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CONTACT: Mountainwise of Macon County RESOURCES & DOWNLOADS 2007 Health Assessment Appendixes
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Macon County Public Health
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Expanding Access To Health Care
Our Top Priority: Establish a medical clinic in Franklin to provide free or subsidized care for the poor and those without insurance.
Other Priorities:
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Expanding Access To Mental Health Services Other Priorities:
For those with mental health problems, lack of access means waiting—in a jail cell, in the hospital emergency room, in a squad car. Emergency admission to a mental health facility with beds can take over 24 hours. Seeing a counselor can take weeks. Seeing a psychiatrist can take months. One possible implication of this lack of access is our finding that the suicide rate in Macon County was 67% higher than the state average from 2001 to 2005. Mental health issues include the problem of substance abuse, including methamphetamine addiction. Many mental health crises are triggered by substance abuse. Many families and children in crisis are the result of meth addiction. One solution is to help those who are providing mental health services, such as the Smoky Mountain Center, to provide more services through recruitment. We can help them sell prospective employees on the opportunities and quality of life available in Macon County. We can also work to encourage those who are already working here by facilitating communication and collaborative efforts to address problems and improve the system. How the emergency response system deals with those in mental health crisis is one area where local providers, regional providers, law enforcement, hospitals and others can work to produce local solutions. |
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Macon County 2005 Youth Risk Behavior Survey Our Top Priority: Involve all areas of the community "recreation, churches, schools, business, community groups" to promote the importance of families spending time together and communicating effectively. Other Priorities:
At the same time the economic pressures of simply earning a living make it more difficult for families to connect. Parents and children alike decry the loss of family mealtime and simple, inexpensive shared experiences. Parents want help. For example, most support sex education in the schools. School leaders want parents to be more involved as well. Efforts to increase awareness and equip families with information and resources can work to increase family connections and reduce youth risky behavior. There are numerous examples of successful parent and youth initiatives. Churches, schools, employers and other interested groups have important roles to play in the communications and education effort. back to top |
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Our Top Priority: Develop a community wide, long-range plan to address the needs of aging Macon County residents in 2015 and beyond. Our Rationale: Many of the traditional concerns for seniors—isolation, transportation, socialization, access to care—seem to be less acute in Macon County. Our research shows that while all these are vitally important, current service providers in Macon County are doing a good job to meet them, at least for now. We believe the greater problems lie 8 to 15 years in the future, when many of the county’s current healthy and mobile retirees become less mobile and more frail, and when greater numbers of Baby Boomer adults enter their post-65 years. We are not aware of any comprehensive community planning for this inevitable event. Retirement living is important to many elements in the Macon County economy, not just the health and human services network. A comprehensive plan that takes into account the future needs of the aging will be an opportunity for many perspectives—public and private, not-for-profit and for-profit, Highlands, Nantahala and Franklin, acute care and long term care--to work together. back to top |
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Our Top Priority: Promote water quality by providing information on the importance of maintaining effective sewer and septic systems and wastewater management. Other Priorities:
Information gathered by HCMC raises concern that many of the septic systems in the county are aging and either failing now or likely to fail. The numbers and ages of septic systems are largely unknown, which in itself is a concern. Maintenance of systems is left to the property owner, which in Macon County, may be someone who lives in the area only part time, or who operates a lake or mountain home as vacation rental property. Rental properties often attract far more occupants than septic systems were designed to support. |
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Our Top Priority: Establish a formal advocacy group to work with state and federal representatives and governmental agencies to provide education and information about Macon County health needs and priorities. Other Priorities:
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The 2007 HCMC Comprehensive Healthcare Assessment Report provides a more thorough analysis and discussion of these priority issues and recommendations. |
Community Health Assessment Report
Impeded access to care due to lack of insurance or resources to pay was the major theme of interviews with community leaders, many of whom see the problem as getting larger and worse in the near future. A more thorough discussion of the health access issue is provided later in this report. Major Health Indicators To help measure health status, Healthy Carolinans of Macon County questioned those in the survey about key health indicators such as obesity, diabetes, high blood pressure, heart disease, exercise and cancer prevention. Results provide some interesting insights into these common health risks and the diseases they promote. back to top Obesity Participants in the telephone study were asked to provide their height and weight, information that was used to compute a Body Mass Index (BMI) for every participant. Computations show that 61% of Macon adults are overweight or obese. Over a third of Macon Countians –34%--are overweight and an additional 27% are obese. According to the CDC, obesity is defined as a BMI of 30 or more. A healthy BMI is between 18.5 and 25. A BMI of 25 to 30 is considered overweight, but not obese. Only 2% reported being underweight, which is a BMI less than 18.5. The obesity problem is most acute among 23-to-34 year olds, 39% of whom are obese. This is the highest rate of obesity found in the study. It is interesting to compare the rate of obesity in young adults to the rates found in youth. At a health fair for Macon County high school youth in 2006, 22% were found to be overweight and at risk. Similar health fairs for middle school children found an at-risk and overweight rate of 26%. So there seems to be a considerable increase in the rate of obesity from the teen to young adult years. Childhood and adult obesity were major topics of discussion among the community focus groups, where participants tend to blame sedentary lifestyles, TV and video games, a lack of emphasis on outdoor play, and fast food diets. Parents in the focus groups would like to see more emphasis in physical activity beyond team sports such as football and baseball, which many students are unable to participate in, especially as they reach middle and high schools. Fast food and the two-income lifestyle for couples are blamed for the rise in obesity among young adults. Those in the focus groups believe many young adults never learned to eat healthily, are too tired from work to cook or exercise, and spend too much time with television and video pastimes. Some see employers as having the best opportunity to educate and influence young adults toward healthier lifestyles. Income and education are factors to rates of obesity. Among those who earn less than $25,000 annually, the obesity rate is 33%, compared to 21% for those who earn between $60,000 and $80,000. Among those whose education is limited to high school or less, the obesity rate is 29%, compared to only 20% for those with college degrees. back to top Diabetes Diabetes and weight are often connected. Among those in the HCMC study, 14% report they have been told by a doctor or health professional that they have diabetes. If accurate, this rate of diabetes is twice the national adult average. Among the obese in the study, the rate of diabetes rises to 25%. The degenerative health effects of diabetes can be deterred or delayed with effective management and treatment. Among Macon adults reporting diabetes, 48% report they do not measure their blood sugar daily and 26% report they do nothing to control their diabetes. Treatment is lowest among those who report they have no health insurance. back to top Fitness & Exercise A do-it-yourself prescription for excess weight and diabetes is exercise and a high level of physical fitness. According to the survey results, almost half of Macon Countians exercise at least three times per week. However, only 18% rate their level of fitness as excellent. The chart below compares exercise patterns among some diverse groups. The age group that exercises the least is 35 to 44, while the age that exercises the most is 65 to 74. Income makes a difference, too. Those who earn less than $25,000 exercise the least while those who earn over $80,000 exercise the most.  It is interesting that being active in the community means one is also active at exercise. Among those who volunteer in the community, 53% exercise at least three times a week, the highest response in the study. Those who are overweight or obese also exercise less; 32% report they exercise rarely or not at all. back to top Hypertension Over four in 10 in the study—41%--report they have hypertension, or high blood pressure, a major risk contributor to heart disease and stroke. Among those who are obese, 60% report hypertension. Most take medication for their hypertension, unless they lack health insurance. While 84% of those with hypertension report they take medication, 56% of those without health insurance do not. back to top Cholesterol Another heart and stroke risk factor is high cholesterol. Adults are encouraged to know their total cholesterol number and to manage it with diet and/or take medication if it is above 200. Almost half of Macon County adults in the study—47%--do not know what their cholesterol number is. The percent who do not know goes up to 70 among those without insurance. As can be seen in the chart below, a majority of those with other risk factors for heart disease also do not know their cholesterol number.  back to top Women’s Health Women in the study were asked about health and prevention practices related to identifying cancer risks early. Almost all the women in study—96%--report they know how to perform a breast self-exam, but only 60% do it regularly. Again, almost all (98%) report they have had a pap smear at some point their lives, but 49% have not had a pap smear in the past year. Further, 74% of low-income women, and 59% of women without health insurance have not had a pap smear in the past year. Similar patterns emerge for women and mammograms. While 85% have had a mammogram at some time in the past, 37% of all women over 40, and 53% of women age 45 to 54 have not had one in the past year. Insurance and income is again a factor; 70% of those without insurance have not had a mammogram in the past year. While not every adult woman needs a mammogram each year, it is clear that insurance and income can discourage even those women who do. Over 25% of women over age 55 have not had a mammogram in the past year, most of them low income or without insurance. Among women over age 50, 72% have had a bone density scan and 59% have had a colonoscopy. However, among over-50 women without health insurance, only 32% have had a bone density scan and 41% have had a colonoscopy. back to top Men's Health The men who participated in the study were asked about some of their health practices. Substantially more men over age 50 have had colonoscopies than women—82% to 59%. This is a significant difference that should interest health professionals, especially gastroenterologists. There seems to be a lot of older women who are so far avoiding this important screening procedure. Over 50 is also the age when men begin to be tested for prostate cancer using a PSA screening. Among Macon men, 85% report having a PSA test, and the rate goes up to 92% for men over age 75. back to top Tobacco Use About one-third of Macon County’s young adults light up cigarettes on a regular basis. This compares to only 21% of adults nationally, in the NHIS. The young adult years are also the beginning of childbearing, and data show that as many as 22% of mothers in Macon County smoked during pregnancy (Source: NC Department of Health and Human Services, 2004). It is interesting to note that cigarette use declines with age (see chart below). It appears the transitional age where smoking falls off dramatically is around 55. While the study did not measure the reasons for the decline in smoking, the rise in health complications (and even death) associated with smoking are more likely to present around this time of life.  The data indicate that smoking that starts in high school continues at pretty much the same rate into the young adult and middle age years. An implication is that if youth smoking can be reduced, adult smoking will be reduced over time as well. According the NCMC survey, 13% of Macon County smokers have tried to quit in the past year, but failed to do so. Among smokers under age 35, 24% have tried to quit in the past year, but failed and resumed smoking. An even higher number of smokers at the lowest income levels—26%--tried to quit in the past year and failed. Sadly, given the cost of cigarettes, smoking is substantially higher among low-income adults than those at the higher income levels. For example, 31% of those earning less than $25,000 a year smoke regularly compared to 6% of those at the highest income levels. Education is also a indicator—27% of those with high school educations or less smoke cigarettes, compared to 8% of those with college degrees and 6% of those with post graduate degrees. Use of other tobacco products—chewing tobacco and snuff—lags well behind cigarettes. Only 6% of Macon adults use these products. Use is highest among those over age 75. back to top Alcohol Use The education factor is reversed for alcohol use, however. As a rule, better educated and wealthier Macon County adults are more likely to use and abuse alcohol. Overall 7% of Macon residents say that within the past 12 months they have consumed more than 5 alcoholic beverages in a single day. Among those whose income is above $80,000, the number rises to 12%. Younger users of alcohol are also far more likely to consume a lot of alcohol in one day. The rate of those who say they have consumed more than 5 alcoholic beverages in a single day rises to 20% among those 23-34. There is evidence that alcohol use is a common experience at the high school, and even middle school, level. Those participating in the student focus group say that weekend drinking is a common occurrence because “there is nothing else to do.” Youth view alcohol consumption as a rite of passage and something that begins at middle school ages when adolescents are trying to assert their maturity. The 2005 YRBSS shows that about 31% of middle-schoolers and 26% of high school students consume alcohol at some level, rates that are a little lower than the 2002 YRBSS findings. back to top Access To Medical & Dental Care As referenced above, access to health care services is a major issue in the minds of Macon County leaders. The worries are wide-ranging:
Access to care for some low-income adults may be improved by the anticipated VA Clinic to be opened in Franklin in the near future. There are approximately 4,000 veterans in Macon County. How many of them might be low income and having difficulty with access is uncertain. Access to health services is more acute for adults than for children. Parents seem to be finding ways to get care for their kids. The State Children’s Health Insurance Program (SCHIP) provides health care coverage for many low-income children, which contributes to better access to care. No parent in the Macon County study reported delaying medical care for children due to lack of resources to pay.  There is evidence that the Hispanic experience is different. Hispanic families are more likely to delay care, sometimes due to finances, and sometimes due to lack of transportation, language barriers, cultural differences and fear of deportation. The experience of the Community Care Clinic of Highlands-Cashiers provides insight into the uninsured world and efforts to obtain medical care. The Highlands Clinic is affiliated with Volunteers in Medicine, a loose network of medical clinics across the country that provide free services to those without insurance. The Highlands Clinic is open for four hours on Thursday evenings, providing primary medical care out of a converted press box at a recreation field about three miles from downtown Highlands. The Highlands Clinic provided 750 free patient visits during its first year of operation. Even though the primary mission of the clinic is to serve those in the Highlands area, 45% of patients in the first year were from Franklin. Many patients are Hispanic, and the Clinic provides Spanish language translators most weeks. Even though appointments are encouraged, patients often arrive without notice and crowd into the small waiting room, where the compassionate staff of volunteer doctors and clinical personnel eventually work them in. The story of the Highlands Clinic assumes its greater meaning when one considers the road from Franklin to Highlands—over16 miles of winding, two-lane peril and persistence that takes about 40 minutes on the best of days. The clinic itself is not easy to find, located out of town on a side street. Yet the uninsured doggedly seek out the clinic, in winter even traveling in the dark both ways. When prescriptions are required, the Highlands Clinic issues vouchers that can be used for free prescriptions at a pharmacy in Highlands. That pharmacy closes at 5:00 PM, so that means most patients to the Clinic make a return trip along the Highlands Road to get a prescription filled the following day. Dental care is even more difficult to obtain for some low-income families in Macon County. The HCMC telephone study reveals that 41% of residents polled travel outside of Macon County for dental care, many of them outside the state, presumably to Georgia, where there are dentists who provide Medicaid services. There are no private practice dentists in Macon County that participate in the Medicaid program. The Molar Roller, a mobile dental clinic operated by the Macon County Health Department is making dental care more accessible to low-income families, especially to children. The Molar Roller visits schools in the area and sets up in rural communities. Still, as noted above, 28% of Macon County adults have not seen a dentist in the past year and 14% have delayed dental care because they could not afford it. One-quarter of those who make less than $25,000 or less have not seen a dentist in the past five years. back to top Mental Health Care In 2001 the state of North Carolina embarked on a mission to reform its mental health care system. Almost overnight the system of state employed psychologists and counselors was replaced by a managed care model. Formerly employed mental health professionals were encouraged to set up private practices and provide services via contracts with new, local management entities (LMEs). The bottom line is that many mental health professionals across the state and in Macon County chose to find other jobs and move rather than assume the risk of private practice. Those who did enter private practice sometimes found it difficult to work with their area LMEs, which were struggling to make sense of the new roles they had been given. The LME for the Macon County area is Smoky Mountain Center, headquartered in Sylva. While Smoky Mountain has been determined and dogged in their efforts to make the new system work, there are significant problems:
There are indications some of the problems of reform may be easing. Smoky Mountain is stepping up efforts too recruit professional personnel to Western North Carolina, which will benefit Macon County, as well as other counties served by the LME. Private providers are pursuing improved relationships with the LME, or have restructured their practices to focus on those who are insured or pay for services privately. Yet there is no doubt that difficulties of access and coordination of care are impacting Macon County. The HCMC survey reveals that 17% of respondents say someone in their family has had difficulty accessing mental health or substance abuse services. That percentage rises to 26% among adults 23 to 34. Difficulty accessing services is also more acute in rural areas. Even among those who have used the mental health system in the past, and thus have some familiarity with its ins and outs, are having difficulty accessing care. Among those who have accessed mental health in the past, 26% report difficulty getting care. That rises to 38% among those in the 35 to 44 age group, and 36% among those from rural areas. Why? Lack of access to appropriate, local treatment options were citied by 76% all respondents who felt they needed such care.  The demand for mental health services is often below the radar for many in a community. Because the percentage of the population with mental health and substance abuse needs is smaller than those with physical needs, the unmet demand for services can be harder to detect. Addiction to methamphetamine is a particular substance abuse issue that is obviously devastating, but also difficult to measure. Those working in social services and substance abuse counseling observe that the meth problem is widespread in Macon County and throughout Western North Carolina. Treatment resources for meth addiction are difficult to access, especially for those with low income, which largely describes the meth user population. The HCMC survey asked participants questions related to their personal mental health. Responses indicate there are significant percentages of Macon County adults struggling with potentially serious feelings of depression and anxiety. Local results are somewhat higher than regional results from the CDC’s National Health Interview Survey.  Applied to the total Macon County population, these findings could mean that as many as 1,280 area adults feel so down in the dumps nothing can cheer them all or most of the time. These feelings become even more acute among the low income, the population most affected by reduced access related to North Carolina’s mental health care reform initiatives.  There is evidence that the suicide rate is higher in Macon County than in other areas of North Carolina. According to mortality statistics tracked by the North Carolina Department of Health, the suicide rate for Macon County is 67% higher than state averages. The extent to which depression, economic factors and the lack of treatment options contribute to this higher rate can only be speculated. Further, according to the 2005 YRBSS, over 27% of high school youth have felt sad or hopeless every day in the past year and 17% have considered suicide. While these rates are down a little from 2002 findings, they are still higher than North Carolina averages for other teens. As with medical care, access to mental health services for children is somewhat less acute than with adults. This is due to the good work of agencies like Kid’s Place who provide advocacy and counseling to children affected by abuse. There is a team of social workers and counselors associated with Kid’s Place who also provide services to children. Pediatricians fulfill a vital role diagnosing and referring children for mental health services, as do school nurses and counselors play vital roles as advocates and protectors of children, as does the Department of Social Services. Nevertheless, as noted earlier, 2% of survey respondents say they have delayed mental health services for their children because they could not afford it. This is about the same percent as among adults. back to top Community Worries About Families, Violence & Risky Behavior A major theme from the community interviews and the focus groups is concern about Macon County families and youth. Parents, school leaders and others express concern that cultural and economic pressures are damaging Macon County families. Participants in the telephone study often agreed. Here are the major findings:
It is interesting to compare some responses from parents about youth behavior with the responses from youth and the 2005 YRBSS. The chart below contrasts some key findings from the two studies.   Parents polled by telephone agreed strongly with those in the focus groups that sex education should be taught in public schools. Support is around 90% or higher among parents active in church and parents of all education and income levels. Over three fourths of parents (75.1%) who support sex education believe it should start in middle school.  Most parents participating in focus groups believe that past school efforts to teach sex education have been inadequate. Students agree, but are unsure about how any new class might be implemented. Some students believe classes that emphasize abstinence would be “religious” and not appropriate for public school. back to top Healthy Attitudes & Quality of Life The health of a community can also be reflected in the attitudes and optimism of its people. The healthier the attitudes of its people toward their neighbors, jobs, and future, the healthier Macon County is likely to become. About half of respondents in the telephone survey (49%) say quality of life in Macon County is good, and another 39% rate it excellent. Those who rate quality of life the highest tend to be the highest wage earners. Those in the lowest income brackets are about six times more likely to say life in Macon County is fair or poor than those who make over $80,000 annually. Those who live in Highlands are also more likely to rate quality of life as excellent compared with those in Franklin. Here are some highlights from the research that reflect key community attitudes.
The largest percentage of those who said no they do not feel they have adequate transportation—11%--live in Highlands. Cynicism and pessimism run counter to a healthy community. Participants in the study were asked to agree or disagree with some statements reflecting their attitudes toward community life. The results, shown below, are interesting. back to top Diversity About a third (31%) of Macon residents agree that the community is diverse and accepting of persons of all races, religions and lifestyles. Those most likely to disagree with this statement are young adults, those age 23-34, and those at the highest income levels. Among young adults, 30% disagree that the community is a diverse and welcoming place. A major topic of the community interviews and focus groups was the growth of the Latino community in Macon County. Some express the belief that county leaders are not prepared to deal with the rapidly increasing Hispanic population and choosing to ignore related problems in the hope they will go away. A complicating factor is that many feel that “illegal” residents are breaking the law, should not be here, and should not be welcomed or accommodated. Others see Macon County as caught up in long-term cultural and demographic trends, and that the community must accept and adapt accordingly. They note that fear of deportation keeps many Hispanic families from seeking out essential health care services, which in the long run is harmful to the community. They would like to see Macon employers, schools and health facilities be more welcoming and accommodating to overcome language and cultural barriers sooner rather than later. back to top Confidence In Leadership & Schools About one-fifth of respondents agree strongly with positive statements about community leaders and schools. Most--61%--of Macon Countians say they somewhat agree that Macon leaders are working to make the community a better place. Those more likely to disagree with this statement are between the ages of 35 and 54, and are probably in the lower income brackets. The profile of responses is similar for evaluation of schools. Responses among those with children under age 18 vary little from the community overall.  back to top Attitudes Toward Work One half of respondents in the study were employed, and their attitudes about the working life seem very positive. Most feel their jobs are secure for at least the year ahead. Those with educations at the high school level or less, and those at the lowest income levels, are somewhat less secure, however. While a positive response is expected, that 100% of respondents feel adequately prepared for their jobs is surprising. One might wonder if this finding is the result of work not being challenging enough, but 92% say they are happy in their jobs. Not surprisingly, those who make the smallest amounts of money are most likely to be unhappy at work. It is interesting that those who have some college education or an associates degree, are more likely to be unhappy at work than those with only a high school diploma or less education. back to top Quality of the Environment Most in the county view the area as an environmentally attractive place to live, but there are significant concerns, especially in the area of water quality. There is friction between some who favor and benefit from the home construction industry, and some who worry about the effects of construction on water quality. Due to the mountainous terrain of Macon County, sewer systems are impractical in all but the most densely populated areas of Franklin and Highlands. This means most county homes use a septic system. The number of septic systems in the county is unknown, as are the ages of many of them. Census data estimate 21,000 housing units in the county, but environmental health experts associated with the Macon County Health Department estimate the number of septic systems could be much higher. Of greater concern is how many of these septic systems are failing or are in danger of failing soon. According to a national study of septic systems by West Virginia University, over 10% of septic systems fail annually. There has been a residential building boom in the Macon County area that began in the 1970, which means many septic systems are now 25 to 30 years old. A large number of mountain and lake properties are rented out, which means their septic systems are used by large numbers of people, often more than the systems were designed to support. A significant number of rural homes in the county—estimated at several hundred--continue to use illegal straight pipe systems, dumping sewage directly into streams. The telephone study shows that while most in the county think water quality is at least somewhat clean, those in Highlands are more critical. Young adults, representing a generation that is more sensitive to environmental issues, are also more critical of air and water quality.  While better methods such as GIS mapping systems to locate and monitor septic systems are in the future, current information systems to measure the size of the problem are lacking. One low-tech solution would be to conduct surveys of homeowners to inquire about the age of their septic systems. back to top Advocacy Community leaders interviewed as part of the assessment process express optimism about the county’s ability to address its problems and work for positive change. They also express support for elected leadership and confidence in the future. Yet many feel advocates for health and related community priorities must be more effective in communicating with governmental decision makers, especially at the state and federal levels. The severe and unanticipated problems with state mental health reform is an example of how decisions made in Raleigh can have devastating consequences in Macon County. Many believe it is important for county perspectives to be heard to prevent or minimize negative effects of future decisions. Priority issues that community leaders would like to see promoted are funding for expanded mental health services and efforts to increase medical access for those without health insurance. Efforts to advocate for any cause must be approached carefully. Healthy Carolinians of Macon County is a public-private partnership that must and will avoid any appearance of partisanship or political posturing. Our purpose must and will remain focused on advocating for greater health and safety that benefits the entire community. |
© 2010 Macon County, North Carolina |
