2016 Community Health Needs Assessment

2016 COMMUNITY HEALTH NEEDS ASSESSMENT

EH-West, Fargo, North Dakota WEST REGION LEAD PARTIES ON THE ASSESSMENT

Overview Peter Jacobson, Senior VP of Primary Care Essentia Health-West (EH-West) 3000 32nd Avenue South Ann Malmberg, Regional Director of Community Fargo, North Dakota 58103 Health

Brie Taralson, Community Health and Director Innovis Health DBA Essentia Health-West is part of of Cancer Center Essentia Health, a nonprofit, integrated health system caring for patients in Minnesota, Wisconsin, North Dakota and Idaho. Headquartered in Duluth, Minn., Essentia Health combines the strengths and TABLE OF CONTENTS talents of 14,000 employees, who serve our patients Overview ...... 1 and communities through the mission of being called Essentia Health: Here With You ...... 2 to make a healthy difference in people’s lives. Executive Summary ...... 3

Essentia Health-West is comprised of a Progress to Date on 2013 Community Health Needs Assessment . 4 multispecialty hospital and clinic, which are just 2016 Community Health Needs Assessment ...... 4 steps apart. In addition, the health system includes Objectives ...... 7 twenty (20) other clinics providing primary and other specialty services. The campus offers 104 private Description of Community Served by EH-West ...... 7 patient rooms, including critical care, medical Process Overview ...... 11 surgical care, pediatric, neonatal intensive care, and Assessment Process ...... 13

maternity care. Services onsite include a 24-hour Phase 1: Assessment ...... 13 Emergency Department with Level II trauma Phase 2: Prioritization ...... 13 designation and 10 operating room suites, which Phase 3: Design of Strategy and Implementation Plan ...... 14 include both inpatient and day surgery. Urgent or walk in care is offered throughout the service area at Conclusion ...... 14 local clinics. Appendix A: Essentia Health Top 80% by zip code

The hospital opened November 1, 2000 and serves Appendix B: Asset Map of Cass Clay the Fargo-Moorhead area and has additional clinics Appendix C: 2015 Greater Fargo-Moorhead Community Health in West Fargo, Wahpeton, Jamestown, Valley City, Needs Assessment of Residents and Lisbon. The hospital also serves as the tertiary Appendix D:.Stakeholder meeting care center for the four (4) other Essentia Health West Region health systems. Appendix E: Prioritization voting tool

EH-West is an Advanced Primary Stroke Center and is accredited as a Breast Center and Cancer Center with Commendation. The health system has earned Joint Commission Accreditation.

Essentia Health: Here With You At Essentia, our mission and values guide us every day. Together, we deliver on our promise to be here with our patients and members of our communities from the beginning to the end of life, both in our facilities and where they live, work and play.

Mission We are called to make a healthy difference in people's lives. Vision Essentia Health will be a national leader in providing high quality, cost effective, integrated health care services. Values • Quality • Hospitality • Respect • Justice • Stewardship • Teamwork

Belief Statements • Our highest priority is the people we serve. • We believe that the highest quality health care requires a regard for both the soul and science of healing and a focus on continuous improvement. • We believe in the synergy of sponsorship among faith-based and secular organizations. • We believe in the value of integrated health care services. • We believe in having a meaningful presence in the communities we serve. Executive Summary

At EH-West, Fargo we provide health care on a daily basis to make a healthy difference in our patients lives. We are also committed to investing in making a healthy difference to the broader community that we serve. To that end, we’ve been getting community feedback on the greatest health issues which can be most readily impacted for our service area. There are many opportunities to collaborate with our local partners to improve the health of our population in Cass and Clay Counties

In 2012, obesity was identified as the greatest issue. In response, we’ve been providing the National Diabetes Prevention class to the community. Other interventions beyond that to improve health include:

• Cass Clay Alive collaborative to improve the health of our children • Re Think Mental Health, a collaborative that is now funded through a Bush Grant to delineate all mental health services, particularly those required for children. • Aging Collaborative that is working on a systems, process, and environmental levels to drive better care for seniors and their caregivers. EH-West partnered with Sanford, Cass and Clay Public Health to conduct a survey done through North Dakota State University Center for Social Research in March, 2015. We obtained the results, reviewed and discussed them with a broad stakeholder group July 15, 2015. The smaller group reconvened and used the feedback to prioritize 2 areas of physical and mental health. Essentia will address these and continue work with the Aging Collaborative also. The 3 areas chosen are:

A. Physical Health with a focus on fitness and diet • Continue Center for Disease Control “National Diabetes Prevention Program” (adults) • Pilot National Institute of Health “We Can” Program (children) • Collaborate with Cass Clay Alive to drive increased activity and improved nutrition from prenatal care to adulthood. B. Mental Health services • ReThink Mental Health • COAT Reduction alignment with community addiction services C. Aging services • Aging Collaborative • Community project on Advance Care Planning Action planning around these priorities will continue to evolve with a three year strategy identified by this fall.

At EH-West we’re committed to continue the work with our partners to improve the overall health of our community.

Caring for our Community Our commitment to community health and wellness goes well beyond the work of the Community Health Needs Assessment. Through donations of funds, along with employees’ time and talents, Essentia Health invests in a variety of programs and outreach efforts. Across the organization, we support community coalitions, housing, food shelves, mental health, congregational outreach, community infrastructure, public health, education, safety and other nonprofit organizations. These investments are designed to promote better health, help lessen inequities in our communities, improve access to health care and strengthen relationships with those we serve.

Progress to Date on 2013 Community Health Needs Assessment: Obesity, physical inactivity and poor nutrition as risk factors for chronic Priority Area diseases such as Type 2 Diabetes. Adults, aged 18 and over, who are currently pre-diabetic or possess risk factors Target Population for developing Type 2 Diabetes Reduced body weight and increase physical activity in program participants, Goal thereby reducing their risk for Type 2 Diabetes.

Performance Measures • Participants will lose weight; program goal is 5-7% of body weight. o Baseline and post-course (1 year) weight will be tracked • Participants will increase physical activity; program goal is 150 minutes/week. o Baseline* and post-course (1 year) progress for physical activity minutes will be tracked. Objective 1: Implementation of a community wide intervention, the National Diabetes Prevention (NDPP) Program, to address the hospital facility’s highest priority health need as identified by the 2013 Community Health Needs Assessment. Accomplishments to Date: • 51 Participants have completed the program to date • 1 additional Essentia Health West Employee became a of Lifestyle Coach trained by Essentia Health’s Master Trainer • 15 other individuals attended the training completed by the Essentia Health Master Trainer on January 12-13, 2015 in Fargo, ND *Physical activity minutes are tracked beginning at week #7 of the NDPP.

EH-West in partnership with the North Dakota State University (NDSU) Extension Program continues to offer NDPP in Fargo and has increased to three (3) classes this fiscal year. The program has also now extended to Valley City and Wahpeton, with a coach from Essentia working with an NDSU Extension coach. Wahpeton is still in the first sixteen weeks so specific outcomes aren’t available. Valley City has completed the first sixteen weeks and had fourteen (14) participants complete it and the class total loss was 219 pounds. Their next class will start in early September. Education has been given to providers and nursing at the Essentia Health Fargo-Moorhead area primary care clinics. Email announcements are sent to Essentia Health, Cass County Government and area employers who have expressed interest in the course. This includes John Deere, NDSU and Clay County Public Health. Additionally, NDPP brochures are available at Essentia Health clinics and the Dakota Medical Foundation outlining the program, qualifications and how to enroll. Other activities to improve nutrition and increase activity include: • Participation in Cass Clay Alive community initiative with schools, colleges, health care, childcare and other partners to improve the environment for children to ensure healthier choices. This group has focused on education to schools and daycares to ensure sixty (60) minutes of activity per day and increased fruits and vegetables. A “snacktivist” program is now driving improvement in concessions. Recently a new offshoot of this group, “Healthier Babies” has convened to promote breast-feeding and the nutrition of mothers prenatally and after the birth of their newborn. • EH-West has a new partnership with Ed Clapp Elementary School. Residing in what is now the “inner city” this school has a high percentage of children in poverty, many who are new Americans. Currently, almost 60% of students are on free or reduced lunches. Our volunteers have helped with bike to school and walk to school days. We also have a mentor program with volunteers meeting high risk children for lunch on a regular basis.

Additional Accomplishments:

Access to Mental Health Care Essentia Health West has worked to increase access to mental health care through the addition of staff at the Moorhead Clinic to improve the integrative primary care model.

The hospital is also participating as a sub-group facilitator and steering committee member for the ReThink Mental Health collaborative in the Fargo-Moorhead community. This collaborative is investigating options from the crisis model to a preventative model in addressing mental health. This effort was recently awarded a two-year, $200k Bush Foundation grant to further efforts in this area. The position has been hired and work continues.

Substance Use/Abuse • Community Forums in Fargo-Moorhead, Valley City and Jamestown to healthcare, law enforcement and county organizations on Chronic Opioid Analgesic Reduction (COAT) program. • Physician panelist on “Eyes Wide Open” Community Forum for the F-M area on opioid and heroin addiction. The hospital is working with Dakota Medical Foundation, Sanford Health, local legislators, and other key stakeholders to increase focus on substance use and abuse. This is in early discussion and further actions will be identified for the implementation plan completed by November.

Violence & Safety The hospital is implementing the Minnesota Hospital Association “Culture of Safety” roadmap, including improved hand-off communication. This also includes training staff on the Team STEPPS program. Team STEPPS is a teamwork system designed for health care professionals that is a powerful solution to improving patient safety through the optimization of information, people and resources and eliminating barriers to quality and safety.

The hospital participates in the Clay/Cass Elder Abuse Coordinated Community Response Coalition and holds an annual Awareness Day Summit geared to both those in a professional role and the community- at-large that need awareness of elder abuse signs and ways to intervene. The mission of this group is to reduce abuse in the Fargo-Moorhead community.

Tobacco Use The hospital provides tobacco cessation and has a dedicated tobacco cessation counselor position. Tobacco cessation information is shared at all health clinics. In addition, EH-West partnered with public health and Sanford in Fargo, and public health and St. Francis CHI Hospital in Breckinridge/Wahpeton to provide a panel discussion for parents on the dangers of e-cigarettes and other nicotine products.

Preventative Care The hospital provides car seat checks free of charge to the public and has also provided training to OB nursing to teach parents how to safely install car seats.

Aging Services • EH West is partnering with Sanford, Cass and Clay Public Health, NDSU and other social services to address care for those aging. The group provided a Health Fair for seniors and their Caregivers last fall and will host the event annually. • EH Therapy Services provides “Stepping On” as a community outreach to those at risk for falls. Last fiscal year, twenty eight (28) attended (attendance limited to fifteen (15). Curriculum is evidence-based. • Medicare Quality (Stratis in Minnesota and QIO in ND) is partnering with EH-West, Sanford and skilled nursing facilities in the area to improve the percentage of people who have an Advance Care Plan. This group hosted a community event for Health Care Directives Day and has provided other educational opportunities throughout the area.

Poverty/Underserved • EH-West partnered with the FM Homeless Coalition, Sanford, and a broad base of social services to host the Second Chance Job Fair. Our health booth focused on smoking reduction, hypertension, and improvement in diet. • EH-West and Sanford partnered with North Dakota Public Health Association to obtain American Indian feedback on the health survey and provide health information. EH-West provided information on tobacco cessation, hypertension, and healthy dietary choices. • EH-West and Sanford partnered with the Fargo Moorhead Powwow Committee to do health screenings at the first international Powwow held in Fargo in May, 2016. Lipid panels and colorectal cancer screenings will be done along with blood pressure checks and information on hypertension.

Our CHNA activities are available on the website with updates reported annually. No written comments have been submitted at the time of this report. 2016 Community Health Needs Assessment

Objectives Essentia Health is called to make a healthy difference in people’s lives. To fulfill that mission, we seek opportunities to both enhance the care we provide and improve the health of our communities. In conducting the Community Health Needs Assessment, Essentia Health has collaborated with community partners to embrace these guiding principles:

• Seek to create and sustain a united approach to improving health and wellness in our community and surrounding area; • Seek collaboration towards solutions with multiple stakeholders (e.g. schools, work sites, medical centers, public health) to improve engagement and commitment focused on improving community health; and • Seek to prioritize evidence-based efforts around the greatest community good that can be achieved through our available resources.

The goals of the 2016 Community Health Needs Assessment were to: 1. Assess the health needs, disparities, assets and forces of change in **Hospital’s** service area 2. Prioritize health needs based on community input and feedback 3. Design an implementation strategy to reflect the optimal usage of resources in our community 4. Engage our community partners and stakeholders in all aspects of the Community Health Needs Assessment process

Description of Community Served by EH-West

The community served at EH-West is primarily Cass and Clay County. As a tertiary center, 66.2% of patients come from these counties. The other 35% come mainly from the other four (4) hospitals in West Region where they access specialty services such as neurosurgery, orthopedics, cardiology and cardiovascular surgery (Appendix A: EH: Top 80% by zip code)

The primary barriers to care for the region are the disparities that come into play for those with lower incomes. Both Cass and Clay have high median household incomes but the poverty rate in both counties is over 11%. There is a significant population of new Americans shown by English as a second language. Diversity is noted in both Cass and Clay Counties but is comparable to or below the state levels. There are no Indian Reservations within these counties but there are American Indians living in the area. Poverty, education, age and race are all factors contributing to the inequitable health outcomes in this community. According to the Minnesota Department of Health’s White Paper on Income and Health, “Poverty in Minnesota is not evenly distributed across racial/ethnic groups, ages or educational levels. Poverty is concentrated among populations of color, children, people with less education, female headed households and rural Minnesotans.” 1

People in Minnesota with lower incomes are more likely to:

• Have an infant die in the first year of life • Report that their health is fair or poor • Report having diabetes • Report having seriously considered attempting suicide2

While this report focuses on Minnesota, similarities are assumed in the border county of Cass, ND. Secondary data has been solicited to better understand the specific health needs of the American Indian population. As reported by the Indian Health Service, “The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. These are broad quality of life issues rooted in economic adversity and poor social conditions.

• Diseases of the heart, malignant neoplasm, unintentional injuries, and diabetes are leading causes of American Indian and Alaska Native deaths (2007-2009). • American Indians and Alaska Natives born today have a life expectancy that is 4.4 years less than the U.S. all races population (73.7 years to 78.1 years, respectively). • American Indians and Alaska Natives continue to die at higher rates than other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases.”3 Overall demographics description:

Cass Clay ND. Est. Minn. Est. 2014 Population 171,512 62,324 756,927 5,489,594 Diversity: White 90.5 93 89.1 85.7 Black 3.7 1.7 2.1 5.9 American

1 Minnesota Department of Health, White Paper on Income and Health, March 3, 2014 https://www.health.state.mn.us/data/legislative/docs/2014incomeandhealth.pdf 2 Minnesota Department of Health, White Paper on Income and Health, March 3, 2014 https://www.health.state.mn.us/data/legislative/docs/2014incomeandhealth.pdf 3 U.S. Department of Health and Human Services, Indian Health Service, Indian Health Disparities https://www.ihs.gov/newsroom/factsheets/disparities/ Indian 1.3 1.6 5.4 1.3 Hispanic or Latino 2.4 4.3 3.2 5.1 Language other than English spoken at home, % of 7.5 5.2 5.4 10.9 persons age 5 and over (2010-2014) Unemployment 2.8 4.3 3.1 3.7 Median 52,993 55,582 55,579 60,828 household income in 2014 dollars, 2010- 2014 Persons in 11.3 13.3 11.5 11.5 poverty, percent High school 94.8 93.9 91.3 92.3 graduate or higher Bachelor’s 37.4 30.5 27.3 33.2 degree or higher Persons under 6.9 6.7 6.9 6.4 age 5 Persons under 22.1 23.2 22.8 23.5 age 18 Persons age 65 10.8 12.7 14.2 14.3 and over Data from US Census Bureau: http://quickfacts.census.gov/qfd/states/July1,2015, (v2015)

Unemployment from MN Department of Employment and Economic Development (March, 2016 not seasonally adjusted): http://mn.gov/deed/data/current-econ-highlights/county-unemployment.jsp

ND Workforce Intelligence Network March, 2016(www.ndworkforceintelligence.com/gsipub/index.asp?docid=543).

Health concerns are identified by those responding to the survey as seen below:

Cass Clay CHNA Survey 2015 Overall health excellent, very good, or good 89.5% Overweight or obese 61.3% Reach recommended moderate physical activity (5 days/30 20% min./week) Reach recommended vigorous activity (3 days/30 min./week) 20% Indicate they eat 3-5 vegetables per day (recommended amount) 25% Indicate they eat 2-4 servings of fruit per day (recommended) 50% Diabetes 7% Informed by a healthcare professional they have high blood 17% pressure State having a problem with alcohol 7% Binge drinking in the last month 33.3% Informed they have depression 22.3% Informed they have anxiety/stress 20.0%

While almost 90 % perceive health as good or better, the respondents have a high rate of obesity, are not following CDC recommendations for diet and are not getting enough exercise.

The greatest areas of concern among respondents are for the aging population including the cost of long term care, access to affordable health care, and access to affordable prescription drugs. Safety especially around the presence of drugs and alcohol was identified and health concerns included both physical and mental health. (Full report: Appendix C)

Level of concern from CHNA Survey Scale from 1 (low concern) to 5 (high concern) Cost of long term care 4.11 Access to affordable health care 3.92 Access to affordable prescription drugs 3.9 Physical health including cancer 3.97 Presence of street drugs, prescription drugs, and alcohol in the 3.94 community Cancer 3.97 Chronic disease (e.g. diabetes, heart disease, multiple 3.81 sclerosis) Depression 3.78 Stress 3.65 Obesity 3.64 Poor nutrition 3.62

Other health resources in the community to assist in addressing these issues include Sanford Health, Cass Public Health and Clay Public Health. Another resource is Family Healthcare Center, an independent ambulatory clinic that provides care to those in poverty and to new Americans. Family Healthcare also houses the Homeless Health Clinic that operates from the same location and does outreach to homeless shelters and other locations where homeless congregate. These services and the social services and Homeless Coalition of service providers all position us to meet the needs of our community (Asset map of available resources Appendix B). Process Overview

Essentia’s Community Health Committee developed a shared plan for the 15 hospitals within the system to conduct their 2016 Community Health Needs Assessments (CHNA). This plan was based on best practices from the Catholic Health Association and lessons learned from the completion of Essentia’s first CHNAs in 2013. This process was designed to:

• Incorporate community surveys and existing public data • Directly engage community stakeholders • Collaborate with local public health and other healthcare providers

From there, each of Essentia’s three regions was responsible for adapting and carrying out the plan within their communities and hospital service areas. EH-West partnered with the Fargo-Moorhead Community Collaborative that includes Sanford Health, Cass, and Clay County Public Health Departments. The study was conducted by the Center for Social Research at North Dakota State University (NDSU). All agreed on the survey tool that included 54 questions focused on general community concerns, community health and wellness concerns, personal health, preventive health and demographics. A total of 1500 surveys were mailed to Cass and Clay using a stratified random sample to match proportions. 401surveys were returned for a response rate of 27%. (Appendix C: Includes full methodology and detailed results,).

The EH-West assessment was conducted in four stages: assessment, prioritization, design and finalization. The process began in March, 2015 and was completed in May, 2016 with the final presentation of the Community Health Needs Assessment for EH-West presented to leadership and the Board of Directors on May, 17, 2016 for final approval. The following graphs the assessment steps and timeline.

ASSESS Conduct Asset Service Area Analyze Secondary Gather Community Mapping of Available Evaluate Progress on Define Service Area (May - October Demographics Data Input Community 2013 CHNA Priorities 2015) Resources

PRIORITIZE Set Criteria for Choose Prioritization Choose Needs to (December 2015 Prioritized Needs Method Address - March 2016)

DESIGN Design Identify the "team" Determine strategy Choose Set SMART Implementation Plan Goal Setting (March - April for each strategy options Strategies/Programs Objectives and Evaluation 2016) Framework

FINALIZE Review with key Present to Hospital stakeholders for final Board for Approval (May 2016) feedback May 17th, 2016 Assessment Process

Phase 1: Assessment As discussed in the Overview, Essentia Health partnered with Sanford Health, Cass and Clay Public Health, and the Center for Social Research at North Dakota State University to conduct a Community Health Needs Assessment of Cass County, ND and Clay County, MN. The survey results were provided to a broad stakeholder group in July, 2015. Additional information from 2015 County Health Rankings & Roadmap was also provided for Cass and Clay County.

This group included representation from the broader community including mayors, legislators, educators, social services and others. Minorities, those underserved, uninsured and in poverty were represented through Family Healthcare Services, the county health services and other non-profit organizations in the community. In addition to the CHNA survey results, these stakeholders were specifically polled and their feedback was compared with the community at large. The attendees then participated in focus groups and provided feedback. (See Appendix D: Key Stakeholder Meeting minutes July 15, 2015). Overarching themes were around physical health and mental health services. There was concern about aging services as well.

The limitations of the study are that there was over-representation for older, white, more highly educated and higher income earners. This corresponds with other studies that show lower response for younger groups and those that are socially, culturally, or financially disadvantaged. Essentia Health and Sanford Health partnered with North Dakota Public Health Association to specifically solicit feedback from American Indians in the community. At a health fair July 30, 2015 American Indians answered the same survey tool questions. Ninety five (95) provided feedback. Results have not yet been compared with the overall survey. The collaborative group will meet to review the results and interventions will be part of the full implementation plan that will be finalized by November.

Phase 2: Prioritization Feedback from the stakeholder group was reviewed by the Cass Clay Collaborative including Essentia Health, Sanford Health, Cass Public Health and Clay Public Health (who represent underserved and those in poverty). This smaller group discussed priorities with criteria to identify the problem including:

• Cost and/or return on investment • Availability of solutions • Impact of problem • Availability of resources (staff, time, money, equipment) to solve problem • Urgency of solving problem (Ebola or air pollution) • Size of problem (e.g. # of individuals affected) Criteria to identify interventions included: • Expertise to implement solution • Return on investment • Effectiveness of solution • Ease of implementation/maintenance • Potential negative consequences • Legal considerations • Impact on systems or health • Feasibility of intervention

Voting was completed in one round and physical and mental health needs were prioritized. Work on the Aging Collaborative will continue since this is a demographic consideration for both physical and mental health. Areas that won’t be addressed include Lifestyle, Children and Youth, Safety, Healthcare, and Preventive Health. The group all agree that work will continue in these areas when possible but our limited resources will be focused where we can have the greatest impact. Essentia Health lacks resources and/or expertise in addressing lifestyle (affordable housing) and healthcare costs. Both our physical and mental health priorities will address children and youth. The highest safety concerns are around drug and alcohol addiction and these will be a component of the work in mental health as well. Health needs will be categorized within the Essentia Health goal areas of Healthy Choices, Mental Fitness, Workplace Wellness and Community Connections. (Appendix E: Prioritization voting tool).

Phase 3: Design of Strategy and Implementation Plan Priorities and beginning strategies have been decided and the full implementation plan will be developed and available by November 1, 2016.

SUMMARY OF COMMUNITY DEFINED PRIORITIES/STRATEGIES

PRIORITY AREA: GOALS Physical Health with a focus on fitness and diet 1. Intervene to improve physical health for the community.

STRATEGIES FOR EACH PRIORITY

Priority: Physical Health Goal: Partners: Essentia Health, Cass Clay Alive (includes NDSU, Cass and Clay Public Health, Sanford Health, Fargo and West Fargo Public Schools), NDSU Extension Service, Court’s Plus Strategy 1: Cass Clay Alive Initiative with new focus of Healthier Babies Strategy 2: Continue and expand National Diabetes Prevention Program (NDPP). Strategy 3: Implement child focused “We Can” Program PRIORITY AREA: GOALS Mental Health services to include both mental health and 1. Intervene to improve mental health for the community. addiction services Priority: Mental Health services to include both mental health and Partners: Essentia Health, Cass and Clay Public Health, addiction services Sanford Health, Prairie at St. John’s, ReGroup, Face It Together, and others. Strategy 1: ReThink Mental Health Strategy 2: COAT program and partnership with FM Addiction Services PRIORITY AREA: GOALS Aging Services 1. Help to address access to services for seniors and their caregivers. Priority Goal: Aging Services Partners: Essentia Health, Cass and Clay Public Health, Sanford Health, NDSU Extension Service, Cass and Clay Social Services Strategy 1: Aging Collaborative will address policy Strategy 2: Coalition will drive Advance Care Planning Conclusion

As part of a nonprofit health system, EH-West is called to make a healthy difference in people’s lives. This needs assessment and implementation plan illustrates the importance of collaboration between our hospital and its community partners. By working collaboratively, we can have a positive impact on the identified health needs of our community during Fiscal Years 2017-2019. There are other ways in which EH-West will indirectly address local health needs, including the provision of charity care, the support of Medicare and Medicaid programs, discounts to the uninsured and others. Over the next three years, EH-West will continue to work with the community to ensure that this implementation plan is relevant and effective and to make modifications as needed. Zip Code City SumOfDischarges Percentage Cumulative Percentage 58103 Fargo 4309 17.1% 17.1% 56560 Moorhead 3134 12.4% 29.5% 58104 Fargo 2944 11.7% 41.2% 58078 West Fargo 2342 9.3% 50.5% 58102 Fargo 1406 5.6% 56.1% 56501 Detroit Lakes 841 3.3% 59.4% 56470 Park Rapids 582 2.3% 61.8% 58401 Jamestown 461 1.8% 63.6% 56529 Dilworth 429 1.7% 65.3% 56514 Barnesville 413 1.6% 66.9% 58054 Lisbon 370 1.5% 68.4% 58075 Wahpeton 346 1.4% 69.8% 58072 Valley City 333 1.3% 71.1% 56549 Hawley 296 1.2% 72.3% 56544 Frazee 254 1.0% 73.3% 58012 Casselton 251 1.0% 74.3% 58047 Horace 250 1.0% 75.3% 56547 Glyndon 220 0.9% 76.1% 56510 Ada 210 0.8% 77.0% 56572 Pelican Rapids 189 0.8% 77.7% 56464 Menahga 188 0.7% 78.5% 56537 Fergus Falls 182 0.7% 79.2% 58041 Hankinson 172 0.7% 79.9% 56520 Breckenridge 166 0.7% 80.5% 58051 Kindred 152 0.6% 81.1% 56554 Lake Park 145 0.6% 81.7% 58027 Enderlin 143 0.6% 82.3% 56484 Walker 140 0.6% 82.8% 56542 Fosston 137 0.5% 83.4% 56467 Nevis 131 0.5% 83.9% 56589 Waubun 130 0.5% 84.4% 58059 Mapleton 111 0.4% 84.9% 56557 Mahnomen 102 0.4% 85.3% 58474 Oakes 97 0.4% 85.6% 56580 Sabin 95 0.4% 86.0% 58042 Harwood 94 0.4% 86.4% 58053 Lidgerwood 91 0.4% 86.8% 58421 Carrington 88 0.3% 87.1% 56570 Osage 83 0.3% 87.4% 56584 Twin Valley 79 0.3% 87.7% 58060 Milnor 79 0.3% 88.1% 56511 Audubon 75 0.3% 88.4% 56575 Ponsford 71 0.3% 88.6% 58052 Leonard 68 0.3% 88.9% 56433 Akeley 67 0.3% 89.2% 56569 Ogema 67 0.3% 89.4% 56240 Graceville 66 0.3% 89.7% 58077 Walcott 65 0.3% 90.0% 58045 Hillsboro 63 0.3% 90.2% 58079 Wheatland 62 0.2% 90.5% 56587 Vergas 62 0.2% 90.7% 58005 Argusville 56 0.2% 90.9% 58021 Davenport 54 0.2% 91.1% 56621 Bagley 53 0.2% 91.4% 58081 Wyndmere 52 0.2% 91.6% 58031 Fingal 47 0.2% 91.7% 56585 Ulen 46 0.2% 91.9% 58064 Page 44 0.2% 92.1% 56556 McIntosh 44 0.2% 92.3% 58040 Gwinner 44 0.2% 92.5% 58006 Arthur 41 0.2% 92.6% 58033 Fort Ransom 40 0.2% 92.8% 56578 Rochert 40 0.2% 92.9% 56573 Perham 39 0.2% 93.1% 56521 Callaway 38 0.2% 93.2% 56594 Wolverton 36 0.1% 93.4% 58071 Tower City 36 0.1% 93.5% 58032 Forman 35 0.1% 93.7% 58011 Buffalo 34 0.1% 93.8% 58048 Hunter 34 0.1% 93.9% 58068 Sheldon 34 0.1% 94.1% 58030 Fairmount 33 0.1% 94.2% 58467 Medina 33 0.1% 94.3% 58425 Cooperstown 33 0.1% 94.5% 56535 Erskine 32 0.1% 94.6% 58018 Colfax 31 0.1% 94.7% 56525 Comstock 30 0.1% 94.8% 56579 Rothsay 30 0.1% 94.9% 56461 Laporte 29 0.1% 95.1% 56566 Naytahwaush 29 0.1% 95.2% 56221 Chokio 28 0.1% 95.3% 57262 Sisseton 28 0.1% 95.4% 56515 Battle Lake 27 0.1% 95.5% 58015 Christine 27 0.1% 95.6% 58461 Litchville 27 0.1% 95.7% 56528 Dent 26 0.1% 95.8% 56477 Sebeka 26 0.1% 95.9% 58004 Amenia 25 0.1% 96.0% 56545 Gary 24 0.1% 96.1% 58049 Kathryn 24 0.1% 96.2% 56634 Clearbrook 24 0.1% 96.3% 56534 Erhard 23 0.1% 96.4% 56296 Wheaton 22 0.1% 96.5% 56519 Borup 21 0.1% 96.6% 58008 Barney 21 0.1% 96.7% 56592 Winger 19 0.1% 96.7% 56546 Georgetown 19 0.1% 96.8% 58433 Edgeley 19 0.1% 96.9% 56651 Lengby 19 0.1% 97.0% 56550 Hendrum 19 0.1% 97.0% 56225 Clinton 19 0.1% 97.1% 56236 Dumont 19 0.1% 97.2% 56540 Fertile 18 0.1% 97.3% 58061 Mooreton 18 0.1% 97.3% 56571 Ottertail 18 0.1% 97.4% 56684 Trail 17 0.1% 97.5% 56567 New York Mills 17 0.1% 97.5% 58038 Grandin 17 0.1% 97.6% 58105 Fargo 16 0.1% 97.7% 58036 Gardner 16 0.1% 97.7% 56522 Campbell 16 0.1% 97.8% 58057 McLeod 15 0.1% 97.9% 56536 Felton 15 0.1% 97.9% 56586 Underwood 14 0.1% 98.0% 57255 New Effington 14 0.1% 98.0% 58035 Galesburg 14 0.1% 98.1% 58458 Lamoure 14 0.1% 98.1% 57260 Rosholt 13 0.1% 98.2% 58017 Cogswell 13 0.1% 98.2% 58472 Montpelier 12 0.0% 98.3% 58056 Luverne 12 0.0% 98.3% 56552 Hitterdal 12 0.0% 98.4% 56742 Oklee 12 0.0% 98.4% 58476 Pingree 12 0.0% 98.5% 56458 Lake George 12 0.0% 98.5% 56574 Perley 12 0.0% 98.6% 58013 Cayuga 12 0.0% 98.6% 58029 Erie 12 0.0% 98.7% 56646 Gully 11 0.0% 98.7% 56576 Richville 11 0.0% 98.8% 58069 Stirum 11 0.0% 98.8% 58481 Spiritwood 11 0.0% 98.8% 56553 Kent 11 0.0% 98.9% 56543 Foxhome 11 0.0% 98.9% 56583 Tintah 10 0.0% 99.0% 58046 Hope 10 0.0% 99.0% 58455 Kensal 10 0.0% 99.0% 58466 Marion 10 0.0% 99.1% 58480 Sanborn 10 0.0% 99.1% 58492 Wimbledon 10 0.0% 99.2% 58442 Gackle 10 0.0% 99.2% 56644 Gonvick 10 0.0% 99.2% 57270 Veblen 10 0.0% 99.3% 58067 Rutland 9 0.0% 99.3% 58007 Ayr 9 0.0% 99.4% 56590 Wendell 9 0.0% 99.4% 56219 Browns Valley 9 0.0% 99.4% 58490 Verona 8 0.0% 99.5% 56676 Shevlin 8 0.0% 99.5% 58062 Nome 8 0.0% 99.5% 58420 Buchanan 8 0.0% 99.6% 58076 Wahpeton 8 0.0% 99.6% 58058 Mantador 7 0.0% 99.6% 56678 Solway 7 0.0% 99.6% 58479 Rogers 7 0.0% 99.7% 58483 Streeter 6 0.0% 99.7% 58426 Courtenay 6 0.0% 99.7% 58497 Ypsilanti 6 0.0% 99.7% 56278 Ortonville 6 0.0% 99.8% 56565 Nashua 6 0.0% 99.8% 58424 Cleveland 5 0.0% 99.8% 56551 Henning 5 0.0% 99.8% 58043 Havana 5 0.0% 99.8% 58429 Dazey 4 0.0% 99.9% 56531 Elbow Lake 4 0.0% 99.9% 58496 Woodworth 3 0.0% 99.9% 58454 Jud 3 0.0% 99.9% 56736 Mentor 3 0.0% 99.9% 56652 Leonard 3 0.0% 99.9% 56577 Richwood 3 0.0% 99.9% 56516 Bejou 3 0.0% 100.0% 57224 Claire City 2 0.0% 100.0% 56533 Elizabeth 2 0.0% 100.0% 58002 Absaraka 2 0.0% 100.0% 58448 Hannaford 1 0.0% 100.0% 58431 Dickey 1 0.0% 100.0% 58016 Clifford 1 0.0% 100.0% 58415 Berlin 1 0.0% 100.0% 56210 Barry 1 0.0% 100.0% 56563 Moorhead 1 0.0% 100.0% 25193 1

Fargo/Moorhead/Cass/Clay Asset Mapping

Economics • Availability of • Availability of • Affordable 14.7 % of the Cass Affordable Housing resources: affordable housing affordable housing County population • Cass Co. Social Services 2.99 housing 3.88 • Homelessness lives below the FPL (help w/utility costs) 701- • Homelessness 3.23 • Homelessness 241-5765 3.63 • Down payment & Closing Costs Assistance Program 1-800-292-8621 • Wells Fargo Assist (to help those with payment challenges) • Home Key Program 701- 238-8080 • Housing Rehab Program 701-241-1474 • Lake Agassiz Habitat for Humanity 218-284-5253 • Presentation Partners in Housing 701-235-6861 • ReStore (thrift store for construction, homes, etc.) 218-284-5253 • Salvation Army (provides assistance with hsg. & utilities 701-232-5565 • SENDCAA weatherization program & low income hsg. 701-232-2452 • Xcel Energy Share Program • 1-866-837-9762 • YWCA Supportive & Transitional Hsg 701-232- 3449 2

Identified Generalizable Non-Generalizable American Indian Key stakeholder Secondary Data Community resources that are Gap concern Survey Specific areas of Survey specific areas Survey specific area Focus group Specific Report available to address the need concern of concern of concern specific areas of concern 383 surveys 51 surveys area of concern Subsidized public housing: • Cass Co. Housing Authority 701-282-3443 • Fargo Housing & Redevelop. Authority 701-293-6262 • ND Housing & Finance Agency 701-239-7255 • Century Square 701-287-4775 • Community Homes 701-293- 6014 • Lashkowitz High Rise 701-293- 6262 • New Horizons Manor 701-293- 7870 • Pioneer Manor 701-293-7870 • River Square apts. 701-364- 2620 • The 400 701-232-9412 • Trollwood Village 701-293- 6843 • University Drive Manor 701- 232-4423 • VA Housing for Homeless Vets 701-239-3700 ext. 9-3472 • Windwood Townhomes 701- 232-1887 • Moorhead Public Housing 218-299-5458 • Lakes & Prairies Community Action Partnership 218-299- 7314 • Arbor Park Village 218-359- 9999 • Fieldcrest Townhomes 701- 232-1887 (Metro Mgmt. • Parkview Terrace Apts. 218- 233-8548 • Riverview Heights 218-299- 5458 3

8558

• YWCA Women’s Shelter 701- 233-3449 • Churches United (shelter, food baskets, meals) - 218- 236-0372 • Clay Co. Social Service Center 218-299-7057 • Lakes & Prairies CAP (transitional hsg. program)

218-299-7014 • Motivation, Education & Training (emergency shelter)

218-299-7262

• Dorothy Day House (shelter, meals, food pantry) 218-285- 8895 • New Life Center (shelter & meals) - 701-235-4453 • Salvation Army (shelter & meals) - 701-232-5565 • Faith Home & Love church 218-236-7692 • Centro Cultural 218-236-7318 Aging • Cost of LTC 4.11 • Cost of LTC 4.16 • Long term care Nursing Homes – Cass County: population • Availability of • Availability of • Elderly nutrition • Bethany 701-239-3000 / 701- memory care 3.63 memory care • Elder care 478-8900 (2 locations) • • Availability of LTC 3.71 • Aging life case Ecumen Evergreens – 701-239- 4524 3.51 • Availability of LTC manager at • Edgewood Vista – 701-365- 3.26 LSSND should be 4742 publicized • Elim 701-271-1800 • What are we • Eventide @ Sheyenne

seniors in their • Good Samaritan (Arthur) – homes 701-967-8316 • • No clear aging ManorCare 701-237-3030 • plan for aging Maple View Memory Care – 701-478-8655 issues and unsure • Prairie Villa (Arthur) – 701-

how to support 967-8316 • The public is not • Rosewood 701-277-7999 aware of issues • Villa Maria 701-293-7750 such as elder abuse Nursing Homes – Clay Co: • Eventide 218-233-7608 • Golden Living Center 218-233- 7578

Alzheimer’s/Dementia resources: • After the Diagnosis Support Group – 701-277-9757 (Sanford) • Alzheimer’s Support Group (Hjemkomst Center) – 701- 277-9757 • Early Onset Memory Loss Support Group – 701-277-9757 • Morning Out (for those who have Alzheimer’s or other dementia) – 218-233-7521 • Alzheimer’s Assn – 701-277- 9757 • Arbor Park Village – 218-359- 9999 • Eventide/Fairmont – 218-233- 8022 • River Pointe – 218-287-6900 • Evergreens, Mhd. – 218-287- 6900 • Bethany – 701-239-3000 • Edgewood Vista – 701-365- 8200 • Elim – 701-271-1800 5

Caregiver resources: • Community of Care (Casselton) – 701-347-0032 • Caregiver Support & Respite program – 1-800-488-4146 • Caregivers Support Group – 701-261-3142 • Caregiver Discussion Group – 218-233-7521 • Mhd Caregiver Discussion Group – 218-233-7521 • Rural Cass Caregivers – 877- 815-8502 • Support Group for Alzheimer’s Caregivers (young onset) – 701-277-9757 • Alzheimer’s Support Group for those with family member in Eventide – 218-233-7508 • Family Caregiver Support program – 701-298-4480 • Hospice support for widows & widowers – 701-356-1500

Elder Abuse resources: • Adult Protective Services – Fargo - 701-241-5747 • Adult Protective Services - Moorhead – 218-299-5200 • Rape & Abuse Center (Abuse in Later Life Advocate) – 701- 293-7273 • Clay Co. Elder Abuse Project – 218-299-7542 • Protection & Advocacy Project – 701-239-7222 • Guardian & Protective Services – 701-297-8988

Identified Generalizable Non-Generalizable American Indian Key stakeholder Secondary Data Community resources that are Gap concern Survey Specific areas of Survey specific areas Survey specific area Focus group Specific Report available to address the need concern of concern of concern specific areas of concern 383 surveys 51 surveys area of concern Resources to assist the elderly in staying in their homes: • Community of Care (Casselton) – 701-347-0032 • Sanford Healthcare Accessories – 701-293-8211 • Sanford Home Care – 701-234- 4900 • Sanford Personal Care – 701- 232-2452 • Access – 218-233-3991 • Care 2000 – 218-233-1000 • Change is Good – 218-329- 7442 • Homewatch – 218-233-1667 • LSS Caregiver Respite Services – 218-233-7521 • Midwest Community Residential Services – 218- 287-5422 • Accent Multi Services – 701- 293-6000 • Active at Home Helpers – 701- 200-4328 • At Home Caregiver Services – 701-293-7294 • Comfort Keepers – 701-237- 0004 • Community Living Services – 701-232-3133 • C & R Quality Living – 701-235- 5744 • Ebenezer Human Care – 701- 412-5525 • Heart 2 Heart – 701-200-7828 • Sisters of Mary Home Care – 701-235-5750 • Home Instead Home Care – 701-478-1010 • Prairieland Home Care – 701- 293-8172 • Tami’s Angels – 701-237-3415 7

Elderly Nutrition Services: • Cash Wise (grocery delivery) • Hornbachers (grocery delivery) • Family Fare (grocery delivery) • LSS Senior Nutrition Program 218-233-7521 • Meals on Wheels (Fargo, W Fargo & Moorhead) • Congregate Meals (Fargo, W Fargo & Moorhead)

Elder Care (adult day care): • Bethany Day Services 701-239- 3544 • Cass Co. Social Services 701- 241-5747 • Home Instead Senior Care 701-478-1040 • Johnson Elder Care Home 701-277-7195 • Kinder-er Care Home 701-281- 3016 • Rainbow Square (adult daycare at Rosewood) 701- 8

Children • Bullying 3.82 • Bullying 3.57 • 11% of Resources for at risk children & and Youth children in youth: • Cost of quality • Cost of quality Cass County • Center for Parenting & childcare 3.53 childcare 3.88 live in poverty Children 218-233-6258 • 13% of (Moorhead); 701-235-6433 (Fargo) • Cost of quality • Cost of quality children in • Stepping Stones Resource Clay County infant care 3.50 infant care 3.86 Center 701-356-8585 live in poverty • Clay Co. Social Services 218- • Availability of 299-5200 quality infant • Cass Co. Social Services 701- care 3.88 241-5761 • Catholic Family Services 701- • Availability of 235-4457 quality child care • Early Intervention Program 3.84 • 218-284-3800 • Follow Along Program 218- 299-5200 • Availability of • Head Start 218-299-7002 services for at- • Lutheran Social Services of risk youth 3.71 MN 218-236-1494 • Lutheran Social Services of ND • Cost of services 701-235-7341 for at-risk youth • Village Family Service Center 3.55 218-451-4900 • Caring Program for Children 701-277-2227 • Cass Co. Parenting, Children & Family Resources 701-241- 9

Infant Child Care resources: • Child Care Resource & Referral 218-299-7026 • Child Care Assistance Program 701-328-2332 • Child Care Aware 1-800-997- 8515 • Baby Bloomers 701-356-1299 • Lots-4-Tots 701-235-5789 • Tot Spot 701-232-6999 • Hope Lutheran 701-235-6629 • Children of Hope 701-936- 9616 • Cobber Kids’ Corner 218-299- 4204 • Centered on Kids 218-284- 2774 • YMCA 701-293-9622 • Our Redeemer 218-233-8270 • ABC Sandcastle 701-293-0149 10

218-299-5200 • Cass Co. Social Services

701-241-5761

• Lutheran Social Services of ND 701-235-7341 • Lutheran Social Services of MN 218-236-1494 • Village Family Service Center 218-451-4900 • Lakes & Prairies Community Action Partnership 218-299-7314 • Child Care Assistance Program 701-328-2332

• Homeless Shelters

• Food Pantries

Crime/ • Presence of street • Presence of • Violent crimes Cass County Sheriff Safety drugs, prescription street drugs, in Clay County 701-241-5800 drugs and alcohol prescription 284 3.84 drugs and alcohol • Violent crimes Clay County Sheriff • Presence of drug 3.90 in Clay 218-299-5151 dealers in the • Domestic Country 115 community 3.74 violence 3.78 • Alcohol Fargo Police 701-235-4493 • Crime 3.74 • Presence of drug impaired • Child abuse and dealers in the deaths in Cass Moorhead Police 218-299-5120 neglect 3.72 community 3.64 County are at • Domestic violence • Presence of gang 30% and at ND Crime Victim & Witness 3.72 activity 3.58 22% in Clay Assistance Program – 701-241- • Sex trafficking 3.50 • Crime 3.52 County 5850

Child Abuse & Neglect resources: • Sanford Child & Adolescent Maltreatment Center – 701-

Domestic Violence resources: • Rape & Abuse Crisis Center • 701-293-7273 • YWCA Shelter 701-232-3449 • ND Victim Assistance Assn. • 701-241-5850 • Migrant Health Hispanic Battered Women & Children Program 218-236-6502 • Community Health Services, Inc. Domestic Violence Community Advocacy Program 218-236-6502 • Clay Co. Crime Victim Advocacy Program. 218-299- 7513 • Churches United 218-236-0372 • Mujeres Unidas del Red River Valley 218-236-9884

Alcohol abuse resources: • AA Red Road to Sobriety 701- 298-8233 • Alcoholics Anonymous (more than 50 groups in the area) 701-235-7335 / 701-232-9930 • Celebrate Recovery 701-232- 0003 • Codependents Anonymous 701-235-73335 • SMART Recovery 701-235- 5229 • ADAPT, Inc. 701-232-1225 • Centre Inc. 701-237-9340 12

Identified Generalizable Non-Generalizable American Indian Key stakeholder Secondary Data Community resources that are Gap concern Survey Specific areas of Survey specific areas Survey specific area Focus group Specific Report available to address the need concern of concern of concern specific areas of concern 383 surveys 51 surveys area of concern • Chris Shiaro Counseling 701- 271-0600 • Cass Co. Public Health (detox) 701-364-0116 • Claudia McGrath Counseling 701-277-0654 • Dakota Foundation (detox) 701-223-4517 • Discovery Counseling 701- 237-4542 • Drake Counseling 701-293- 0736 • VA Substance Abuse Treatment Program. 701-239- 3700 • First Step Recovery 701-293- 3384 • Lynn W. Olund DUI Seminar Program 701-298-3874 • Pathways Counseling & Recovery Center 701-232-5955 • PSJ Dui Seminar 701-476-7200 • ShareHouse 701-282-6561 • Sister’s Path 701-478-8440 • Prairie St. Johns 701-476-7200 • Simon Chemical Dependency Services 701-298-8108 • SE Human Service Center 701- 298-4500

Timely access to • Affordable care Affordable health care mental health • LTC costs resources: providers 4.00 • Underinsured • Community Care/Charity Care • • Timely access to • Uninsured programs at Sanford & substance abuse • Community- Essentia • Family HealthCare Center – providers 3.82 based services 701-271-3344 • • Use of need to be • Fargo Cass Public Health - 701- emergency room emphasized 241-1360 for services for • Clay Co. Public Health – 218- primary health 299-5220 • 3.72 • Prescription Assistance Cost/ • Access to • Access to affordable health Healthcare insurance 4.04 Access to affordable health care 3.92 Access to affordable prescription drugs 3.90 Cost of affordable 13

3.66 affordable Reduced cost dental resources: prescription • drugs 3.65 RRV Dental Access – 701-364- 5364 • Access to • Family HealthCare Center –

affordable health 701-271-3344

care 3.55 • Coordination of care between providers and services 3.51 Physical • Cancer 3.97 • Inactivity 3.82 • Cancer screening • Obesity is 27% Obesity resources Health • Chronic Disease 51% report rates in Cass County • EH Dietitians 3.81 exercise at a • Need more and 30% in • Sanford Eating Disorders & High moderate level 3 informaito0n on Clay County Wt. Management Center – 701-234-4111 Cholesterol or more times oral care, mental • Eating Disorders Support

Hypertension per week health Group – 701-234-4111 Arthritis • Poor nutrition • Healthy • Gastric Bypass Support Group • Inactivity 3.78 3.76 initiatives – need – 701-235-8502 48.3% report Only 39.4% to make an • EH/NDSU Extension NDPP moderate exercise report having 3 impact on obesity class-701-241-5700 at least 3x/week or more and healthy • Valley Fitness – 701-277-9010 • Obesity vegetables/day habits • Planet Fitness (Fargo) – 701- 61.3% of Only 14.3% • Chronic Disease 478-3300 • respondents report report having 3 • Obesity Planet Fitness (Mhd) – 218- 477-1955 they are or more • Cancer • Courts Plus – 701-237-4805 overweight or fruits/day • Worksite health • Core Fitness – 701-356-2044 • Obesity 3.75 obese • Community • Anytime Fitness (Fargo) – 701- • Poor nutrition 3.62 69.5% of walkability 566-8507 Only 24.1% report respondents • Physical health • Anytime Fitness (Mhd) – 218- having 3 or more report they are issues 227-0010 vegetables/day overweight or • 2020 Only 20.1% report obese • Sanford Family Wellness having 3 or more Center – 701-234-2400 fruits/day • Touchmark Fitness – 701-526- 1055 14

• Infectious disease • TNT Kids’ fitness – 701-365- such as the flu 3.50 8868 • YMCA – 701-232-2547 • Max Training – 701-359-0220 • Metro Rec Center – 701-235- 9211

Farmers Markets: • Great Plains Community Farmers Market – 701-793- 5532 • New Festival – 7801-588-4316 • Hildebrant’s – 701-281-1539 • Farmer’s Market & Beyond – 701-433-5360 • Mhd Center Mall Market – 218-299-5296 • Farmers Market & Beyond – 701-433-5360 • FM Farmers Market – 701- 281-1539 • Ladybug Acres produce stand – 701-799-3787 • Red River Farmer’s Market – 701-491-8892 • Sydney’s Health Market – 218- 233-3310 • Veggie Bus – 701-799-3787 • Whistle Stop Farmers Market – 701-367-0490 • Old Trail Market/Legacy Garden – 701-361-2111 or 701-361-3028

Chronic Disease resources: • Sanford Better Choices, Better Health • Adult Connect Support Group (for epilepsy/seizure disorders) – 701-429-1165 • Epilepsy Support Group – 701- 232-8521

Identified Generalizable Non-Generalizable American Indian Key stakeholder Secondary Data Community resources that are Gap concern Survey Specific areas of Survey specific areas Survey specific area Focus group Specific Report available to address the need concern of concern of concern specific areas of concern 383 surveys 51 surveys area of concern • Parkinson’s Support Group – 701-365-8200 • Young Onset Parkinson’s Support Group – 701-261-3142 • FM Pelvic Pain Support Group – 218-790-0432 • Post-Polio Support Group – 701-232-8417 • Hepatitis Support Group – 701-234-2353 • Life Threatening Illness Support Group – 218-233-3875 • HIV/AIDS Support Group – 218-287-4636 • Huntington’s Disease Support Group – 701-492-3123 • Fibromyalgia Support Group – 701-235-9359 (First Lutheran) • Fibromyalgia Support Group – 701-799-4200 (Sanford) • American Chronic Pain Assn. support group – 701-280-2472 • Chronic Pain Support Group- 701-234-6600 (Sanford) • Chronic Pain Support Group – 701-261-3142 (HeartSprings Community Healing Center) • Crohn’s & Colitis Support Group – 701-388-4025 (Sanford) • Diabetes Support Group – 701-364-8900 (Essentia) • Diabetes Support Group – 701-234-2245 (Sanford) • American Diabetes Association – 701-235-3080 • NDSU Extension “dining with diabetes” class – 701-231- 8944 • Celiac Support Group – 701- 232-3896

• Red River Celiacs – 701-235- 16

Cancer resources: • Sanford Roger Maris Cancer Center – 701-234-6161 • Essentia Cancer Center – 701- 364-8910 • Atonement Cancer Care Support Group – 701-237-9651 • Cancer Support Group – 218- 236-1333 • Us Too Support Group (for prostate cancer survivors) – 218-233-1176 • Embrace Cancer Survivorship Program – 701-234-7463 • American Cancer Society – 701-232-1385

Mental • Depression 3.78 • Depression 3.94 • Mental Health • 26.9% of Mental Health resources: Health/ • Dementia and • Suicide 3.65 • Stigma respondents • Alzheimer’s Association – 701- Behavioral Alzheimer’s 3.76 • Other psychiatric in Cass County 277-9757 Health • Stress 3.65 diagnosis 3.64 • Binge drinking report binge • ARC of West Central MN – 218-233-5949 • Underage drug use • Stress 3.61 drinking levels • Catholic Family Services – 701- • 11.9% of the and abuse 3.66 • Alcohol use and 235-4457 • Underage drinking abuse 3.90 respondents • CCRI – 218-236-6730 3.54 in Cass County 17

abuse 3.52 drinking 3.68 days in the 299-5200 • Community Outreach Center • 33.2% of • Underage drug last 30 days at MSUM – 218-477-2513 • Adult smoking respondents report use and abuse • Crisis Responders – 800-223- binge drinking 3.66 in Cass County 4512 • Smoking and is 16% and • Drake Counseling Services – tobacco/smokele 17% in Clay 701-293-5429 ss tobacco use County • EAP in the workplace 3.53 • Essentia (Fargo & Mhd locations) • Fargo Cass Public Health – 701-241-1360 • FirstLink – 701-293-6462 • Human Service Associates – 218-291-1658 • Lakeland Mental Health – 218- 233-7524 • Lutheran Social Services of MN – 218-236-1494 • Lutheran Social Services of ND – 701-235-7341 • Mental Health Association (Mental Health America) – 701-237-5871 • Mobile Mental Health Crisis Team – 800-223-4512 • Prairie St. John’s (Mhd Clinic) – 218-284-0300 • Prairie St. John’s (Fargo clinic) – 701-476-7216 • Rape & Abuse Crisis Center – 701-293-7273 • Safe Harbour – 218-287-2593 • Sanford Health Behavioral Health – 701-234-6000 • SE Mental Health – 701-298- 4500 • SENDCA – 701-232-2452 • Social Connection – 218-284- 18

Substance Abuse/Addictions resources: • AA Club House – 701-232-9930 • Anchorage, The – 218-287- 1500 • Centre Detox – 701-237-3341 • Clay Co. Chemical Dependency Services – 218-299-5200 • Clay County Detox – 218-299- 5171 • Clay Co. Public Health 218- 299-5220 • Clay Co. Social Services – 218- 299-5200 • First Step Recovery – 701-293- 3384 • Gamblers Choice – 701-235- 7341 • Gambling Problem Hotline – 800-472-2911 • Lost & Found Ministry/ Recovery Worship – 218-287- 2089 • Prairie St. John’s (Mhd Clinic) – 218-284-0300 • Prairie St. John’s (Fargo clinic) – 701-476-7216 • Safe Harbour – 218-287-2593 • Sharehouse Wellness Center – 218-233-6398 • Prairie St. John’s – 701-476- 19

Smoking Cessation resources: • BAN Program (Break Away from Nicotine) – 701-476-4083 (City of Fargo program) • ND Quits (ND Dept. of Health) – 701-214-4170 • Essentia Health (tobacco treatment specialist) – 701- 364-4524 • Sanford Health – 701-234- 5191 (tobacco cessation counselor) • Sanford Health – 701-234- 6452 (tobacco & asthma education) • Fargo Cass Public Health (health educator) – 701-241- 1367

Preventive 51% not getting a flu Essentia Health Clinics – 701- health shot 364-8000

Sanford Clinics – 701-234-2000

Family HealthCare Center – 701-271-3344

Clay Co. Public Health – 218- 299-7777

Rev. 10/2/15

2015 Greater Fargo-Moorhead Community Health Needs Assessment of Residents

August 2015

Results from a March 2015 generalizable survey of community residents in the Greater Fargo-Moorhead Metropolitan Area including Cass County, North Dakota and Clay County, Minnesota

Conducted through a partnership between

• Greater Fargo-Moorhead Community Health Needs Assessment Collaborative

• Center for Social Research at North Dakota State University

Center for Social Research North Dakota State University CSR www.ndsu.edu/csr PREFACE

This report, entitled 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents, presents the results of a March 2015 generalizable survey of residents in Cass County, North Dakota and Clay County, Minnesota.

The study was conducted by the Center for Social Research at North Dakota State University on behalf of the Fargo‐Moorhead Community Health Needs Assessment Collaborative. Funding for the study was provided by Collaborative member organizations.

Fargo-Moorhead Community Health Needs Assessment Collaborative Members Sanford Health Essentia Health Fargo Cass Public Health Clay County Public Health

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 1

TABLE OF CONTENTS

PREFACE ...... 1

TABLE OF CONTENTS ...... 2

EXECUTIVE SUMMARY ...... 5 Introduction ...... 5 Study Design and Methodology ...... 5 Limitations of the Study ...... 5 Key Findings ...... 6 Comparisons between Community Residents and Community Leaders ...... 8

SURVEY RESULTS ...... 10

General Health and Wellness Concerns about the Community ...... 10

Figure 1. Level of concern with statements about the community regarding ECONOMICS ...... 10 Figure 2. Level of concern with statements about the community regarding TRANSPORTATION ..... 11 Figure 3. Level of concern with statements about the community regarding the ENVIRONMENT .... 11 Figure 4. Level of concern with statements about the community regarding CHILDREN AND YOUTH ...... 12 Figure 5. Level of concern with statements about the community regarding the AGING POPULATION ...... 13 Figure 6. Level of concern with statements about the community regarding SAFETY ...... 14 Figure 7. Level of concern with statements about the community regarding HEALTH CARE ...... 16 Figure 8. Level of concern with statements about the community regarding PHYSICAL AND MENTAL HEALTH ...... 17 Figure 9. Level of concern with statements about the community regarding SUBSTANCE USE AND ABUSE ...... 18

General Health ...... 18

Figure 10. Respondents’ rating of their health in general ...... 18 Figure 11. Respondents’ weight status based on the Body Mass Index (BMI) scale ...... 19 Figure 12. Number of servings of vegetables, fruit, and fruit juice that respondents had yesterday ...... 20 Figure 13. Number of days in an average week respondents engage in MODERATE and VIGOROUS activity ...... 21

Mental Health ...... 22

Figure 14. Percentage of respondents who have been told by a doctor or health professional that they have a mental health issue, by type of mental health issue ...... 22 Figure 15. Number of days in the last month that respondents’ mental health was not good ...... 22 Figure 16. How often, over the past two weeks, respondents have been bothered by mental health issues ...... 23

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 2

Tobacco Use ...... 23

Figure 17. Whether respondents have smoked at least 100 cigarettes in their entire life ...... 23 Figure 18. How often respondents currently smoke cigarettes and use chewing tobacco or snuff ... 24 Figure 19. Location respondents would first go if they wanted help to quit using tobacco ...... 24

Alcohol Use and Prescription Drug/Non‐prescription Drug Abuse ...... 25

Figure 20. Number of days during the past month that respondents had at least one drink of any alcoholic beverage ...... 25 Figure 21. During the past month on days that respondents drank, average number of drinks per day respondents consumed ...... 25 Figure 22. Number of times during the past month that respondents consumed at least 4 or 5 alcoholic drinks (4 for females, 5 for males) on the same occasion ...... 26 Figure 23. Whether respondents have ever had a problem with alcohol use or prescription or non‐ prescription drug abuse ...... 26 Figure 24. Of respondents who ever had a problem with alcohol use or prescription or non‐ prescription drug abuse, whether respondents got the help they needed ...... 27 Figure 25. Whether alcohol use or prescription or non‐prescription drug abuse has had harmful effects on respondents or a family member over the past two years ...... 27

Preventive Health ...... 28

Table 1. Whether or not respondents have had preventive screenings in the past year, by type of screening ...... 28 Table 2. Of respondents who have not had preventive screenings in the past year, reasons why they have not, by type of screening ...... 29 Figure 26. Whether respondents have any of the following chronic diseases ...... 30 Figure 27. Length of time since respondents last visited a doctor or health care provider for a routine physical exam and length of time since they last visited a dentist or dental clinic for any reason ...... 31 Figure 28. Where respondents get most of their health information ...... 32 Figure 29. Best way for respondents to access technology for health information ...... 32

Demographic Information ...... 33

Figure 30. Age of respondents ...... 33 Figure 31. Highest level of education of respondents...... 33 Figure 32. Gender of respondents...... 34 Figure 33. Race and ethnicity of respondents ...... 34 Figure 34. Annual household income of respondents ...... 35 Figure 35. Employment status of respondents ...... 35 Figure 36. Length of time respondents have lived in their community ...... 36 Figure 37. Whether respondents own or rent their home ...... 36 Figure 38. Whether respondents have health insurance (private, public, or governmental) and oral health or dental care insurance coverage ...... 37 Figure 39. Whether respondents have one person who they think of as their personal doctor or health care provider ...... 37 Figure 40. Facilities that respondents go to most often when sick and take their children when they are sick ...... 38

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Figure 41. Number of children younger than 18 and number of adults age 65 or older living in respondents’ household ...... 38 Figure 42. Whether all children in home are current on their immunizations and all children age 6 months or older get a flu shot or flu mist each year ...... 39 Table 3. Location of respondents based on zip code ...... 39

APPENDICES ...... 40 Appendix Tables ...... 40 Introductory and Reminder Postcards ...... 53 Survey Instrument ...... 54

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 4

EXECUTIVE SUMMARY

Introduction

The purpose of this generalizable survey of residents in the greater Fargo‐Moorhead area (i.e., Cass County, North Dakota and Clay County, Minnesota) was to learn about the perceptions of area residents regarding, community health, their personal health, preventive health, and the prevalence of disease.

Study Design and Methodology

A generalizable survey was conducted of residents in Cass County, North Dakota and Clay County, Minnesota. The survey instrument was developed in partnership with members of the Greater Fargo‐ Moorhead Community Health Needs Assessment collaborative (CHNA) and the Center for Social Research (CSR) at North Dakota State University (NDSU).

Staff at the CSR, along with members of the collaborative, created the cover letter. Elements of informed consent were included in the letter ensuring that the NDSU Institutional Review Board requirements were met and the protection of human subjects maintained.

The survey instrument was designed as a scannable 8‐page mail survey containing 54 questions. The questions focused on general community concerns, community health and wellness concerns, personal health, preventive health, and demographic characteristics.

Obtained through a qualified vendor, the sample was a stratified random sample to ensure that appropriate proportions from each of the two counties were included. A total of 1,500 records with names, addresses, and a few demographic indicators were included in the sample.

Residents listed in the sample were first mailed an introductory postcard briefly explaining the project and notifying them that a survey packet would be arriving in their mail. Surveys packets, which contained the cover letter, scannable paper survey, and a pre‐paid return envelope, were mailed three days after the introductory postcards; 2 percent of the packets were returned as undeliverable. A reminder postcard, containing a link to an online version of the survey, was mailed to non‐responders approximately 10 days after the initial survey was mailed. A total of 398 paper surveys were returned for scanning and an additional three surveys were completed online for a total of 401; the response rate was 27 percent. It was apparent that elderly and male respondents were overrepresented in the scanned results. Therefore, post‐ stratification weights were used to ensure proper representation of the population with respect to age and gender. Respondents who did not enter a gender and age response were eliminated from the analyses. A total of 382 surveys were analyzed providing a generalizable sample with a confidence level of 95 percent and an error rate of plus or minus 5.2 percentage points.

Limitations of the Study

The findings in this study provide an overall snapshot of behaviors, attitudes, and perceptions of residents living in Cass County, North Dakota and Clay County, Minnesota. However, when comparing certain demographic characteristics (i.e., age, income, minority status) with the current population estimates from the U.S. Census Bureau1, it was evident that older, white, more highly educated, and higher income earners were overrepresented. Overrepresentation of this nature is typical in health needs assessments.

1 U.S. Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States, States, and Counties: April 1, 2010 to July 1, 2013. Released June 2014. Available from http://www.census.gov/popest/. 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 5

Literature reviews indicate that there are nonresponse rate issues among younger respondents2. In particular, response rates to health care and community health needs assessment surveys have often been found to be higher for older respondents3. Studies have also shown lower response rates for socially disadvantaged groups4 (i.e., socially, culturally, or financially).

In order to supplement the findings of this study, particularly for the subpopulations that are underrepresented, one might consider utilizing other data resources, such as local public health data, North Dakota Compass5, Behavior Risk Factor Surveillance System6, Minnesota Center for Health Statistics7, and Minnesota Compass8.

Given the nature of this study, it may be necessary to reach out to community partnerships and implement a variety of recruitment techniques in order to gather information from underrepresented groups in future studies. However, one should be mindful of increased time commitments and financial resources that may be necessary when gathering data from hard‐to‐reach populations.

Key Findings

Research indicates that optimal health and well‐being is much more than merely physical health. Optimal health is an integrated and interconnected state where all components of health, such as physical, mental, social, spiritual, emotional, environmental, intellectual, and occupational health, are balanced to contribute to an individual’s quality of life.

The Greater Fargo‐Moorhead Community Health Needs Assessment indicated a number of possible health challenges within the metropolitan area. Local health agencies may want to consider these key findings when developing and implementing education and advocacy efforts for the community.

Community Health Concerns. The greatest areas of concern among respondents are for the aging population, including the cost of long term care; health care, including access to affordable health insurance, access to affordable health care, and access to affordable prescription drugs; and physical health, including cancer.

Respondents have moderately high levels of concern with respect to safety issues (i.e., presence of street drugs, prescription drugs, and alcohol in the community; crime; presence of drug dealers in the community; domestic violence; child abuse and neglect) as well as issues relating to children and youth (i.e., bullying, cost of quality child and infant care, youth crime). Other moderately high concerns relate to substance use and abuse issues (i.e., underage drug use and abuse, underage drinking, drug use and abuse, alcohol use and abuse), health care issues (i.e., cost of affordable dental insurance coverage), and physical and mental health issues (i.e., chronic disease, depression, inactivity and lack of exercise, and dementia and Alzheimer’s disease).

2 Michael J. Stern, Ipek Bilgen, and Don Al Dillman. Field Methods 2014, Vol. 26(3) 284‐301. The State of Survey Methodology: Challenges, Dilemmas, and New Frontiers in the Era of the Tailored Design. 3 See the following examples: http://www.mathematica- mpr.com/~/media/publications/PDFs/internetmailsurvey.pdf; http://www.allied-services.org/wp- content/uploads/2013/06/CHNA-lackawanna-2013.pdf; http://www.hcno.org/pdf/counties/Cuyahoga%20County%20Health%20Assessment%20FINAL.pdf. 4 See the following literature review: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974746/# ffn_sectitle. 5 See North Dakota Compass site: http://www.ndcompass.org/. 6 See Behavior Risk Factor Surveillance site: http://www.cdc.gov/brfss/index.html. 7 See Minnesota Center for Health Statistics site: http://www.health.state.mn.us/divs/chs/. 8 See Minnesota Compass site: http://www.health.state.mn.us/divs/chs/. 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 6

Respondents are least concerned about issues regarding transportation (i.e., driving habits, availability of good walking or biking options, the cost and availability of public transportation), the environment (i.e., water quality, air quality, hazardous waste, home septic systems), and economics (i.e., homelessness, hunger, and the availability of affordable housing).

Personal Health Concerns. The study results suggest possible discrepancies between respondents’ perceived personal health and their actual health status as determined by objective measures. For example, using the Body Mass Index (BMI) which calculates weight status using an individual’s weight and height, the majority of respondents in the metro area are overweight or obese. However, the vast majority of community respondents rate their own health as excellent, very good, or good. With good overall health habits in mind, it is important to note that within the past year, three in four respondents visited a doctor or health care provider for a routine physical and the vast majority visited a dentist or dental clinic.

Preventive health care promotes the detection and prevention of illness and disease and is another important component of good health and well‐being. Community results indicate that within the past year, the majority of respondents had a blood pressure screening, blood sugar screening, cholesterol screening, dental screening, flu shot, pelvic exam (females), breast cancer screening (females), and cervical cancer screening (females). However, there are many screenings and tests that a majority of respondents did not receive (i.e., bone density test, cardio screening, glaucoma test, hearing screening, immunizations, STD test, vascular screening, colorectal cancer screening, prostate cancer screening (males), and skin cancer screening) in the past year. Many tests and screenings may be conditional upon guidelines, which can be age sensitive/appropriate. With that in mind, a number of screenings and tests were analyzed more closely based on age. With respect to the bone density test, older respondents are three times more likely than respondents overall to get tested. Regarding the glaucoma test, older respondents are more likely than respondents overall to get screened. With respect to colorectal cancer screening, older respondents are nearly two times more likely than respondents overall to get tested/screened. Pertaining to the prostate cancer screening, older male respondents are nearly two times more likely than male respondents overall to get screened. Among respondents not screened, reasons cited most often are that the screening was not necessary or the doctor hadn’t suggested it.

As the majority of community respondents are overweight or obese, it is important to consider that obesity is related to many chronic diseases and conditions, such as heart disease, stroke, type 2 diabetes, and certain types of cancer ‐ many of which are leading causes of preventable death. When compared to the prevalence of chronic diseases in the U.S. overall, a slightly smaller proportion of metro area respondents report having high cholesterol (one in five respondents), half the proportion report having hypertension (one in six respondents), a smaller proportion report having arthritis (one in six respondents), and a slightly smaller proportion report having diabetes (one in 15 respondents).

According to the Office of Disease Prevention and Health Promotion, it is recommended that individuals consume 3 to 5 servings of vegetables per day and 2 to 4 servings of fruit per day depending on age. Study results suggest that the majority of respondents do not meet vegetable and fruit recommended dietary guidelines. Specifically, one in four respondents eat the daily recommended serving size of vegetables and half of respondents eat the daily recommended serving size of fruit.

Other healthy behavior recommendations are related to physical activity levels. Guidelines from the Centers for Disease Control and Prevention recommend that individuals participate in 150 minutes of moderate physical activity per week or 75 minutes of vigorous physical activity per week to help sustain and improve health. Study results suggest that the majority of respondents do not meet physical activity guidelines. Specifically, in an average week, one in five respondents reach the weekly recommended moderate physical activity level (5 or more days of at least 30 minutes of moderate physical activity). An additional one in five respondents reach the weekly recommended vigorous activity level (3 or more days of at least 30 minutes of vigorous physical activity).

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Other lifestyle choices individuals make about how they live have a significant impact on their overall health. Study results indicate that the vast majority of community respondents are not currently tobacco users. However, one in three respondents have smoked at least 100 cigarettes in their lifetime, which indicates a former smoker status according to the Centers for Disease Control and Prevention.

Beyond physical health, mental health is an important component of well‐being at every stage of life and impacts how we think, act, and feel. Mental health influences our physical health, how we handle stress, how we make choices, and relate to others. Among Fargo‐Moorhead respondents, mental health is a moderately high area of concern, particularly depression, dementia and Alzheimer’s disease. One in five respondents have been told or diagnosed by a doctor or health professional that they have anxiety or stress and a similar proportion have been told they have depression. In addition, half of respondents self‐report that in the last month, there were days when their mental health was not good. One in 10 respondents say their mental health was not good for at least half of the days in the last month. Furthermore, when asked specifically about particular mental health issues, one in five respondents reported little interest or pleasure in doing things for several days or more in the last two weeks and one in six respondents say that for at least several days in the last two weeks they were feeling down, depressed, or hopeless.

Substance abuse is also a mental health disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV), and can stem from mental health concerns. In the Fargo‐ Moorhead community, one in five respondents drank alcoholic beverages on at least half of the days in the last month. On days they drank, one in eight respondents drank an average of four or more drinks per day. In regards to binge drinking, one in three respondents report binge drinking at least once per month. Specifically, 5 percent say they binge drink 2 to 3 times a week and an additional 3 percent binge drank almost every day in the past month.

When asked if they have ever had a problem with alcohol use, one in 15 of respondents say they have. Among those who had a problem, one‐fourth say they received the help they needed. Overall, one in six respondents say alcohol use has had harmful effects on themselves or a family member.

Other forms of substance abuse include the use of prescription or non‐prescription drugs. No respondents in the metro area reported having had a problem with prescription or non‐prescription drug abuse. However, one in 17 respondents say prescription on non‐prescription drug abuse has had harmful effects on themselves or a family member.

Comparisons between Fargo-Moorhead Community Residents and Community Leaders

In addition to the perception of community residents, the Collaborative wanted to obtain insight from key leaders and stakeholders within the Fargo‐Moorhead community. A similar survey was administered to community leaders in the area (e.g., health professionals, social workers, educators, elected leadership, and nonprofit leaders) to capture their views on community and personal health in the Fargo‐Moorhead metro area. The survey was developed as an online tool and a link to the survey instrument was distributed via email to various agencies, at times using a snowball approach. Thus, the sample is not representative of the area’s leadership and the results of this stakeholder survey are not generalizable to the community at large. However, the results do offer an opportunity to explore the similarities and differences between the perceptions of the stakeholders surveyed and those of community members who responded to the generalizable survey of residents.

Overall, community leaders have higher levels of concern about community issues than residents. When looking at the top 10 concerns, the number one concern among community leaders and residents alike relates to the aging population, specifically the cost of long term care. Community leaders and residents also prioritized the availability of memory care as a concern regarding the aging population. Other top

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 8 concerns among community leaders focused on mental health, child care, and safety issues. Top concerns for residents tended to focus more on health care, physical health and safety issues.

When addressing health care concerns, top priorities among residents relate to cost issues (i.e., access to affordable health insurance, affordable health care, and affordable prescription drugs), whereas top priorities among community leaders relate to service delivery (i.e., timely access to mental health providers, access to substance use providers, and the use of emergency room services for primary health care).

Both community leaders and residents have moderately high levels of concern for physical and mental health issues. The top concern among community leaders is depression, whereas the top concerns among residents are cancer and chronic disease. Community leaders have slightly higher levels of concern than residents about inactivity and lack of exercise, poor nutrition and eating habits, and obesity. Depression and stress are other moderately high mental health concerns among residents. However, community leaders are more concerned than residents about suicide.

Regarding issues relating to children and youth, bullying is ranked as the main concern among residents. The costs and availability of quality child and infant care are ranked as top concerns among community leaders and residents, however community leaders have higher levels of concern in these areas. The cost and availability of services for at-risk youth is also a moderately high concern among community leaders, however, residents rank the issue as a moderate concern.

Regarding safety issues, overall, residents have higher levels of concern than community leaders. However, the presence of street drugs, prescription drugs, and alcohol in the community is the top safety concern among both residents and community leaders. Crime, the presence of drug dealers in the community, child abuse and neglect, and domestic violence are other moderately high concerns among residents and community leaders, although at higher levels of concern among residents.

With respect to substance use and abuse issues, community leaders are more concerned than residents about adult alcohol use and abuse and adult drug use and abuse. Residents, on the other hand, are more concerned than community leaders about underage usage of drugs and alcohol than about adult usage.

Community leaders are more concerned than residents about economic issues. Community leaders are most concerned about the availability of affordable housing and homelessness. Although a moderate level of concern, residents are most concerned about homelessness and hunger.

Both residents and community leaders have moderate concerns with transportation issues (i.e., driving habits, availability of good walking or biking options, availability of public transportation, and the cost of public transportation).

Overall, both community leaders and residents have moderate concerns about environmental issues (i.e., water quality, air quality, hazardous waste, and home septic systems). However, residents have a moderately high concern about water quality.

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SURVEY RESULTS

General Health and Wellness Concerns about the Community

Using a 1 to 5 scale, with 1 being “not at all” and 5 being “a great deal,” respondents were asked to rate their level of concern with various statements regarding ECONOMICS, TRANSPORTATION, the ENVIRONMENT, CHILDREN AND YOUTH, the AGING POPULATION, SAFETY, HEALTH CARE, PHYSICAL AND MENTAL HEALTH, and SUBSTANCE USE AND ABUSE.

Overall, respondents have a moderate level of concern regarding economic issues (Figure 1, Appendix Table 1). • On average, respondents are most concerned about homelessness and hunger (mean=3.23 and mean=3.22, respectively).

Figure 1. Level of concern with statements about the community regarding ECONOMICS

Homelessness (N=377) 3.23

Hunger (N=377) 3.22

Availability of affordable housing (N=375) 2.99

1 2 3 4 5

Mean (1=Not at All; 5=A Great Deal)

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Overall, respondents are moderately concerned about transportation issues in their community (Figure 2, Appendix Table 1). • On average, respondents are most concerned about driving habits (mean=3.12) and the availability of good walking or biking options (mean=3.01). • On average, respondents are least concerned about the cost of public transportation (mean=2.45).

Figure 2. Level of concern with statements about the community regarding TRANSPORTATION

Driving habits (e.g., speeding, road rage) (N=373) 3.12

Availability of good walking or biking options (as alternatives 3.01 to driving) (N=377)

Availability of public transportation (N=375) 2.55

Cost of public transportation (N=372) 2.45

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

Overall, respondents are moderately concerned about environmental issues in their community (Figure 3, Appendix Table 1). • On average, respondents are most concerned about water quality (mean=3.41); 34.0 percent of respondents have a great deal of concern. • On average, respondents are least concerned about home septic systems (mean=2.40).

Figure 3. Level of concern with statements about the community regarding the ENVIRONMENT

Water quality (N=378) 3.41

Air quality (N=378) 3.00

Hazardous waste (N=378) 2.96

Home septic systems (N=374) 2.40

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

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Overall, respondents are moderately concerned about issues relating to children and youth in their community (Figure 4, Appendix Table 1). • On average, respondents are most concerned about bullying (mean=3.82); 31.3 percent of respondents have a great deal of concern. • On average, respondents have a moderately high level of concern about: o The cost of quality child care (mean=3.53); 24.8 percent are concerned a great deal. o The cost of quality infant care (mean=3.50); 28.3 percent are concerned a great deal. o Youth crime (mean=3.49); 20.5 percent are concerned a great deal. • Although still moderately concerned, on average, respondents are less concerned about: o Cost of services for at‐risk youth (mean=3.18). o Teen pregnancy (mean=3.14). o Availability of services for at‐risk youth (mean=3.13). o School dropout rates (mean=3.12). o School absenteeism (mean=2.94).

Figure 4. Level of concern with statements about the community regarding CHILDREN AND YOUTH

Bullying (N=371) 3.82

Cost of quality child care (N=370) 3.53

Cost of quality infant care (N=365) 3.50

Youth crime (N=368) 3.49

Cost of activities for children and youth (N=367) 3.44

Availability of quality infant care (birth to 2 years) (N=370) 3.40

Availability of quality child care (N=369) 3.40

Availability of activities for children and youth (N=367) 3.39

Cost of services for at-risk youth (N=369) 3.18

Teen pregnancy (N=370) 3.14

Availability of services for at-risk youth (N=371) 3.13

School dropout rates (N=370) 3.12

School absenteeism (N=369) 2.94

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

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Overall, respondents are moderately concerned about issues related to the aging population in their community (Figure 5, Appendix Table 1). • On average, respondents have a high level of concern about the cost of long term care (mean=4.11); 51.1 percent of the respondents have a great deal of concern. • On average, respondents have a moderately high level of concern about: o The availability of memory care (mean=3.63); 27.7 percent are concerned a great deal. o The availability of long term care (mean=3.51); 27.0 percent are concerned a great deal. • On average, respondents are moderately concerned about: o The availability of resources for family/friends caring for and making decisions for elders (mean=3.44). o The availability of resources to help the elderly stay safe in their homes (mean=3.40). • While still moderately concerned, on average, respondents are less concerned about: o The availability of activities for seniors (mean=3.23). o The availability of resources for grandparents caring for grandchildren (mean=3.18). o The cost of activities for seniors (mean=3.15).

Figure 5. Level of concern with statements about the community regarding the AGING POPULATION

Cost of long term care (N=378) 4.11

Availability of memory care (N=377) 3.63

Availability of long term care (N=377) 3.51

Availability of resources for family/friends caring for and 3.44 making decisions for elders (N=375)

Availability of resources to help the elderly stay safe in their 3.40 homes (N=370)

Availability of activities for seniors (N=375) 3.23

Availability of resources for grandparents caring for 3.18 grandchildren (N=372)

Cost of activities for seniors (N=374) 3.15

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

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Overall, respondents have a moderately high level of concern about issues of safety in their community (Figure 6, Appendix Table 1). • On average, respondents are most concerned about: o The presence of street drugs, prescription drugs, and alcohol in the community (mean=3.84); 36.1 percent have a great deal of concern. o Crime (mean=3.74); 30.1 percent have a great deal of concern. o The presence of drug dealers in the community (mean=3.73); 37.6 percent have a great deal of concern. o Child abuse and neglect (mean=3.72); 31.6 have a great deal of concern. o Domestic violence (mean=3.72); 30.0 percent have a great deal of concern. • While still moderately concerned, on average, respondents are less concerned about: o Sex trafficking (mean=3.50). o The presence of gang activity (mean=3.48). o Elder abuse (mean=3.40).

Figure 6. Level of concern with statements about the community regarding SAFETY

Presence of street drugs, prescription drugs, and alcohol in 3.84 the community (N=374)

Crime (N=375) 3.74

Presence of drug dealers in the community (N=378) 3.73

Child abuse and neglect (N=376) 3.72

Domestic violence (N=377) 3.72

Sex trafficking (N=376) 3.50

Presence of gang activity (N=376) 3.48

Elder abuse (N=377) 3.40

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

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Overall, respondents are moderately concerned about issues relating to health care (Figure 7, Appendix Table 1). • On average, respondents are highly concerned about: o Access to affordable health insurance (mean=4.04); 43.4 percent have a great deal of concern. o Access to affordable health care (mean=3.92); 38.2 percent have a great deal of concern. o Access to affordable prescription drugs (mean=3.90); 39.4 percent have a great deal of concern. o Cost of affordable dental insurance coverage (mean=3.83); 35.4 percent have a great deal of concern. o Cost of affordable vision insurance (mean=3.66); 29.9 percent have a great deal of concern. • On average, respondents are moderately concerned about: o Timely access to doctors, physician assistants, or nurse practitioners (mean=3.30). o Timely access to physician specialists (mean=3.29). o Use of emergency room services for primary health care (mean=3.27). • On average, respondents are least concerned about: o Timely access to transportation (mean=2.37). o Timely access to registered dietitians (mean=2.32). o Timely access to exercise specialists or personal trainers (mean=2.22). o Timely access to bilingual providers and/or translators (mean=2.11).

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Figure 7. Level of concern with statements about the community regarding HEALTH CARE

Access to affordable health insurance (N=374) 4.04

Access to affordable health care (N=378) 3.92

Access to affordable prescription drugs (N=377) 3.90

Cost of affordable dental insurance coverage (N=376) 3.83

Cost of affordable vision insurance (N=377) 3.66

Timely access to doctors, physician assistants, or nurse 3.30 practitioners (N=378)

Timely access to physician specialists (N=375) 3.29

Use of emergency room services for primary health care 3.27 (N=373) Availability of non-traditional hours (e.g., evenings, 3.14 weekends) (N=377)

Coordination of care between providers and services (N=372) 3.14

Providers not taking new patients (N=375) 3.12

Timely access to mental health providers (N=372) 2.98

Timely access to substance abuse providers (N=369) 2.87

Timely access to dental care providers (N=376) 2.79

Availability of transportation (N=377) 2.74

Timely access to prevention programs and services (N=366) 2.66

Distance to health care services (N=376) 2.66

Timely access to vision care providers (N=372) 2.56

Timely access to transportation (N=363) 2.37

Timely access to registered dietitians (N=361) 2.32

Timely access to exercise specialists or personal trainers 2.22 (N=367)

Timely access to bilingual providers and/or translators 2.11 (N=370)

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal) 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 16

Overall, respondents have moderately high levels of concern about issues relating to physical and mental health (Figure 8, Appendix Table 1). • On average, respondents are most concerned about: o Cancer (mean=3.97); 38.4 percent have a great deal of concern. o Chronic disease (i.e., diabetes, heart disease, multiple sclerosis) (mean=3.81); 30.1 percent have a great deal of concern. o Depression (mean=3.78); 29.4 percent have a great deal of concern. o Inactivity and lack of exercise (mean=3.78); 32.3 percent have a great deal of concern. o Dementia and Alzheimer’s disease (mean=3.76); 28.7 percent have a great deal of concern. • On average, respondents have moderately high levels of concern about: o Stress (mean=3.65). o Obesity (mean=3.64). o Poor nutrition and eating habits (mean=3.62). o Infectious diseases such as the flu (mean=3.50). • On average, respondents are moderately concerned about: o Suicide (mean=3.38). o Other psychiatric diagnosis (mean=3.11). o Sexually transmitted diseases (e.g., AIDS, HIV, chlamydia) (mean=2.92).

Figure 8. Level of concern with statements about the community regarding PHYSICAL AND MENTAL HEALTH

Cancer (N=372) 3.97

Chronic disease (e.g., diabetes, heart disease, multiple 3.81 sclerosis) (N=377)

Depression (N=378) 3.78

Inactivity and lack of exercise (N=376) 3.78

Dementia and Alzheimer's disease (N=374) 3.76

Stress (N=377) 3.65

Obesity (N=375) 3.64

Poor nutrition and eating habits (N=377) 3.62

Infectious diseases such as the flu (N=374) 3.50

Suicide (N=376) 3.38

Other psychiatric diagnosis (N=373) 3.11

Sexually transmitted diseases (e.g., AIDS, HIV, chlamydia) 2.92 (N=370)

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 17

Overall, respondents have moderately high levels of concern about issues relating to substance use and abuse (Figure 9, Appendix Table 1). • On average, respondents are most concerned about: o Underage drug use and abuse (mean=3.66); 27.4 percent of respondents have a great deal of concern. o Underage drinking (mean=3.54); 25.4 percent have a great deal of concern. o Drug use and abuse (mean=3.53); 26.8 percent have a great deal of concern. o Alcohol use and abuse (mean=3.52); 24.9 percent have a great deal of concern. • While still moderately concerned, on average, respondents are less concerned about: o Smoking and tobacco use (mean=3.44). o Exposure to second‐hand smoke (mean=3.37).

Figure 9. Level of concern with statements about the community regarding SUBSTANCE USE AND ABUSE

Underage drug use and abuse (N=376) 3.66

Underage drinking (N=376) 3.54

Drug use and abuse (N=377) 3.53

Alcohol use and abuse (N=377) 3.52

Smoking and tobacco use (N=377) 3.44

Exposure to second-hand smoke (N=377) 3.37

1 2 3 4 5 Mean (1=Not at All; 5=A Great Deal)

General Health

Respondents were asked to rate their health in general (Figure 10, Appendix Table 2). • Half of respondents say their health is very good or excellent (52.5 percent); 37.0 percent say their health is good and 10.5 percent say their health is fair or poor.

Figure 10. Respondents’ rating of their health in general

Excellent 11.2

Very Good 41.3

Good 37.0

Fair 9.1

Poor 1.4

Don't know 0.1

0 10 20 30 40 50 Percent*

N=367 *Percentages do not total 100.0 due to rounding.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 18

Respondents were asked to report their height and weight. The weight status of respondents in Figure 11 was calculated using the Body Mass Index (BMI), which is derived from a person’s height and weight. • The majority of respondents are overweight or obese (61.3 percent); including 31.7 percent who are overweight and 29.6 percent who are obese (Figure 11, Appendix Table 3).

Figure 11. Respondents’ weight status based on the Body Mass Index (BMI)* scale

Underweight (BMI less than 18.5) 0.5

Normal weight (BMI from 18.5 to 24.9) 38.2

Overweight (BMI from 25.0 to 29.9) 31.7

Obese (BMI of 30.0 or greater) 29.6

0 10 20 30 40 50 Percent

N=346 *For information about the BMI, visit the Centers for Disease Control and Prevention, About BMI for Adults, http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 19

Respondents were asked to report the number of servings of vegetables, fruit, and fruit juice they had yesterday (Figure 12, Appendix Table 4). • One in four respondents had three or more servings of vegetables the previous day (24.1 percent); 36.6 percent had one serving. • Half of respondents had two or more servings of fruit the previous day (51.1 percent); 29.7 percent had one serving. • One in three respondents had one serving of fruit juice the previous day (30.6 percent); 55.7 percent had no servings of fruit juice.

Figure 12. Number of servings of vegetables, fruit, and fruit juice that respondents had yesterday

7.6 None 19.2 55.7

36.6 1 29.7 30.6

31.7 2 31.0 10.2

14.8

Number of servings 3 16.0 1.6

8.1 4 3.0 1.6

1.2 5 or more 1.1 0.3

0 20 40 60 80 100 Percent

Vegetables (N=381) Fruit (N=378) Fruit juice (N=382)

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 20

Moderate physical activity causes only light sweating and a small increase in breathing or heart rate. Vigorous activity causes heavy sweating and a large increase in breathing or heart rate. Respondents were asked to report the number of days, in an average week, they get at least 30 minutes of moderate physical activity and 30 minutes of vigorous activity (Figure 13, Appendix Table 5). • One in five respondents engage in 30 minutes or more of moderate physical activity five or more days a week (19.5 percent); 35.2 percent get 30 minutes of moderate activity one to two days a week and 16.5 percent say there are no days where they get 30 minutes of moderate activity. • One in five respondents get 30 minutes of vigorous physical activity three or more days a week (21.0 percent); 32.9 percent get 30 minutes of vigorous activity one to two days a week and 46.2 percent do not engage in vigorous physical activity for 30 minutes in an average week.

Figure 13. Number of days in an average week respondents engage in MODERATE and VIGOROUS activity

16.5 None 46.2

35.2 1 to 2 days 32.9

28.8 3 to 4 days 13.3

19.5 5 or more days 7.7

0 10 20 30 40 50 Percent*

MODERATE activity (N=380) VIGOROUS activity (N=377)

*Percentages may not total 100.0 due to rounding.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 21

Mental Health

Respondents were asked whether they have ever been told by a doctor or health professional that they have depression, anxiety or stress, panic attacks, or other mental health problems (Figure 14, Appendix Table 6). • One in five respondents have been diagnosed with depression by a doctor or health professional (22.3 percent); 20.0 percent have been diagnosed with anxiety or stress. • A small percentage of respondents were told they have panic attacks or other mental health problems (2.9 percent and 3.6 percent, respectively).

Figure 14. Percentage of respondents who have been told by a doctor or health professional that they have a mental health issue, by type of mental health issue

Depression 22.3

Anxiety/Stress 20.0

Other mental health problems 3.6

Mental health issue Panic attacks 2.9

0 10 20 30 40 50 Percent*

N=382 *Percentages do not total 100.0 due to multiple responses.

Respondents were asked to report how many days during the past month their mental health was not good (Figure 15, Appendix Table 7). • Half of respondents say their mental health was not good sometime during the past month (49.5 percent); including 32.0 percent who say their mental health was not good for about one week or less. One in 10 respondents say that their mental health was not good for at least half of the last month (10.1 percent).

Figure 15. Number of days in the last month that respondents’ mental health was not good

None 50.4

1 to 7 32.0

8 to 14 7.4

Number of days 15 to 21 7.1

22 to 31 3.0

0 20 40 60 80 100 Percent*

N=358 *Percentages do not total 100.0 due to rounding. 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 22

Respondents were asked to report how often over the last two weeks they had been bothered by two specific mental health issues (Figure 16, Appendix Table 8). • One in five respondents reported little interest or pleasure in doing things for several days in the past two weeks (18.9 percent); 2.2 percent expressed little interest or pleasure in doing things nearly every day. • One in six respondents say that for several days in the last two weeks they were feeling down, depressed or hopeless (17.9 percent); 2.9 percent say they feel down, depressed or hopeless more than half the days and 1.0 percent say they feel that way nearly every day.

Figure 16. How often, over the past two weeks, respondents have been bothered by mental health issues

77.2 Not at all 78.3

18.9 Several days 17.9

1.7 More than half the days 2.9

2.2 Nearly every day 1.0

0 20 40 60 80 100 Percent*

Little interest or pleasure in doing things (N=377) Feeling down, depressed or hopeless (N=372)

*Percentages may not total 100.0 due to rounding.

Tobacco Use

Respondents were asked whether they had smoked at least 100 cigarettes in their entire life (Figure 17, Appendix Table 9). • One in three respondents (33.1 percent) indicated they have smoked at least 100 cigarettes in their entire life.

Figure 17. Whether respondents have smoked at least 100 cigarettes in their entire life

Yes, 33.1%

No, 66.9%

N=379 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 23

Respondents were asked how often they currently smoke cigarettes or use chewing tobacco or snuff (Figure 18, Appendix Table 10). • A vast majority of respondents report they do not currently smoke cigarettes (92.1 percent) or use chewing tobacco or snuff (96.1 percent).

Figure 18. How often respondents currently smoke cigarettes and use chewing tobacco or snuff

4.7 Every day 1.1

3.2 Some days 2.7

92.1 Not at all 96.1

0 20 40 60 80 100 Percent*

Smoke cigarettes (N=382) Use chewing tobacco or snuff (N=377)

*Percentages may not total 100.0 due to rounding.

Respondents were asked where they would first go for help to quit using tobacco (Figure 19, Appendix Table 11). • One in 10 respondents say they would first go to their doctor if they wanted to quit smoking (9.9 percent); 5.9 percent would use Quitline.

Figure 19. Location respondents would first go if they wanted help to quit using tobacco

Quitline 5.9

Doctor 9.9

Pharmacy 0.6

Private counselor/therapist 0.1

Health Department 0.1

Don't know 7.2

Not applicable 71.9

I don't want to quit 0.5

Other* 3.8

0 20 40 60 80 100 Percent

N=349 *Other responses listed in Appendix Table 11.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 24

Alcohol Use and Prescription Drug/Non‐prescription Drug Abuse

Respondents were asked how many days in the past month they had at least one drink of any alcoholic beverage (Figure 20, Appendix Table 12). • Two in five respondents say they drank at least one alcoholic beverage from 1 to 7 days in the past month (39.2 percent); 20.1 percent say they drank an alcoholic beverage on more than half of the days in the past month. • One in four respondents did not have any alcohol during the past month (26.1 percent).

Figure 20. Number of days during the past month that respondents had at least one drink of any alcoholic beverage

None 26.1

1 to 7 39.2

8 to 14 14.6

Number of days 15 to 21 10.8

22 to 31 9.3

0 10 20 30 40 50 Percent N=376

Respondents who drank an alcoholic beverage during the past month were asked to report the average number of drinks per day that they consumed (Figure 21, Appendix Table 13). • Two in five respondents say they averaged one alcoholic beverage per day during the last month (42.0 percent); 51.9 percent of respondents averaged 2 to 4 alcoholic drinks per day and 6.1 percent averaged 5 or more drinks per day.

Figure 21. During the past month on days that respondents drank, average number of drinks per day respondents consumed

1 42.0

2 29.3

3 16.2

Number of drinks 4 6.4

5 or more 6.1

0 10 20 30 40 50 Percent N=277

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 25

Respondents were asked how many times during the past month they consumed at least 4 or 5 alcoholic drinks (4 for females, 5 for males) on the same occasion, also defined as binge drinking** (Figure 22, Appendix Table 14). • One in six respondents report binge drinking at least once a week (15.9 percent); including 3.1 percent who binge drink almost every day. • One in six respondents report binge drinking once a month (17.3 percent)

Figure 22. Number of times during the past month that respondents consumed at least 4 or 5 alcoholic drinks (4 for females, 5 for males) on the same occasion

Almost every day 3.1

2 to 3 times a week 4.8

Once a week 8.0

Once a month 17.3

Never 66.7

0 20 40 60 80 100 Percent*

N=379 *Percentages do not total 100.0 due to rounding. ** For information about binge drinking, visit the National Institute on Alcohol Abuse and Alcoholism, Drinking Levels Defined, http://www.niaaa.nih.gov/alcohol‐health/overview‐alcohol‐consumption/moderate‐binge‐drinking.

Respondents were asked whether they have ever had a problem with alcohol use and prescription or non‐ prescription drug abuse. • The vast majority of respondents report never having a problem with alcohol use (93.2 percent) (Figure 23, Appendix Table 15). • Nearly all respondents report not ever having a problem with prescription or non‐prescription drug abuse (99.9 percent).

Figure 23. Whether respondents have ever had a problem with alcohol use or prescription or non- prescription drug abuse

6.8 Alcohol use (N=376) 93.2

0.1 Prescription or non-prescription drug abuse (N=377) 99.9

0 20 40 60 80 100 Percent Yes No

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 26

Respondents who have ever had a problem with alcohol use or prescription or non‐prescription drug abuse were asked if they had gotten the help they needed (Figure 24, Appendix Table 16). • Most respondents who have had problems with alcohol indicated they didn’t need any help (43.8 percent). • One in four respondents who had a problem with alcohol use say they got the help they needed (25.6 percent); 30.5 percent did not get the help they needed. • No respondents reported needing help with prescription or non‐prescription drug abuse.

Figure 24. Of respondents who ever had a problem with alcohol use or prescription or non-prescription drug abuse, whether respondents got the help they needed

25.6 Alcohol use (N=25) 30.5 43.8

0.0 Prescription or non-prescription drug abuse (N=0) 0.0 0.0

0 10 20 30 40 50 Percent*

Yes No Didn't need help

*Percentages do not total 100.0 due to rounding.

Respondents were asked if alcohol use or prescription or non‐prescription drug abuse had harmful effects on themselves or a family member over the past two years (Figure 25, Appendix Table 17). • Although the vast majority of respondents say that alcohol use has not had harmful effects on themselves or a family member over the past two years (83.9 percent), 16.1 percent say they or a family member have suffered harmful effects from alcohol use. • The vast majority of respondents say that prescription or non‐prescription drug abuse has not had harmful effects on themselves or a family member over the past two years (94.2 percent); 5.8 percent say they or a family member have suffered harmful effects from prescription or non‐ prescription drug abuse.

Figure 25. Whether alcohol use or prescription or non-prescription drug abuse has had harmful effects on respondents or a family member over the past two years

Alcohol use had harmful effects on respondent or family 16.1 member (N=380) 83.9

Prescription or non-prescription drug abuse had harmful 5.8 effects on respondent or family member (N=380) 94.2

0 20 40 60 80 100 Yes No Percent

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 27

Preventive Health

Respondents were asked to indicate whether they had preventive screenings and procedures in the past year (Table 1). • Within the past year, a majority of respondents had a blood pressure screening, blood sugar screening, cholesterol screening, dental screening, flu shot, pelvic exam (females), breast cancer screening (females), and cervical cancer screening (females). • The majority of respondents did not receive a bone density test, cardio screening, glaucoma test, hearing screening, immunizations, STD test, vascular screening, colorectal cancer screening, prostate cancer screening (males), and skin cancer screening in the past year. • Many tests and screenings may be conditional upon guidelines, which can be age sensitive or appropriate. With that in mind, a number of tests and screenings were analyzed based on age. o With respect to the bone density test, older respondents are three times more likely than respondents overall to get tested. o Regarding the glaucoma test, older respondents are more likely than respondents overall to get tested/screened. o With respect to colorectal cancer screening, older respondents are nearly twice as likely as respondents overall to get screened. o Regarding the prostate cancer screening, older male respondents are nearly two times more likely than male respondents overall to get screened.

Table 1. Whether or not respondents have had preventive screenings in the past year, by type of screening Percent of respondents Type of screening Yes No Total GENERAL SCREENINGS Blood pressure screening (N=380) 84.3 15.7 100.0 Blood sugar screening (N=379) 58.7 41.3 100.0 Bone density test (N=367) 10.8 89.2 100.0 Cardiovascular screening (N=373) 26.4 73.6 100.0 Cholesterol screening (N=378) 62.3 37.7 100.0 Dental screening and X‐rays (N=378) 86.4 13.6 100.0 Flu shot (N=380) 62.1 37.9 100.0 Glaucoma test (N=374) 46.7 53.3 100.0 Hearing screening (N=377) 17.8 82.2 100.0 Immunizations (tetanus, hepatitis A or B) (N=374) 19.3 80.7 100.0 Pelvic exam (N=189 Females) 67.0 33.0 100.0 STD (N=369) 4.2 95.8 100.0 Vascular screening (N=368) 11.3 88.7 100.0 CANCER SCREENINGS Breast cancer screening (N= 189 Females) 65.2 34.8 100.0 Cervical cancer screening (N=185 Females) 63.4 36.6 100.0 Colorectal cancer screening (N=368) 32.3 67.7 100.0 Prostate cancer screening (N=182 Males) 39.4 60.6 100.0 Skin cancer screening (N=365) 22.5 77.5 100.0

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 28

Respondents who did not get preventive screenings, were asked to specify the reasons why they did not (Table 2). • For most types of screenings, the most common reasons for not getting the test or procedure are that it is not necessary and the doctor has not suggested one. • For dental screening and x‐rays, the most common reason for not being tested is cost (28.9 percent). • For the flu shot screening, most respondents cite other reasons for not getting the shot (51.6 percent).

Table 2. Of respondents who have not had preventive screenings in the past year, reasons why they have not, by type of screening Percent of respondents* Doctor Unable Not hasn’t Fear of Fear of to access Other Type of screening necessary suggested Cost procedure results care reason GENERAL SCREENINGS Blood pressure screening (N=60) 60.8 23.0 5.5 0.0 0.0 0.8 21.3 Blood sugar screening (N=157) 49.6 36.8 2.1 0.0 0.0 0.4 6.7 Bone density test (N=327) 48.8 44.6 1.1 0.0 0.0 0.2 3.6 Cardiovascular screening (N=274) 45.4 47.3 2.9 0.0 0.0 1.5 3.8 Cholesterol screening (N=143) 50.7 35.8 4.6 0.0 0.0 0.1 10.5 Dental screening and X‐rays (N=52) 23.1 9.0 28.9 14.7 0.4 0.0 33.4 Flu shot (N=144) 40.9 3.9 0.3 0.7 1.3 0.3 51.6 Glaucoma test (N=199) 51.9 23.9 4.0 0.0 0.0 0.1 17.6 Hearing screening (N=310) 54.2 36.1 1.8 0.0 0.1 0.0 6.4 Immunizations (N=302) 67.6 21.9 1.3 0.0 0.0 0.0 6.6 Pelvic exam (N=62 Females) 60.2 12.1 1.6 0.7 0.0 0.0 14.3 STD (N=353) 84.9 7.2 0.0 0.0 0.0 0.0 2.8 Vascular screening (N=326) 56.0 34.3 1.2 1.0 0.0 0.2 4.7 CANCER SCREENINGS Breast cancer screening (N=66 Females) 35.5 28.3 11.4 0.0 5.0 0.0 20.0 Cervical cancer screening (N=68 Females) 53.6 24.9 0.0 0.0 0.0 0.0 9.2 Colorectal cancer screening (N=249) 54.1 25.2 1.0 4.7 0.3 0.0 14.8 Prostate cancer screening (N=110 Males) 44.1 38.9 0.6 3.9 0.2 0.0 13.4 Skin cancer screening (N=282) 46.4 38.7 1.6 0.2 1.2 1.3 9.2 *Percentages do not total 100.0 due to multiple responses.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 29

Respondents were asked to report whether they have any chronic diseases (Figure 26, Appendix Table 18). • The top four chronic diseases that respondents reported having are: o High cholesterol (19.8 percent) o Hypertension (15.1percent) o Arthritis (14.9 percent) o Diabetes (6.2 percent).

Figure 26. Whether respondents have any of the following chronic diseases

High cholesterol 19.8

Hypertension 15.1

Arthritis 14.9

Diabetes 6.2

Cancer 5.1

Asthma 3.5

COPD 1.3

Congestive Heart Failure 0.8

Stroke 0.8

Alzheimer's 0.1

0 10 20 30 40 50 Percent*

N=382 *Percentages do not total 100.0 due to multiple responses.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 30

Respondents were asked how long it had been since they last visited a doctor or health care provider for a routine physical exam and how long it had been since they last visited a dentist or dental clinic for any reason (Figure 27, Appendix Table 19). • Three in four respondents say they have visited a doctor or health care provider within the past year (73.0 percent); 13.8 percent say it has been, at most, 2 years and 2.8 percent say it has been 6 or more years since they have visited a doctor or health care provider for a routine physical exam. Two percent say they have never visited a doctor or health care provider for a routine physical exam (1.9 percent). • The vast majority of respondents say they have visited a dentist or dental clinic within the past year (87.2 percent); 4.8 percent say it has been, at most, 2 years and 1.6 percent say it has been 6 or more years since they last visited a dentist or dental clinic.

Figure 27. Length of time since respondents last visited a doctor or health care provider for a routine physical exam and length of time since they last visited a dentist or dental clinic for any reason

73.0 Within the past year 87.2

13.8 1 to 2 years 4.8

7.1 3 to 5 years 5.0

2.8 6 or more years 1.6

1.5 Don't know 1.3

1.9 Never 0.2

0 20 40 60 80 100 Percent*

Doctor or health care provider (N=382) Dentist or dental clinic (N=381)

*Percentages do not total 100.0 due to rounding.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 31

Respondents were asked where they get most of their health information (Figure 28, Appendix Table 20). • Four in five respondents get most of their health information from a medical professional (79.9 percent); 32.1 percent of respondents say they get most of their health information from a non‐ government website; 29.9 percent get their health information from family or friends; and 21.1 percent get health information from magazines, newspapers, or books.

Figure 28. Where respondents get most of their health information

Medical professional 79.9

32.1

Family or friends 29.9

Magazine, newspapers, or books 21.1

Television 16.8

Government websites (i.e., local public health, CDC) 8.3

Alternative health specialist 5.9

Health Helpline (telephone) 3.3

Other** 5.1

0 20 40 60 80 100 Percent*

N=382 *Percentages do not total 100.0 due to multiple responses. **Other responses listed in Appendix Table 20.

Respondents were asked their preferred way to access technology for health information (Figure 29, Appendix Table 21). • Four in five respondents say that a personal computer or tablet is the best way to access technology for health information (82.7 percent), 22.9 percent say a smart phone, and 1.2 percent say a public computer is the best way to access technology for health information.

Figure 29. Best way for respondents to access technology for health information

Personal computer or tablet 82.7

Smart phone 22.9

Public computer (e.g., library, community center) 1.2

Other** 4.7

0 20 40 60 80 100 Percent*

N=382 *Percentages do not total 100.0 due to multiple responses. **Other responses listed in Appendix Table 21. 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 32

Demographic Information

• The majority of respondents are 18 to 54 years of age (72.1 percent); 13.8 percent are ages 55 to 64, and 14.2 percent are 65 years or older (Figure 30, Appendix Table 22).

Figure 30. Age of respondents

Prime labor force (18 to 54 years of age) 72.1

Pre-retirees (55 to 64 years of age) 13.8

Retirees (65 years or older) 14.2

0 20 40 60 80 100 Percent*

N=382 *Percentages do not total 100.0 due to rounding.

• Half of respondents (55.2 percent) have a Bachelor’s degree or higher, including 20.2 percent who have a graduate or professional degree (Figure 31, Appendix Table 23).

Figure 31. Highest level of education of respondents

Some high school 0.1

High school diploma or GED 10.4

Some college, no degree 16.8

Associate's degree 17.1

Bachelor's degree 35.0

Graduate or professional degree 20.2

Prefer to not answer 0.4

0 10 20 30 40 50 Percent

N=379

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 33

• The gender of respondents is evenly split between males and females (Figure 32, Appendix Table 24).

Figure 32. Gender of respondents

Male Female 50.1% 49.9%

N=382

• Nearly all respondents are white (97.3 percent) (Figure 33, Appendix Table 25).

Figure 33. Race and ethnicity of respondents

White 97.3

Hispanic 0.9

Black or African American 0.2

Native American or Alaska Native 0.1

Asian or Pacific Islander 0.1

Prefer to not answer 1.3

0 20 40 60 80 100 Percent*

N=372 *Percentages do not total 100.0 due to multiple responses.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 34

• The majority of respondents (61.1 percent) have an annual household income of $70,000 or more, including 30.8 percent who have incomes of $120,000 or more (Figure 34, Appendix Table 26).

Figure 34. Annual household income of respondents

Less than $20,000 3.2

$20,000 to $39,999 9.5

$40,000 to $69,999 16.2

$70,000 to $119,999 30.3

$120,000 or more 30.8

Prefer to not answer 10.0

0 10 20 30 40 50 Percent

N=378

• The majority of respondents are employed for wages (65.9 percent), 11.1 percent are self‐ employed, and 15.6 percent are retired (Figure 35, Appendix Table 27).

Figure 35. Employment status of respondents

Employed for wages 65.9

Self-employed 11.1

Homemaker 3.8

Retired 15.6

A student 2.7

Unable to work 0.8

Out of work - less than 1 year 0.0

Out of work - 1 year or more 0.1

0 20 40 60 80 100 Percent

N=371

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 35

• The vast majority of respondents have lived in their community for more than 5 years (91.3 percent) (Figure 36, Appendix Table 28).

Figure 36. Length of time respondents have lived in their community

Less than 2 years 3.7

2 to 5 years 5.0

More than 5 years 91.3

0 20 40 60 80 100 Percent

N=381

• The vast majority of respondents own their home (93.3 percent) (Figure 37, Appendix Table 29).

Figure 37. Whether respondents own or rent their home

Own 93.3

Rent 6.6

Prefer to not answer 0.1

Other 0.0

0 20 40 60 80 100 Percent

N=381

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 36

• Nearly all respondents report having some form of health insurance (99.0 percent); 76.5 percent report having oral health or dental care insurance coverage (Figure 38, Appendix Table 30).

Figure 38. Whether respondents have health insurance (private, public, or governmental) and oral health or dental care insurance coverage

99.0 Health insurance (Private, public, or 1.0 governmental) (N=378) 0.0

76.5 Oral health or dental care insurance coverage 23.3 (N=381) 0.2

0 20 40 60 80 100 Percent

Yes No Don't Know

• Half of respondents (53.4 percent) say they have one person who they think of as their personal doctor or health care provider; 28.5 percent say they have more than one person and 18 percent say they do not have a personal doctor or health care provider (Figure 39, Appendix Table 31).

Figure 39. Whether respondents have one person who they think of as their personal doctor or health care provider

Yes, only one 53.4

Yes, more than one 28.5

No 18.0

Don't know 0.1

0 20 40 60 80 100 Percent

N=379

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 37

• The majority of respondents most often go to a physician’s office when they are sick (66.2 percent); 28.4 percent say they go to urgent care (Figure 40, Appendix Table 32). • Respondents who are parents most often take their children to a physician’s office when they are sick (63.5 percent); 28.8 percent take their sick children to urgent care and 7.8 percent utilize other free or discounted clinics.

Figure 40. Facilities that respondents go to most often when sick and take their children when they are sick

66.2 Physician's office 63.5

28.4 Urgent care 28.8

0.0 Public Health Department 0.0

1.6 Hospital emergency room 0.0

3.8 Other free or discounted clinic 7.8

0 20 40 60 80 100 Percent*

Where respondents go (N=367) Where respondents take their children (N=173)**

*Percentages may not total 100.0 due to rounding. **Of respondents who have children younger than age 18 living in their household.

• Nearly half of respondents have children younger than 18 living in their household (46.6 percent); including 35.8 percent who have 1 to 2 children and 10.8 percent who have 3 or more children (Figure 41, Appendix Table 33). • A vast majority of the respondents do not have adults aged 65 or older living in their household (82.0 percent).

Figure 41. Number of children younger than 18 and number of adults age 65 or older living in respondents’ household

53.4 None 82.0

35.8 1 to 2 17.9

10.8 3 to 5 0.1

0.0 6 or more 0.0

0 20 40 60 80 100 Percent

Children younger than 18 (N=373) Adults 65 or older (N=377)

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 38

Respondents who have children younger than 18 years living in their household were asked whether all children in their home are current on their immunizations and whether all children age 6 months or older get a flu shot or flu mist each year (Figure 42, Appendix Table 34). • Almost all the respondents with children in their home say all children younger than 18 years are current on immunizations (98.1 percent). • Nearly three‐fourths of the respondents with children say all children age 6 months or older get a flu shot or flu mist each year each year (73.5 percent); 26.0 percent say the children do not get a flu shot or flu mist each year.

Figure 42. Whether all children in home are current on their immunizations and all children age 6 months or older get a flu shot or flu mist each year*

Yes 98.1 73.5

No 1.9 26.0

0.0 Don't know 0.5

0.0 Not applicable 0.0

0 20 40 60 80 100 Percent

Children are current on immunizations (N=174) Children age 6 months or older get flu shot or flu mist each year (N=174)

*Of respondents who have children younger than age 18 living in their household.

Table 3. Location of respondents based on zip code Percent of respondents* Cass County, ND 69.3% North Fargo 11.5% South Fargo 30.1% West Fargo 14.5% Rural 13.2%

Clay County, MN 28.4% Moorhead 16.3% Rural 12.1%

Unknown or missing 2.7% N=382 *Percentages do not total 100.0 due to rounding.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 39

APPENDICES

Appendix Table 1. Level of concern with statements about the community regarding general health and wellness Percent of respondents* Level of concern (1=not at all, 5= a great deal) Statements Mean 1 2 3 4 5 Total ECONOMICS Availability of affordable housing (N=375) 2.99 15.0 20.5 29.1 21.6 13.8 100.0 Homelessness (N=377) 3.23 13.3 12.1 30.7 25.8 18.1 100.0 Hunger (N=377) 3.22 9.9 18.9 25.5 30.5 15.3 100.1 TRANSPORTATION Availability of public transportation (N=375) 2.55 25.1 22.4 28.1 20.8 3.7 100.1 Cost of public transportation (N=372) 2.45 28.8 22.2 29.3 14.2 5.5 100.0 Driving habits (e.g., speeding, road rage) (N=373) 3.12 13.1 16.9 29.9 24.7 15.3 99.9 Availability of good walking or biking options (as alternatives to driving)(N=377) 3.01 13.2 22.3 28.3 22.8 13.4 100.0 The ENVIRONMENT Water quality (N=378) 3.41 17.8 12.1 15.6 20.5 34.0 100.0 Air quality (N=378) 3.00 23.4 15.6 18.7 22.4 20.0 100.1 Home septic systems (N=374) 2.40 38.3 18.5 19.0 12.7 11.4 99.9 Hazardous waste (N=378) 2.96 19.0 15.3 32.2 17.8 15.7 100.0 CHILDREN AND YOUTH Availability of services for at‐risk youth (N=371) 3.13 9.3 18.1 36.1 23.0 13.5 100.0 Cost of services for at‐risk youth (N=369) 3.18 9.6 16.4 35.4 24.0 14.6 100.0 Youth crime (N=368) 3.49 4.6 12.9 31.6 30.4 20.5 100.0 School dropout rates (N=370) 3.12 10.1 16.3 37.5 23.4 12.8 100.1 School absenteeism (N=369) 2.94 15.0 18.8 35.2 19.5 11.5 100.0 Teen pregnancy (N=370) 3.14 7.5 21.2 34.9 22.2 14.1 99.9 Bullying (N=371) 3.82 4.8 8.8 17.4 37.7 31.3 100.0 Availability of activities for children and youth (N=367) 3.39 8.4 15.4 26.7 28.1 21.5 100.1 Cost of activities for children and youth (N=367) 3.44 5.3 13.3 32.9 29.4 19.1 100.0 Availability of quality child care (N=369) 3.40 9.6 15.3 22.8 30.8 21.6 100.1 Cost of quality child care (N=370) 3.53 10.2 10.0 21.4 33.7 24.8 100.1 Availability of quality infant care (birth to 2 years) (N=370) 3.40 13.4 11.3 22.8 27.3 25.2 100.0 Cost of quality infant care (N=365) 3.50 11.8 9.1 25.3 25.6 28.3 100.1 THE AGING POPULATION Availability of activities for seniors (N=375) 3.23 7.6 15.9 32.7 33.1 10.7 100.0 Cost of activities for seniors (N=374) 3.15 9.5 20.3 30.2 25.6 14.4 100.0 Availability of resources to help the elderly stay safe in their homes (N=370) 3.40 8.2 15.6 23.7 32.8 19.8 100.1 Availability of resources for family/friends caring for and making decisions for elders (N=375) 3.44 6.9 16.9 21.4 34.8 19.9 99.9 Availability of resources for grandparents caring for grandchildren (N=372) 3.18 10.0 17.0 32.2 26.1 14.6 99.9 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 40

Percent of respondents* Level of concern (1=not at all, 5= a great deal) Statements Mean 1 2 3 4 5 Total Availability of long term care (N=377) 3.51 8.4 16.1 18.8 29.7 27.0 100.0 Cost of long term care (N=378) 4.11 4.8 5.6 14.5 24.1 51.1 100.1 Availability of memory care (N=377) 3.63 6.2 10.5 24.6 31.0 27.7 100.0 SAFETY Child abuse and neglect (N=376) 3.72 3.0 15.1 20.2 30.1 31.6 100.0 Elder abuse (N=377) 3.40 6.8 19.1 22.3 31.3 20.5 100.0 Domestic violence (N=377) 3.72 2.8 10.8 28.2 28.2 30.0 100.0 Presence of street drugs, prescription drugs, and alcohol in the community (N=374) 3.84 1.5 13.6 20.6 28.2 36.1 100.0 Presence of drug dealers in the community (N=378) 3.73 6.8 10.6 22.7 22.3 37.6 100.0 Presence of gang activity (N=376) 3.48 10.0 12.4 26.8 20.8 30.0 100.0 Crime (N=375) 3.74 3.1 11.5 23.6 31.6 30.1 99.9 Sex trafficking (N=376) 3.50 9.7 15.0 20.8 25.0 29.6 100.1 HEALTH CARE Access to affordable health care (N=378) 3.92 4.3 9.9 14.0 33.6 38.2 100.0 Access to affordable prescription drugs (N=377) 3.90 3.6 10.2 18.0 28.8 39.4 100.0 Access to affordable health insurance (N=374) 4.04 2.2 8.2 16.7 29.5 43.4 100.0 Cost of affordable vision insurance (N=377) 3.66 5.8 11.6 22.7 30.0 29.9 100.0 Cost of affordable dental insurance coverage (N=376) 3.83 4.2 11.9 16.5 32.0 35.4 100.0 Distance to health care services (N=376) 2.66 22.4 25.2 27.8 12.7 11.8 99.9 Providers not taking new patients (N=375) 3.12 12.9 19.0 28.3 22.8 17.1 100.1 Coordination of care between providers and services (N=372) 3.14 10.2 22.8 24.6 28.1 14.3 100.0 Availability of non‐traditional hours (e.g., evenings, weekends) (N=377) 3.14 9.2 17.3 36.1 25.5 12.0 100.1 Availability of transportation (N=377) 2.74 19.3 19.0 39.7 12.6 9.5 100.1 Use of emergency room services for primary health care (N=373) 3.27 15.1 12.9 22.6 28.7 20.7 100.0 Timely access to vision care providers (N=372) 2.56 22.9 23.7 33.8 13.4 6.1 99.9 Timely access to dental care providers (N=376) 2.79 17.8 22.0 33.6 16.9 9.6 99.9 Timely access to prevention programs and services (N=366) 2.66 19.9 24.3 33.0 15.6 7.2 100.0 Timely access to bilingual providers and/or translators (N=370) 2.11 38.9 26.9 22.5 7.9 3.8 100.0 Timely access to transportation (N=363) 2.37 28.5 26.2 30.1 10.2 5.0 100.0 Timely access to doctors, physician assistants, or nurse practitioners (N=378) 3.30 7.0 17.5 29.5 30.3 15.7 100.0 Timely access to physician specialists (N=375) 3.29 8.8 17.1 27.2 30.7 16.3 100.1 Timely access to registered dietitians (N=361) 2.32 29.5 27.6 29.1 9.5 4.3 100.0 Timely access to exercise specialists or personal trainers (N=367) 2.22 35.3 24.2 27.2 9.6 3.6 99.9 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 41

Percent of respondents* Level of concern (1=not at all, 5= a great deal) Statements Mean 1 2 3 4 5 Total Timely access to mental health providers (N=372) 2.98 17.7 20.5 23.6 22.5 15.7 100.0 Timely access to substance abuse providers (N=369) 2.87 20.1 20.6 25.1 20.7 13.6 100.1 PHYSICAL AND MENTAL HEALTH Obesity (N=375) 3.64 5.1 9.5 27.5 31.9 26.0 100.0 Poor nutrition and eating habits (N=377) 3.62 4.9 9.6 28.4 33.2 23.9 100.0 Inactivity and lack of exercise (N=376) 3.78 3.8 8.4 26.1 29.3 32.3 99.9 Cancer (N=372) 3.97 4.0 3.1 23.6 30.9 38.4 100.0 Chronic disease (e.g., diabetes, health disease, multiple sclerosis) (N=377) 3.81 4.8 3.9 27.2 34.0 30.1 100.0 Sexually transmitted diseases (e.g., AIDS, HIV, chlamydia) (N=370) 2.92 14.4 23.5 30.5 18.7 13.0 100.1 Infectious diseases such as the flu (N=374) 3.50 1.8 14.8 33.9 30.6 18.8 99.9 Dementia and Alzheimer’s disease (N=374) 3.76 1.7 10.5 26.0 33.1 28.7 100.0 Depression (N=378) 3.78 4.5 6.2 25.5 34.4 29.4 100.0 Stress (N=377) 3.65 3.3 8.7 33.4 28.6 26.0 100.0 Suicide (N=376) 3.38 11.9 13.7 25.3 22.4 26.7 100.0 Other psychiatric diagnosis (N=373) 3.11 11.0 18.4 33.6 22.1 14.8 99.9 SUBSTANCE USE AND ABUSE Alcohol use and abuse (N=377) 3.52 8.3 10.1 27.2 29.4 24.9 99.9 Drug use and abuse (N=377) 3.53 7.7 12.5 25.6 27.4 26.8 100.0 Underage drinking (N=376) 3.54 6.6 13.1 25.2 29.7 25.4 100.0 Underage drug use and abuse (N=376) 3.66 6.1 10.4 22.0 34.1 27.4 100.0 Smoking and tobacco use (N=377) 3.44 8.8 12.8 25.9 30.4 22.2 100.1 Exposure to second‐hand smoke (N=377) 3.37 12.1 15.8 21.0 25.4 25.6 99.9 *Percentages may not total 100.0 due to rounding.

Appendix Table 2. Respondents’ rating of their health in general Percent of Response respondents* Excellent 11.2 Very Good 41.3 Good 37.0 Fair 9.1 Poor 1.4 Don’t know 0.1 Total 100.1 N=367 *Percentages do not total 100.0 due to rounding.

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Appendix Table 3. Respondents’ weight status based on the Body Mass Index (BMI)* scale Percent of Weight/BMI status respondents Underweight = (BMI less than 18.5) 0.5 Normal weight = (BMI from 18.5 to 24.9) 38.2 Overweight = (BMI from 25.0 to 29.9) 31.7 Obese = (BMI of 30.0 or greater) 29.6 Total 100.0 N=346 *For information about the BMI, visit the Centers for Disease Control and Prevention, About BMI for Adults, http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/.

Appendix Table 4. Number of servings of vegetables, fruit, and fruit juice that respondents had yesterday Percent of respondents Number of servings 5 or Type of servings None 1 2 3 4 more Total Vegetables consumed yesterday (N=381) 7.6 36.6 31.7 14.8 8.1 1.2 100.0 Fruit consumed yesterday (N=378) 19.2 29.7 31.0 16.0 3.0 1.1 100.0 Fruit juice consumed yesterday (N=382) 55.7 30.6 10.2 1.6 1.6 0.3 100.0

Appendix Table 5. Number of days in an average week respondents engage in MODERATE and VIGOROUS physical activity Percent of respondents Number of days 1 to 2 3 to 4 5 or Type of exercise None days days more days Total At least 30 minutes of MODERATE activity in an average week (N=380) 16.5 35.2 28.8 19.5 100.0 At least 30 minutes of VIGOROUS activity in an average week (N=377) 46.2 32.9 13.3 7.7 100.1 *Percentages may not total 100.0 due to rounding.

Appendix Table 6. Percentage of respondents who have been told by a doctor or health professional that they have a mental health issue, by type of mental health issue Percent of Mental health issue respondents* Depression 22.3 Anxiety/Stress 20.0 Other mental health problems 3.6 Panic attacks 2.9 N=382 *Percentages do not total 100.0 due to multiple responses.

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Appendix Table 7. Number of days in last month when respondents’ mental health was not good Percent of Number of days respondents* None 50.4 1 to 7 days 32.0 8 to 14 days 7.4 15 to 21 days 7.1 22 to 31 days 3.0 Total 99.9 N=358 *Percentages do not total 100.0 due to rounding.

Appendix Table 8. How often, over the past two weeks, respondents have been bothered by mental health issues Percent of respondents* More than Not Several half the Nearly Issues at all days days every day Total Little interest or pleasure in doing things (N=377) 77.2 18.9 1.7 2.2 100.0 Feeling down, depressed or hopeless (N=372) 78.3 17.9 2.9 1.0 100.1 *Percentages may not total 100.0 due to rounding.

Appendix Table 9. Whether respondents have smoked at least 100 cigarettes in their entire life Percent of Response respondents Yes 33.1 No 66.9 Total 100.0 N=379

Appendix Table 10. How often respondents currently smoke cigarettes and use chewing tobacco or snuff Percent of respondents* Every Some Not Tobacco use day days at all Total How often do you currently smoke cigarettes? (N=382) 4.7 3.2 92.1 100.0 How often do you currently use chewing tobacco or snuff? (N=377) 1.1 2.7 96.1 99.9 *Percentages may not total 100.0 due to rounding.

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Appendix Table 11. Location respondents would first go if they wanted help to quit using tobacco Percent of Resources respondents Quitline 5.9 Doctor 9.9 Pharmacy 0.6 Private counselor/therapist 0.1 Health Department 0.1 Don’t know 7.2 Not applicable 71.9 I don’t want to quit 0.5 Other: 3.8 Would quit by themselves/Cold Turkey (10) Don’t smoke (4) Family doctor ND Quits helpline N=349

Appendix Table 12. Number of days during the past month that respondents have had at least one drink of any alcoholic beverage Percent of Number of days respondents None 26.1 1 to 7 days 39.2 8 to 14 days 14.6 15 to 21 days 10.8 22 to 31 days 9.3 Total 100.0 N=376

Appendix Table 13. During the past month on days when respondents drank, average number of drinks per day respondents consumed Percent of Number of drinks respondents 1 42.0 2 29.3 3 16.2 4 6.4 5 or more 6.1 Total 100.0 N=277

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Appendix Table 14. Number of times during the past month that respondents consumed at least 4 or 5 alcoholic drinks (4 for females, 5 for males) on the same occasion Percent of Number of days respondents* Almost every day 3.1 2 to 3 times a week 4.8 Once a week 8.0 Once a month 17.3 Never 66.7 Total 99.9 N=379 *Percentages do not total 100.0 due to rounding.

Appendix Table 15. Whether respondents have ever had a problem with alcohol use or prescription or non‐ prescription drug abuse Percent of respondents Had a problem with… Yes No Total Alcohol use (N=376) 6.8 93.2 100.0 Prescription or non‐prescription drug abuse (N=377) 0.1 99.9 100.0

Appendix Table 16. Of respondents who have ever had a problem with alcohol use or prescription or non‐ prescription drug abuse, whether respondents got the help they needed Percent of respondents* Didn’t need Got help needed for… Yes No help Total Alcohol use (N=25) 25.6 30.5 43.8 99.9 Prescription or non‐prescription drug abuse (N=0) 0.0 0.0 0.0 0.0 *Percentages do not total 100.0 due to rounding.

Appendix Table 17. Whether alcohol use or prescription or non‐prescription drug abuse has had harmful effects on respondents or a family member over the past two years Percent of respondents Over the past two years… Yes No Total Has alcohol use had harmful effects on you or a family member? (N=380) 16.1 83.9 100.0 Has prescription or non‐prescription drug abuse had harmful effects on you or a family member? (N=380) 5.8 94.2 100.0

Appendix Table 18. Whether respondents have any of the following chronic diseases Percent of Chronic diseases respondents* Diabetes 6.2 Hypertension 15.1 High Cholesterol 19.8 Congestive Heart Failure 0.8 COPD 1.3 Arthritis 14.9 Alzheimer’s 0.1 Asthma 3.5 Stroke 0.8 Cancer 5.1 N=382 *Percentages do not total 100.0 due to multiple responses.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 46

Appendix Table 19. Length of time since respondents last visited a doctor or health care provider for a routine physical exam and length of time since they last visited a dentist or dental clinic for any reason Percent of respondents Within the 1 to 2 3 to 5 6 or more Don’t Length of time since… past year years years years know Never Total Respondents last visited a doctor or health care provider for a routine physical exam (N=382) 73.0 13.8 7.1 2.8 1.5 1.9 100.1 Respondents last visited a dentist or dental clinic for any reason (N=381). 87.2 4.8 5.0 1.6 1.3 0.2 100.1 *Percentages do not equal 100.0 due to rounding.

Appendix Table 20. Where respondents gets most of their health information Percent of Source of health information respondents* Government websites (i.e., local public health, CDC) 8.3 Non‐government websites (i.e., WebMD) 32.1 Television 16.8 Magazine, newspapers, or books 21.1 Medical professional 79.9 Alternative health specialist 5.9 Family or friends 29.9 Health Helpline (telephone) 3.3 Other: 5.1 Medical journals (2) Mayo newsletter (2) My doctor Libraries Radio Web services N=382 *Percentages do not equal 100.0 due to multiple responses.

Appendix Table 21. Best way for respondents to access technology for health information Percent of Type of technology respondents* Personal computer or tablet 82.7 Public computer (e.g., library, community center) 1.2 Smart phone 23.0 Other: 4.7 Books and other reading materials (8) Doctors, nurses, medical professionals (6) Research VA [Veteran’s Administration] Don’t use technology Regular landline telephone N=382 *Percentages do not equal 100.0 due to multiple responses.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 47

Appendix Table 22. Age of respondents Percent of Age respondents* 18 to 54 years (Prime labor force) 72.1 55 to 64 years (Pre‐retirees) 13.8 65 years and older (Retirees) 14.2 Total 100.1 N=382 *Percentages do not total 100.0 due to rounding.

Appendix Table 23. Highest level of education of respondents Percent of Education respondents Some high school 0.1 High school diploma or GED 10.4 Some college, no degree 16.8 Associate’s degree 17.1 Bachelor’s degree 35.0 Graduate or professional degree 20.2 Prefer to not answer 0.4 Total 100.0 N=379

Appendix Table 24. Gender of respondents Percent of Gender respondents Male 50.1 Female 49.9 Prefer to not answer 0.0 Total 100.0 N=382

Appendix Table 25. Race and ethnicity of respondents Percent of Race/ethnicity respondents* White 97.3 Black or African American 0.2 Native American or Alaska Native 0.1 Asian or Pacific Islander 0.1 Hispanic 0.9 Prefer to not answer 1.3 Total 99.9 N=372 *Percentages do not total 100.0 due to multiple responses.

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 48

Appendix Table 26. Annual household income of respondents Percent of Annual household income respondents Less than $20,000 3.2 $20,000 to $39,999 9.5 $40,000 to $69,999 16.2 $70,000 to $119,999 30.3 $120,000 or more 30.8 Prefer to not answer 10.0 Total 100.0 N=378

Appendix Table 27. Employment status of respondents Percent of Employment status respondents Employed for wages 65.9 Self‐employed 11.1 Homemaker 3.8 Retired 15.6 A student 2.7 Unable to work 0.8 Out of work – less than 1 year 0.0 Out of work – 1 year or more 0.1 Total 100.0 N=371

Appendix Table 28. Length of time respondents have lived in their community Percent of Length of time in community respondents Less than 2 years 3.7 2 to 5 years 5.0 More than 5 years 91.3 Total 100.0 N=381

Appendix Table 29. Whether respondents own or rent their home Percent of Response respondents Own 93.3 Rent 6.6 Prefer to not answer 0.1 Other 0.0 Total 100.0 N=381

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Appendix Table 30. Whether respondents have health insurance (private, public, or governmental) and oral health or dental care coverage Percent of respondents Have health insurance Have oral health or dental care Response (N=378) coverage (N=381) Yes 99.0 76.5 No 1.0 23.3 Don’t know 0.0 0.2 Total 100.0 100.0

Appendix Table 31. Whether respondents have one person who they think of as their personal doctor or health care provider Percent of Response respondents Yes, only one 53.4 Yes, more than one 28.5 No 18.0 Don’t know 0.1 Total 100.0 N=379

Appendix Table 32. Facilities that respondents go to most often when sick and take their children when they are sick Percent of respondents* Where respondents go Where respondents take their Location (N=367) children (N=173) Physician’s office 66.2 63.5 Urgent care 28.4 28.8 Public Health Department 0.0 0.0 Hospital emergency room 1.6 0.0 Other free or discounted clinic 3.8 7.8 Total 100.0 100.1 *Percentages may not total 100.0 due to rounding.

Appendix Table 33. Number of children younger than 18 and number of adults age 65 or older living in respondents’ household Percent of respondents Children younger than 18 in Adults 65 or older in household Number of children/adults household (N=373) (N=377) None 53.4 82.0 1 to 2 35.8 17.9 3 to 5 10.8 0.1 6 or more 0.0 0.0 Total 100.0 100.0

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Appendix Table 34. Whether all children in home are current on their immunizations and all children age 6 months or older get a flu shot or flu mist each year* Percent of respondents Children are current on Children 6 months or older get immunizations flu shot or flu mist each year Response (N=174) (N=174) Yes 98.1 73.5 No 1.9 26.0 Don’t know 0.0 0.5 Not applicable 0.0 0.0 Total 100.0 100.0 *Of respondents who have children younger than 18 years of age living in their household.

Appendix Table 35. Additional comments by respondents Comments At 86+ with no family in this area, I feel rather cut off. Wife passed lot of years ago after 50+ years together. Still have problems being alone. Have 2 miniature dachshunds for loving company. Becoming fearful of being attacked in my home. Have medic alert instrument. Have great disillusionment of government and fear of Muslim religion. Fargo needs to stop putting so much money into sports (NDSU) and give the community other options for family activities that don’t cost a lot of money. Our zoo is a joke. Why not help expand and make it affordable for a family of limited funds? Bismarck and Minot have great zoos. Why can’t Fargo? Also camping facilities are needed. How about bus service on Sunday's for those who work? I use the Moorhead tech dental hygiene program for exams and cleaning but, there could be dental care with affordable fees for children, older adults and others without insurance. While many new 'dental places' have opened, they are too expensive to use. For me one tooth repair, root canal and crown on an important molar cost $2800. I had to take out a loan to pay this bill which added more. Could we get some basic affordable dental care without the frills? Thank you for this survey. I believe community resources need to be focused on children’s prevention programs, education, health care, nutrition, etc., as senior citizens generally have more of their own resources and can provide these things for themselves. I do not feel that our MDs and family physicians and some specialists care too much about people over 80. It is so evident in care and attitudes. Some should not be MDs. Being a BSNE graduate I have worked for many years with good MDs and today am very disappointed. I've paid my health insurance through my job as a union employee, but with new health care laws I'm going to be taxed because I want the best health care available, this is wrong. I've worked hard for this and because it's a Cadillac plan the legislature thinks it's a premium. It is a rather skewed demographic that ignores the LGBT health needs. Why is there no information requested concerning the health needs of these marginalized people? My [medical facility] doctor and nurse have neglected to give me a yearly exam. I sit in a room, on a chair, fully clothed. No exam. The nurse told me to stop taking my medicine and that I did not have Epilepsy and refuses to code as such. Medicare and Medicaid, therefore, don’t have proper coding and I don’t get exam and coverage. [Retirement facility] provides nurses everyday who follow doctor recommended medication. The health office has nurses [to] help 24 hours a day. So I feel I have several persons watching my health and following plans offered by doctors. Records of pills are on list for what medication I regularly take. I touch base daily with doctors. Too many refugees are using up monies in our social programs. We have American citizens that are going without because of the refugees draining the system. American citizens are going to bed hungry are homeless in Fargo. In regard to Q18, 19, and Q28 and 30, my husband died 2 months ago of Alzheimer's and COPD. I have been his caregiver along with his sister who also has Alzheimer's ‐ 13 years. These issues brought about alcohol and mental health issues which have been resolved. In regards to questions 19 and 20, my wife had health problems, my sister had back surgery and my niece died from cancer. It has been a stressful month! Normally, I am very upbeat and happy with the way my life is going. There are lots of buildings sitting empty in Moorhead that would work to serve the homeless with not too much expense. 2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 51

I have a neighbor that has 3 dogs and they don’t clean up after them. People don’t know what a garbage can is. Whenever they are done with what they are eating or drinking, they just throw it on the ground. I pick up stuff constantly in my yard. But these things are a health hazard. I’ve tried to remedy it but I’m not getting help from above. The need for some form of affordable dental care is very important. The U.S. should provide free health care to all citizens. Big business is greedy. There are NO questions about developmental disability services ‐ glaring omission ‐ SHAMEFUL. I truly believe this area needs more assistance with help for alcoholism, drug abuse and mental illness. There should be questions regarding abortion as well. Questions regarding vaccination preference. I am 84 years old. I get my health care at the VA. I think they take good care of me. I get wonderful care at the VA Hospital. Vaccination a huge problem today. Why did you gloss over weight? That is more pervasive in our society. You forgot to ask if the health care, dental care, etc. I have is affordable. It is not, we can barely afford it. I am very lucky ‐ am not sick often. Enforce snow and ice removal from sidewalks. No easy follow up for health questions. It would be appreciated if the results of this survey would be made public and also any action plans that are formulated. As a former health care administration developer I applaud your efforts. Everybody should do one of these.

Comments relating to the survey instrument: There are questions some prefer not to answer and that option should always be available. There are questions that do not apply (#44 above) "does not apply" should be an option. This was difficult to read. Instead of the circles in red, black would be better. Also, a line under each question. I am completing this survey and trusting I will NOT be bothered with phone calls or other types of solicitation. Having a test in the color red is a rookie mistake! I immediately questioned the rigor of the testing method prior to engaging. It is way too long. Community Health Needs Assessment‐‐sorry, but I got tired of filling in bubbles. I guess that means I have no burning concerns in that extremely generalized section (albeit exhaustive).

2015 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents page 52

DRAFT MINUTES

Community Health Needs Assessment Key Stakeholders Meeting

July 15, 2015

Present: Mark Altenburg, M State Lynne Kovash, Moorhead Schools Chip Ammerman, Cass Co. Social Services Tiffany Lawrence, Sanford Health Kathy Anderson, Clay Co. Public Health Ben Lien, MN State Representative Rick Axelson, NDSU Center for Social Research Kristen Limb, Essentia Health Ruth Bachmeier, Fargo Cass Public Health Kim Lipetzky, Fargo Cass Public Health Shannon Bacon, American Cancer Society Tim Mahoney, Mayor of Fargo Linda Bartholomay, Sanford Health Ann Malmberg, Essentia Health Keith Bennett, Essentia Health Kathy McKay, Clay Co. Public Health Anne Blackhurst, MSUM Lindsey Miller, Dakota Medical Foundation Justin Bohrer, Fargo Cass Public Health Ryan Nagle, Heidi Heitkamp’s office Mari Dailey, Moorhead City Council Karen Nitzkorski, Clay Co. Public Health Jessie Doschadis, Family HealthCare Center Gina Nolte, Clay Co. Public Health Dykshoorn, Shirley, LSS of ND Katie Nystuen, SE Human Services Kent Eken, MN State Senator Sue Oatey, Concordia College Anna Frissell, Red River Children’s Advocacy Ctr. Paul Richard, Sanford Health Kaylin Frappier, Family HealthCare Center Carol Roth, Fargo Cass Public Health Greg Glasner, Essentia Health Tim Sayler, Essentia Health Dinah Goldenberg, Fargo School Board Kay Schwarzwalter, NDSU Center for Social Research Dan Griebling, Essentia Health Leah Siewert, Gladys Ray Shelter Kristi Halvarson, Community Health Service, Inc. Diane Solinger, Jeremiah Program Maryann Harris, Clay Co. Public Health Sara Stolt, Dakota Medical Foundation Julie Hinkel, Gladys Ray Shelter Brie Taralson, Essentia Health Keely Ihry, Dakota Medical Foundation Annette Thompson, American Cancer Society Kristie Invie, Sanford Health John Vastag, BCBSND Tom Kaitlyn Kline, Kevin Cramer’s office Mike Williams, Fargo City Commissioner Tiffany Knauf, Center for Rural Health Jones, American Jaimie Witt, Center for Rural Health Heart Association

Welcome – Ruth Bachmeier and Kathy McKay • Discussed the work that has been done since the last key stakeholder event three years ago. Because regulations require hospitals to do an assessment and many agencies were working on different initiatives, it was decided to work together as a collaborative. • Purpose of today’s meeting: o Review work that has happened in the last three years and how we can move forward in the future with the findings o Review April 2015 survey data.

1 Opening Remarks – Tim Sayler and Paul Richard • Discussed what has been done since the last assessment re: the three areas of major concern that were uncovered in the survey: obesity, mental health, elderly issues.

2015 Survey Results – Rick Axelson • Gave a brief overview of the community health needs assessment done in April 2015. • Discussed status of the project and methods used to collect data. Surveyed 1,500 randomly selected individuals in Cass and Clay Counties – 401 completed the survey (27%)…..an increase over three years ago. Caution: Minorities and individuals from lower education/income background were under-represented. • Focused on key findings about community concerns and selected findings about residents’ personal healthcare and preventive healthcare practices. • Top 10 community concerns: o Cost of LTC o Access to affordable health insurance o Cancer o Access to affordable healthcare o Access to affordable prescription drugs o Presence of street drugs, prescription drugs and alcohol in the community o Cost of affordable dental insurance coverage o Bullying o Chronic disease o Depression • #1 community concern was the same for both residents and stakeholders – cost of LTC.

Key Community Strategic Initiatives

Obesity Initiative – Kim Lipetzky • Discussed obesity-related initiatives in our communities; decided to work with the initiatives already in place. • Reviewed the major initiatives: Cass Clay Alive, Streets Alive, Faith Communities Alive, Gardens Alice, Cass Clay Food Systems Initiative, PartnerSHIP 4 Health, Barry Foundation, Bike-Related Activities, ND Worksite Wellness Initiative, and Breastfeeding Initiative. • Distributed a handout that listed all initiatives and their updated activities.

ReThink Mental Health Initiative – Gina Nolte • Looked at a comprehensive approach re: substance abuse and mental health issues. • Used the same model healthcare reform used – for a better experience at less cost. • Goals: improved policies, improved practices, improved system, improved partnerships, improved environments, improved community support. • Mentioned frustration of disorganization and duplication among agencies, states, initiatives. • Reviewed the timeline of planned events and funding support.

Services for the Elderly Initiative – Carol Roth • Identified and prioritized needs and issues. • First major project was to work with the ND Legislature on adult protective issues.

2 • Currently determining what else to work on – two areas of greatest need are: (1) education for the general public and organizations/professionals; and (2) and gaps in service.

Facilitated Discussion

These questions were discussed at the individual tables: • What surprised you about what you’ve heard this morning? • Based on the results, what do you feel is the biggest need for dedicated work in our community? • How can your organization address this need internally? • What ideas do you have in ways your role/organization could partner with other community resources to impact this need? • How do you plan to communicate the information from today to your organization?

Wrap-Up and Next Steps

• Determine priorities • Make sure there is no duplication • Complete the gap analysis to find out where the needs are • Needs will become priorities and the group will be asked to help in ranking them • Implementation strategies will be developed • Reports will be available in early 2016 • Participants were asked to take the information learned today back to their organization/colleagues

Key takeaways from today: • Progress has been made; more work needs to be done • Biggest increase from the 2012 survey was mental health/dementia/depression • Volunteers were asked to help with these initiatives

7/21/15

3 Fargo 2016 Community Health Needs Assessment Prioritization Worksheet

Criteria to Identify Priority Problem Criteria to Identify Intervention for Problem • Cost and/or return on investment • Expertise to implement solution • Availability of solutions • Return on investment • Impact of problem • Effectiveness of solution • Availability of resources (staff, time, money, equipment) to solve problem • Ease of implementation/maintenance • Urgency of solving problem (Ebola or air pollution) • Potential negative consequences • Size of problem (e.g. # of individuals affected) • Legal considerations • Impact on systems or health • Feasibility of intervention Health Indicator/Concern Round 1 Vote Round 2 Vote Round 3 Vote Lifestyle • Availability of affordable housing Aging • Cost of long term care • Availability of memory care • Availability of LTC Children and Youth • Bullying • Cost of quality child care • Cost of quality infant care Safety • Presence of street drugs and alcohol in the community • Presence of drug dealers in the community Crime • Child abuse and neglect • Domestic violence • Sex trafficking Health care • Access to affordable health insurance • Access to affordable health care • Access to affordable prescription drugs • Cost of affordable dental insurance coverage • Cost of affordable vision insurance Physical Health • Cancer • Chronic disease o High Cholesterol o Hypertension o Arthritis • Inactivity and lack of exercise o 48% report moderate activity 3x/week • Obesity o 61.3% of respondents report they are overweight or obese • Poor nutrition and eating habits o Only 24.1% report having 3 or more vegetables/day o Only 20.1% report having 3 or more fruits/day o High Cholesterol o Hypertension • Infectious disease such as flu Mental Health • Depression • Dementia and Alzheimer’s • Stress • Underage drug use and abuse • Underage drinking • Drug use and abuse • Alcohol use and abuse o 33.2% of respondents report binge drinking Preventive Health • Flu shots 37.9% of respondents report not having a flu shot last year

Present:

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