or Al-Anon) 64 29.9% School counselor 16 7.5% Hospital 10 4.7% Doctor 67 31.3% Minister/religious official 56 26.2% Health Department/New Horizons 67 31.3% I don’t now 6 2.8% Other 12 5.6% “Other” responses included: family (2), DCSS, out of county (2), social worker, Teen Challenge, Healtharama, “someone they are comfortable with”

 The largest proportion of survey respondents (37.4%) would refer someone who needed mental health or drug/alcohol abuse counseling to a private counselor or therapist.  The second most common options for counseling were the Health Department/New Horizons (31.3%) and a doctor (31.3%) followed by a support group such as AA (29.9%).  Only 2.8% of respondents didn’t know a place to refer someone needing mental health care.

12. In the past 30 days, have there been any days when feeling sad or worried kept you from going about your normal business?

Emotional Health Number Percent Yes 34 15.9% No 180 84.1% Total 214 100.0%

 15.9% of the survey respondents reported that feeling sad or worried interfered with their normal business within the past month.

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13. During a normal week, other than your regular job, did you engage in any exercise activity that lasted at least half an hour?

Exercise Number Percent Yes 164 76.6% No 50 23.4% Total 214 100.0%

 76.6% of survey respondents (n=164) reported engaging in more than 30 minutes of exercise activity in a normal week.

14. If yes, how many times would you say you engaged in this activity in a typical week?

Number of Times Exercised in Past Month Number Percent 1-3 times 71 43.8% 4-6 times 62 38.3% 7 or more 29 17.9% Total 162 100.0%

 Nearly 44% of the survey respondents engaged in at least 30 minutes of exercise activity 1 to 3 times a week.  Approximately 18% of the respondents exercised seven or more times in an typical week.

15. Where do you go to exercise or engage in physical activities? Note that respondents could select more than one answer.

Where exercise (Percent of those who answered yes to # 13; n=162) Number Percent Outer Banks YMCA 17 10.4% Park 14 8.5% Public Recreation Center 15 9.1% Private gym 24 14.6% Home 73 44.5% Walking Trails 96 58.5% Other 37 22.6% Other responses: beach (18), kayaking (2), biking (3), running on the roads (4), cardiac rehab (2), Baum Center, Duck Woods Country Club, golf, horse pen, tennis center, dance studio

 The largest proportion of respondents (58.5%) utilize walking trails for exercise.  44.5% of respondents reported exercising at home.  Nearly 43% reported they exercised at a facility of some sort (YMCA, a public park, a private gym, or a public rec center).

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16. If no, why didn’t you engage in exercise/physical activity? Note that respondents could select more than one answer.

Reasons for not Exercising (Percent of those who said no to #13; n=50) Number Percent My job is physical or hard labor 9 18.0% Exercise is not important to me 0 0.0% I don’t have access to a facility that has what I like 1 2.0% I don’t have enough time to exercise 7 14.0% I would need child care and don’t have it 2 4.0% I don’t know how to find exercise partners or teams 0 0.0% I don’t like to exercise 11 22.0% It costs too much to exercise 3 6.0% There is no safe place to exercise 0 0.0% I’m too tired to exercise 5 10.0% I’m physically disabled 5 10.0% I don’t know 3 6.0% Other 10 20.0% “Other” responses included: lazy (5), injury (2), need knee replacement, “sick daughter”, “can’t get in the habit”

 Among the 50 respondents who do not engage in more than 30 minutes of exercise in a typical week, the most common reason is that they do not like to exercise (22.0%). The second most common reason is that their job involved physical or hard labor (18.0%).

17. How many hours per day to you watch TV, play video games, or use the computer for recreation?

TV/Computer Use Number Percent 0-1 hours 38 17.8% 2-3 hours 126 59.2% 4-5 hours 35 16.4% 6+ hours 14 6.6% Total 213 100.0%

 The largest propostion of respondents (59.2%) reported engaging in recreational computer, TV or video game use for 2-3 hours per day.  23% percent of the respondents spend more than four hours each day using the TV, computer or video games; 6.6% report spending 6 or more hours in these activities.

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18. During the past 30 days, have you had any physical pain or health problems that made it hard for you to do your usual activities, such as driving, working around the house, or going to work?

Pain/health problems Number Percent Yes 57 26.6% No 157 73.4% Total 214 100.0%

 More than a quarter of the respondents (26.6%) reported that physical pain or health problems interfered with their daily activities at some time within the previous month.

19. Not counting juice, lettuce salad and potato products, how many cups of fruits and vegetables do you eat in a week?

Fruits Vegetables Number Percent Number Percent None 8 3.7% None 3 1.4% 1-7 cups 152 71.4% 1-7 cups 135 63.7% 8-14 cups 37 17.4% 8-14 cups 53 25.0% More than 15 cups 16 7.5% More than 15 cups 21 9.9% Total 213 100.0% Total 212 100.0%

 3.7% of the survey respondents reported that they consumed no fruit; 1.4% reported consuming no vegetables in a typical week.  Of the respondents who ate fruit, the largest proportion (71.4%) ate 1-7 cups per week; 17.4% ate 8-14 cups per week.  Of the respondents who ate vegetables, the largest proportion (63.7%) ate 1-7 cups per week; 25% ate 8-14 cups per week.

20. Are you exposed to second-hand smoke in any of the following places? Note that respondents could select more than one answer.

Location of second hand smoke exposure Number Percent Home 44 20.6% Workplace 22 10.3% Hospitals 1 0.5% Restaurants 3 1.4% School 0 0.0% Other 8 3.7% I am not exposed to secondhand smoke 150 70.1% 251 Dare County Community Health Assessment – Volume One Community Health Survey

 Approximately 70% of survey respondents say they are not exposed to secondhand smoke.  Among respondents exposed to second-hand smoke, the largest proportion (20.6%) report that the exposure is at home.

21. Do you smoke cigarettes?

Current smoker Number Percent Yes 46 21.6% No 167 78.4% Total 213 100.0%

 21.6% of the survey respondents reported that they smoke cigarettes.

22. If yes, where would you go for help if you wanted to quit? Note that respondents could select more than one answer.

Help to quit (n=43) Number Percent Quit Now NC 0 0.0% Doctor 12 27.9% Church 1 2.3% Pharmacy 2 4.7% Private counselor/therapist 0 0.0% Health Department 2 4.7% I don’t know 3 7.0% Other 13 30.2% Not applicable; I don’t want to quit 10 23.2% “Other” responses included: by myself/on my own (12)

 27.9% of the survey respondents would seek help from a doctor to quit smoking. The same number (12) and percentage (27.9%) of respondents wrote-in that they would try to quit by themselves. (See footnote to table.)  Ten respondents who smoke (23.2%) reported that they did not want to quit smoking.

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23. Have you ever been told by a doctor, nurse, or other health professional that you have any of the following?

Asthma Diagnosis Number Percent Yes 24 11.3% No 188 88.7% Total 212 100.0%

 11.3% of the survey respondents reported having been diagnosed with asthma.

Depression Diagnosis Number Percent Yes 34 16.0% No 178 84.0% Total 212 100.0%

 16.0% of survey respondents reported having been diagnosed with depression. Note that this is approximately the same percentage that previously reported having felt sad or worried to the point of its interfering with daily activities (15.9%).

High Blood Pressure Diagnosis Number Percent Yes 82 38.7% No 130 61.3% Total 212 100.0%

 38.7% of survey respondents reported having been diagnosed with high blood pressure, making it the most commonly reported diagnoses among this survey sample.

High Cholesterol Diagnosis Number Percent Yes 61 28.8% No 151 71.2% Total 212 100.0%

 28.8% of the survey respondents reported having been diagnosed with high cholesterol.

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Diabetes Diagnosis Number Percent Yes 18 8.5% No 194 91.5% Total 212 100.0%

 8.5% of the survey respondents reported having been diagnosed with diabetes.

Obesity/overweight Number Percent Yes 62 29.2% No 150 70.8% Total 212 100.0%

 29.2% of survey respondents reported having been diagnosed with obesity/overweight, making it the second most commonly reported diagnosis among this survey sample.

Osteoporosis

Number Percent Yes 21 9.9% No 191 90.1% Total 212 100.0%

 9.9%% of survey respondents reported having been diagnosed with osteoporosis.

Questions for Parents

One section of the survey was directed only to parents of children between the ages of 9 and 19.

24. Do you have children between the ages of 9 and 19?

Children aged 9-19 Number Percent Yes 46 21.5% No 168 78.5% Total 214 100.0%

 21.5% of the survey respondents have a child, or children, between the ages of 9 and 19.

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25. Do you think your child is engaging in any of the following high risk behaviors?

High Risk Teen Behaviors (n=46) Number Percent Alcohol use 7 15.2% Tobacco use 6 13.0% Eating disorders 0 0.0% Sexual intercourse 9 19.6% Drug Abuse 2 4.3% Reckless driving/speeding 3 6.5% I don’t think my child is engaging in any high risk behaviors 32 69.6%

 A majority of respondents (69.6%) with children aged 9-19 do not think their child is engaging in any high risk behaviors.

26. Are you comfortable talking to your child about the risky behaviors listed above?

Comfortable talking Number Percent Yes 42 93.3% No 3 6.7% Total 45 100.0%

 A vast majority of the survey respondents (93.3%) with children between the ages of 9 and 19 reported that they are comfortable talking to their child about the risky behaviors cited in the list.

27. Do you think your child needs information about any of the following problems?

Child Needs Information (Percent of those who said yes to #24) Number Percent Alcohol 14 30.4% Tobacco 12 26.1% HIV 10 21.7% Eating Disorders 9 19.6% Sex 16 34.8% STDs 12 26.1% Drug Abuse 11 23.9% Reckless driving/speeding 14 30.4% Mental health issues 10 21.7% Other 9 19.6% Other responses included: all (5), none (1)

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 Despite their comfort in talking with their children about risky behaviors, more than one-quarter of the respondents with children aged 9-19 think their child needs more information about: alcohol, tobacco, sex, STDs, and reckless/drunk driving.

Emergency Preparedness

Since as a coastal county Dare County experiences periodic weather emergencies, the survey sponsors were interested in assessing the level of emergency preparedness of the survey respondents.

28. Does your household have working smoke and carbon monoxide detectors?

Detectors Number Percent Yes, smoke detectors only 123 57.7% Yes, carbon monoxide detectors only 11 5.2% Yes, both 69 32.4% No, both 10 4.7% Total 213 100.0%

 Nearly 58% of the respondents reported having working smoke detectors in their homes.  Approximately 32% of the respondents reported having both smoke and carbon monoxide detectors.

29. Does your household have a Family Emergency Plan?

Emergency Plan Number Percent Yes 99 46.5% No 114 53.5% Total 213 100.0%

 Fewer than half of the survey respondents (46.5%) reported having a household Family Emergency Plan.

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30. Does your family have a basic emergency supply kit? If yes, how many days to you have supplies for?

Emergency supply kit Number Percent No 95 44.6% 3 days 47 22.1% 1 week 37 17.4% 2 weeks 22 10.3% More than 2 weeks 12 5.6% Total 213 100.0%

 Almost 45% of the respondents reported that they do not have an emergency supply kit in their home.  Of the 55.4% of survey respondents who do have a basic emergency supply kit (n=118), 60% (n=71) have supplies sufficient for a week or more.

31. Are you or someone in your household a special needs citizen who may need assistance during a disaster or emergency? This includes individuals with physical, mental or medical care needs who may require additional assistance beyond their usual resources and support network during a disaster or emergency.

Special Needs Number Percent Yes 22 10.3% No 191 89.7% Total 213 100.0%

 10.3% (n=22) of the survey respondents reported having a special needs citizen in their household.

32. If you said yes, have you or the special needs citizen in your household signed up for the Dare County Special Needs Registry?

Special Needs Registry Number Percent Yes 8 38.1% No 13 61.9% Total 21 100.0%

 Among the survey respondents with special needs family members, 38% had signed up for the Special Needs Registry.

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Chapter Five

Community Stakeholder Interviews

258 Dare County Community Health Assessment – Volume One Community Stakeholder Interviews

Chapter Five: Community Stakeholder Interviews

Methodology

In July through September of 2010, a researcher conducted telephone interviews with 25 key community stakeholders in Dare County. Interviewees represented leaders from agencies and organizations in key sectors of the community, such as local health and human services, business, education, law enforcement, and government.

Each community stakeholder was asked to describe the services his or her agency or organization provides, what clients were most likely to use these services, and how that clientele and the problems with which they present have changed over the past five years. They also were asked to describe the barriers clients may face in accessing their services, and the methods their organizations use to eliminate or reduce these barriers. Finally, interviewees were asked to name any services they thought were needed in the county, to describe the county’s general strengths and challenges, and to name Dare County’s greatest health problems and suggest possible causes and solutions for these problems.

Qualitative data were systematically collected and initially recorded in narrative form. Themes in the data were identified and representative quotes were drawn from the data to illustrate these themes. Interviewees were assured that personal identifiers, such as names or organizational affiliations, would not be connected in any way to the information presented in this report. Therefore, quotes included in the report may have been altered slightly in order to preserve confidentiality. The interview script and protocol appear in Appendix B.

Interview Participants

Representatives of the following agencies and organizations participated in the stakeholder interviews:

Local pharmacy Dare County Sheriff’s Department Local nursing home Dare County Water Department Children and Youth Partnership Eastern Carolina Behavioral Health Community Care Clinic of Dare Environmental Health Division, DCDPH Community Development Corporation Healthy Carolinians of the Outer Banks Cooperative Extension Service New Horizons, Substance Abuse Division, DCDPH Dare County Board of Health Older Adult Services Dare County Chamber of Commerce Outer Banks Community Foundation Dare County Department of Public Health (DCDPH) Outer Banks Hospital Dare County Department of Social Services Outer Banks Hotline Dare County Emergency Medical Services Local dental services provider Dare County Parks & Recreation Department Local urgent care provider Dare County Schools

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Interview Responses

The responses presented here reflect—and sometimes quote—statements made by the interview subjects in answering the interviewer’s questions. These statements may represent either fact or opinion; no attempt has been made to verify the content of the interviewees’ responses.

Programs and Services

Stakeholders were asked to describe the services their organizations offer to county residents. The purpose of this inventory is to help identify the kinds of community resources presently available to address the county’s health and social service concerns. Respondents described a broad range of programs and services. The descriptions below are not exhaustive, but instead highlight key services provided by each interviewee’s agency or organization. In some cases, several community leaders worked in different capacities for the same organization and their responses have been combined.

Local pharmacy: The pharmacy fills prescriptions and offers over-the-counter medicines, home health needs, and medical equipment for purchase.

Local nursing home: The facility provides nursing and assisted living services to county residents; its primary service is long-term residential care for elderly people, including skilled care such as IV fluid transmission and wound care. It also offers physical, occupational, and speech therapy services as well as an Alzheimer’s care unit and respite care services for relatives of the elderly who need a break from caretaking.

Children and Youth Partnership (CYP): This organization administers the Dare County Smart Start program, the state-funded early childhood initiative that supports child care-related health and family support services on behalf of children ages 0-5 with the goal that all children start school healthy and ready to learn. In addition, it offers a wide range of services and sources of information for families, including a searchable on-line family resource guide, and the Family Support Program, a clearinghouse of information and services available to Dare County youth. It runs numerous programs, including WINGS, a preschool literacy program, Imagination Library, which mails books directly to children’s’ homes, and Parents as Teachers, a parenting and education support program for at-risk children. The partnership also provides child care subsidies to families in need, wage supplements to salaries of day care workers, and contact with registered nurses through home-visits with the Baby LINKS program. This agency also convenes a How Are the Children? conference.

Community Care Clinic of Dare: The Community Care Clinic provides no-fee basic healthcare, medication assistance, and wellness education for financially challenged and uninsured people in Dare County. The Community Care Clinic has three locations: Kitty Hawk, Manteo, and Frisco. It provides acute and chronic care but not urgent or emergency medical care. The clinic was established in 2005 as a grassroots response to the needs of the community’s uninsured citizens. The clinic and its success have depended greatly on the generous volunteerism of both medical and non-medical personnel. It receives financial and material resources from countless devoted organizations

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and individuals and support from its partners, the county Health Department, Albemarle Regional Health Services, and Outer Banks Hospital.

Community Development Corporation (CDC): The CDC is a not-for-profit organization that provides a full array of housing services. It helps county residents with home purchasing and rental counseling, as well as cases involving loan modification, lost mitigation, and reverse mortgages. It also manages some properties and puts together funding for certain development packages.

Cooperative Extension Service: The nationwide cooperative extension service is an educational network involving the US Department of Agriculture, the state land-grant university system, and county governments. Dare County Extension office is an outreach effort of NC State University and has as its main goal education—in particular non-formal education in agriculture and family consumer science. There are four main program areas offered through the Cooperative Extension Service: (1) the Agriculture and Natural Resources program, which focuses on education regarding the coastal environment, dune stabilization, urban horticulture, lawn and tree care, landscaping, waste and pest management; (2) Family and Consumer Education programs, which seek to improve families’ human development, childcare, food safety and nutrition; (3) the Expanded Foods and Nutrition Education Program (EFNEP), which provides obesity-fighting resources for limited-income families with young children and shows families how to “eat smart, move more, and weigh less”; and (4) the 4-H and Youth Development Program, which helps youth develop basic life skills through participation in clubs, afterschool programming, and summer camps.

Dare County Board of Health: The Dare County Board of Health is responsible for policy making and rule making, and acts as the adjudicatory body for the Dare County Department of Public Health.

Dare County Chamber of Commerce: The Chamber of Commerce serves several purposes: as a tourism office for the distribution of maps and information; as a welcome and information center providing relocation packets to newcomers; and as a supporter of business and of economic development by promoting local businesses and offering seminars, training and networking opportunities. In addition, it helps promote the annual area Health and Fitness Expo.

Dare County Department of Public Health (DCDPH): The Health Department’s stated mission is to “protect the public's health by promoting healthy living and optimizing quality of life for all who reside in [the] community through prevention, education, outreach, clinical care services and environmental protection.” It offers population-based health services to the entire community including prevention, intervention, and treatment options for health concerns such as smoking, diabetes, and communicable disease. The DCDPH maintains a proactive, preventive medicine-focused approach, offering programs designed to decrease the rate of illness or death due to disease, infection, or lack of proper medical care. A few of the areas covered are family planning, prenatal care, nutrition, and fitness. The Health Department is staffed by nurses, nurse’s aides, social workers, environmental health specialists, and health educators who work together to “Assess, Address, and Assure” the public’s health. It operates offices in Manteo, Kill Devil Hills, Nags Head and Frisco.

Dare County Department of Social Services (DSS): Dare County DSS offer a broad array of services and economic programs for county residents including: Medicaid; child welfare services; foster care and adoption; Adult Protective Services; Food and Nutrition Services (formerly Food Stamps); child support assistance; and Work First (the state Temporary Assistance for Needy Families, or TANF, program).

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Dare County Emergency Medical Services (EMS): Dare County EMS provide 911 emergency health care services for the entire county. It manages a dispatch center and takes care of inter-facility transports and transfers to trauma centers by ambulance, or, when needed, through its Emergency Medical Helicopter service. Every emergency call is met with Advanced Life Support (ALS) capabilities. All paramedics must maintain current certifications in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and Basic Trauma Life Support (BTLS). Despite having a challenging geographical layout, with barrier islands stretching across 108 miles from top to bottom, Dare County EMS call response times were reported to be lower than the state average.

Dare County Parks and Recreation Department: The Parks and Recreation Department provides many sporting and other activities for Dare County residents, both youth and adult. Parks and Recreation sponsors some special community events and runs numerous week- long summer camps ranging from cheerleading, surf fishing, and bicycle camps to performing arts and toddler camps. The department owns three primary facilities and maintains several of the school sporting facilities; these include gymnasiums, playgrounds, tennis courts, and soccer, football, and baseball fields. It supports the Special Olympics. Besides sports, the department also maintains computer and study rooms and offers music lessons in addition to classes in science, arts and crafts, sign language, and babysitting.

Dare County Schools: The local public schools provide education first and foremost to the county’s children, but offer some school health services and health education programs as well. Each of the county schools is staffed by a school health nurse that offers a variety of services including immunization audits, vision screenings, educational programs, and communicable disease prevention. School health also offers acute injury triage, seasonal flu clinics, and psychological counseling. The majority of the school health nursing staff is employed by the Dare County Department of Public Health, which offers other services to Dare County Schools, including the Peer Power health education program. Miles of Smiles is a mobile dental service operated by the Health Department for children at local area schools.

Dare County Sheriff’s Department: The Sheriff’s Department is a full-service law enforcement agency. It handles patrol, court duties, detention center inmates, and a 911 emergency call center. The department aims to earn the trust of the community and protect the rights of all citizens. It operates the Are you Okay? telephone reassurance program designed to check in with elderly and homebound residents at designated times to monitor their status and ensure that they are well enough to answer the phone.

Dare County Water Department: The Dare County Water Department “promotes safe, clean, healthy, fresh water for drinking and other purposes.” The water department operates five water plants, four of which are reverse osmosis plants while the other one is a fresh water softening facility. It provides water production and distribution services and routine maintenance of fire hydrants and valves. It also conducts safety and efficiency tests.

Eastern Carolina Behavioral Health (ECBH): Eastern Carolina Behavioral Health works in partnership with people who face significant challenges related to mental health, substance abuse, and/or developmental disabilities. It is a local management entity (LME) that pays for mental and behavioral health services to be provided through a network of providers. Psychiatric care and therapy are traditionally provided on an outpatient basis. ECBH offers some limited substance abuse treatment services: withdrawal, detox, and methadone treatments. It helps provide direct care in the form of respite care to homes, group homes, as well as some day care. ECBH also pays for personal care (bathing, feeding) when necessary for its clients.

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Environmental Health (EH) Division, DCDPH: Environmental Health is a division of the Dare County Department of Public Health. It is responsible for water protection of on-site wastewater systems, private drinking water wells, and for conducting lead investigations. It seeks to protect the public’s health and well-being by conducting health and sanitation inspections and enforcing state and local government health and safety regulations in food and lodging establishments, school cafeterias, tattoo parlors, meat markets, and respite-, child-, and adult- care facilities. It also issues permits for swimming pools and spas and recently dealt with an illegal methamphetamine lab. Another EH task is monitoring the water quality of recreational waters at ocean and sound access sites.

Healthy Carolinians of the Outer Banks (HCOB): A Healthy Carolinians partnership is comprised of key community leaders, agencies, and healthcare providers who come together to mobilize resources and efforts around a shared vision of health and safety. It supports health education and awareness, and promotes resource accessibility. The Outer Banks chapter focuses on four main areas, or “health priorities,” as identified through recent needs assessments: Cancer Prevention, Child Abuse and Neglect Prevention, Heart Disease and Stroke Prevention, and Obesity Prevention. The HCOB also operates taskforces to deal with two major concerns in the county: Motor Vehicle Injury Prevention and Access to Healthcare.

New Horizons, Substance Abuse Division, DCDPH: New Horizons is an outpatient substance abuse treatment center designed to be accessible to anyone who needs help, regardless of their ability to pay. It offers assessments, home visits, and both individual and group counseling for adolescents, adults and families. It also coordinates some community and school-based prevention programs and runs a toll- free substance abuse hotline, New Horizons’ Help Line, which is available to county residents after hours and on weekends. The program contracts with clinical service providers. It opened its doors in June of 2008 after a needs assessment showed an urgent need in the community for such a facility. It is an agency of the Health Department that is currently run as a demonstration project funded through state and county monies.

Older Adult Services (OAS): Older Adult Services is a portal of entry to services for the county’s aging people as well as for their families. It is predominantly a recreational organization, coordinating for instance the Senior Games which attract a wide range of participants aged 55 and older to 54 different sporting activities. OAS maintains an 11,000 square-ft. recreational facility and two others, and employs five full- time staff members. One is a fitness coordinator who teaches a number of classes, while others provide more direct health services such as Medicare counseling, referrals to social services, substance abuse counseling, and health screenings. Its nutritional program also provides home-delivered meals.

Outer Banks Community Foundation: The Outer Banks Community Foundation is a public charity that was set up to meet some of the local needs in the Outer Banks area that are not ordinarily funded through other governmental, church, or non-profit groups. It is not a direct service provider; rather it provides grants to some of those agencies that are direct service providers. Some, but not all, of these grants are health-related. Recent grants, for example, were awarded to the Community Care Clinic, Food For Thought, and Interfaith Community Outreach. Through careful investment of funds, it strives to provide a base of financial support that will last into the future.

Outer Banks Hospital (OBH): The Outer Banks Hospital is a full service, critical access hospital offering a wide range of inpatient and outpatient services. It is located in Nags Head, and opened in March 2002, making it one of the newest hospitals in eastern NC. OBH has 21 patient rooms, two of which are labor/delivery/recovery/postpartum rooms; over 400 babies are delivered there annually. Its Emergency -

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Department employs physicians, who are board certified in emergency medicine, and trauma-trained registered nurses. It provides emergency medical care coverage 24 hours a day, seven days a week, with a Minor Care section added in the summer to help accommodate the increased number of patients in the tourist season. When needed, the department works with the county EMS to provide medical air transports from its helipad.

Outer Banks Hotline: The Hotline is a domestic and sexual violence crisis intervention and prevention center. It maintains a 24-hour crisis hotline which has been in local existence for 30 years. All of its services are available free of cost to anyone who suffers or has suffered abuse from a partner. These services include safety planning, shelter, options counseling, accurate information, relocation assistance, case management, referrals to legal counsel, advocacy during certain legal proceedings, support groups, and financial and career counseling. It also provides assistance in resource and financial emergencies, and during mental health crises, for example with depression or suicide. Besides operating a shelter for abuse survivors, it runs volunteer-staffed thrift stores that raise much-needed funds.

Local dental services provider: This organization provides specialty dentistry services to residents of Dare County, including dental implant and gum disease care. It also provides plaque and tartar removal services and education about proper dental hygiene.

Local urgent care provider: This organization provides comprehensive family health care for people of all ages, including routine check- ups, urgent care, and weight loss treatment. The practice accepts Medicaid and Medicare and most types of insurance, but also serves uninsured patients.

Utilization of Services

Clients Utilizing Services

Interview subjects were asked to describe the county residents who currently were most likely to use their services in terms of demographic characteristics such as age, race and ethnicity, gender, and income level. Answers to this question naturally varied depending on the particular service; e.g., services provided by Dare County Schools are intended for school-aged children, while Older Adult Services are intended for older residents. Many times agency leaders reported that their clientele tended to be reflective of the demographics of the county as a whole, i.e., predominately white without many racial minorities. Whenever that was not the case or when there was some interesting finding regarding client composition, it will be noted here.

Income: Not surprisingly, county residents who take advantage of economic assistance programs tend to be from low to moderate income levels. However, according to the interviewees, a sizable proportion of those utilizing such programs now are also from what “used to be” the middle class. Many of the health care services provided by the interviewees’ agencies were accessed by the underserved, uninsured, or those insured with sub-standard or costly health insurance. According to one interviewee, in terms of income:

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It is a myth that this is just an affluent retirement community. We deal with so many young, low-earning, underemployed working class families every day. It is hard for them to make ends meet.

Others seconded that sentiment:

This place is not as affluent as people think; most of our clients are working class. The cost of living is high while service jobs’ pay is low.

A representative of a direct service organization not charged with providing economic assistance estimated that its clients were one-third middle-to-upper class and two-thirds in the lower income bracket. In a couple of agencies, rates of uninsured clients were reported as being very high—as high as 90%. According to the respondents, the population accessing services for older adults is actually predominantly affluent, with some moderate to middle income clients, and about 10% low income.

Gender: According to most interview subjects, women, especially young mothers, tend to take advantage of more health and human services than men do. Some services, such as WIC (Women, Infants, and Children), are aimed directly at the female population. More single mothers than single fathers access DSS programs. Whether married or not, mothers tended to seek services for their children more often than fathers; women are still the predominant caregivers. The ratio of women to men accessing the county’s domestic violence services is about nine to one. Typically women are more likely to seek out health care – routine and otherwise – than men are. Likewise, women tend to be somewhat more proactive in seeking substance abuse treatment. On the other hand, men with addiction problems might go through the criminal justice system before coming around to services through forced referral. There are substantially more males than females in detention centers and the criminal justice system, which is in line with larger societal trends. More males than females utilize services of the Parks and Recreation Department. Among providers focusing on services for the elderly, the gender split was fairly even for recreational activities but rather uneven in the utilization of residential services, with a ratio of three females to one male.

Race: Many interview subjects felt that generally speaking, racial minorities were over represented among their clientele compared to their representation in the overall population. Interviewees’ estimates put the composition of the Dare County population at roughly 95% white, 3% black, and 2% other. They said the Hispanic population composes just over 2% of the county’s residents, based on a figure from the 2000 Census. The actual make-up is probably a bit higher than that with some stakeholders estimating approximately 5%. A few agencies served clients with this approximate racial composition: 10% Hispanic, 5% black, 1% other, and the rest white. According to the interviewees, most of the Hispanics using county services are from Mexico, and they are often second generation. The schools report a higher percentage of Hispanics enrolled in the schools than Hispanic representation in the county population as a whole. It was observed that many Hispanic men were forced to move away in the past five years because their jobs in the construction trade have virtually dried up. African Americans were slightly over-represented and Hispanics under-represented in their use of the Department of Social Services programs. Just over two-thirds of those who access the domestic violence programs are Caucasian, which means that racial and ethnic minorities – especially blacks – are actually over represented in their use of these services. African Americans using these services are between 10-15% of users, and Hispanics are about the same (roughly 1% are other minorities, Asian or Native American). Blacks were also

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over-represented in nursing homes, accounting for an estimated 25% of the total. It was reported that a disproportionately greater number of African Americans also utilized behavioral health services, but that fewer elderly minorities utilized recreational and wellness programs for older adults.

Age: The age composition of people using the wide range of services provided by this stakeholder group varied according to those specific services and their targeted clients/patients. There were few surprising or unusual findings regarding the age-based utilization of services. For example, the majority of the Hotline’s callers tended to be between the ages of 20 and 50. One interesting finding, however, regards students using the free and reduced lunch program. There were somewhat more children of younger ages utilizing this service compared to middle or high school students, not because fewer older students qualify, but apparently because they were more apt to fear social stigma from being “outed” as a free or reduced lunch recipient, “a charity case.” In general, there were a lot of young families – single-parent or not – accessing Dare County’s services.

Changes in Clients Utilizing Services

Changes in Client Composition in the Past Five Years: Interviewees were asked whether in the past five years there had been any changes in the composition of people who use their services. Some interview subjects reported that their agency’s client base has stayed more or less steady. The change most often reported was that considerably more people – individuals and families at varying socioeconomic levels – were in need of services due to the sustained economic downturn. “We’re seeing a need for more services across the board,” was a common sentiment.

Listed next are some of the other ways that the utilization of community services has changed. First, the volume of demand has greatly increased for most services. There were more requests from residents for grants and financial assistance overall. People that used services before need more services now, and there are new clients who add to the demand. A greater proportion of the county’s population (and their children) is now considered “at risk.” Therefore, agencies that provide services for young children – e.g., Smart Start, pre-literacy programs, and Baby LINK, (the nurse home visiting program) – have experienced increased enrollment. Young families are having more trouble affording child care. On the other end of the age spectrum, elderly people in the community used to have very little to do outside of recreational activities; they stayed at the senior center all day. Providers have observed the same elderly people are busier now, at times working part-time jobs to supplement their fixed incomes.

According to the interviewee’s, more clients from all income levels are seeking help with housing issues because of the scarcity of affordable housing in the area. More middle and even upper-middle class people are struggling to pay their bills. The social stigma of poverty has decreased to some extent due to the recession, and now more people are willing to come in for help. This apparently holds true for people on the margins who have long been struggling to get by, but also for people who have never had to worry about paying their bills before. They all feel they have “permission” to get help in the current economic climate. One service provider did claim that while s/he had seen a slight uptick in demand, more had been expected than actually materialized; this was the exception, however. In the past five years, substance abuse agencies have been seeing more high profile and higher income-patients coming in for the first time to utilize services. 266 Dare County Community Health Assessment – Volume One Community Stakeholder Interviews

As mentioned previously, the Hispanic population in Dare County public schools has increased dramatically in recent years; presently there is a greater proportion of Hispanics in the county schools than in the county population as a whole. Hispanic children comprised approximately 200 of the district’s students just a few years ago, but reportedly have increased to 300 this year—a leap of 50%. While these numbers may not be huge in a more populated area, the implications for local services is said to be substantial. There has been only a modest increase in the demand for English as a second language (ESL) programming for Spanish-speakers, likely because younger, US- born Hispanic students have grown up speaking English. ESL and interpretation services in the county as a whole have been somewhat mixed in the levels of need, but mostly characterized by a modest increase. Others stakeholders report having seen less demand and fewer Hispanics altogether (such as the criminal justice system). The domestic violence hotline, on the other hand, has seen a markedly increased demand for Spanish-language services. African-Americans are making up a declining proportion of the population using several services, including the county schools.

One agency that has been experiencing a significant surge in volume is Emergency Medical Services, due primarily to the large seasonal population influx instead of economic conditions, as in most other cases discussed here. Whereas fifteen years ago they answered 2,000 calls, last year Dare County EMS responded to a total of 7,300 emergency calls. In terms of community utilities utilization, water consumption was reported to have decreased a bit recently because of the economic downturn and the subsequent dip in the number of second-home owners and tourists visiting the county. It was noted that this may be starting to turn around a bit, perhaps a sign of local economic recovery. One stakeholder said that the year-round population had “dwindled,” with people leaving the area due to economic and unemployment pressures. While “dwindled” may be somewhat of an exaggeration when looking at the actual figures, in some segments of the population at least, people have left.

Changes in Client Problems in Past Five Years: Community stakeholders were asked whether there were any changes in the kinds of problems residents have presented in the past five years. Once again, the overall economy has posed a major problem; in terms of reported problems, “the downturn has exacerbated everything.”

There are more people in need, the interview subjects report, and fewer emergency financial resources are available. Some families are unable to afford to pay for child care, and therefore child care agencies are struggling to keep their doors open. There is a very long wait list for child care subsidies. The demand for food assistance is up as well. A number of businesses have had to close. The client base of some services used to be gainfully employed, but are no longer. The tourism industry has been suffering, meaning those who are employed in it are, too. A number of older and elderly people that used to survive on a fixed income were finding it harder to do so and therefore getting part-time jobs, if possible, to make ends meet. The problem of prescription drug abuse is said to be worsening. In a few specific instances (in certain pockets of elderly and youth), interviewees report they are seeing more behavioral problems and that their clients are getting more “combative”.

According to several interview subjects, more mental health problems are surfacing under duress of the current economic environment. With the recent budget cuts and group home closures, some organizations (schools, outpatient mental health centers) are not equipped to deal with the significant needs of the population with mental health needs. As stated previously in this report, service providers found that county residents were experiencing a whole host of more complicated, co-occurring diagnoses and issues simultaneously. These include

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but are not limited to, mental health issues, poverty, unaffordable housing, a high cost of living, unemployment, underemployment and substance abuse. Service providers have become more cognizant of and more skilled at recognizing the co-occurrence of mental illness, prescription drug abuse, alcoholism, developmental disabilities – and how they might interact with other economic and social strains.

As the problem of finding affordable housing worsens, so subsequently, does homelessness. Some organizations report seeing an increasing number of homeless youth and elderly people. Interview subjects praised DSS Adult Protective Services for its handling of this latter problem. This rise in the number of homeless people locally is, apparently, on par with the national trend. Before the collapse in the real estate market and the economy in general, people needed more basic help such as loan assistance. Now, the problems related to housing are more severe: foreclosures, loss mitigation, loan modification, etc. When the real estate market collapsed, it left some with declining house values and others with a dire need to sell their house. Local foreclosures, especially of second homes, left behind environmental health problems such as private pools with stagnant, mosquito-infested water that additionally pose drowning risks to passers-by. The summer population swelling to six or eight times the year-round population results in an increased strain infrastructure, in the case of disposing sewage, for example. There is more of a need to recycle gray water and to overhaul the sewage system. These infrastructure and environmental health problems in turn create a greater need for tax dollars from a small tax base at a difficult time when people and businesses are going bankrupt and budgets are tight. Finally, with the threat of new laws focused on illegal immigrants, Hispanics have encountered a new-found level of distrust and suspicion regarding their residency status, and that makes them less likely to seek services, find legitimate employment, get driver’s licenses or other documents, and be able to support their families. The stakes are high for being “outed” as an “illegal” – not only could they lose much-needed services, but they could be sent “home” without their families and social support network.

Unmet Community Needs

Respondents were asked what services or programs are needed now that are not currently available? There were several recurring answers to this question as well as some lone concerns. The responses below generally start with the most common answers and proceed to answers reported less frequently:

Detox Facility: A substance abuse detoxification facility is at the top of the list of missing services, as evidenced by the volume of stakeholder responses pointing to this need. Interviewees reported some chance that funding will come through for this in the not so distant future. As it currently stands, however, there are not enough conveniently accessible inpatient services for substance abuse.

Mental Health Care: The other major service identified as lacking is mental health care. Programs, according to interviewees, are needed across the range of mental health problems. Particularly lacking, reportedly, are psychiatric crisis and inpatient care services. Another voiced concern is treatment options for adolescents affected by the closure of residential facilities. Interviewees identified a need for day treatment programs for the adolescents and support for their families. Group parenting sessions for families of children with behavioral problems were also identified as needed. More funding for mental health services was said to be high-priority right now, particularly because of the difficult transition to a new management entity, and added mental health stressors of the poor economy.

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Primary Care Providers and Specialists: Numerous interview subjects stressed the need for additional medical specialists, such as neurologists, psychiatrists, and ear/nose/throat doctors. Also, according to interviewees, there are not enough primary care providers in the county, especially for children; pediatricians are needed. Only one doctor in the county currently specializes in chronic pain management so more may be needed to keep up with the demands of an aging population. On a “wish list” for the hospital, interviewees cited pulmonography, endocrinology, and gastroenterology. Many respondents would like to see an intensive care unit added to hospital services. Interviewees recognized, however, that because of the county’s rather small population, it is simply not possible to have every type of specialist.

Transportation: There is almost no organized public transportation, and certainly not an overall public transit system, in Dare County. There is limited van service, but according to interviewees it was not accessible for a lot of people, or convenient for patients with unpredictable schedules or changing medical needs. Greater transportation support is said to be needed currently for medical patients who require care for chronic conditions and for those trying to travel with fragile and compromised health. According to interview subjects, people in Dare County basically need a car to get anywhere, though for financially-challenged people, other options would be preferable. An extended bus network was mentioned as a possible solution, though interviewees recognized that there are formidable geographical challenges to such a service. Planning and making such a system cost-effective would be challenging given the many remote, isolated parts of the county. From a geographical and logistical viewpoint, there are not a whole lot of possibilities for constructing alternative modes of transport (e.g., trains) with the limited space and the fragile infrastructure of the populated areas along the chain of barrier islands.

Access to Health Care: Service providers and patients they serve are waiting—somewhat anxiously—to see how national health care reform will play out. In the meantime, many cannot afford access.

Services for Young Families: It appears from the interview results that young, struggling families are “falling through the cracks”. Many of the “working poor” do not qualify for Medicaid, but cannot afford insurance. A free health care clinic for children is said to be needed, perhaps modeled after the Community Care Clinic available to adults in Dare County. The demand for different types of family services may be higher than it ever was, but the supply is being cut. An afterschool program for over 40 youth reportedly was totally cut although the demand remained steady. A teen parenting program was also slashed. The demand for accessing food pantries has increased dramatically in families with lost income. Additionally, finding good quality, affordable child care is difficult, since it is a struggle to maintain services and keep facilities’ doors open.

Funding: With so much competition for financial resources nowadays, funds are dwindling. There are many worthy causes and wonderful services in the community; the real challenge is to maintain adequate funding. As one service provider lamented: “The need didn’t go away. The funds did.”

Sewer: There is a need to improve the sewer system. The infrastructure in general needs improvement to accommodate the population influx.

Aging Population Needs: More dementia services and better diagnostic capabilities are needed. The one program that exists has limited offerings.

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Service Guidebook: One respondent mentioned that a guide to basic services and programs in the county would be a good idea; this would not be just a phone book, but rather a useful, thorough resource. Some services, for example, are not described online. Furthermore, not all people – especially poor people – have regular access to the Internet. Such a guide was said to be “in the works” now, but reportedly has been “in process” for over a decade.

Teen Activities: Another unmet need, according to interviewees, is for teen and “tween” programs: wholesome activities that can keep youth safe and out of trouble.

Interpretation Services: There was some, but not extensive, comment among interviewees that more and better language translation and interpretation services were needed. The comment apparently applied mostly for Spanish-speaking clients, but one interviewee also alluded to Chinese and Japanese residents as well.

Barriers to Access

Stakeholders were asked what barriers residents encountered in accessing their services. There were several recurring answers to this question as well as some lone concerns. The responses below generally start with the most common answers and proceed to answers reported less frequently.

Transportation and Accessibility: The lack of transportation was the most frequently-reported major barrier to access. People from more remote, isolated areas of the islands and the mainland especially were said to run into trouble when trying to access health and other human services. Specialty services and acute care are reportedly particularly difficult to access. While the existing county van service helped a few, it was said to be too limited and small-scale to be of much practical use to most people. For example, an agency’s client was told they could receive much-needed food from a pantry, but the client was not able to get transportation for the 20-mile, one-way trip to the agency. The unique geography of the spread-out county caused sizeable logistic barriers to access. Sometimes hours of business interfered with access as well.

Lack of Health Insurance: Interviewees realize that residents struggle with this problem. A lack of good health insurance was also a problem. Even if insured patients were able to access health care, they might well be unable to afford the high co-pays, co-insurance and costs of necessary prescription drugs. A lack of dental insurance was of particular concern, too, as most people simply do not have it.

Costs: There is a lack of affordable housing in Dare County. Prohibitively high housing costs are barriers to being able to transition out of domestic violence and/or homeless shelters, for example, but this barrier is an issue in some way or another for many organizations and their clients. A number of services—a rather impressive array, actually—are indeed free, but many are not. Agencies did not always have the funds to advertise their services, creating a lack-of-information barrier to access. Sometimes residents were not aware that they qualified for free services.

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Language/Cultural Barriers: There was not a great deal of concern about this issue among interview subjects. According to most interviewees, Spanish is the foreign language for which interpreters, translators, and bilingual forms are most needed. Language support also may be needed in certain planning and inspecting situations involving Chinese- and Japanese-speaking restaurant and tourist business proprietors. Some organizations had bilingual staff and interpreters on hand, but other organizations that needed them had none. For some Hispanics apparently just being a native Spanish-speaker is actually the barrier, via a real or perceived worry of repercussions for not having legal residency in this country.

Personal Barriers: Interviewees identified a few “personal” or “attitudinal” issues that interfere with people getting the services they need. Sometimes, they report, people can be so overwhelmed by being poor and having many problems related to financial insecurity that they seem to “freeze”, or are unable to “get it together.” They may not know how, or where, or when even to begin to address them all. Depression or substance abuse may play a role for these struggling individuals as well. In terms of the reluctance of the elderly to seek services, certain personal attitudes toward receiving residential or other care were said to pose barriers: a reluctance to leave home and “the only way of life they’ve known”, fear of change, or an unwillingness to concede that they need help at all. These can be valid concerns, but it may keep them from improving their situations. As assessed by one interviewee, “They do not want access. They want to stay at home.”

Awareness of services: For the most part, interviewees felt that the agencies they represented did not suffer from a lack of visibility in the community. They noted, however, that sometimes it was hard to reach people who needed the services the most. For example, instead of reaching obese residents, wellness programs might only reach the physically fit – people who are proactive and already have wellness and nutrition “on their radar”.. Some potential clients lived far away from the service they need, were only in the area temporarily, were not literate or English-speaking, or were just not “in the loop” when it came to all that the county had to offer. Some providers admitted that clients were at times surprised to know about specific aspects of their agencies.

Overcoming Access Barriers

Community leaders were asked what their agencies did to try to help clients overcome the barriers discussed above.

Transportation and Accessibility: Interviewees’ agencies generally did not offer many ways of meeting the transportation needs of clients. Vans were available in some cases, but not many organizations had cars or vans of their own to provide transportation service. Providers often had to take a piecemeal, situational-approach to helping people; for example, sometimes they reimbursed clients for travel costs, or got informal rides for them. In some limited situations where safety was an issue, law enforcement was able to help with transportation. EMS was said to be good at what it does, but limited in its range. Reportedly, in some cases the lack of available transportation severely affected an organization’s ability to carry out its duties.

Cost of Services: The Community Care Clinic, the Missions of Mercy free dental clinic, non-profit and church groups, and various health department and private practice offerings all helped patients in the county to deal with, and in many cases overcome, the cost barrier to health care access. Many health care practitioners—doctors, nurses, and dentists—were said to be personally very generous in helping to overcome this barrier. Patients were by and large not turned away from medical care even if they could not pay for it. Many other kinds of 271 Dare County Community Health Assessment – Volume One Community Stakeholder Interviews

service providers said they were able to offer free or very low-cost services to residents, sometimes through grants or by partnering with other organizations. Volunteers in many cases came in to make certain services possible without clients incurring costs.

Language / Cultural Barriers: Some of the interview subjects’ agencies have interpreters; other organizations are able to use the bilingual skills of staff or members to meet clients’ Spanish language needs. There might still be some need for accommodating language barriers in various organizations.

Personal Barriers: Service providers did what they could to help people overcome their personal barriers. For elderly people reluctant to use residential care services or respite care, the agencies were usually able to get them to “stay for a day,” and that usually helped them overcome their personal barriers to accessing health care, recreational, or wellness programs. Drawing on the community’s strength of caring people also helped in many cases: individuals reached out to help others in a kind, compassionate, and sensitive way. Staff also often used hard work and diligence to reach people.

Awareness: Services and service providers variously used flyers, word-of-mouth, websites, social networking sites (e.g., Facebook), and mailings to give residents the information they needed to access their programs and services. A comprehensive, all-in-one Resource Guide was also said to be under development. According to interviewees, their organizations were able to advertise when they had the funds.

Health Problems and Concerns

The stakeholders were asked to look specifically at health and describe what they thought were the most important health problems or health concerns in Dare County. In addition they were asked what factors were causing these problems, and what could be done to solve or overcome them. The health problems and concerns listed below are listed in order of those mentioned by respondents most often.

Substance Abuse: In the view of most interviewees, widespread alcohol overuse and abuse represents the most serious health challenge to the people of Dare County. It was repeatedly identified as “endemic” to the culture of beach life, as an “anything goes” mentality that county residents began witnessing at a young age and emulated based on vacationers’ relaxed, party behaviors. Liquor store sales were said to be higher per capita in Dare County than anywhere else in the state. According to the interviewees, alcohol abuse is an intergenerational problem that has been historically related to the seasonality of work. Fishermen, hotel, bar, and restaurant employees, for example, are very busy during the summer months and then suddenly, in the off-season, they are left with nothing productive to do. Interview subjects said the current unemployment situation is not helpful in this regard. Temptations for underage drinking are great; young people may start drinking before their teen years, finding it easy to steal from tourists’ coolers, or working in the restaurant industry where “everyone does it.” While a few interviewees said a lower socioeconomic status lends itself to this problem, others observed that alcoholism spanned the entire range of classes and income levels. One opinion was that the lack of supervision in single-parent families was a contributing factor. Financial strain and its inherent stress were noted as current “compounding” problems. Interviewees recognized the connection between substance abuse and diminished overall health; one noted that insulin-resistant diabetes is linked with alcohol abuse. Interview subjects cited education and prevention programs as ways to help solve this problem, particularly if paired with early screenings and improved accessibility to the full range of treatment options. The Health Department’s New Horizons program was cited for its great 272 Dare County Community Health Assessment – Volume One Community Stakeholder Interviews

track record in achieving outcomes for its alcohol and substance abusing clients. But they maintained that the county still needed more treatment options for inpatient care and detox. More crisis care—for alcohol and drug overdose—including inpatient care and acute psychiatric help, was also cited as needed. Raising taxes on alcohol to go toward prevention and treatment was offered as a means to pay for the needed services.

Interviewees also said that prescription drug abuse is a serious health concern faced by county residents, a problem that has gotten markedly worse in the past decade. They noted particularly an increase in the severity of pharmaceutical drug abuse, and said it is increasingly problematic in the elderly population. They said the incidence of drug overdoses is up. Some have knowledge that people “doctor shop” for numerous prescriptions, or buy pharmaceuticals on the street. They may use pain medications – that perhaps were originally indicated – inappropriately and for too long. Interviewees recognize prescription drug abuse as a part of the culture of addiction and dependence prevalent in the county. Prescription drugs have become more readily available as their use has become more and more widespread; interviewees noted that doctors can and have overprescribed medications. To overcome these issues interviewees once again propose education, prevention, intervention, and treatment as steps forward. They especially call for a better-centralized system for monitoring patient prescriptions through the use of electronic record-keeping of every prescription a patient has ever had filled, and say that even doctors in private practice, not just in county or state facilities, should be required to participate in such a database.

Other recreational drugs also ranked as problems in the area of substance abuse. One interviewee maintained that marijuana use among many adults is a “leftover” from the ‘60s and ‘70s hippie culture, and now their children are modeling this behavior. Smoking cigarettes was sometimes lumped into this category because it can tend to cluster with other addiction problems, and can be part of the “party culture.” Some respondents said that great strides had been made with the no-tobacco policies recently put into effect. A proposed solution for tobacco use was to raise taxes on cigarettes to go toward prevention and cessation programs, especially because this has been proven to also decrease smoking rates.

Mental Health: Mental health tied with substance abuse in being identified as the most severe health problem in the county. There was palpable concern and fear among interviewees that “we have fallen backwards in terms of mental health.” As mentioned above, the stress of joblessness, underemployment, struggling to pay for expensive housing, and sustained substance abuse all combine to leave one vulnerable to mental distress and illness. In the context of recent state-level mental health reforms and the replacement of the former local management entity with another, some respondents sense a void. Better ability to recognize mental health problems and addictions among their client base is helping some organizations be more proactive. The hospital representative described the hospital’s efforts to conduct SBIRT steps (Screening, Brief Intervention, Referral, and Treatment) with all patients in order to tease out mental health problems early; reportedly it is the first community hospital to do so, and has produced positive results. Deinstitutionalization apparently has not helped solve mental health problems in Dare County, as there remains a certain population of people in the county in need of residential care unavailable to them. School officials report seeing more behavioral and emotional problems in children as a result of parental substance abuse and financial strain; these problems often present in low-income households already at-risk for myriad other problems. School officials anticipate that student self-abuse may become a problem in such situations. The Health Department’s New Horizons Program is said to be helping students. Interviewees suggest that employment, education and a more reasonable cost of living might ease some of the

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pressures, as might an overall, holistic approach to health and preventive medicine. Increasing awareness and decreasing the stigma of mental health diagnoses may also help get more people and their family members the services and medications they require.

Cancer: A number of interviewees brought up the problem of cancer, mentioning that there seemed to be higher than usual rates of various kinds of cancer in Dare County as compared with other parts of the state and country. There was considerable discussion and questioning about whether this was merely a perception or a reality backed up by statistics. Interview subjects’ statements about cancer were frequently accompanied with the caveat that, “I could be wrong,” or “I heard, but I don’t know for sure…” Interviewees were uncertain of why cancer seemed to e more prominent in Dare County than elsewhere. One feared the water quality was not very good; others thought it had to do with diet. Fortunately, according to respondents, Dare County recently made a great step forward in terms of cancer care in implementing the Dare County demonstration of the UNC Cancer Outreach Program (an effort of the UNC Lineberger Comprehensive Cancer Center and the NC Cancer Hospital), which was said to have improved cancer care and support in the county (and elsewhere in the state) through Telemedicine consultations and videoconferencing.

Stroke, Heart, and Cardiovascular Problems: Several respondents mentioned that stroke and heart disease and other cardiovascular problems were faced by many people in the county. These, along with diabetes, were believed to occur often as a result of inactivity, poor nutrition and obesity—which also were among the interviewees’ health concerns. Interview subjects cited smoking and chronic obstructive pulmonary disease (COPD) as important related problems. Prevention, education, and intervention again were identified as important strategies in helping to solve these health problems. Locally, some strides apparently have been made regarding EMS protocol for better serving victims of heart attack and stroke. Interview subjects thought a neurology program and an ICU department at the local hospital would be assets in addressing these problems.

Affordability and Access to Healthcare: Community stakeholders were very concerned about the high costs of healthcare, recognizing that lack of health insurance, inadequate insurance, and the lack of ability to pay for care and medicines are barriers to proper health care. Interviewees cited the tendency to hold off on routine care until things become urgent as a problem in itself. In the context of under- and unemployment, employee benefits in Dare County have been either cut back or have become non-existent. The high cost of living in the county and low average wages for those who are employed (e.g., seasonally, in the service industry) are further barriers in this area. Still, some respondents thought healthcare access was better in Dare County than in some other places, and that it was definitely better than it had been in the recent past. The new Community Care Clinic, the Health Department, and others were said to have “come together” to collaborate on a range of services. Access to specialty health care was considered a great, lingering problem because of the lack of providers. The travel distance to certain health care facilities also was seen to pose a problem, especially for residents of more rural, isolated areas. According to the less optimistic of the interviewees, even if public transportation in the county could be improved, the accessibility of specialty care probably can never be entirely resolved, because the small size of the population will prohibit Outer Banks Hospital from offering every kind of medical specialty. However, interviewees note that Telemedicine will be a very valuable approach to helping address the problem of access to specialty care. Continued support for programs like BabyLINK, will help in other health care situations when young, low-income parents need newborn and infant care.

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Health Problems of an Aging Population: The issues associated with aging mentioned by some service providers were heart attacks, strokes, dementia, hearing problems, and a high number of falls. Additionally, Dare County’s elderly population is believed to be having some trouble with prescription drug abuse.

Obesity, Diabetes: One person thought that the county had one of the highest rates of childhood obesity in the state while others disagreed, stating that it was not such a big problem in Dare County, relatively speaking. Nevertheless, it was felt that collaborative efforts between schools, government, and the medical field should be made to deal with weight problems among youth. Diabetes was noted as a health problem related to obesity. Interviewees blamed obesity on diet, lack of exercise and a sedentary lifestyle. Some interviewees said that the problem of childhood obesity related to parents failing to teach and/or encourage their children to make healthy choices. Obesity was of particular concern for school-aged children living in poverty, as some parents in that population may work shifts that do not enable them to prepare healthy meals for their children. Community leaders offered some ideas about what could help reduce the problems of obesity, including more nutrition and physical fitness programs as well as early education and prevention in the schools. They also cited improving the built environment—through walking and biking paths, for example—as strategies to help address the obesity problem among all age groups.

Injuries and Drowning: Because of the county population’s proximity to the ocean and sound, the risk of drowning is significant, especially when alcohol is involved. Interviewees cited strict enforcement of alcohol policies at the beach and for underage persons as important and necessary, along with water safety training.

Hepatitis C: There are currently no resources in the county to treat the liver problems associated with Hepatitis C. It is a very specialized treatment and there are no doctors in the area who are able or willing to treat the condition. This problem is seen as related to poor lifestyle choices: poor diet, lack of exercise, alcohol and intravenous drug use, and education regarding this condition and its prevention was recommended in the schools.

Community Strengths

Interviewees were asked what they considered to be Dare County’s greatest strengths. Most were quick and enthusiastic in responding to the question, naming the first three areas repeatedly. Stakeholders felt that the community was generally going in the right direction, and while proud of the positive strides made, they were eager to find out more about the nature of the county’s problems (e.g., from this health assessment) in order to be able to move forward in making the community even stronger.

The People / Community Involvement: Respondents overwhelmingly agreed that the people in the community were its greatest strength. They had no shortage of things to say about why this was the case. These sentiments are typical:

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We have an absolutely remarkable community of people: kind-hearted, giving, caring, neighborly.

I’ve been a public servant for many years in a lot of different places, and I’ve never lived anywhere else where there’s such a strong, overall sense of community.

Caring, community-oriented, and generous were the most commonly-used descriptive words for county residents. They were further described as hard-working, industrious, “basically good,” and charitable. Even with the recession, evidently people still donate. From all reports, the interviewees take pride in the community and like living there.

We have a small-town feel where neighbors help neighbors. And people are connected. There is a ‘sense of village.’

People in Dare County tend to try to look out for each other. When people are in need, they have somewhere to turn.

Citizens are concerned with others and work together to “get the job done.” The community has a wonderful volunteer resource pool; whenever there is a need, more than enough volunteers come forward. At a free dental clinic held last year, for example, more than 150 local volunteers made it possible to serve 1,000+ patients that needed treatments.

Having worked elsewhere in dozens of other counties, [I can say that] no other county even holds a candle to it in terms of the level of volunteerism.

Stakeholders felt that the county was able to offer an incredible array of services – over 100 non-profits exist in the county – especially given that it is a rather small community, with a population of only around 36,000. The caring, community-oriented people of the county come together in different ways to “look out for each other.”

I’ve lived all over on the East coast, and we have the best array of public services anywhere. The community facilities are second to none. With a population of only 36,000 people, we have facilities on par with places that have more than ten times our population!

Collaboration Between Agencies: That county residents are so well-supported—through volunteers, non-profits, and involved citizens— speaks not only to the strength of community-oriented individuals, but also to the inter-agency collaboration of service providers and non- profits that come together to cover needs of county residents. Many disparate entities—service providers, elected officials, health care practitioners, businesses, charitable organizations, county departments, and grassroots taskforces—come together around community problems and needs in order to improve the health and quality of life of people in Dare County. It was common in interviews to repeatedly hear such language as “working together”, “collaborating”, “cooperating”, “partnering to sponsor” when describing community efforts and successes.

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By many accounts, there do not seem to be the kinds of problems that can and do stymie collaborative efforts in other locales, such as contentious turf issues, showboating or ego issues, rushing to take credit, or in-fighting between different entities. Instead, in Dare County there seems to be a genuine and almost inherent level of trust and a willingness to come together to achieve common goals. There is a strong desire to “make things happen.”

How people pull together here is what’s most amazing: ‘The community needs this, so let’s get it done!’

People don’t just sit around and complain. They push up their sleeves and get involved in solutions.

Besides having the willingness and desire to collaborate, the community is often successful in its efforts because it invests a lot of time and effort into needs assessment and is then committed to addressing and resolving identified community issues, even when they are tough. They put specific strategies in place for making improvements.

Despite current budget strains, a few people mentioned that there was actually quite a lot of money available in the community to fund and address problems. Even when funding is limited, however, agencies and their staffs seem adept at overcoming adversity, as was demonstrated in the following examples of successful collaborations. After a grassroots task force and needs assessment determined that substance abuse was a huge problem – one without any real services available to deal with it – in the county, a wide range of groups showed perseverance in collaborating to open a treatment facility. They included a group of concerned citizens, the county health department, CASA (Coalition against Substance Abuse), the state government (for funding), and other non-profit organizations. That treatment center, the Health Department’s New Horizons program, has met with incredible success in its first two years of service, achieving rates of participation said to be far beyond those of state and national averages. Though there is a long way to go yet, people are energized, heartened, and excited that there have been signs of improvement regarding local substance abuse activity.

Another inter-agency success has been getting the cost-free Community Care Clinic up and running and sustained by its all-volunteer medical and non-medical staff. The establishment of the community hospital, Outer Banks Hospital, was a triumph of collaboration as well. A number of health care entities—the Community Care Clinic, New Horizons, EMS, etc.—are said to do a good job of working together to avoid overloading the hospital’s emergency department. When county government was unable to adequately address the issue of homelessness, a number of non-profits and church groups worked together to helped indigent residents, especially in the winter months. They reportedly managed to get every indigent person that they helped into either rehabilitation or gainful employment. Healthy Carolinians of the Outer Banks (HCOB) has worked on these and other issues as well. HCOB partnered with the health department and the state Dental Society to hold a free adult dental clinic called the NC Missions of Mercy. The event was so successful last year that in two days more than 150 volunteer dentists and hygienists performed 2,950 dental procedures and over $400,000 in services to roughly 1,000 adults. They aim to exceed that goal this year.

Natural Environment: The natural environment—the stunning beauty and richness of the beaches, ocean, and sounds—is one of the greatest strengths of Dare County. It is one that in some ways is “just understood,” something that while it is clearly very valuable and beloved, was not referenced a great deal by interviewees. Perhaps it was mentioned as an afterthought, or briefly: “And there’s nature, of

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course.” Besides the economic opportunities and the beauty that come from the natural environment, residents were said to be more or less healthy in part because of the opportunities to get outside and not be exposed to air pollution. Nature itself contributes to a great quality of life. Fishing, surfing, birding, boating, kite boarding and other water sports are outdoor activities enjoyed by many – locals as well as tourists. The lifestyle can be described as simple, quiet, healthy, open, outdoorsy, and beach-loving.

People are drawn to the area – to the beauty and to the incredible beaches. We have an 85-mile stretch of sand around the ocean. Our natural resources are our greatest assets.

In addition to being a popular tourist magnet, the remarkable environs are starting to become a popular sporting destination in ways unlike in the past. Sporting events such as marathons and triathlons, for example, are becoming more popular on the Outer Banks.

Becoming more of a destination for marathons and triathlons is a development that I think is helping to improve the quality of life in Dare County. Besides being good for the economy – which is important – it raises awareness and encourages people to become more health-conscious.

Overall Quality of Life: A great quality of life is in many ways related to the county’s nature: its air quality, its beauty, and its special opportunities. There are many “fun” things to do, including plenty of informal and formal, organized activities for adults and children. This quality is one reason that so many retirees and second-home owners come to Dare County. “This is a great place to live, raise kids, and grow old,” as one person summed it up. The reports of a high quality of life are also associated with Dare County’s people, its “sense of village.” There are strong community ties and people help each other out. Furthermore, it is very safe, with low rates of violent crime.

You don’t have to worry that you’re in danger here. There are no gangs and, at least in my opinion, no racial problems. And having kids, that is the main reason we stayed here: It is a nice, safe place to live.

This is a great place to live, work, and visit. If I could move or live anywhere, it would be Dare County.

Community Leadership: Respondents also felt that the county had good, strong leadership. The Health Department’s proactive leadership was praised strongly by several people, as was the leadership of the Fire Department, EMS, and county Parks and Recreation Department. County leaders try to get input where needed by listening. Because of the small-scale, close-knit nature of the community, leaders were said to be accessible.

The local governments are very conscientious in trying to take care of citizens’ needs and provide the necessary resources.

The County Commissioners and department heads are really doing the best they can. They pay attention; they listen to residents, and are in-tune with their needs.

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Public School System: Those who mentioned the school system had very positive things to say about it: compared to other counties, it is a “superior school district” with “excellent schools, which are routinely ranked among the top in the state.” Another pointed out that the schools in the county enjoy “the highest level of spending per student in the state.”

Emergency Medical Services: Several praised the excellent paramedic care throughout the county, and said it was rare to have a helicopter that is owned and used solely in the county. The Fire Department is also highly regarded, and is said to work well with EMS and the Emergency Department of the hospital.

Health Care System: Interviewees seemed to feel that there is a good overall health care system in place. They declared “impressive” how the hospital, the Health Department along with its substance abuse demonstration project, New Horizons, and the Community Care Clinic work together to meet the needs of the community, and manage to avoid overloading the emergency room, a costly problem that a lot of other counties face. A couple of respondents commented on how “remarkable” it was that the community was able to pull together resources to build a community hospital just in the past decade. Finally, the UNC Cancer Outreach Program was recognized as having improved cancer care at the Outer Banks hospital through telemedicine.

Community Challenges

Stakeholders were asked what they felt were the major challenges facing Dare County. The first two areas of great concern were very much interconnected: the economic downturn and unemployment. Again, responses are listed from those most frequently occurring to those less frequently occurring, although some were ranked similarly.

Poor Economy/Unemployment: Tough economic conditions and unemployment were overwhelmingly cited as the most difficult interrelated challenges that Dare County residents face. The national economic downturn has reportedly hit the coastal region very hard, particularly in the construction and tourism industries. This is devastating because these are the two main areas that residents have traditionally relied upon for economic viability. Following are two illustrative quotes.

When the real estate sector is doing well, everyone here does well. We are now seeing that the converse is also true.

It is a huge problem for us to maintain tourism here because we are fully dependent on the rest of the world having money to come here. And in poor economic times, people have to cut back on things like vacations.

Some community stakeholders argued that Dare County has been hurt more significantly than other places, not only now but conceivably in the long-term. Construction in the county has all but halted entirely, and it was feared that the real estate market may never fully rebound. Those who were laid off from their construction jobs or other employment are now in need of more services. Some, such as a number of

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Hispanics that were in the construction trade in particular, have been forced to move out of the county altogether. Foreclosures, especially of second homes, are also a problem and have contributed to the freezing of construction.

Stakeholders were generally somewhat more positive about the tourism industry than about construction, one citing the success of the summer season that is just coming to a close. Still, these responses were tempered in that interviewees expressed concern over the county’s overdependence on, and therefore vulnerability to, a single revenue-generating industry – especially one so tied to others’ disposable income. It was further noted that a single major hurricane could wipe out the entire tourist base. The question posed by many respondents, therefore, was how to expand and diversify the range of income sources. The county currently has very little in the way of corporations, industry, or manufacturing and therefore a limited tax base relying only on the small population of year-round residents and the businesses (hotels and restaurants) that make up the tourism and hospitality industry. A need to diversify employment is a major challenge for Dare County.

An especially troubling aspect of the stagnant economy cited by the interviewees is the unemployment and underemployment of the county’s citizens. Dare County reportedly has one of the highest rates of unemployment in NC, and underemployment was said to be “rampant”. Stakeholders reported that available jobs do not pay living wages commensurate with the local cost of living and housing. Many of the existing jobs are in the service industry and characterized by seasonal and often part-time employment, with relatively low pay and no benefits such as health insurance. Although some workers, such as restaurant servers, were said to earn quite a bit during the summer, they were likely to have to collect unemployment to sustain themselves and their families throughout the off-season. Others said that certain employers routinely kept part-time service employees on with minimal shifts at a level too low to survive on, yet just high enough that they were unable to collect unemployment insurance at all.

Unemployment creates a greater demand for social services, which is a problem in light of the county’s challenge to balance the budget without cutting services. Economic stressors also put a lot of strain on families and at times exacerbate substance abuse and mental health issues, as stated in other sections of this chapter.

People, including myself, are very worried and fearful about their future. Both personally and professionally I’ve seen the impact of the economic downturn on people’s lives.

There is a very tangible sense that people are suffering.

Budget crises have been experienced at all levels of government in the past few years, including state and county government. A few stakeholders noted that although this year’s county budget was “sort of okay,” they expected it to be worse next year. All units of county government are being forced to “do more with less.”

Substance Abuse: Alcohol abuse was reported as the worst type of problem in this area, endemic in the very culture and mentality of the beach, with underage drinking starting early – sometimes in children as young as eleven. Interview subjects maintained that county alcohol abuse rates are markedly higher than state averages; indeed, liquor store sales from one of the county’s ABC stores are actually the highest

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per capita of any in the state. Prescription drugs, the overuse and abuse of which have significantly risen in the past several years, were reported as the second worst aspect of substance abuse, with other narcotics ranking third. Although stakeholders generally agreed that great strides had been made in dealing with substance abuse and its related problems—especially because of the new and oft-praised intervention program New Horizons—it still was cited as a very significant problem and ongoing challenge. The resort area’s “party culture” and mentality that “anything goes” contribute to this problem. Vacationers as a rule consume more alcohol than usual in their short-term summer vacations, but a lot of county residents emulate the behavior of vacationers all year-round, according to a number of health and human service providers who were interviewed. It was thought that the heightened economic pressures have increased and exacerbated substance abuse issues as well. This is especially true when they are complicated by a co-mingling with mental illness, which is not uncommonly the case (one statistic cited by an interviewee was a 65% co-occurrence rate). The county faces significant challenges in related crisis situations, such as in the case of overdose, according to interviewee comment.

Geography/Transportation: Dare County’s unique, spread-out geography coupled with a lack of public transportation pose logistical challenges for many count residents. There is no widespread public transit system, only a very limited, small-scale van service and ferries that operate at varying intervals between the islands and mainland. Without a good transit system, a car is more or less a necessity. Transportation and access to services is often challenging, especially for those people living in remote, isolated areas along the Outer Banks or at the edges of the county. The great traveling distances pose a challenge in particular for residents with major medical issues or those that necessitate specialty care. Service providers seem well aware of these logistical challenges, both from the provider and patient’s points of view. The geographical layout of Dare County certainly poses some hurdles to improving the transportation infrastructure: in some cases there is very limited potential for constructing alternatives (such as road expansion). There is no centralized business area in which to concentrate resources, either. It is quite costly to build and maintain necessary structures such as bridges. Two bridges, in particular, are said to have been in grave need of repair for 20 years now, but are being held up by disputes regarding environmental regulations. Traffic congestion is a challenge inherent to the tourist industry. Geographical vulnerability to storms, hurricanes, flooding and erosion are others problems more unique to Dare County. Given these threats to the unusually fragile barrier island ecosystem, one interviewee pointed out that fighting with homeowner insurance companies was also sometimes an issue. Environmental preservation and conservation are related challenges.

Managing Tourism and Infrastructure: The tourist season, which extends from mid-April through Thanksgiving, but peaks in summer, is characterized by an incredible swelling of the county’s population. From its modest year-round count of about 36,000 residents, the population skyrockets to eight or ten times that level – or more – with 250,000 people (both tourists and seasonal residents) crowding in and exerting strain on the county’s infrastructure. Leaders expressed concern over how to maintain the critical balance between developing the infrastructure needed for a smooth, well-functioning tourist destination and preserving the unique, fragile, and irreplaceable beauty of the ecosystem and beaches, some of which had already been lost or is vulnerable to loss.

An up-side to the economic slow-down has been the slowing down of development in the county. It’s important to keep the right balance and maintain the high quality of life.

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A smart, high-level planning approach to planning and development was cited by a community leader as an important challenge:

We need a sound, long-term in-fill plan. That includes providing incentives for better and more efficient use of the land. For example, instead of building one house on a lot in an older neighborhood, build two, or one house and a convenience store.

The following example illustrates the challenge: Most of the county population is served by septic systems, which take up more space than a sewage system would. Of the cost of improving such infrastructure may be high upfront, but a prudent investment in the long-term, according to some community experts. Several cited the expansion of infrastructure – including water, sewer, and waste disposal – as necessary to accommodate the seasonal population influx. The county’s annual summer inundation of visitors and its subsequent infrastructure strain also poses very real challenges to emergency preparedness efforts in the event that hurricanes or health epidemics were to strike, for example. Combined with the unique geography, the strain creates an increased potential for “things to happen,” as one interviewee put it. There can be a struggle to maintain certain services. Although the EMS was praised by others for doing a great job with what it has, at times they have been down to one truck, it was reported, which is risky. Finally, a few interviewees maintained that while necessary for the income it brings to the county, tourism is not a community strength but rather a liability in that the influx of vacationers and their “party” mentality negatively impacts residents’ substance use and abuse.

Mental Health: Some interviewees ranked this priority as very high on the list of challenges. Several others said they preferred rather to take a “wait and see” approach, since the new Local Management Entity (LME) that recently took over “hasn’t gotten its foothold yet”. It is now trying to establish the necessary network of service providers. In the context of tighter funds and hiring freezes, agencies that provide mental health supports and services may be getting the most out of the staff they do have, but that doesn’t mean they can always meet the demand. Psychiatric services for acute problems apparently is lacking in the county. One service provider with knowledge of the subject noted that suicide was a particular problem with the tourist influx to the Outer Banks because “many people come to the beach to commit suicide.” It was noted by a few service providers that the community was definitely doing a better job of recognizing and identifying the co- occurrence of complicated mental health, substance abuse and behavioral/developmental issues. Still, after “naming the problems” it remains a challenge to deal with this complicated set of issues. Better recognition is one thing; the challenge of dealing with and treating this complicated range of issues is another.

Cost of Living/Lack of Affordable Housing: Some respondents said that the cost of housing in Dare County was higher than anywhere else in the state. That it is a resort area and a popular destination, not only for tourists but retirees and second-home owners, drives up the cost of properties. The average young person or couple reportedly cannot afford to live there, with the cost of a two-bedroom apartment rental being about $950 per month. Likewise, many people mentioned that the overall cost of living in Dare County was higher than the state average (though there was not total agreement on this, as one expert in the field noted that it was costly housing alone that accounts for the high cost of living). The high cost of living complicates some agencies’ ability to find and hire adequate staff, especially health care workers at the lower end of the pay scale, such as nurse’s aides, and adult and special needs residential service providers. Many of these workers must live elsewhere and then drive long distances to get to work in Dare County, sometimes an hour each way.

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In terms of development, not only are there significant financial barriers to additional construction, but also the county apparently is running out of buildable land in the more valuable, “desirable” areas, as for example, on the barrier islands. Additionally, efforts to build affordable housing are said to have been occasionally “stymied” by affluent people’s biases and the feeling that “those types of places” should not be built “in my back yard.” Some unemployed persons have had to move out of the county because of the high cost of living; it may also prevent young couples or individuals from moving to or staying in the county.

Attracting Medical Specialists: Some stakeholders also listed the problem of attracting and retaining enough medical specialists, including psychiatrists and pediatricians, as a community challenge.

Political Issues: A few issues and disagreements of a political nature were also cited by interviewees as community challenges. One respondent mentioned that construction and/or repair on two bridges were being held up by environmental regulations, although they were “already there” and improvements were much-needed. This person felt it a colossal waste that purportedly sixteen environmental impact studies had been conducted and still there was no consensus. The debate over offshore drilling was also mentioned as a political issue of significance. Offshore drilling was seen as a potential threat, with catastrophic images of the recent Gulf oil spill clearly still embedded in mind and eye. Another interviewee expressed frustration over “constantly having to fight” with the national park service and a few environmental organizations about shutting down beaches on Hatteras Island “because of a few birds.” Interviewees also mentioned certain aspects of local politics as a community challenge. One person thought that a disadvantage to Dare County’s small-town nature and approach was that, in terms of local government, “Change does not come easy. New ideas are slow to be accepted,” – for instance, the notion of moving the local economy away from its overdependence on tourism.

Allocating Funds and Avoiding Waste: Though there may be ample funding for community services, according to some stakeholders it can be a challenge to use the funds wisely and allocate them correctly. One interviewee felt, for instance, that the county overspent for a new courthouse. Also, some schools were said to be torn down even though they were not in such poor shape that demolition was justified. Another interview subject stated that there was some waste and overlap that probably could be eliminated, citing, for example, that each municipality has its own fire chief.

Other Community Challenges: Other challenges mentioned during the stakeholder interviews included: challenges associated with an aging population (e.g., increasing demand on senior services, and high costs of care of the aging population); getting seasonal second home owners to become more integrated and involved in the local community; and residents moving to the county without any extended family or built-in network of support.

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Chapter Six

Issues Prioritization

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Chapter Six: Issues Prioritization

The 2010 Community Health Assessment was conducted by the Dare County Department of Public Health (DCDPH) and Healthy Carolinians of the Outer Banks (HCOB). Across the state, local public health departments partner with community groups such as Healthy Carolinian organizations to conduct a community health assessment once every four years. The purpose is to identify factors that affect the health of people living in the community and to determine the availability of resources to address these factors. HCOB has used this information to select the priority health and lifestyle issues that will be addressed during the next four years.

About the Dare County Department of Public Health

The Dare-Currituck District Health Department was established in 1938. Since then, the Dare County Health Department has become a single county organization. It has grown steadily, adding new services every year. These services are instrumental in meeting the health needs of the citizens and visitors of Dare County.

The Dare County Department of Public Health is governed by an 11 member Board of Health and administered by Health Director, Anne Thomas. This board is responsible for policy making, rule making and adjudication. The DCDPH provides services through five divisions; clinic, environmental health, substance abuse, home health and hospices, and health education.

Public Health has made great strides in the area of prevention. Programs are designed to decrease the occurrence of illness or death due to disease, infection, or lack of preventive care. Promoting good health through education is a priority.

DCDPH Mission Statement. The mission of the DCDPH is to protect the public's health by promoting healthy living and optimizing quality of life for all who reside in our community through prevention education, outreach, clinical care services and environmental protection.

About Healthy Carolinians of the Outer Banks

Healthy Carolinians of the Outer Banks (HCOB) was formed in April of 2001. HCOB is “A Partnership for A Healthier Dare County” and was developed as a model for the Dare County Department of Public Health to collaborate with members of the community in identifying and addressing health and safety issues. Simply stated, the mission of Healthy Carolinians of the Outer Banks is to mobilize the community to make Dare County a healthier and safer place for all who live here.

HCOB completed comprehensive community health assessments of Dare County in 2002, and 2006 and 2010. Each assessment is used to mobilize concerned citizens into Task Forces to combat the community health problems uncovered by the assessment.

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Dare County Community Health Assessment 2002

Accomplishments

After the 2002 assessment, four Task Forces were formed and developed plans of action to address Barriers to Access to Health Care, Substance Abuse, Aging Issues, and Motor Vehicle Injuries. A summary of the accomplishments of those task forces is below.

Access to Health Care Task Force

The 2002 Community Health Assessment identified access to health care as a main concern of Dare County residents. was determined that at least 1 in 5 residents did not have health insurance and over 50% of employable residents work in service industry jobs with no health benefits. To address this concern, the Access to Health Care Task Force was formed. The Task Force determined that health care for those under/uninsured was of the highest priority. The Dare County Department of Public Health (DCDPH), Albemarle Hospital Foundation, and the Outer Banks Hospital partnered to form the Community Care Clinic of Dare, a system of free clinics to provide quality health care and prescription assistance to the under/uninsured who live and work in Dare County.

The first clinic opened in April, 2005 in Kitty Hawk. Volunteer physicians, nurses and support staff insure that quality health care is available to those in need. A pharmacy assistance program helps people to access medications that their physicians have ordered. A second location opened in September on Hatteras Island and a third location in Manteo began seeing patients in November, 2006.

The Community Care Clinic of Dare has formed their Board of Directors, obtained their 501(c)(3) status and maintains a high profile in Dare County to provide access to medications and primary health care.

Aging Task Force

The Aging Task Force of HCOB held the “Aging Wisely on the Outer Banks” Symposium in October of 2005. A capacity crowd attended educational sessions ranging from elder abuse to Medicare Part D. Representatives from state and local government, healthcare and various community organizations were available to answer questions and facilitate discussion groups.

The Aging Task Force received a grant from the Duke Endowment Rural Church Division for funds to support a respite care program. Dare Respite Care is a program that ecumenically serves the respite needs of caregivers in Dare County, caring for frail, elderly and shut-in family members in their homes. The program is administered by the Dare County Department of Public Health. The program brings high quality, dependable respite care to caregivers in our community while also providing companionship and supervision to the care recipient.

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Substance Abuse Task Force

The Substance Abuse Task Force of HCOB has worked with a partnership of local healthcare and mental health providers, representatives from the school system, law enforcement officials, and concerned citizens. They have worked to educate the community about substance abuse issues through community events such as Trick or Treat Under the Sea, the Outer Banks Health and Fitness Expo and Manteo High School’s SADD-sponsored Soccer Day. They held a highly successful Strategic Planning Kickoff Day in September, 2005 attended by a wide representation of community volunteers and leaders. In addition, the task force organized a multi-faceted community wide forum, titled “Shhh .. let’s talk about it” to further increase community awareness about the issue of Substance Abuse and a representative sample of Dare County residents participated.

This task force then evolved into Dare CASA (Dare Coalition Against Substance Abuse) and received their 501(c)(3) status as of October, 2005. Their mission is working collaboratively to positively alter the impact of substance abuse in Dare County by changing awareness, attitudes and behaviors through ensuring access to a comprehensive array of prevention, treatment, aftercare, and recovery resources.

Motor Vehicle Injury Task Force

In efforts to reduce motor vehicle accidents the, Motor Vehicle Injury Task Force of HCOB has increased the number and visibility of milepost markers along the bypass and beach road as a first attempt to curtail the number and severity of motor vehicle injuries in Dare County. The Task Force worked with the North Carolina Department of Transportation, the Outer Banks Chamber of Commerce, Outer Banks Tourist Bureau and others to leverage funds to make this happen. The Task Force designed a brochure for visitors and residents with tips on safely navigating the Outer Banks. The brochure is in its third printing of over 60,000 copies.

Dare County Community Health Assessment 2006

Accomplishments

After the 2006 assessment, five Task Forces were formed and developed plans of action to address Child Abuse and Neglect, Obesity, Cancer, and Heart Disease and Stroke. At the request of the Health Director the Access to Health Care Task Force reformed to address access to dental care and patient advocacy issues in the county. A summary of the accomplishments of those task forces is below.

Child Abuse and Neglect Prevention Task Force

The Child Abuse and Neglect Task Force has worked with local healthcare and mental health providers, representatives from the school

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system, law enforcement officials, and concerned citizens to develop an active communication plan. They have worked to educate the community about child abuse and neglect issues through community events and newspaper articles highlighting such dangers as leaving children unattended in hot cars, summer safety tips, and other evidence-based preventive education. In April 2009 the task force implemented a large scale community awareness campaign that consisted of large cut-out kids representing the number of reported child abuse cases in Dare County. The project was displayed in different parts of the county throughout Child Abuse Prevention Month. This awareness campaign will be an annual activity of HCOB. The task force also worked with Prevent Child Abuse NC to host trainings for local child care providers. The task force has also developed an informative power-point presentation which will be shown to various local organizations to promote awareness and increase prevention education. The task force presented a proclamation to Dare County Commissioners recognizing April, 2009 as Child Abuse Awareness Month in Dare County.

Obesity Prevention Task Force

The Obesity Task Force, which was established based on data reflecting that obesity in Dare County is on an upward trend. The task force partnered with Dare County Parks and Recreation to host a large scale community awareness project titled “Dare Unplugged”. This widely participated-in event promoted physical activity and reducing TV and screen time for children. The event also worked with local media outlets to promote different physical activities in the county everyday for one week in April by publishing an events calendar and documenting the events. The event included dog walks, horseshoes, rock wall climbing, and many more fun activities. The Obesity Task Force plans to host and promote Dare Unplugged on an annual basis. The Obesity Task Force also supported the Dare County Department of Public Health’s Childhood Obesity Prevention Project (COPP). This grant successfully collaborated efforts of multiple agencies in Dare County including Dare County School, Children and Youth Partnership, Parks and Recreation, the Outer Banks Hospital, and many more. The COPP had 12 interventions that address childhood obesity in Dare County including partnership development, self assessment for child care facilities, in school prevention of obesity and disease initiative, pediatric obesity tools and training, hospital worksite wellness, coordinated school health initiative, school worksite wellness, faith community intervention, the implementation of a large scale community awareness campaign, support of the construction of a bike/pedestrian path, and conduction of a 12-week intervention called “Energize” for children at risk for Type II diabetes.

Cancer Prevention Task Force

The 2006 HCOB Community Health Assessment identified Breast and Lung Cancer as a main concern for Dare County residents. Cancer is the leading cause of death in North Carolina and the Cancer is the number #1 cause of death in Dare County. Dare County has seen an increase in cancer mortality rates. The highest mortality rates are seen in breast cancer and lung cancer. Based on this data the Cancer Task Force “divided to conquer” – they split into two groups to focus on each area.

In October, 2009 the Breast Cancer Task Force celebrated “Pink Sunday” in recognition of Breast Cancer Awareness Month. Breast health information was provided to churches, and restaurants gave discounts and pink desserts to those wearing pink at lunch on that designated day. Representatives of the taskforce presented a proclamation to the Dare County Commissioner’s to recognize the 288 Dare County Community Health Assessment – Volume One Issues Prioritization

importance of the month. Dare County Libraries, along with DCDPH and the Department of Social Services provided displays for the public, sharing information about early detection and local resources.

The Lung Cancer Task Force developed a localized Tobacco Cessation Resource Guide to assist the public and the medical community to help tobacco users quit. This guide details tobacco cessation and treatment resources available in Dare County and has been widely distributed to physicians, dentists, clinics, pharmacies and healthcare providers throughout the County. The HCOB Lung Cancer Task Force also offered a tobacco cessation program to businesses and Dare County employees at no-cost. Dare County supported county employees to participate in the cessation classes without taking time off from work. The HCOB Lung Cancer Task Force also co-sponsored two Regional 5A Trainings for medical professionals including: physicians, nurses, respiratory therapists, PA’s, dentists, hygienists and billing clerks. The 5A Training educates the healthcare community about: Asking, Advising, Assessing, Assisting and Arranging for patients to quit tobacco.

Heart Disease and Stroke Task Force

The Heart Disease & Stroke Task Force of HCOB has provided community education to the public including the signs and symptoms of stroke in addition to how to live a healthy lifestyle to prevent heart disease and stroke. The task force has participated in various health screenings throughout the county and is working on the production of an informational commercial starring local physicians and the Health Director, to educate the public on the importance of early detection and calling 911 if someone is suspected of having a heart attack or stroke. This task force is also exploring opportunities for grants in efforts to expand the current stroke treatment program in Dare County by purchasing teleconference medical equipment for local health care facilities. In February 2009, the task force presented a proclamation to the County Commissioners recognizing American Heart Month in Dare County.

Access to Health Care Task Force

Dare County data reflects that 22.6% of adults are un-insured compared to 19.5% in North Carolina in 2006-2007. This data prompted the Dare County Department of Public Health to re-establish the Access to Health Care Task Force in collaboration with HCOB. The Access to Health Care Task Force joined forces with the NC Dental Society to host a large scale dental clinic to provide free dental care to adults. The dental clinic was held in October 2009 and provided over $400,000 of dental services to over 900 adults in Dare County. The clinic was a huge success and will be an annual event in Dare County with the continued support of the Dare County Department of Public Health and the Healthy Carolinians of the Outer Banks.

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Dare County Community Health Assessment 2010

Determining Health Priorities

As information was gathered it was presented to the Dare County Department of Public Health and the Health Carolinians of the Outer Banks Partnership, at monthly HCOB meetings. In October 2010, HCOB used a formal process to determine its community health priorities. Each member was given a list of the leading health and community issues as identified through the 2010 Community Health Assessment then evaluated each according to a set of criteria. A score was assigned to each community health indicator. Average scores were calculated and each indicator was ranked in descending order. The following criteria were used to evaluate the health indicators:

1. The Magnitude of the Problem – How many persons does the problem affect? 2. Seriousness of the Consequences – What degree of disability or premature death occurs because of the problem? What are the potential burdens to the community such as social or economic burdens? 3. Feasibility of Correcting the Problem – Is the problem amenable to interventions? Is the problem preventable? Is the community concerned about the problem? Is the intervention feasible scientifically as well as acceptable to the community?

As a result of this process, the HCOB will develop action plans addressing the top community health issues. This will guide the work of the Healthy Carolinians of the Outer Banks for the next four years.

Prioritization Process

Based on findings from the 2010 Community Health Assessment members of Healthy Carolinians of the Outer Banks Partnership identified the following health or social concerns for the county. The issues identified by consensus and are listed in no particular order below:

1. Youth Issues 2. Flu/Pneumonia 3. Economy 4. Substance Abuse 5. Mental Health 6. Access to Health Care 7. Transportation 8. Aging Population Issues 9. Accidental Injuries/Non Motor Vehicle 10. Obesity 11. Smoking while Pregnant 12. Heart Disease and Stroke 13. Cancer

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Members discussed these issues, asked questions and then came to a consensus on the list. Then they participated in a formal prioritization process. Each participant was asked to evaluate each of the issues according to three criteria: (1) magnitude of the problem; (2) seriousness of the consequences; and (3) feasibility of correcting the problem. The scores are listed below.

Magnitude of the Problem (ranked 1-13 with 1 being the issue with the largest magnitude)

Ranked Issues Average 1. Economy 2.83 2. Youth Issues 3.67 3. Substance Abuse 3.67 4. Access to Health Care 5.00 5. Mental Health 5.17 6. Transportation 6.33 7. Aging Population Issues 7.33 8. Obesity 8.08 9. Heart Disease and Stroke 8.42 10. Flu/Pneumonia 8.50 11. Cancer 9.17 12. Accidental Injuries/Non Motor Vehicle 10.50 13. Smoking while Pregnant 12.33

Seriousness of the Consequences (ranked 1-13 with 1 being the issue with the largest consequences)

Ranked Issues Average 1. Substance Abuse 3.33 2. Access to Health Care 4.25 3. Mental Health 5.83 4. Economy 6.00 5. Flu/Pneumonia 6.00 6. Heart Disease and Stroke 6.00 7. Youth Issues 6.67 8. Cancer 6.67 9. Obesity 6.92 10. Transportation 8.83 11. Accidental Injuries/Non Motor Vehicle 9.00 12. Aging Population Issues 9.92 13. Smoking while Pregnant 10.75

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Feasibility of Correcting the Problem (ranked 1-13 with 1 being the issue most feasible to correct)

Ranked Issues Average 1. Youth Issues 3.58 2. Flu/Pneumonia 3.58 3. Smoking while Pregnant 4.25 4. Obesity 5.83 5. Transportation 6.42 6. Substance Abuse 6.58 7. Access to Health Care 6.92 8. Mental Health 7.17 9. Heart Disease and Stroke 7.58 10. Accidental Injuries/Non Motor Vehicle 8.17 11. Aging Population Issues 9.25 12. Cancer 9.33 13. Economy 12.33

Average of all three questions, (ranked 1-13 with 1 being the issues with average of the largest magnitude, most serious consequences and most feasible to correct)

Ranked Issues Average 1. Substance Abuse 4.52 2. Youth Issues 4.64 3. Access to Health Care 5.39 4. Flu/Pneumonia 6.02 5. Mental Health 6.05 6. Obesity 6.94 7. Economy 7.05 8. Transportation 7.19 9. Heart Disease and Stroke 7.33 10. Cancer 8.39 11. Aging Population Issues 8.83 12. Smoking while Pregnant 9.11 13. Accidental Injuries/Non Motor Vehicle 9.22

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Next, the Healthy Carolinians of the Outer Banks Partnership Executive Committee held a meeting to review all of the information and feedback provided from the Partnership. In addition to the feedback from the Partnership the Executive Committee considered several other factors such as the data collected in the 2010 CHA, groups already addressing health issues in Dare County, and available resources to developed recommendations for future direction of the Partnership. The recommendation will be presented and voted on by the Partnership.

By not duplicating existing efforts, the following issues remain for developing taskforces and action plans:

Example:

1. Youth Issues 2. Flu/Pneumonia

In addition to forming task force to address the above issues, the Partnership will continue its efforts addressing Obesity, and Access to Health Care in Dare County.

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References

294 Dare County Community Health Assessment – Volume One References

References

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36. Albemarle Health, Regional Medical Center; http://www.albemarlehealth.org/facilities/regional_medical/index.html (accessed July, 2010)

37. Community Care Clinic of Dare; http://www.dareclinic.org/AboutUs.asp (accessed July, 2010).

38. CiteHealth, Dare County Dialysis; http://citehealth.com/dialysis-centers/north-carolina/cities/manteo/dare-county-dialysis (accessed July, 2010)

39. Dare County Department of Public Health, Dare Home Health and Hospice; http://www.co.dare.nc.us/depts/health/hhhome.htm (accessed July, 2010).

40. NC Division of Aging and Adult Services; http://www.ncdhhs.gov/aging/ (accessed July, 2010).

41. Medicare, Nursing Home Compare; http://www.medicare.gov/NHCompare/Include/DataSection/Questions/ProximitySearch.asp (accessed July, 2010).

42. Dare County Department of Social Services, Adult Services, In-Home Aide Services; http://www.dcdss.org/ (accessed July, 2010).

43. NC Division of Mental Health, Develolpmental Disabilities and Substance Abuse Services, Local Contacts, LME Listing by County; http://www.dhhs.state.nc.us/MHDDSAS/lmedirectory.htm (accessed July, 2010).

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44. Gap Analysis, Albemarle Local Management Entity, March 2010. Prepared for East Carolina Behavioral Health by the Behavioral Healthcare Resource Program, School of Social Work, UNC-Chapel Hill.

45. America’s Health Rankings; http://www.americashealthrankings.org/ (accessed June, 2010).

46. Mobilizing Action Toward Community Health, County Health Rankings; http://www.countyhealthrankings.org/about-project (accessed June, 2010).

47. NC State Center for Health Statistics, County-level Data, County Health Data Book (2010), Pregnancy and Live Births, Live Birth Rates per 1,000 Population, 2004-2008; http://www.schs.state.nc.us/SCHS/data/databook (accessed June, 2010).

48. March of Dimes, Medical References, Quick Reference and Fact Sheets, Pregnancy, Things to Avoid During Pregnancy, Smoking During Pregnancy; http://www.marchofdimes.com/professionals/14332_1171.asp (accessed July, 2010).

49. NC Division of Medical Assistance, Child Service Coordination Program; http://www.ncdhhs.gov/dma/medicaid/csc.htm (accessed July, 2010).

50. America’s Health Rankings, A Call to Action for Individuals and Their Communities (2009), State by State Snapshots, North Carolina; http://www.americashealthrankings.org/2009/report/AHR2009%20Final%20Report.pdf (accessed July, 2010).

51. NC State Center for Health Statistics, County-level Data, County Health Databook (2010), Mortality, 2004-2008 NC Resident Race- Specific and Sex-Specific Ade-Adjusted Death Rates, by County; http://www.schs.state.nc.us/SCHS/data/databook/ (accessed June, 2010).

52. National Institutes of Health, Health Information, Health Topics A-Z, Browse Health Topics Alphabetically; http://health.nih.gov (accessed August, 2010).

53. NC State Center for Health Statistics, County-level Data, County Health Databook (2010), Morbidity, Inpatient Hospital Utilization and Charges by Principal Diagnosis and County of Residence, North Carolina, 2008; http://www.schs.state.nc.us/SCHS/data/databook/ (accessed July, 2010).

54. Healthy Carolinians Goals 2010 or 2020

55. Healthy People Goals 2010 or 2020.

56. NC State Center for Health Statistics, County-level Data, County Health Databook (2010), Mortality, 2004-2008 NC Resident Race and Sex Specific Age-Adjusted Death Rates, by County; http://www.schs.state.nc.us/SCHS/data/databook/ (accessed June, 2010).

298 Dare County Community Health Assessment – Volume One References

57. Dare County Cancer Outreach Program; http://www.unclineberger.org/darecounty/ (accessed August, 2010).

58. Personal communication from Judith Flagge, Dare County Department of Public Health to Laura Willingham, Dare County Deparatment of Public Health; email sent on July 11,2010.

59. Definition of communicable disease; http://www.merriam-webster.com/medical/communicable%20disease (accessed August, 2010).

60. NC Division of Public Health, Oral Health Section, Safety Net Dental Clinics in North Carolina; http://www.communityhealth.dhhs.state.nc.us/dental/safety_net_clinics.htm (accessed July, 2010).

61. NC Healthy Weight Initiative, Eat Smart Move More, Data, NC NPASS, http://www.eatsmartmovemorenc.com (accessed July 2010).

62. Dare County Community Health Assessment, 2002

63. Dare County Community Health Assessment, 2006.

64. Dare County Schools Random Drug Testing Annual Program Report, 2009-2010.

65. Healthy Carolinians, North Carolina 2010 Health Objectives, http://www.healthycarolinians.org/healthobj2010.htm (accessed June 2008).

66. National Center for Health Statistics, Information Showcase, Health United States, 2007 Edition with Interactive Links, http://www.cdc.gov/nchs/data/hus/hus07.pdf (accessed June 2008).

67. Healthy People, Publications, Healthy People 2010, Volumes 1 and 2., http://www.healthypeople.gov/Document/tableofcontents.htm#volume1 and http://www.healthypeople.gov/Document/tableofcontents.htm#Volume2 (accessed June 2008).

68. American Health Association, Heart Attack/Coronary Heart Disease Risk Assessment, http://www.americanheart.org/presenter.jhtml?identifier=539 (accessed June 2008).

69. North Carolina State Center for Health Statistics, Cancer. Cancer Facts and Figures, North Carolina Cancer Facts and Figures 2004, http://www.schs.state.nc.us/SCHS/CCR/FactsFigures2004.pdf (accessed June 2008).

70. Biology-Online, Communicable Disease, http://www.biology-online.org/dictionary/Communicable_disease (accessed June 2008).

299 Dare County Community Health Assessment – Volume One References

71. Town of Southern Shores, http://www.southernshores-nc.gov/ (accessed September, 2010).

72. Dare County’s first homeless shelter to open, http://hamptonroads.com/2009/01/dare-countys-first-homeless-shelter-open (accessed September, 2010).

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Appendices

Appendix A: Community Health Survey Instrument Appendix B: Community Stakeholder Interview Protocol

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Dare County Community Health Survey

PART 1: Quality of Life Statements

The first questions are about how you see certain parts of DARE County life. Please tell us whether you “strongly disagree”, “disagree”, “agree” or “strongly agree” with each of these statements.

How do you feel about these statements?

Choose a number for each Statements statement below. Strongly Strongly Disagree Disagree Agree Agree 1 “There is a good healthcare system in DARE County”? Consider the cost and quality, number of options, and availability of healthcare in DARE County. 1 2 3 4

2. “DARE County is a good place to raise children”? Consider the quality and safety of schools and child care programs, after school programs, and places to play in 1 2 3 4 this county. 3. “DARE County is a good place to grow old”? Consider our county’s elder-friendly housing, transportation to medical services, recreation, and services for the 1 2 3 4 elderly.

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4. “There is plenty of economic opportunity in DARE County”? Consider the number and quality of jobs, job training/higher education opportunities, and availability of affordable housing in DARE County. 1 2 3 4 5. “DARE County is a safe place to live”? Consider how safe you feel at home, in the workplace, in schools, at playgrounds, parks, and shopping centers in 1 2 3 4 DARE County. 6. “There is plenty of help for individuals and families during times of need in DARE County”? Consider social support in DARE County: neighbors, support groups, faith community outreach, community 1 2 3 4 organizations, and emergency monetary assistance.

PART 2: Community Problems and Issues

Health Problems

7. These next questions are about health problems that have the largest impact on the community as a whole. Please look at this list of health problems and choose 5 of the most important health problems in DARE County. Remember this is your opinion and your choices will not be linked to you in any way. If you do not see a health problem you consider one of the most important, please let me know and I will add it in. I can also read these out loud as you think about them.

a.___ Aging problems j.___ Infant death q.___ Other injuries (drowning, choking, home (Alzheimer’s, arthritis, k.___ Infectious/Contagious diseases (TB, or work related) hearing or vision loss, etc.) salmonella, r.___ Obesity/overweight b.___ Asthma pneumonia, flu, etc.) s.___ Lung disease c.___ Birth defects l.___ Kidney disease (emphysema, etc.) d.___ Cancer m.___ Liver disease t.___ Sexually transmitted What kind? ______n.___ Mental health (depression, diseases (STDs) e.___ Dental health schizophrenia, suicide etc.) u. ___ HIV/AIDS f. ___ Diabetes o.___ Motor vehicle accidents v.___ Stroke g.___ Gun-related injuries p. ___ Neurological disorders (Multiple Sclerosis, w.___ Teenage pregnancy h.___ Heart disease/heart muscular dystrophy, A.L.S.) x. ___ Other ______attacks i.___ Autism

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Unhealthy Behaviors

8. These next questions are about unhealthy behaviors that some individuals do that have the largest impact on the community as a whole. Please look at this list of unhealthy behaviors and choose 5 of the most unhealthy behaviors in DARE County. Remember this is your opinion and your choices will not be linked to you in any way. If you do not see an unhealthy behavior that you consider one of the most important, please let me know and I will add it in. I can also read these out loud as you think about them.

a.___ Alcohol abuse g.___ Not using seat belts k.___ Poor eating habits b.___ Drug abuse h.___ Not going to a dentist for l.___ Reckless/drunk driving c.___ Having unsafe sex preventive check-ups / care m.___ Smoking/tobacco use d.___ Lack of exercise i.___ Not going to the doctor for yearly check-ups n.___ Suicide e.___ Not getting immunizations and screenings o.___ Violent behavior (“shots”) to prevent disease j.___ Not getting prenatal (pregnancy) care. p.____ Other: f.___ Not using child safety seats ______

Community Issues

9. These next questions are about community-wide issues that have the largest impact on the overall quality of life in DARE County. Please look at this list of community issues and choose 5 community issues that have the greatest effect on quality of life in DARE County. Remember this is your opinion and your choices will not be linked to you in any way. If you do not see a community problem you consider one of the most important, please let me know and I will add it in. I can also read these out loud as you think about them.

a.___ Animal control issues k. ___ Lack of health care providers q. ___ Low income/poverty b.___ Availability of child care What kind? ______r. ___ Racism c. ___ Affordability of health services l.___ Lack of recreational facilities (parks, trails, s. ___ Lack of transportation options d.___ Availability of healthy food choices community centers, etc.) t. ___ Unemployment e.___ Bioterrorism m.___ Availability of healthy family activities u. ___ Unsafe, un-maintained roads f. ___ Dropping out of school n. ___ Availability of positive teen activities v .___ Violent crime (murder, assault) g.___ Homelessness o. ___ Neglect and abuse (specify type) w.___ Rape/sexual assault h.___ Inadequate/unaffordable housing 1. ___ Elder abuse x. ___ Domestic violence i. ___ Lack of/inadequate health insurance 2. ___ Child abuse y.___ Other ______j. ___ Lack of culturally appropriate health p. ___ Pollution (air, land, water) services

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PART 3: Personal Health

Now I am going to ask you some questions about your own personal health. Remember, the answers you give for this survey will not be linked to you in any way.

10. How would you rate your own health? Please choose only one of the following:

a. ___ Very healthy b. ___ Healthy c. ___ Somewhat healthy d. ___ Unhealthy e. ___ Very unhealthy

11. Where do you get most of your health-related information? Please choose only one.

a. ____ Friends and family e. ____ Hospital i. ___ School b. ____ Doctor/nurse/pharmacist f. ____ Help lines j. ___ Church c. ____ Internet g. ____ Books/magazines k. ___ Other ______d. ____ TV h. ____ Radio

12. Where do you go most often when you are sick or need advice about your health? Choose the one that you usually go to.

a. ____ Doctor's office d. ____ Medical clinic f. ____ Community Care Clinic b. ____ Health department e. ____ Urgent Care Center g. ____ Other ______c. ____ Hospital

13. Where do you receive most of your medical care?

a. ____ Dare County b. ____ Other city in NC c. ____ Elizabeth City d. ____ Out of state

14. In the past 12 months, did you ever have a problem getting the health care you needed from any type of health care provider or facility?

____ Yes ____ No (now skip to question #16)

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15. If you said “yes”, which of these problems did you have? Choose all that apply. If there was a problem you had that we do not have here, please tell us and I will write it in.

a. ___ I didn’t have health insurance. f. ___ I didn’t have a way to get there. b. ___ My insurance didn’t cover what I needed. g. ___ I didn’t know where to go c. ___ My share of the cost (deductible/co-pay) was too high. h. ___ I couldn’t get an appointment d. ___ Doctor would not take my insurance or Medicaid. i. ___ Other ______e. ___ Hospital would not take my insurance.

16. In the past 12 months, did you have a problem filling a medically necessary prescription?

____ Yes ____ No (now skip to question #18)

17. If you said “yes”, which of these problems did you have? Choose all that apply. If there was a problem you had that we do not have here, please tell us and I will write it in.

a. ___ I didn’t have health insurance. f. ___ I didn’t have a way to get there. b. ___ My insurance didn’t cover what I needed. g. ___ I didn’t know where to go c. ___ My share of the cost (deductible/co-pay) was too high. h. ___ I couldn’t get an appointment d. ___ Pharmacy would not take my insurance or Medicaid. i. ___ Other ______e. ___ Hospital would not take my insurance.

18. Was there a time during the past 12 months when you needed to get dental care, but could not?

____ Yes ____ No (now skip to question #20)

19. If you said “yes”, why not? Choose all that apply. If there was a problem you had that we do not have here, please tell us and I will write it in.

a. ___ I didn’t have dental insurance. f. ___ I didn’t have a way to get there. b. ___ My insurance didn’t cover what I needed. g. ___ I didn’t know where to go c. ___ I couldn’t afford the cost . h. ___ I couldn’t get an appointment d. ___ Dentist would not take my insurance or Medicaid. i. ___ Other ______e. ___ My share of the cost (deductible/co-pay) was too high.

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20. If a friend or family member needed counseling for a mental health or a drug/alcohol abuse problem, who would you tell them to contact? Choose as many as you want.

a. ____ Private counselor or therapist f. ____ Minister/religious official b. ____ Support group (e.g., AA. Al-Anon) g. ____ Health Department/New Horizons c. ____ School counselor h. ____ Don’ know d. ____ Hospital i. ____ Other ______e. ____ Doctor

21. In the past 30 days, have there been any days when feeling sad or worried kept you from going about your normal business? ____ Yes ____ No

22. During a normal week, other than in your regular job, do you engage in any exercise activity that lasts at least half an hour?

____ Yes ____ No (now skip to question #25)

23. If you said yes, how many times would you say you engage in this activity during a normal week? ______

24. Where do you go to exercise or engage in physical activity? Choose all that apply.

a.____ Outer Banks Family YMCA b.____ Park (such as Nags Head Park, Hayman Street Park, Wescott Park) c.____ Public Recreation Center (such as KDH Parks & Rec, Manteo Parks & Rec, Dare Co. Center) d.____ Private gym (such as Curves, OBX Sports Club, Crossfit) e.____ Home f.____ Walking Trails around your neighborhood g.____ Other: ______

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25. If you said “no”, what is the primary reason you do not exercise for at least half an hour during a normal week?

a.____ My job is physical or hard labor b.____ Exercise is not important to me c.____ I don’t have access to a facility that has what I like: a pool, golf course, track d.____ I don’t have enough time to exercise e.____ I would need child care and I don’t have it f.____ I don’t know how to find exercise partners g. ____ I don’t like to exercise h. ____ It costs too much to exercise (equipment, shoes, gym costs) i. ____ There is no safe place to exercise J. ____ I’m too tired to exercise k. ____ I’m physically disabled l. ____ I don’t know m. ___ Other ______

26. How many hours per day do you watch TV, play video games, or use the computer for recreation?

a. ____ 0-1 hour b. ___ 2-3 hours c.____ 4-5 hours d. ____ 6+ hours

27. During the past 30 days, have you had any physical pain or health problems that made it hard for you to do your usual activities such as driving, working around the house, or going to work?

_____ Yes ______No

28. Not counting juice, lettuce salad, or potato products, how many cups of fruits and vegetables would you say you eat in a week? (For example, one apple or 12 baby carrots equal one cup)

a. Number of cups of fruit _____ b. Never eat fruit ______c. Number of cups of vegetables _____ d. Never eat vegetables ______

Lettuce salad is the typical “house salad” with iceberg lettuce, or the salad mixes you get at the store or fast food type restaurants, even if they have meat on top.) Potato products are french fries, baked potatoes, hash browns, mashed potatoes… anything made from white potatoes.) For the purposes of this study, ketchup is not considered a vegetable.)

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29. Are you exposed to secondhand smoke in any of the following places? Choose all that apply.

a.____ Home d. ____ Restaurants f. ____ Other ______b.____ Workplace e. ____ School g. ____ I am not exposed to secondhand smoke c.____ Hospitals

30. Do you currently smoke? ____Yes ____ No (skip to question #32)

31. If yes, where would you go for help if you wanted to quit? Choose all that apply

a.____ Quit Now NC d. ____ Pharmacy g. ____ I don’t know b.____ Doctor e. ____ Private counselor/therapist h .____ Other ______c.____ Church f. ____ Health Department i. ____ Not applicable; I don’t want to quit d.____ Pharmacy

32. Have you ever been told by a doctor, nurse, or other health professional that you have any of the following conditions?

a. Asthma ____ Yes ____ No b. Depression or anxiety disorder ____ Yes ____ No c. High blood pressure ____ Yes ____ No d. High cholesterol ____ Yes ____ No e. Diabetes (not during pregnancy) ____ Yes ____ No f. Osteoporosis ____ Yes ____ No g. Overweight/Obesity ____ Yes ____ No

33. Do you have children between the ages of 9 and 19?

____ Yes (now go to question #34) ____ No (now skip to question #37)

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34. Do you think your child is engaging in any of the following high risk behaviors? Choose all that apply.

a.___ Alcohol Use d.___ Sexual Intercourse f. ___ Reckless driving/speeding b.___ Tobacco Use e. ___ Drug Abuse g. ___ I don’t think my child is engaging in any high risk behaviors c.___ Eating Disorders

We are aware that there are other risky behaviors. For the purposes of this survey, however, we are only requesting information about these 6 behaviors or none at all.

35. Are you comfortable talking to your child about the risky behaviors we just asked about?

____ Yes ____ No

36. Do you think your child or children need more information about the following problems? Choose all that apply.

a.___ Alcohol e.___ Sexual intercourse h. ___ Reckless driving/speeding b.___ Tobacco f.___ STDs i. ___ Mental health issues c.___ HIV g.___ Drug Abuse j. ___ Other ______d.___ Eating Disorders

Part 4. Emergency Preparedness

37. Does your household have working smoke and carbon monoxide detectors? Choose only one.

a. ___ Yes, smoke detectors only c. ____ Yes, both b. ___ Yes, carbon monoxide detectors only d. ____ No, both

38. Does your household have a Family Emergency Plan?

______Yes ______No

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39. Does your family have a basic emergency supply kit? If yes, how many days do you have supplies for?

a. ___ No b. ___ 3 days c. ___ 1 week d. ___ 2 weeks e. ___ More than 2 weeks

40. Are you or someone in your household a special needs citizen who may need assistance during a disaster or emergency? This includes individuals with physical, mental or medical care needs who may require additional assistance beyond their usual resources and support network during a disaster or emergency.

_____ Yes _____ No (now skip to question #42)

41. If you said “yes”, have you or the special needs citizen in your household signed up for the Dare County Special Needs Registry?

_____ Yes _____ No

Part 5. Demographic Questions

The next set of questions are general questions about you, which will only be reported as a summary of all answers given by survey participants. Your answers will remain anonymous.

42. How old are you? Choose your age category.

a. ____ 15-19 c.____ 25-34 e.____ 45-54 g.___ 65-74 b. ____ 20-24 d.____ 35-44 f.____ 55-64 h.___ 75 or older

43. Are you Male or Female?

_____ Male _____ Female

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44. What is your race?

a. ___ Black or African American c. ___ American Indian or Alaskan Native e. ___ Other ______b. ___ Asian or Pacific Islander d. ___ White

45. Are you of Hispanic origin? ____ Yes ____ No

46. A. Do you speak a language other than English at home? (If no, skip to #47.) ____ Yes ____ No

B. If yes, what language do you speak at home? ______

47. What is your marital status? Choose only one. (No explanation needed for “other”.)

a. ____ Never Married/Single d. ___ Domestic Partner. f. ____ Widowed b. ____ Married e. ___ Separated g. ____ Other c. ____ Divorced

48. What is the highest level of school, college or vocational training that you have finished? Choose only one.

a. ____ Some high school, no diploma e. ___ Bachelor’s degree b. ____ High school diploma or GED f. ___ Graduate or professional degree c. ____ Associate’s Degree or Vocational Training g. ___ Other ______d. ____ Some college (no degree)

49. What was your total household income last year, before taxes? Which category do you fall into? Choose only one.

a. ____ Less than $14,999 c. ___ $25,000 to $34,999 e. ___ $50,000 to $74,999 b. ____ $15,000 to $24,999 d. ___ $35,000 to $49,999 f. ___ Over $75,000

50. How many people does this income support? ______(If you are paying child support but your child is not living with you, this still counts as someone living on your income.)

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51. What is your employment status? Choose all that apply.

a. ____ Employed full-time d. ___ Military g. ___ Student b. ____ Employed part-time e. ___ Unemployed h. ___ Homemaker c. ____ Retired f. ___ Disabled i. ___ Self-employed

52. Do you have access to the Internet? ____ Yes ____ No

53. What is your zip code? (Write only the first 5 digits.) ______

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Key Stakeholder Telephone Interviews

Appointment Call Script

Hello, my name is ______and I’m working with the Dare County Department of Public Health and Healthy Carolinians of the Outer Banks on a community health assessment project The goal of the project is to learn more about health and quality of life in Dare County, and to identify strengths and challenges in the community.

The project sponsors* contacted you recently about participating in a telephone interview to learn your opinions about important health and human service issues, existing services, and service gaps in Dare County. [Seek some confirmation that the subject received that contact and is willing to participate.]

Thank you for agreeing to participate. I’m calling you today to schedule an appointment when we can have a full conversation. The interview will take approximately 30 minutes. Would you please suggest a date and time when I could call back and conduct the interview? [OR: you could begin by suggesting an appointment slot that is most convenient for your schedule, as in, “Would you be available to talk on ___ (day) ___ (date) at ___ (time)?” If your suggestion is not convenient for the client, then ask then for a day/time that would be.]

Thank you! I will call you then on [repeat appointment in detail: day of the week, month, day, and time.] I look forward to talking with you. Goodbye.

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Key Stakeholder Telephone Interviews

Interview Guide

Hello, my name is ______and I’m working with the Dare County Department of Public Health and Healthy Carolinians of the Outer Banks on a community health assessment project. The goal of the project is to learn more about health and quality of life in Dare County, and to identify strengths and challenges in the community.

We’ve completed a survey among members of the public and now are interviewing “key stakeholders” -- people like you who represent organizations that provide health and human services to the people in Dare County. You received an initial communication from the Department of Public Health and Healthy Carolinians of the Outer Banks inviting you to participate in an interview. You have received a [letter/phone call/email] from ______inviting you to participate in an interview, and given your initial agreement to participate at this time.

Thank you for agreeing to participate in the interview. What we discuss will be kept confidential. Nothing you say will have your name or organization attached, since all of the responses we gather in interviews will be combined and then summarized.

Do you have any question? Shall we begin? ------

A. The first questions are about your agency and its clients:

1) What services does your agency provide for Dare County residents?

2) Please describe county residents who currently are most likely to use your services (age, gender, race, income level, etc.).

3) In the past 5 years have there been any changes in the composition of the people who use your services? If yes, please describe.

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4) Similarly, in the past 5 years have there been any changes in the kinds of the problems you clientele present? If yes, please describe.

5) What do you think are the barriers residents encounter in accessing your services?

6) What do you think needs to happen to help people overcome those barriers?

B. The next questions are about Dare County as a whole.

1) Generally speaking, what do you consider to be Dare County’s greatest strengths?

2) Generally speaking, what do you feel are the major challenges Dare County is facing?

3) Are there any specific services or programs needed now in the county that are not currently available?

4) Looking specifically at health, what do you think are the most important health problems and concerns in Dare County?

5) What factors do you believe are causing these health problems or concerns?

6) What do you think could be done to solve or overcome these health problems or concerns?

7) Are there any other thoughts that you’d like to share?

Thank you for your time!

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