Roanoke Valley Community Health Assessment - Final Report by Carilion Clinic

Contents Executive Summary..................................................................................................................................... 4 Current Environment ............................................................................................................................... 4 2021 RVCHA Key Findings ........................................................................................................................ 5 Mental Health ...................................................................................................................................... 5 Socioeconomic Factors ........................................................................................................................ 6 Primary Care ........................................................................................................................................ 6 COVID-19 ............................................................................................................................................. 7 Board Adoption ........................................................................................................................................... 8 Disclaimer .................................................................................................................................................... 8 Acknowledgements .................................................................................................................................... 8 Project Management Team ..................................................................................................................... 8 Project Support Team .............................................................................................................................. 8 Healthy Roanoke Valley ........................................................................................................................... 8 Roanoke City and Alleghany Health Districts ........................................................................................... 9 Community Health Assessment Team (CHAT) ......................................................................................... 9 CHAT Members and Area of Expertise ................................................................................................ 9 Community Served.................................................................................................................................... 12 Carilion Medical Center Principal Functions .......................................................................................... 12 Geographic Area .................................................................................................................................... 12 Target Population .................................................................................................................................. 13 Service Area Demographics ................................................................................................................... 13 Community Health Assessment Process .................................................................................................. 15 Identification of Significant Health Needs ............................................................................................. 15 Prioritization of Significant Health Needs .............................................................................................. 15 Identification of Resources to Address Needs ....................................................................................... 16 Community Input ...................................................................................................................................... 17 Community Impact ................................................................................................................................... 18 Impact of Actions Taken in Response to 2018 RVCHA........................................................................... 18 Data Collection and Analysis Methods ..................................................................................................... 20 Community Health Survey ..................................................................................................................... 20 Stakeholder (CHAT) Focus Group .......................................................................................................... 21 Stakeholder Survey ................................................................................................................................ 21 2

Secondary Data ...................................................................................................................................... 22 Collaboration............................................................................................................................................. 23 Data Review .............................................................................................................................................. 24 Clinical Data ........................................................................................................................................... 24 Vital Conditions for Well-Being.............................................................................................................. 29 Vital Condition: Basic Needs for Health & Safety .............................................................................. 29 Vital Condition: Lifelong Learning ...................................................................................................... 35 Vital Condition: Meaningful Work & Wealth ..................................................................................... 37 Vital Condition: Humane Housing...................................................................................................... 39 Vital Condition: Thriving Natural World ............................................................................................ 41 Vital Condition: Reliable Transportation ........................................................................................... 43 Vital Condition: Belonging & Civic Muscle ......................................................................................... 44 Self-Reported Data ................................................................................................................................ 45 Equity ..................................................................................................................................................... 49 Appendices ................................................................................................................................................ 50 Appendix 1: Gantt Chart ........................................................................................................................ 50 Appendix 2: Community Health Survey ................................................................................................. 51 Appendix 3: Stakeholder Survey and Data Summary ............................................................................ 55 Appendix 4: Prioritization Worksheet ................................................................................................... 61 Appendix 5: Resource List ...................................................................................................................... 63 Appendix 6: Community Health Survey Results .................................................................................... 70 Appendix 7: Secondary Data from University of Missouri CARES SparkMap ...................................... 101 Appendix 8: Links to Other Assessments ............................................................................................. 178 Appendix 9: Cancer Community Health Survey Results ...................................................................... 179

Executive Summary Carilion Clinic is committed to joining with our partners to pursue the essential work of improving and maintaining the health of the Roanoke Valley. To ensure that current needs are being addressed, we assess the health concerns of each community every three years to uncover issues, indicate where improvement is needed, and track and promote progress. Carilion Medical Center’s (CMC) 2021 Roanoke Valley Community Health Assessment (RVCHA) is complete with the adoption and dissemination of this report. The Community Health Assessment (CHA) process and the public availability of its findings enables our community to effectively maintain and improve health1.

Current Environment Since the 2018 RVCHA, significant changes have impacted our community’s health. There is no doubt that the COVID-19 pandemic has greatly disrupted all aspects of life. In Virginia, a state of emergency was declared on March 13, 2020, leading to temporary business closures, halting of routine health care services, and closures of schools—among a host of other challenges. Cases peaked in January of 2021, which also marked the end of the Community Health Survey period. The COVID-19 pandemic has led to an increase in substance use and mental health issues, with the Virginia Department of Health (VDH) reporting a 22% increase in drug overdoses from 2019 to 2020 for Southwest Virginia2. Social isolation increased due to stay at home orders. Health care access was temporarily halted for a wide range of preventative and maintenance needs and, together with required protocols to prevent exposures in health care settings, has created more demand and lower patient throughput. Unemployment rates skyrocketed, going as high as 13% in Roanoke City in April of 2020— and the economic impact is still being felt3. Finally, the additional mortality from COVID-19 led to a projected decrease nationwide in life expectancy of greater than one year, with a larger impact on Black and Latino populations4. Virginia’s Medicaid program also expanded since the 2018 RVCHA, leading to an increase in Medicaid enrollees across the Commonwealth. Over 27,000 adults in the RVCHA service area enrolled in Medicaid thanks to the expansion5. Medicaid coverage will also include adult dental care beginning July 1, 2021. This expansion is a step in the right direction to ensure health care access for the entire community, but challenges will continue to arise on how to best meet health care needs. Awareness of health disparities, inequities and racial injustices continues to grow throughout the community and the United States. Health status, access and outcomes can be widely impacted by

Carilion Clinic began conducting Community Health Assessments prior to the IRS adoption of the 501(r)(3) which requires not-for-profit hospitals to conduct a Community Health Needs Assessment (CHNA) every three years. While meeting the CHNA requirement, Carilion maintains the longstanding formal name, Community Health Assessment, for our process and reports. 2 Virginia Department of Health, Emergency Department Visits for Unintentional Drug Overdose among Virginia Residents, accessed via https://www.vdh.virginia.gov/content/uploads/sites/13/2021/01/Emergency-DepartmentVisits-for-Unintentional-Drug-Overdose-2020-COVID-19-report_Final.pdf. 3 US Department of Labor, Bureau of Labor Statistics. Accessed via SparkMap. 4 https://www.pnas.org/content/pnas/118/5/e2014746118.full.pdf 5 https://www.dmas.virginia.gov/open-data/medicaid-expansion-enrollment/

individual experiences. We are committed to improving equity in care—both within and outside of the hospital walls.

2021 RVCHA Key Findings Carilion, Healthy Roanoke Valley (HRV) and the Roanoke City and Alleghany Health Districts (RCAHD) collaborated to conduct the 2021 RVCHA. The findings revealed 10 priority health-related issues in the community, identified by the Community Health Assessment Team (CHAT) after review of the data collected. Like-issues were grouped into categories to promote upstream and out-of-the-box thinking to address the top needs.

Top Needs Mental Health

Access to mental/behavioral health services Access to substance use services Alcohol and drug use Mental health problems (general)

Poverty/low average household income Socioeconomic Affordable/safe housing Factors Transportation/transit system Lack of family/social support systems Primary Care Access to primary care COVID-19 COVID-19 impact

Mental Health Mental health continues to be a top health issue in the Roanoke Valley according to the community, stakeholders and as seen through additional data points. •

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The Community Health Survey results indicate mental health as the top issue impacting the health of the community. Mental health services are the second most difficult health care service to access6. Mental health and substance use are top issues according to the CHAT stakeholders7. Drug overdose rates increased 22% in the Southwest Virginia from 2019 to 20208. 49% of households surveyed by the United Way of Roanoke Valley reported mental health issues as a top concern during the pandemic9.

2021 Roanoke Valley Community Health Survey 2021 Stakeholder Survey 8 Virginia Department of Health, Emergency Department Visits for Unintentional Drug Overdose among Virginia Residents, accessed via https://www.vdh.virginia.gov/content/uploads/sites/13/2021/01/Emergency-DepartmentVisits-for-Unintentional-Drug-Overdose-2020-COVID-19-report_Final.pdf. 9 United Way of Roanoke Valley ALICE COVID-19 Report, accessed via https://www.uwrv.org/alice-covid-19-surveyresults/. 7

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The Roanoke Valley has a mental health provider deficit, with 42.4% of the population considered underserved10.

Socioeconomic Factors Socioeconomic factors and their contribution to poor health status and outcomes continue to be of concern for the Roanoke Valley. According to United Way, prior to COVID-19, 45% of households within the Roanoke Valley were already struggling to get by on their household income11. Across the assessment service area: • •

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12.05% of the population live below the Federal Poverty Level. When looking at only Roanoke City, the rate jumps to over 20%12. 25.17% of households are cost-burdened, with household expenses totaling more than 30% of household income. The highest individual locality rates are in Roanoke City (36.61%), Salem (25.45%) and Franklin County (22.59%)13. 6.54% of households are without a motor vehicle. The highest individual locality rates are in Roanoke City (13.06%), Craig County (7.84%) and Salem (7.04%)14.

In addition to the needs presented above, broadband internet access was a topic of discussion in the final CHAT meeting. CHAT members agreed that to improve access to all resources mentioned— including health care, social services and education—affordable and reliable internet is a basic need. • •

Significant pockets across Bedford, Craig and Franklin Counties are considered unserved areas based on slow (or no) download and upload speeds15. Citizen surveys also indicate pockets across Roanoke County with low or no access to broadband16.

Primary Care Access to primary care remains a top concern in the Roanoke Valley. Routine checkups with primary care providers can greatly improve health status and a variety of health outcomes through prompt identification of problems and treatment or lifestyle modifications. • •

Roughly 80% of adults in the service area had a primary care checkup in the last year, according to 2018 data from the Centers for Disease Control and Prevention (CDC)17. 79% of Community Health Survey respondents report that they have had a routine checkup in the last year.

Health Resources & Services Administration, 2019. Accessed via IP3 Assess, courtesy of ReThink Health. United Way of Roanoke Valley ALICE COVID-19 Report, accessed via https://www.uwrv.org/alice-covid-19survey-results/. 12 US Census Bureau, American Community Survey. 2015-19. Accessed via SparkMap. 13 US Census Bureau, American Community Survey. 2015-19. Accessed via SparkMap. 14 US Census Bureau, American Community Survey. 2015-19. Accessed via SparkMap. 15 Virginia Broadband Availability Map and Integrated Broadband Planning and Analysis Toolbox, Virginia Tech. Accessed via https://broadband.cgit.vt.edu/IntegratedToolbox/. 16 Roanoke County Broadband Availability Study, accessed via https://www.roanokecountyva.gov/2583/Broadband-Availability-Study. 17 Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the 500 Cities Data Portal. 2018. Accessed via SparkMap. 11

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The expansion of Medicaid has created an increase in the population insured; however, provider availability has not increased to match the number of newly covered individuals.

COVID-19 The impact of COVID-19 will persist for years to come. In addition to the statistics discussed previously: • •

COVID-19 has been a considerable cause of morbidity and mortality, contributing to 630 deaths, 32,992 infections and 1,055 hospitalizations as of July 1, 202118. 76% of households surveyed by United Way reported contracting COVID-19 as a top concern during the pandemic19.

This report contains the findings of the 2021 RVCHA, including primary and secondary health and social determinant data on the service area and specific populations.

Virginia Department of Health, https://www.vdh.virginia.gov/coronavirus/covid-19-in-virginia-locality/ United Way of Roanoke Valley ALICE COVID-19 Report, accessed via https://www.uwrv.org/alice-covid-19survey-results/. 19

Board Adoption This document was approved by the CMC Board of Directors on July 20, 2021, and formally adopted as the 2021 Roanoke Valley Community Health Assessment.

Disclaimer This document has been produced to benefit the community. Carilion Clinic encourages use of this report for planning purposes and is interested in learning of its utilization. Comments and questions are welcome and can be submitted to Carilion Clinic Community Health & Outreach at communityoutreach@carilionclinic.org. Members of the Project Management Team reviewed all documents prior to publication and provided critical edits. Every effort has been made to ensure the accuracy of the information presented in this report; however, accuracy cannot be guaranteed. Members of the Roanoke Valley Community Health Assessment Team cannot accept responsibility for any consequences that result from the use of any information presented in this report.

Acknowledgements Success of the 2021 RVCHA was due to the strong leadership and participation of its Project Management Team, the Project Support Team, members of Healthy Roanoke Valley, the Roanoke City and Alleghany Health Districts and the Community Health Assessment Team. Thank you to all the community members who participated in the Community Health Survey. Members of these teams included:

Project Management Team Project Director: Shirley Holland, Carilion Clinic – Vice President, Planning and Community Development Project Manager: Aaron Boush, Carilion Clinic – Community Health & Outreach Director Project Manager: Molly Roberts, Carilion Clinic – Community Benefit Manager

Project Support Team Carilion Clinic: Amy Michals, Kenya Thompson, Mandi Shoemaker, Carilion Direct Staff Roanoke City and Alleghany Health Districts: Kristin Adkins, Samara Lott United Way of Roanoke Valley: Hannah Adkins, David Nova (interim)

Healthy Roanoke Valley In 2012, using the Strive Collective Impact model, Carilion and United Way of Roanoke Valley brought together strategic community partners to create HRV. An initiative supported by United Way, HRV is now a partnership of more than 50 organizations striving to enhance health equity and create a “culture of wellness” across our region. For years, HRV has served as a valuable partner with Carilion Clinic. The collaborative updates HRV’s strategic framework to align with the triennial CHA, a community-driven process and a significant component of Carilion’s Health Improvement Implementation Strategy for the Roanoke Valley. Through strategic planning in response to the 2018 RVCHA priorities, HRV identified four goals: 8

1. Reduce barriers to resources that address the social determinants of health 2. Expand access to quality care and support a culture of health 3. Encourage and support lifestyle behaviors that result in improved health and well-being 4. Support and advocate for natural and built environments that cultivate vibrant neighborhoods Carilion provides in-kind support to HRV, with representatives active on the HRV steering committee and action teams focused on wellness, mental health, primary care, oral health and coordination of care.

Roanoke City and Alleghany Health Districts The RCAHD, under the VDH, serve the majority of the RVCHA service area. RCAHD has nine office locations across the service area, serving over 278,400 people. The district promotes and encourages healthy behavior, protects the public against environmental hazards, works to prevent epidemics and the spread of disease, responds to disasters, assists communities in recovery, and assures the quality and accessibility of health services for all community members20. Through its population health management department, RCAHD focuses on the health of the entire population served by the health district and aims to reduce health inequities among specific groups. As a partner in the RVCHA, RCAHD works to identify health needs and the socioeconomic factors impacting the health of the community. In response to the CHA’s findings, RCAHD develops Community Health Improvement Plans to support health improvement across the service area21.

Community Health Assessment Team (CHAT) Carilion Clinic’s CHAs are community-driven projects. Their success is highly dependent on the involvement of citizens, health and human service agencies, businesses, and community leaders. Stakeholder collaborations known as CHATs lead the CHAs. The CHATs are dynamic groups that include health and human service agency leaders, persons with special knowledge of, or expertise in, public health, the local health department officials. The CHATs obtain input from leaders, representatives or members of medically underserved populations who report low-income, are minorities and suffer from chronic disease. In the Roanoke Valley, the HRV Steering Committee serves as the CHAT along with additional key community leaders.

CHAT Members and Area of Expertise This list includes members that attended at least half of the CHAT meetings.

20 21

Name

Organization

Area of Expertise

Aaron Boush

Carilion Clinic

Hospitals, Healthy Food

Abby Hamilton

United Way of Roanoke Valley

Collective Impact, Social Determinants of Health

Aisha Johnson

City of Roanoke- Economic Development

Economic Development

https://www.vdh.virginia.gov/roanoke/about-us/ https://www.vdh.virginia.gov/roanoke/population-health/

Name

Organization

Area of Expertise

Anne Marie Green

Council of Community Services

Community Development, Homelessness

Ashley Trainque

Craig County Health Center

Federally Qualified Health Center

Bill Jones

American National Bank

Financial Well-Being

Brandon Meginley

City of Roanoke, Financial Empowerment Center

Financial Well-Being

Brooke Crouch

New Horizons Healthcare

Primary Care Access/Healthy Communities Development

Chance Welfare

New Horizons Healthcare

Primary Care Access/Healthy Communities Development

Dave Prosser

FreedomFirst

Financial Well-Being

David Nova

Blue Blaze Consulting

Community Development

Debbie Bonniwell

Blue Ridge Behavioral Healthcare

Mental Health, Substance Use, ID

Eileen Lepro

New Horizons Healthcare

Primary Care Access/Healthy Communities Development

Elizabeth (Beth) Leffel

Leffel Consulting Group, LLC

Medical Research

F.L. Slough

Roanoke City Public Schools

Schools

Hannah Adkins

United Way of Roanoke Valley

Community Development, Public Health

Isabel Thornton

Restoration Housing

Housing

Jeremy Holmes

Roanoke Valley Alleghany Regional Commission

Transportation

Joanna Spar Jojo Friday

Roanoke County DSS Sisters of Change

Social Services Community and Business Development, Diversity, Inclusion

Julie Phillips

Botetourt County Libraries

Library

Kim Roe Kristin Adkins

Carilion Clinic Roanoke City & Alleghany Health Districts / VDH

Ambulatory Care Public Health

Lee Clark

Rescue Mission Ministries, Inc.

Health and Human Services for the Homeless

Leslie Clark

United Way of Roanoke Valley, Healthy Roanoke Valley Carilion Oncology

Community Arm of CHA

Leslie Loving

Oncology

Name

Organization

Area of Expertise

Linda Hentschel

Family Service of Roanoke Valley

Mental Health

Lisa Denney Marilyn Herbert-Ashton

Children's Trust Virginia Western Community College

Children Higher Education

Mary Ann Gilmer

Goodwill Industries of the Valleys

Community Development, Employment

Molly Roberts

Carilion Clinic

Public Health

Morgan Romeo

Virginia Blue Ridge Works (Western VA Workforce Development Board)

Workforce Development/Community Planning

N.L. Bishop

Carilion Clinic

Equity, Diversity, Inclusion

Pam Chitwood

Community Impact, Food Insecurity

Pamela Irvine

United Way of Roanoke Valley, Healthy Franklin County Feeding Southwest Virginia

Paula Prince

Radford University Carilion

Rebecca Stackhouse

VAMC

Human Services/ Research/ Homelessness Hospital Based Care

Robin Haldiman

CHIP of Roanoke Valley

Children and Families

Samara Lott

Roanoke City & Alleghany Health Districts / VDH

Public Health

Shirley Holland

Carilion Clinic

Hospitals, Community Development

Steven Martin

City of Roanoke - DSS

Social Services

Timothy Hahn

Roanoke City Public Schools

Schools

Vivien McMahon

United Way of Roanoke Valley

Community Impact

Food Insecurity

Community Served Carilion Medical Center Principal Functions CMC, located in Roanoke, Virginia, includes Carilion’s flagship facility, Carilion Roanoke Memorial Hospital (CRMH), and Carilion Roanoke Community Hospital. CRMH includes a Level 1 Trauma Center, a Neonatal Intensive Care Unit, Carilion Children’s Hospital and 703 patient beds. Offering a wide range of inpatient and outpatient care, specialty care, medical education and fellowships, CRMH has gained recognition as Virginia’s top four hospital by U.S. News and World Report22. Additionally, Carilion Roanoke Community Hospital houses a highly skilled inpatient rehabilitation unit.

Geographic Area The service areas for Carilion Clinic’s CHAs are determined by 70-80% of unique patient origin of the hospital in each respective market. Focus is placed on areas that are considered Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs). In fiscal year 2020, CMC served 121,095 unique patients. Patient origin data revealed that during this year, 74% of patients served by CMC lived in the following localities: • • • • • • •

Roanoke City (27.5%) Roanoke County (19%) Franklin County (8.8%) Botetourt County (7.4%) Salem (5.6%) Bedford County (5.1%) Craig County (0.7%)

https://www.carilionclinic.org/locations/carilion-roanoke-memorial-hospital

The service area for the 2021 RVCHA includes the cities of Roanoke and Salem and the counties of Bedford, Botetourt, Craig and Roanoke, with secondary data included for Franklin County. Franklin County is partly served by Carilion Franklin Memorial Hospital (CFMH) located in Rocky Mount, Virginia. CFMH also conducted its own CHA of Franklin and Henry counties concurrently, so Franklin County is not included as part of the service area for the 2021 RVCHA. Franklin County data are included in secondary data so complete data for the Metropolitan Statistical Area (MSA) will be available in this report. Please note that while Bedford County is included in the service area, it is not part of the Roanoke MSA. Carilion participates in the Bedford Region Community Health Needs Assessment with neighboring Centra Health System.

Target Population The target population for Carilion Clinic’s CHA projects consists of underserved/vulnerable populations disproportionately impacted by the social determinants of health, including poverty, race/ethnicity, education, access and/or lack of insurance. Populations are examined across the different life cycles, including parents of children and adolescents, women of child-bearing age, adults, and the elderly. They are also studied across various race and ethnic groups and income levels. All patients are included in this assessment regardless of insurance payments or financial assistance eligibility.

Service Area Demographics The Roanoke MSA, home to Carilion Clinic’s flagship hospital CRMH, is commonly known as the Roanoke Valley. It is composed of the independent cities of Roanoke and Salem and the counties of Botetourt, Craig, Franklin and Roanoke. The Valley is nestled among the Blue Ridge Mountains with the City of Roanoke at its heart. Roanoke is a destination place, rich in cultural diversity, the arts, shopping, recreational opportunities, natural beauty and services not available in more rural areas of the region. In addition to Carilion, key safety net providers in the region include Veterans Administrations, a federally qualified health center, free clinics, local offices of the VDH and other service organizations. Despite these entities’ presence, however, thousands of low-income, uninsured and underinsured residents do not have access to affordable health care services. The Roanoke Valley is comprised of distinct communities with significant disparities in size, population and social determinants of health. The 2015-2019 American Community Survey (ACS) found the Roanoke MSA’s total population to be 313,009. The cities of Roanoke and Salem had 99,229 residents and 25,317 people, respectively. The counties of Botetourt, Craig, Franklin and Roanoke had 33,343, 5,110, 56,187 and 93,823 residents, respectively. The median age in the MSA localities ranges from 37.8 in the City of Roanoke to 47.2 in Craig and Franklin Counties, all above the state median of 38.223. The Weldon Cooper Center for Public Service predicts positive population change by 2040 for all communities except Craig County, which may have very slight population loss 24. The ACS finds that for most of the Roanoke MSA, a more significant percentage of the population is White than in the Commonwealth of Virginia as a whole, with rates ranging up to 98.6% in Craig County25.

U.S. Census Bureau, 2015-2019 5-year American Community Survey, Table S0101, https://data.census.gov/cedsci/table?q=S0101&tid=ACSST5Y2019.S0101&hidePreview=true. 24 Weldon Cooper Center for Public Service, https://demographics.coopercenter.org/virginia-population-projections. 25 U.S. Census Bureau, 2015-2019 5-year estimates, American Community Survey, Table DP05, https://data.census.gov/cedsci/table?tid=ACSDP5Y2019.DP05&hidePreview=true. 23

The Roanoke Valley’s urban hub, the City of Roanoke, is more racially and ethnically diverse than the rest of the MSA. Roanoke’s population is 62.4% White, 29.0% Black and 3.0% Asian, with 4.4% representing more than one race. The remainder represents small minorities of American Indian/Alaskan Native, Native Hawaiian/Pacific Islander or some other race. Of the population, 6.3% are Hispanic or Latino26. The city is divided into quadrants (Northwest, Northeast, Southwest and Southeast) separated geographically by railroad tracks, the Roanoke River and Interstate 581. These quadrants vary significantly in the demographic and economic make-up of their residents. Specifically, two of the quadrants—Northwest and Southeast—have federal designations as MUAs. The quadrants are home to a large proportion of the low-income individuals and families in the city who may be uninsured, underinsured or are Medicaid recipients facing additional barriers due to cultural differences.

U.S. Census Bureau, 2015-2019 5-year estimates, American Community Survey, Table DP05, https://data.census.gov/cedsci/table?tid=ACSDP5Y2019.DP05&hidePreview=true. 26

Community Health Assessment Process Identification of Significant Health Needs Carilion Clinic, HRV and the RCAHD led the efforts to conduct the 2021 RVCHA. A 43-member CHAT oversaw the planning activities. The CHAT meets four times throughout the process, with each meeting serving a distinct purpose. See Appendix 1, Gantt Chart, for specific meeting dates. • • • •

Meeting 1: Introduction and Overview of the Process Meeting 2: Stakeholder Focus Group Meeting 3: Data Review and Discussion Meeting 4: Prioritized Needs Discussion

Each meeting builds on the one prior and fosters interactive dialogue amongst CHAT members. Due to the impact of COVID-19, all CHAT meetings were held virtually via WebEx. Significant community health needs were identified utilizing the following: • • •

Community Health Survey (Appendix 2) Stakeholder Survey and CHAT Focus Group (Appendix 3) Data Review

Further details are provided in the Data Collection and Analysis section. The main criteria for determining the significance of a need were its presence as a top need through a high percentage of Community Health Survey respondents, high percentage of stakeholder survey respondents, and/or notable worsening trends in either primary or secondary data. To better understand the specific needs of those with cancer, the Community Health Survey was also filtered to show results from respondents who self-identified as having cancer or once having cancer. Their results can be found in Appendix 9. To identify significant health needs in particular parts of the community, additional detail was provided where feasible to make comparisons by county, gender, race and age. In the third CHAT meeting (Data Review), Roanoke City data was compared to the overall service area data to identify needs that may be an issue in the City but did not affect the service area at large.

Prioritization of Significant Health Needs After all primary and secondary data collection is complete, the CHAT reviews all data and participates in a prioritization activity. Each CHAT member selects and ranks the ten most pertinent community needs. The data are combined, and priorities are selected based on the highest weighted score of each need. Please see Appendix 4 to view the prioritization worksheet. Through this process, needs are prioritized by the CHAT members according to: • •

The perceived burden, scope, severity or urgency of the health need The importance the community places on addressing the need through survey responses and other interactions 15

•

Their own unique perspective on the health-related needs of the community

Identification of Resources to Address Needs The CHAT members were integral in identifying resources to address needs. During the Stakeholder Focus Group and subsequent survey, the CHAT was asked to provide feedback on what health resources exist in the service area. The list was compiled from their responses, and additional resource lists that have since been identified have also been included. Please see Appendix 5 for the full resource list.

Community Input Hearing voices from across our service area is crucial to the success of a CHA. Broad-interest community reach is a main qualification when inviting individuals to join the CHAT. In addition to the HRV Steering Committee, we also invite representatives from the RCAHD, local governments, the local school system, social service organizations, and other community organizers and nonprofit leaders. The RCAHD was engaged from the beginning of the planning process (late spring of 2020) all throughout the assessment period and fourth CHAT meeting—despite navigating the pandemic of a lifetime. RCAHD’s involvement helped shape all aspects of this assessment. Its team identified community partners to serve on the CHAT, provided discussion points during the first CHAT meeting and offered feedback on the prioritized needs. Additionally, RCAHD representatives were active on the CHAT, participating in the Stakeholder Survey, CHAT focus group and prioritization activity. In addition to RCAHD, the CHAT included other individuals or organizations serving or representing the community’s medically underserved, low-income and minority populations. Examples include: • • • • •

Free clinics (e.g., Bradley Free Clinic, Fralin Free Clinic) Federally Qualified Health Centers (e.g., New Horizons Healthcare) Social service agencies (e.g., Roanoke County Department of Social Services) The United Way of Roanoke Valley Hospitals, physicians

These organizations and individuals helped gather community input by distributing the Community Health Survey. CHAT member input was solicited through the Stakeholder Survey and Focus Group. Combined, these efforts led to the identification and prioritization of community health needs. Target population focus groups are typically a significant way in which we collect community input, especially for those who are medically underserved, under-resourced or have disadvantages related to health needs. The COVID-19 pandemic impacted our ability to gather in groups and created logistical barriers for these focus groups. The CHAT decided that these focus groups would not be possible for the 2021 assessment due to resource and logistical strains. The 2018 RVCHA and the subsequent Implementation Strategy were posted publicly though multiple electronic channels and shared widely by community partners. An email address was provided for submission of written comments, but none were received.

Community Impact Impact of Actions Taken in Response to 2018 RVCHA Carilion Clinic responds to community health needs in innovative ways. Our initiatives include: • • • • •

Having a robust primary care physician practice network of medical homes Making sure our regions have access to state-of-the-art health care close to home Providing community grants and sponsorships to extend our mission and support other organizations that address health need Creating and implementing community-wide strategies to reduce barriers, coordinate resources and enhance community strengths Providing community-based health and wellness programming

In our commitment to improving the health of the communities we serve, Carilion has focused on projects to improve health in the MUAs of Southeast and Northwest Roanoke City. Southeast neighborhoods border our flagship hospital, CRMH. Much of Carilion’s health programming and grant giving has focused on Southeast in recent years. In Northwest, Carilion now has a Community Health Worker (CHW) at the Roanoke EnVision Center, a one-stop hub that helps low-income residents access important community resources. The CHW helps connect individuals with services like transportation, mental health and substance abuse treatment, housing, clothing, food and more. We continue to explore opportunities to invest in these neighborhoods in ways that will impact health and social determinants. With the onset of COVID-19, Carilion immediately recognized the prominent role we would play in both prevention and treatment for our region. The pandemic demanded a shift in operations and priorities during Virginia’s stay-at-home order. While some of our Implementation Strategies were delayed or altered, Carilion quickly responded to the new and unique social health needs arising from COVID-19. Community response efforts included establishing a community hotline and recovery support phone line, expanding flu shot distribution, and broad community health education and guidance. We also made it our mission to ensure the safety and well-being of patients at higher risk of severe infection from COVID-19 through targeted outreach programs. The Home Alone project, for example, connected senior patients who were living alone with resources such as food, masks, medications and toiletries. Patients with more complex social needs were escalated to CHWs and those with more complex health needs were escalated to a nurse. Care kits and information were also provided to Housing Authority sites that specifically housed older adult populations. Home Alone reached a total of 1,651 high-risk patients across Carilion’s footprint, allowing seniors to stay home safely, avoid the hospital and reduce their exposure to COVID-19. As COVID-19 vaccinations became available, Carilion once again shifted operations to convene regular mass vaccination clinics in Roanoke City, Franklin County and surrounding parts of the Carilion service area. Since December 2020, we've partnered with local health departments and authorities across our region to aid in the fight against COVID-19. From our very first mass vaccination clinic at the Berglund Center to assisting with smaller clinics at churches, parks and community centers, Carilion staff and volunteers have administered hundreds of thousands of COVID-19 vaccine doses to our communities. Each dose moves us one step closer to getting the pandemic under control. 18

To improve health behaviors, over 960 health education events, programs, screenings or immunizations have nearly 16,000 people in response to the 2018 RVCHA identified needs. CMC also awarded more than 40 community grants to support organizations across the Roanoke Valley working to address those needs. The Pathways Community HUB, a program in partnership with the United Way that connects uninsured patients to social services through CHWs, has grown. CHWs are now housed in three Roanoke-area medical offices and can receive referrals from the CRMH Emergency Department. Carilion is also planning to expand CHW work across the Roanoke area. Medicaid expansion continues to increase access to health services across the region. With commitment to continued enrollment in Medicaid and other applicable public programs, Carilion has partnered with MedAssist, a contractor dedicated to determining eligibility and assisting with all aspects of enrollment for eligible patients and community members. Enrollment not only allows access to Carilion services, but to additional dental and mental health services across the community as well. The #ALLin program and Peer Recovery Services were launched to provide mental health awareness and education helping those with addiction and mental health conditions move towards recovery. Through these programs, CMC operates an ED Bridge to Treatment program connecting patients to substance use treatment, has established a mental health collaborative in the Roanoke Valley, and trains community members to utilize Narcan. The Peer Recovery Center, established in 2019, has become a trusted space for individuals struggling with addiction, mental health issues or in need of support.

Data Collection and Analysis Methods Primary and secondary data were collected for the 2021 RVCHA. Additionally, billing data from Carilion Clinic on hospital admissions and emergency department visits for residents within the service area helped corroborate perceived community needs with the clinical conditions being seen at the hospital. Primary data collection included the Community Health Survey, the Stakeholder Focus Group and the Stakeholder Survey. Both primary and secondary data were shared for review with the CHAT in advance of the third CHAT meeting.

Community Health Survey A Community Health Survey was conducted as part of the RVCHA. This survey was used to evaluate the health of the community and identify potential geographic areas to target improvements. Input and oversight of survey development was provided by the CHAT and a planning group consisting of representatives from Carilion, HRV and the RCAHD. A 38-question survey instrument was initially developed in 2011 and updated in 2020 that asked questions about socioeconomic factors, healthy behaviors, physical environment, health outcomes, demographics and access to medical, dental and mental health care (Appendix 2: Community Health Survey). The survey instrument included commonly used questions and metrics from the following established community surveys: • • • • • • •

Community Themes and Strengths Assessments, National Association of County and City Health Officials (NACCHO), Mobilizing for Action through Planning and Partnerships (MAPP) Community Healthy Living Index, YMCA Behavioral Risk Factor Surveillance System, CDC National Health Interview Survey, CDC Youth Risk Behavior Surveillance System, CDC Martin County Community Health Assessment, Martin County, North Carolina Previous Roanoke Valley Community Health Surveys

The population of interest for the survey was Roanoke Valley residents 18 years of age and older. The Roanoke Valley includes the RVCHA service area of Bedford County, Botetourt County, Craig County, Roanoke County, Roanoke City and Salem City. Surveys were distributed from October 2020 through January 2021. A drawing for two $100 grocery store gift cards was offered as an incentive for those completing the survey. The following subpopulations were especially targeted for sampling: •

Underserved/vulnerable populations disproportionately impacted by the social determinants of health, including: o Poverty o Race/ethnicity o Education o Lack of insurance

A non-probability sample method was used, where respondents were not randomly selected. Although the survey was available to all residents living in the Roanoke Valley, oversampling of the targeted 20

subpopulations was attempted through specific outreach efforts through community partners. Despite oversampling efforts to ensure that needs and assets specific to this subpopulation of interest were captured, survey demographic results indicate a lower-than-expected response from these groups. The survey instrument was available in both English and Spanish via the following methods: • • •

Survey Monkey link (www.surveymonkey.com/r/2018CHA) Phone line (888-964-6620) Paper surveys (collected by volunteers and/or staff of partner agencies)

Outreach strategies for survey distribution included: • • • •

Media coverage by the local television and newspaper announcing the URL for the survey Facebook, including geographically targeted advertisements Flyers and posters distributed throughout the community with survey URL and phone line information Survey URL posted on partner agency websites

Due to the impact of COVID-19 on face-to-face interactions, electronic survey completion was emphasized. Although paper surveys were distributed, they represented a lesser share of responses than in prior assessment periods. In total, 1,560 surveys were collected. • • •

183 paper surveys 1,376 online surveys 1 phone survey

All responses were entered into Survey Monkey by survey respondents or by Carilion Direct representatives, who entered responses from paper or phone surveys. Surveys were analyzed and reported using Survey Monkey and Microsoft Excel. Survey results for respondents who have self-identified as having cancer or once having cancer can be found in Appendix 9.

Stakeholder (CHAT) Focus Group The second CHAT meeting consisted of a Stakeholder Focus Group with the CHAT members. The questions discussed were identical to those included in the Stakeholder Survey (Appendix 7: Stakeholder Survey). Carilion Clinic staff from across the organization aided in facilitating small group discussions. In order to quantify focus group data, CHAT members were asked to complete the Stakeholder Survey. An additional Stakeholder Focus Group was held with CMC’s Clinical Advancement and Patient Safety Committee as a representative of the CMC Board of Directors. These participants were also asked to complete a Stakeholder Survey to quantify data from the discussion.

Stakeholder Survey Throughout the RVCHA process, community stakeholders, leaders and providers were encouraged to complete the Stakeholder Survey (Appendix 3: Stakeholder Survey). This survey provided an additional perspective to the needs and barriers to health facing our community. The survey was available online 21

and was shared at the CHAT meetings and via email. Surveys were analyzed and reported using Survey Monkey and Microsoft Excel.

Secondary Data Secondary data was collected through SparkMap, a University of Missouri product that quickly and accurately aggregates data across geographies for 80+ indicators from publicly available sources such as the ACS, County Health Rankings and the VDH. Secondary data analysis was provided through SparkMap’s tables, maps and visual diagrams depicting indicators that are better or worse than the state average, trends over time, and comparisons across different population segments such as race and life cycle. See Appendix 7 for full secondary data report from SparkMap. While SparkMap was the main source of secondary data, additional sources were utilized. The VDH’s Equity Dashboard was utilized for an overview and analysis of equity in the Roanoke Valley.

Collaboration Forming a true community collaborative with lasting impact is no small feat. In response to the 2012 RVCHA, HRV was formed to foster cohesive community development between partners using the Strive Collective Impact Model27. This evidence-based model focuses on “the commitment of a group of important players from different sectors to a common agenda for solving a specific social problem” and has been proven to lead to large-scale change. Collective impact focuses on four conditions for collective success: 1. A Shared Community Vision: a broad set of cross-sector community partners come together in an accountable way to implement a vision for a healthier community and communicate that vision effectively. 2. Evidence-based Decision-Making: The integration of professional expertise and data to make decisions about how to prioritize a community's efforts to improve health outcomes. 3. Collaborative Action: the process by which networks of appropriate cross-sector services/providers use data to continually identify, adopt and scale practices that improve health outcomes. 4. Investment & Sustainability: There is broad community ownership for building civic infrastructure and resources are committed to sustain the work of the partnership to improve health outcomes. Collective Impact also suggests having a neutral anchor institution to serve as the convening body for community collaborative. To ensure long-term impact of the health assessment and resulting community health improvement process implementation, Carilion funds and plays a key role in HRV and supports United Way serving as the anchor institution in the Roanoke Valley. This collaboration earned national attention as a recipient of the 2020 American Hospital Association’s Dick Davidson NOVA Award, an honor awarded annually to five hospital-led collaborations improving community health. The 2021 RVCHA would not have been possible without collaboration with HRV and the RCAHD. In addition, teamwork across all CHAT members was critical to the success of this project.

Kania, J., & Kramer, M. (2011). Collective Impact. Stanford Social Innovation Review. https://ssir.org/images/articles/2011_WI_Feature_Kania.pdf

Data Review In the following sections, data will be presented in a variety of formats to illustrate some of the relevant issues impacting the community’s health. Higher rates of chronic diseases, cancers and many socioeconomic factors exist across the service area to varying degrees when compared with the Commonwealth of Virginia as a whole. Where tables exist, red text indicates a value worse than the Virginia average.

Clinical Data Chronic Diseases in Residents of the Roanoke Valley from Secondary Data Sources In review of secondary data for chronic disease, most Roanoke Valley localities have higher rates of chronic diseases than Virginia overall. Notably, the percentage of adults with asthma in Roanoke City is the highest across the service area at 10.1%, compared to Virginia’s 8.9%. Table C1 shows the percentage of adults with a subset of chronic diseases across the service area according to the CDC’s Behavioral Risk Factor Surveillance System. Diabetes and obesity are variable across the service area. Botetourt and Craig Counties have the lowest rates of diabetes at 4.3% and 5.5%, respectively. This compares to Virginia’s overall rate of 9.7% and the highest rate in the service area of 14.5% in Salem. Adult obesity, defined by a Body Mass Index greater than 30, ranges from a low of 27.6% in Craig County to a high of 39.8% in Franklin County. Virginia’s overall rate is 30.4%. See Table C2 for details. Table C1. Chronic Diseases Across Roanoke Valley Service Area Locality

Percentage of Adults with Asthma

Percentage of Adults Ever Diagnosed with Chronic Lower Respiratory Disease

Percentage of Adults Ever Diagnosed with Coronary Heart Disease

Percentage of Adults Percentage of Adults Ever Having a Stroke with High Blood Pressure

Roanoke Valley Service Area

9.26%

8.33%

7.99%

3.85%

36.88%

Bedford County

9.0%

8.2%

7.8%

3.7%

37.3%

Botetourt County

8.8%

8.1%

8.0%

3.6%

35.5%

Craig County

9.0%

8.8%

8.4%

3.8%

37.3%

Franklin County

9.6%

9.9%

9.5%

4.4%

39.6%

Roanoke County

8.6%

7.3%

7.5%

3.4%

33.9%

Roanoke City

10.1%

8.8%

8.0%

4.3%

39.4%

Salem City

9.1%

7.4%

7.0%

3.3%

32.5%

Virginia

8.9%

6.6%

6.4%

3.2%

32.2%

United States

9.5%

7.2%

6.9%

3.4%

32.9%

Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the 500 Cities Data Portal. 2018. Accessed via SparkMap

Table C2. Diabetes and Obesity for Roanoke Valley Service Area Report Area

Adults with Diagnosed Diabetes, Age- Adjusted

Adults with BMI > 30.0 (Obese), Percent

Rate

Roanoke Valley Service Area

10.8%

33.4%

Bedford County

11.9%

33.4%

4.3%

28.5%

Botetourt County Craig County

5.5%

27.6%

Franklin County

12.5%

39.8%

Roanoke County

11.1%

29.7%

Roanoke City

11.0%

35.9%

Salem City

14.5%

31.3%

9.7%

30.4%

Virginia

United States 9.5% Data Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2017. Source geography: County. Accessed via SparkMap.

29.5%

Chronic Diseases in Patients Seeking Care at Carilion Medical Center by Zip Code The Virginia Hospital and Healthcare Association (VHHA) analyzes hospital discharge data for patients with specific chronic diseases (diabetes, kidney disease, hypertension, heart disease, stroke, hyperlipidemia and heart failure). Diseases selected are based on VHHA funding requirements. In review of this data, a trend of zip codes with high shares of chronic disease was determined. Across the Roanoke Valley, the following zip codes continued to rise to the top: 24012, 24017, 24179, 24014, 24019, 24153, 24018, 24151, 24016 and 24013. Overall, these 10 zip codes account for roughly 50% of all admissions flagged with the included chronic disease. Zip code 24012 has the largest percentage of all chronic diseases examined by VHHA at CMC, despite not being the largest share of the population within the service area. Zip codes 24016 and 24013 were also consistently in the top 10 despite their small share of the population, each with populations below 10% of the total Roanoke Valley service area size. These statistics shed light on zip codes that may be experiencing disproportionate health-related challenges in the Valley. See Table C3 for details.

Table C3. Chronic Disease Discharges, Carilion Medical Center data via Virginia Hospital and Healthcare Association

Total Discharges (2016-2020)

Diabetes

Kidney Disease

Hypertension

Heart Disease

Stroke

Hyperlipidemia

Heart Failure

32,327

35,451

66,953

27,482

4,925

46,818

22,657

8% 5% 6% 5% 5% 5% 6% 4% 2% 3%

9% 6% 6% 5% 5% 5% 6% 4% 3% 3%

Zip Code 24012 8% 9% 24017 7% 6% 24179 6% 6% 24014 5% 5% 24019 5% 5% 24153 5% 5% 24018 5% 5% 24151 4% 4% 24016 3% 3% 24013 3% 3% Data Source: Virginia Hospital and Healthcare Association

Percent of total 8% 6% 5% 5% 5% 5% 6% 4% 3% 3%

8% 5% 6% 5% 5% 5% 5% 4% 2% 3%

8% 5% 5% 5% 5% 4% 5% 3% 3% 2%

Chronic Diseases in Carilion Patients Residing in the Roanoke Valley, Medical Billing Data As the primary source of medical care in the Roanoke Valley, Carilion leverages internal data for insights on the health of the community. Data on inpatient admissions point to some service lines with preventable aspects as top reasons for seeking care. Cardiology, for example, includes heart attacks and heart failure, conditions which can be largely impacted through behaviors and lifestyle. Other Medical, the top service line for admissions, includes systemic issues such as sepsis, urinary tract or kidney issues, ear, diseases of the ear, nose and throat, blood and immune disorders, and diseases of the subcutaneous tissue. Data on emergency department visits for Roanoke Valley residents shows the top category is injuries (broadly). Here we see an opportunity for decreased emergency department visits through education. Table C4 and Table C5 provide further detail on admissions and emergency department visits. When considering only patients identified through the medical record as Hispanic, Mother Baby/GYN accounted for well over 55% of all admissions each year from FY2017-FY2020 ranging from a low of 55% in FY19 to 58% in FY20. This includes admissions for delivery, newborn stays and neonatal admissions. The large percentage of admissions in this service line indicate that Hispanic patients are admitted for other service lines less frequently than the overall patient population, indicating potential gaps in care.

Table C4. Top 10 Inpatient Admission Service Lines for Roanoke Valley Patients Service Line FY2017 FY2018 FY2019 FY2020 IP Mother Baby/GYN 16.72% 16.80% 17.08% 19.02% IP Other Medical 17.39% 18.69% 18.13% 17.53% IP Cardiology 10.41% 10.47% 11.25% 11.51% IP Neurology 7.51% 7.83% 7.71% 7.77% IP Behavioral Health 9.63% 8.79% 8.53% 7.55% IP Pulmonary 6.92% 7.24% 7.33% 7.55% IP Orthopedics 8.00% 7.53% 7.66% 6.73% IP GI 6.30% 6.33% 6.28% 5.92% IP Other Surgery 5.17% 4.79% 4.57% 5.10% IP Pediatrics 3.92% 3.39% 3.37% 2.65% Data Source: Strata

Table C5. Top 10 Emergency Department Visits for Roanoke Valley Patients ICD-10 Category FY2017 FY2018 FY2019 FY2020 Injury, poisoning, and certain other consequences of external causes 17.45% 16.78% 16.49% 16.74% Diseases of the respiratory system 9.11% 9.86% 9.35% 9.13% Symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified 8.37% 7.98% 7.95% 8.17% Diseases of the digestive system 7.12% 7.04% 7.09% 7.25% Diseases of the circulatory system 6.52% 6.51% 6.82% 7.23% Diseases of the musculoskeletal system and connective tissue 7.96% 8.04% 7.80% 7.19% Symptoms, signs, circulatory and respiratory 7.22% 7.14% 6.91% 6.90% Mental, behavioral and neurodevelopmental disorders 5.22% 5.41% 5.74% 6.09% Symptoms, signs, digestive and abdomen 6.94% 6.83% 6.24% 5.88% Diseases of the genitourinary system 5.04% 5.19% 5.22% 5.09% Data Source: Strata

Cancer While most Roanoke Valley localities have a breast cancer rate similar to Virginia’s rate of 127.4 cases per 100,000 people, Roanoke County and Salem stand out as having higher rates of 138.8 and 144.3 cases per 100,000 people, respectively28. When analyzing rates by race, Black residents in Franklin County have a higher incidence of breast cancer at 152.9 per 100,000 people compared to 118.3 per 100,000 people reporting white race. Black residents in Roanoke County have a lower incidence of breast cancer at 117.6 per 100,000 people compared to 138.3 per 100,000 people reporting white race. Colorectal cancer rates across the Roanoke Valley are higher in comparison to Virginia’s incidence rate, with the exception of Roanoke County. Franklin and Craig Counties have the highest colorectal cancer rates across the service area at 45.7 and 52.3 cases per 100,000 people, respectively. When analyzing

State Cancer Profiles. 2013-17. Source geography: County. Accessed through SparkMap.

rates by race, Black residents in Franklin County have a higher incidence of colorectal cancer at 61.9 per 100,000 people compared to 43.9 per 100,000 people reporting white race29. Lung cancer rates are variable across the Roanoke Valley. Rates range from a low of 52.7 cases per 100,000 in Roanoke County to 74.3 cases per 100,000 people in Roanoke City, with Virginia’s overall rate of 56.4. When analyzing rates by race, Black residents in Roanoke County have a higher incidence of lung cancer at 67.9 per 100,000 people compared to 52.1 per 100,000 people reporting white race30. See Table C6 for breast, colorectal and lung cancer incidence rates by locality. Table C6. Cancer Incidence Rates by Locality, 2013-2017 Locality

Cancer Incidence Rate (Per 100,000 Population)

Breast Cancer Incidence

Colorectal Cancer

Lung Cancer Incidence Rate

Rate (Per 100,000

Incidence Rate (Per

(Per 100,000 Population)

Population)

100,000 Population)

Roanoke Valley Service Area

444.3

129.7

40.5

61.5

Bedford County

434.9

126.0

38.9

59.8

Botetourt County

427.2

127.6

40.5

57.7

Craig County

425.4

120.4

52.3

55.1

Franklin County

412.5

120.3

45.7

58.2

Roanoke County

441.5

138.8

33.4

52.7

Roanoke City

466.1

123.5

44.2

74.3

Salem City

485.7

144.3

40.6

67.6

Virginia

416.1

127.4

35.2

56.4

448.7

125.9

38.4

58.3

United States

Data Source: State Cancer Profiles. 2013-17. Source geography: County. Accessed via SparkMap.

29 30

State Cancer Profiles. 2013-17. Source geography: County. Accessed through SparkMap. State Cancer Profiles. 2013-17. Source geography: County. Accessed through SparkMap.

Vital Conditions for Well-Being In addition to addressing the social determinants of health, we are utilizing a framework for viewing health and well-being through seven vital conditions. The WIN Network’s Vital Conditions for Well-Being emphasize the health and well-being of people and places as a necessary component to thrive31. Below we describe each vital condition and present a subset of related data.

Vital Condition: Basic Needs for Health & Safety Basic needs for health and safety include factors like access to physical and mental health care services, nutritious foods, and freedom from addiction, trauma and crime32. The subset of indicators provided below paints a picture of some of the potential barriers across the Roanoke Valley in meeting these basic needs. Additionally, we can pinpoint specific areas within the region that are likely to have more gaps in basic needs based on lower life expectancy. Life Expectancy Disparities in life expectancy are widespread across the Roanoke Valley, ranging from 71.3 years in Franklin County’s census tract 203 to over 81 years in census tracts throughout Bedford, Botetourt and Roanoke Counties. With the exception of census tract 29 (South Roanoke), Roanoke City has some of the lowest life expectancy values across the Valley. Census tract 26 in Southeast Roanoke City has the lowest life expectancy at 68.4 years. Map V1. Life Expectancy by Census Tract, Roanoke Valley Service Area

Data Source: Centers for Disease Control and Prevention and the National Center for Health Statistics, U.S. Small-Area Life Expectancy Estimates Project. 2010-15. Source geography: Tract. Accessed via SparkMap.

31 32

https://winnetwork.org/vital-conditions https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Print-.pdf

Map V2. Life Expectancy Detail, Urban Hub of Roanoke Valley Service Area

Health Professional Shortage Areas A shortage of health professionals is a barrier to care that contributes to poor outcomes. In the Roanoke Valley service area, HPSAs exist for primary care, dental and mental health services. Primary care HPSAs exists in the counties of Bedford, Craig and Franklin, Northern Botetourt County, and Northwest Roanoke City. Dental HPSAs exist in Bedford County and Craig County, and specifically related to lowincome populations in Franklin County, Northern Botetourt County, Roanoke County, Roanoke City and Salem. Mental health HPSAs exist in Craig and Botetourt Counties, and for the low-income populations in Bedford, Franklin, and Roanoke Counties and the Cities of Roanoke and Salem33. This supports the need for expanded access to providers, with specific emphasis on the low-income population. Drug Overdose Higher rates of drug overdoses exist in much of the Roanoke Valley than in Virginia overall, seen through both opioid overdose mortality and drug poisoning (all drugs) mortality. Chart V1. Posioning and Drug Overdose Mortality, Roanoke Valley Service Area

https://data.hrsa.gov/tools/shortage-area/hpsa-find

Table V1. Posioning and Drug Overdose Mortality, Roanoke Valley Service Area Poisoning Age-Adjusted Death Rate (Per

Opioid Overdose Age-Adjusted Death

100,000 Pop.), 2015-2019

Rate (Per 100,000 Pop.), 2015-2019

Report Area Roanoke Valley Service Area

25.4

19.0

Bedford County

16.9

10.4

Botetourt County

15.3

No data

Craig County

No data

Franklin County

25.5

18.0

Roanoke County

22.1

15.6

Roanoke City

38.0

29.1

Salem City

27.9

20.4

Virginia

17.6

13.4

United States

21.6

13.7

Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. 2015-2019. Source geography: County. Accessed via SparkMap.

Binge Drinking Binge drinking across the service area is higher in areas of Franklin and Roanoke Counties than other areas of the Valley. Rates tend to be higher in areas with higher income and lower poverty. Map V3. Adults (age 18+) Binge Drinking by Census Tract, Roanoke Valley Service Area

Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the 500 Cities Data Portal. 2018. Accessed via SparkMap.

Food Insecurity Prior to the pandemic, food insecurity had been at its lowest level in 20 years according to statistics provided by Feeding America. Due to income losses during this time, food insecurity is projected to increase for 2020 and 202134. Additionally, while COVID-19 relief funding has been available to nonprofit organizations addressing food insecurity, it is an unreliable funding stream. It is reasonable to expect that insecurity will persist long after the funding ends. Table V2. Food Insecurity Rate, Roanoke Valley Service Area Food Insecurity Rate (Overall) Bedford 9.1% Botetourt 7.7% Craig 10.6% Franklin 10.8% Roanoke City 13.4% Roanoke County 8.2% Salem 10.1% Virginia 9.4%

Food Insecurity Rate (Children) 10.7% 8.4% 10.8% 15.2% 19.3% 8.3% 11.0% 11.5%

Data source: Feeding America Map the Meal Gap 2019 Resource Requests to Virginia 211

Virginia 211 is a free service that helps connect people to resources they need. An initiative of the Department of Social Services and partners, Virginia 211 is available online, by phone call or by text message. The data dashboard is a useful tool to see what basic needs are not being met in individuals across the commonwealth. Of all requests in the last year for the Roanoke Valley service area, over 30% have been related to housing. Within that category, over half of requests have been related to rent assistance. This overlaps with humane housing vital condition and is a great example of how these conditions are interrelated. Figure V1. Resource Requests to Virginia 211, June 2020-June 2021, Roanoke Valley Service Area

Data Source: https://va.211counts.org/ 34

https://feedingamericaaction.org/resources/state-by-state-resource-the-impact-of-coronavirus-on-foodinsecurity/

Broadband Access Access to the internet is an increasingly important requisite for accessing information and health and social services. Many areas across Virginia suffer from inadequate access. According to the Integrated Broadband Planning and Analysis Toolbox by Virginia Tech’s Center for Geospatial Information Technology, there are pockets within the Roanoke Valley that are considered unserved—a definition based on low or no upload and download speeds35. Roanoke City, Roanoke County and Salem are not considered unserved, but many unserved areas exist across the counties of Craig, Bedford, Botetourt and Franklin, indicated by the dark red sections on the following maps.

Virginia Tech Virginia Broadband Availability Map and Integrated Broadband Planning and Analysis Toolbox, accessed via https://broadband.cgit.vt.edu/IntegratedToolbox/#about

Map V4. Areas Unserved by Broadband, Roanoke Valley Service Area by Locality Bedford County Craig County

Botetourt County

Franklin County

Data Source: https://broadband.cgit.vt.edu/IntegratedToolbox/#about

Vital Condition: Lifelong Learning Lifelong learning is defined as continued education, learning and literacy36. Higher levels of education tend to be reflective of better health status and health outcomes, emphasizing the importance of the data presented below and its impact on health and well-being. Educational Attainment Education is a predictor of health outcomes and economic stability. Understanding the educational attainment for an area is key to developing a strong labor force and economic development. The table below shows educational attainment across the service area. Roanoke City stands out with a higher percentage of the population without a high school diploma compared with Virginia, while the entire area has higher percentages of the population with a high school diploma only and no post-secondary education. Table V3. Educational Attainment, Roanoke Valley Service Area Report Area

No High School Diploma

High Some School College Only

Associates Bachelors Degree Degree

Graduate or Professional Degree

Roanoke Valley Service Area

10.5%

30.8%

20.5%

10.2%

17.4%

10.6%

Bedford County

9.98%

30.2%

21.8%

8.8%

17.4%

11.8%

Botetourt Count

7.24%

32.3%

20.7%

11.4%

17.2%

11.2%

Craig County

9.17%

37.5%

17.7%

12.0%

16.2%

7.4%

Franklin County

11.88%

34.9%

21.2%

10.1%

13.5%

8.3%

Roanoke County

7.67%

25.0%

19.7%

12.1%

22.8%

12.8%

Roanoke City

13.81%

34.1%

19.7%

9.0%

14.4%

9.0%

Salem

10.85%

29.0%

20.9%

11.4%

17.3%

10.6%

Virginia

10.31%

24.0%

19.2%

7.8%

22.0%

16.8%

United States

12.00%

27.0%

20.4%

8.5%

19.8%

12.4%

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: County. Accessed via SparkMap.

https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf

Preschool Enrollment Preschool enrollment is an important indicator for early childhood education and opportunities where programming needs may exist. The map below shows high variability across Roanoke Valley census tracts, ranging from below 35.1% of 3- to 4-year-old children enrolled to over 55% of 3- to 4-year-old children enrolled. Map V5. Preschool Enrollment by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed via SparkMap.

Vital Condition: Meaningful Work & Wealth Meaningful work and wealth refer to rewarding work, careers and standards of living. It can be measured through indicators such as job training, well-paying jobs, income and poverty37. Low economic status is often associated with poor health, as cost and affordability can be barriers to accessing health care and healthy foods. Income and poverty as presented below highlight pockets across the service area that have low income and high poverty. Map V6. Median Household Income by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed via SparkMap.

https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf

Map V7. Percent Population below 200% Federal Poverty Level by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

Vital Condition: Humane Housing Humane housing includes indicators related to safety and security at home, a key need for thriving people and communities. Housing is often the highest expense for a household and can easily set the trajectory for all aspects of health—for better or worse38. Data on cost-burdened households and substandard housing show large variability across census tracts and point to geographic disparities in humane housing. Map V8. Cost Burdened Households (Housing Costs Exceed 30% of Household Income) by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

Map V9. Cost Burdened Households (Housing Costs Exceed 30% of Household Income) by Census Tract, Urban Hub of Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

https://www.communitycommons.org/collections/Humane-Housing-as-a-Vital-Condition

Substandard housing (At Least 1 Substandard Condition Present) Substandard conditions include: 1) lacking complete plumbing facilities, 2) lacking complete kitchen facilities, 3) with 1 or more occupants per room, 4) selected monthly owner costs as a percentage of household income greater than 30%, and 5) gross rent as a percentage of household income greater than 30%. Map V10. Substandard Housing by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

Vital Condition: Thriving Natural World A thriving natural world includes indicators related to clean air, clean water and clean places to live, work and play39. The physical environment plays a large role in health outcomes. It contributes to a wide range of factors, including healthy behaviors like physical activity, and health conditions such as asthma. Although secondary data related to environmental health is largely uneventful for the Roanoke Valley— including generally high air quality and low or no drinking water violations—we know concerns exist in specific neighborhoods in closer proximity to industrial facilities and that have lower walkability and safety concerns impacting the potential to thrive. Social Vulnerability Index The CDC created a measure—the Social Vulnerability Index—to determine how vulnerable a community may be to human suffering and financial loss in a disaster, including environmental issues such as chemical spills or natural disasters, as well as disease outbreaks. By analyzing various social determinant issues, the vulnerability of each census tract is determined and allows for more efficient preparation and response40. Ranging from 0-1, a higher score indicates higher vulnerability. The Roanoke Valley service area and Virginia both have a social vulnerability index score of 0.34, indicating the same level of vulnerability in the Valley overall compared to the Commonwealth. Map V11 shows details by census tract and Table V3 shows overall scores by locality. Map V11. Social Vulnerability Index by Census Tract, Roanoke Valley Service Area

Data Source: Centers for Disease Control and Prevention and the National Center for Health Statistics, CDC - GRASP. 2018. Source geography: Tract. Accessed via SparkMap.

39 40

https://www.communitycommons.org/collections/Thriving-Natural-World-as-a-Vital-Condition https://www.atsdr.cdc.gov/placeandhealth/svi/fact_sheet/fact_sheet.html

Table V3. Social Vulnerability Index, Roanoke Valley Service Area Report Area

Social Vulnerability Index Score

Roanoke Valley Service Area

0.34

Bedford County

0.10

Botetourt County

0.04

Craig County

0.07

Franklin County

0.40

Roanoke County

0.13

Roanoke City

0.80

Salem City

0.31

Virginia

0.34

United States

0.40

Data Source: Centers for Disease Control and Prevention and the National Center for Health Statistics, CDC - GRASP. 2018. Source geography: Tract. Accessed via SparkMap.

Vital Condition: Reliable Transportation Reliable transportation refers to access to transportation that is yes, reliable, but also safe, accessible and close to places for food, work and play41. According to the ACS, Roanoke City residents are more likely to rely on public transportation for their commute, with 3.59% of workers relying on public transportation. All other Roanoke Valley localities show 0.5% or less of workers utilizing public transportation for commuting. The statistics below show a sharp increase in the percentage of households with no motor vehicle for Roanoke City compared to other service area localities. Table V4. Households with No Motor Vehicle, Roanoke Valley Service Area Report Area

Households with No Motor Vehicle, Percent

Roanoke Valley Service Area

6.54%

Bedford County

3.21%

Botetourt County

3.89%

Craig County

7.84%

Franklin County

4.72%

Roanoke County

3.97%

Roanoke City

13.06%

Salem City

7.04%

Virginia

6.10%

United States

8.61%

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract Show more details. Accessed via SparkMap.

https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf

Vital Condition: Belonging & Civic Muscle Belonging and civic muscle refers to a sense of belonging and power to shape the world. It includes indicators such as civic engagement and social associations42. Fulfilling relationships and social supports are key to thriving, engaging and investing in the community. Social Associations This indicator reports the number of social associations per 10,000 population. Associations include membership organizations such as civic organizations, bowling centers, golf clubs, fitness centers, sports organizations, political organizations, labor organizations, business organizations and professional organizations43. Communities with fewer social associations may be more likely to have individuals with a lower sense of belonging. Map V12. Social Associations, Roanoke Valley Service Area

Data Source: US Census Bureau, County Business Patterns. Additional data analysis by CARES. 2018. Accessed via SparkMap.

42 43

https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf US Census Bureau, County Business Patterns. Accessed through SparkMap,

Self-Reported Data The Community Health Survey, the primary method of identifying significant needs based on community input, showed distinct issues regarding health-related needs, health services and social/support resources in the community. Full survey responses can be found in Appendix 6. Figure SR1 shows the demographics of survey respondents. Figure SR1. Roanoke Valley Survey Respondent Demographics

When asked “What do you think are the most important issues impacting health in our community?”, the community indicated overweight/obesity a top issue, as well as issues surrounding access, mental health and substance use such as drugs, alcohol and tobacco. While many of these issues have come out as top needs in previous assessments, the stories behind them are uniquely impacted by COVID-19 for the 2021 RVCHA. Major changes in nearly every aspect of life shook the world starting in 2020 and upended things like economics, lifestyle, health and safety. Figure SR2 shows the top 10 issues impacting health in the community according to the survey. When analyzing responses based on income level, distinct differences were revealed between respondents with lower income ($20,000 or below) and respondents with higher income (above $70,000). Environmental health and housing problems were indicated as health concerns among a significantly higher proportion of the lower income respondents. Homicide, gang activity and neighborhood safety were also significant concerns among lower income respondents. In comparing responses from male and female survey respondents, females chose bullying and domestic violence as top issues impacting health at a significantly higher rate than males. Figure SR2. Survey Responses: What do you think are the most important issues impacting health in our community?

When asked “Which health care services are hard to get in our community?”, the top responses also included services related to mental health and substance abuse. Figure SR3 shows the top 10 health care services hard to get in the community according to the survey.

Adult dental care, while indicated as a difficult health service to access across all income levels, was significantly higher in low-income groups. Similarly, mental health services were indicated as hard to get across all incomes, but significantly higher in high-income groups. Domestic violence services were indicated as a hard-to-get resource for female respondents significantly more than for male respondents. Figure SR3. Survey Responses: Which health care services are hard to get in our community?

When asked “Which social/support resources are hard to get in our community?”, affordable/safe housing was by far the top response. Additional resources in the top 10 included childcare, transportation and those related to the cost/affordability of health care and other social determinants of health. Figure SR4 shows the top 10 social/support resources hard to get in the community according to the survey. Across income levels, banking and financial assistance, rent/utilities assistance, food benefits and unemployment benefits were significantly more difficult to access for lower income respondents. Childcare and domestic violence assistance were indicated as issues significantly more often for females than males, while males indicated health insurance as hard to get significantly more than females.

Figure SR4. Survey Responses: Which social/support resources are hard to get in our community?

The survey also included questions as indicators of connectedness. Across the Roanoke Valley, 25% of survey respondents report feeling not connected with the community and those around them, an indicator significantly higher for low-income respondents than those with higher incomes. Higher income respondents also reported eating meals together with their household on a regular basis over the seven days prior to taking the survey. Self-reported data from stakeholders supported similar concerns as those of the community. The most important issues were access to care or services and mental health and substance use. Stakeholders also identified two areas of Roanoke City as having the greatest unmet needs: Northwest and Southeast Roanoke City, which are both MUAs. Stakeholders also reported the elderly as a population with greatest unmet needs. See Appendix 3 for full stakeholder data summary.

Equity Equity is an increasingly important lens through which to view health issues. The VDH’s Equity at a Glance Dashboard provides a scorecard that highlights income and poverty, educational attainment, food access, unemployment, broadband access and housing insecurity by locality in comparison to Virginia44. See Figure E1 for the scorecards for each locality included in this assessment. Figure E1. Data from Virginia Department of Health Equity at a Glance Locality Scorecards Indicators

Virginia

Bedford County 8.9% 90.1%

Botetourt County 6.5% 92.2%

Craig County 8.9% 91.6%

Franklin County 14.5% 88.2%

Living in Poverty 10.6% Adults with High School 89.7% Diploma Low Access to Food 18.1% 9.8% 35.0% 11.2% 14.9% Labor Force that is 5.1% 5.1% 4.2% 4.5% 5.4% Unemployed Households with 83.9% 76.1% 80.2% 73.5% 73.5% Internet Access Households with 12.5% 7.6% 9.0% 4.3% 11.2% Severe Cost Burden Data Source: Virginia Department of Health Equity at a Glance Locality Scorecard

Roanoke City 20.8% 86.0%

Roanoke Salem County 6.9% 9.1% 91.7% 90.3%

18.4% 7.0%

20.2% 4.6%

42.1% 5.0%

74.9%

84.1%

79.3%

16.7%

9.5%

10.5%

Roanoke City stands out from the rest of the service area as worse than the Virginia average in all six categories on the scorecard. Notably, Roanoke City has a high percent of population living in poverty— nearly twice that of Virginia. The average annual income per person for those identifying as Black or African American and Hispanic or Latino are 60% and 50%, respectively, of the income per person of white Roanoke City residents45. Across the Roanoke Valley, most localities have a lower percentage of households with broadband access than the statewide rate of 83.9%, with Craig County and Franklin County having the lowest access at 74.9%. Additionally, Black or African American households reported the lowest percentages of computer access and broadband across almost all Roanoke Valley localities. These numbers are selfreported by household through the ACS and do not consider reliability or affordability of service46.

https://www.vdh.virginia.gov/equity-at-a-glance/locality-scorecard/ https://www.vdh.virginia.gov/equity-at-a-glance/locality/income-and-poverty/ 46 https://www.vdh.virginia.gov/equity-at-a-glance/locality/broadband/ 45

Appendices Appendix 1: Gantt Chart Tasks: 2021 Roanoke Valley CHA CHA Planning CHA Process CHA Data Collection CHAT Meeting #1 (9/28/20) CHAT Meeting #2 (11/16/20) Data Coding, Organization, Prep. and Visualization CHAT Meeting #3 (2/15/21) CHA Reports CHAT Meeting #4 (5/17/21) CHA Hospital Board Approvals CHA Results Community Communications and Community Recommendations

Assigned To:

Start Date 06-01 Mon

End Date 01-01 Sat

06-01 Mon

10-01 Thu

09-01 Tue 10-01 Thu 09-01 Tue 11-01 Sun

08-01 Sun 01-31 Sun 09-28 Mon 11-16 Mon

Molly

11-01 Sun

03-01 Mon

Molly & Aaron & Partners Molly & CHO Staff Molly & Aaron & Partners Molly (Shirley, Aaron)

02-01 Mon 04-01 Thu 05-01 Sat 07-01 Thu

02-15 Mon 07-01 Thu 05-17 Mon 08-30 Mon

Molly & Aaron & CHO Staff & Partners (PR)

08-01 Sun

01-30 Sun

07-01 Wed

08-01 Sun

10-01 Thu

08-01 Sun

05-01 Sat

09-01 Wed

Amy & Molly (Aaron & Shirley) Molly & CHO Staff Molly & CHO Staff Molly & Aaron & Partners Molly & Aaron & Partners

Implementation Strategy Planning

Shirley with White Paper Team Molly & CHO Staff (Shirley & White Paper Team)

Implementation Strategy Reports (6)

Molly & Aaron & CHO Staff

Implementation Strategy Report Hospital Administrator Approval (on behalf of Boards)

Molly (Shirley, Aaron)

09-01 Wed

10-01 Fri

Molly (Shirley, Aaron)

10-01 Fri

11-30 Tue

Carilion Clinic / HRV

07-01 Thu

07-01 Fri

CB Teams (or hospitals operations teams) and CHO Action Planning (resulting from Implementation Strategies)

Molly & Amy & CHO Staff & CB Teams (Hospital Administrators, Shirley, Aaron)

08-01 Sun

10-01 Fri

First Hospital Board Implementation Strategy Update

Molly & Aaron & CHO Staff

01-01 Sat

01-31 Mon

Carilion Clinic-wide CHIP Planning

Hospital Boards Ratify Implementation Strategy Approval Community Coalitions Planning (as a result of CHAs)

Appendix 2: Community Health Survey

Appendix 3: Stakeholder Survey and Data Summary 2021 Community Health Assessment Stakeholder Survey Survey available in online format only via: https://www.surveymonkey.com/r/2021Stakeholder 1.

Please select the community you and/or your organization represent: a. The Roanoke Valley b. The Rockbridge Area c. Giles County/Monroe County d. New River Valley e. Franklin County/Henry County f. Tazewell County Your name, organization, and title: NAME:

___________________________________________________

ORGANIZATION:___________________________________________________ TITLE:

___________________________________________________

3. What are the most important issues (needs) that impact health in the service area? _____________________________________________________________________________________

4. What are the barriers to health for the populations you serve? _____________________________________________________________________________________

5. Is there one locality / neighborhood with the greatest unmet need? If so, why? _____________________________________________________________________________________

6. Is there one population group with the greatest unmet need? If so, why? _____________________________________________________________________________________

7. What are the resources for health for the populations you serve? _____________________________________________________________________________________

If we could make one change as a community to meet the needs and reduce the barriers to health in the service area, what would that be? _____________________________________________________________________________________

Thank you for your input!

Roanoke Valley Community Health Assessment Team (CHAT) members completed a stakeholder survey following discussion of needs, barriers, resources, and initiatives impacting health of the community. Additionally, a focus group was held with the Carilion Medical Center Clinical Advancement and Patient Safety Committee (CAPS) representing CMC broadly. The results below include the CHAT survey results and responses discussed with the CAPS committee.

What are the most important issues (needs) that impact health in your community? Top themes Responses: 30 Access to Care / Services

33%

Mental Health / Substance Use

30%

Food Access

13%

Chronic Diseases (obesity, diabetes)

13%

Dental Health

13%

COVID-19

13%

Housing

13%

Affordability of Care

10%

Education

10%

Child Safety / Support

10%

Poverty

10%

Transportation

10% 0%

10%

15%

20%

25%

30%

35%

What are the barriers to health for the populations you serve? Top themes Responses: 25

Transportation

64%

Financial Barriers

56%

Accessibility of Care

36%

Health Literacy / Education

20%

Access to Affordable/Healthy Food

16% 0%

10%

20%

30%

40%

50%

60%

70%

Is there one locality/neighborhood with the greatest unmet need? Top themes Responses: 22

Northwest Roanoke City

55%

Southeast Roanoke City

55%

Craig County / New Castle

27%

Low Income Areas

14%

North Botetourt County

9% 0%

10%

20%

30%

40%

50%

60%

Reasons why: Low income, low access, transportation, lack of resources

Is there one population group with the greatest unmet need? Top themes Responses: 26 Elderly

35%

The Working Poor

19%

Immigrants

15%

People in Poverty

15%

Hispanic Community

12%

Homeless

Non-English Speakers

Black / African American Community

Single Parent Families

8% 0%

10% 15% 20% 25% 30% 35% 40%

What are the resources for health for the populations you serve? Responses: 24

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Acute care ARCH Services Blue Ridge Behavioral Health Botetourt Free Clinic Botetourt Resource Center Bradley Free Clinic Carilion Clinic Carilion Clinic Pediatrics Carilion Community Health and Outreach CHIP Churches / Faith Community Craig County Medical Center Department of Social Services Drive through Flu clinics Education through community service organizations. Emergency Care Expanded Medicaid Family practice care Family Service of Roanoke Valley Farmers Markets Fralin Clinic Free clinics Government resources Health care clinics for medical home Health Departments Immunizations LEAP Lewis Gale Libraries Mckinney-Vento program at RCPS Meals on Wheels Medicaid Medicare New Horizons Non-profit organizations that serve vulnerable clients

• • • • • • • • • • • • • •

PCC Physicians to Children RAM House Roanoke Redevelopment and Housing Authority Recreational/fitness opportunities Rescue Mission Safe walking and biking paths Urgent Care Valley Metro VAMC VDH Well-child visits / children's preventive care West End Center WIC

If we could make one change as a community to meet the needs and reduce the barriers to health, what would that be? Top themes Responses: 34

Access

41%

Health Literacy / Education

15%

Transportation

15%

Strengthen Partnerships / Community Relationships

12%

Income / Employment

6% 0%

5% 10% 15% 20% 25% 30% 35% 40% 45%

Appendix 4: Prioritization Worksheet Community Health Assessment Prioritization Please rank from 1-10 the top 10 most pertinent community needs with 1 being the most pertinent. Rank

Community Issue Health Behavior Factors Alcohol and drug use Culture: healthy behaviors not a priority Lack of exercise Lack of health literacy / lack of knowledge of healthy behaviors Lack of knowledge of community resources Poor diet / poor eating habits Risky sexual activity Tobacco use Access to healthy foods Stress Clinical Care Factors Access to primary care Access to dental care Access to mental / behavioral health services Access to specialty care (general) Access to substance use services Communication barriers with providers Coordination of care High cost of care High uninsured / underinsured population Quality of care Social and Economic Health Factors Child abuse / neglect Community safety / violence Domestic violence Educational attainment Lack of family / social support systems Poverty / low average household income Unemployment 61

Physical Environment Factors Air quality Affordable / safe housing Injury prevention / safety of environment Outdoor recreation Transportation / transit system Water quality Health Conditions / Outcomes COVID-19 Overweight / Obesity Mental health problems Cancers Diabetes High Blood Pressure Heart Disease and Stroke High prevalence of chronic disease (general) Write-in section

Appendix 5: Resource List Community Resources listed by Stakeholders in the spring of 2021 are listed below. Please note that information may have changed since the collection date. A more in-depth resource list organized by type of resource is also included courtesy of Carilion’s quarterly Easy Health publication. Community members can also learn more about available resources by calling 2-1-1 or going online to https://www.211virginia.org/consumer/index.php. 2-1-1 is a free service available to help callers find appropriate resources in their local area. Community Resources Listed by Stakeholders • • • • • • • • • • • • • • • • • • • • • • • • •

• • • • • • • • • • • • • • • • • • • • • • • •

Immunizations LEAP Lewis Gale Libraries Mckinney-Vento program at RCPS Meals on Wheels Medicaid Medicare New Horizons Non-profit organizations that serve vulnerable clients PCC Physicians to Children RAM House Roanoke Redevelopment and Housing Authority Recreational/fitness opportunities Rescue Mission Safe walking and biking paths Urgent Care Valley Metro VAMC VDH Well-child visits / children's preventive care West End Center WIC

Resources from Carilion Clinic’s Easy Health Summer 2021 Publication Hotlines: • Al-Anon for Families of Alcoholics 800-344-2666 • Alcohol Abuse Hotline 800-331-2900 • Alcohol & Drug Abuse Helpline 800-821-4357 • Poison Control 800-222-1222 • National Domestic Violence Hotline 800-799-7233 • National Hopeline Network (for Crisis and Suicide) 800-784-2433 • National Suicide Prevention Lifeline 800-273-8255 • National U.S. Child Abuse Hotline 800-422-4453 • National Youth Crisis Hotline 800-442-4673 • SARA (Sexual Assault/Rape) Crisis Hotline 540-981-9352 2-1-1 Virginia Services: referral for food banks, shelters, utility assistance, job training, physical/ mental health resources, support for seniors, ESOL classes, child care and disaster support. Contact: 2-1-1 or 211virginia.org Bernard Healthcare Center Services: medical, pharmaceutical and preventive health care services for uninsured adults. 1171 Franklin St., Rocky Mount, Va. Contact: 540-489-7500 Blue Ridge Behavioral Health Services: counseling, substance abuse recovery and a walk-in clinic. The Burrell Center 611 McDowell Ave., Roanoke, Va. Contact: 540-343-3007 Botetourt Resource Center Services: social and human services, including Department of Social Services programming and assistance. 33 Bedford St., Buchanan, Va. Contact: 540-254-1468 or botetourtva.gov Bradley Free Clinic Services: medical, dental, pharmaceutical and preventive health care services. 1240 3rd St., S.W., Roanoke, Va. Contact: 540-344-5156 Carilion Clinic Community Care Services: primary care services for minor health concerns. 101 Elm Ave., Roanoke, Va. Contact: 540-985-8044 or CarilionClinic.org/locations/carilion-clinic-community-care Carilion Clinic Community Health and Outreach Services: wellness workshops, healthier lifestyle educational programs, community recovery groups and peer support, injury prevention and community health screenings.

1202 Third St., SW, Roanoke, Va. Contact: 540-266-6000 / 800-422-8482 or CarilionClinic.org/community-health-outreach Carilion Diabetes Management Program Services: endocrinology, diabetes and metabolism clinical services, and a support group for diabetes management. 1030 S. Jefferson St., Ste. G101, Roanoke, Va. Contact: 540-266-6000 Commonwealth Catholic Charities Services: pregnancy counseling, foster care and adoption services; interpreter services, refugee resettlement and employment support; immigration services and citizenship instruction; and food pantry, housing and financial counseling. 541 Luck Ave, Ste. 118, Roanoke, Va. Contact: 540-342-0411 or cccofva.org 802 Campbell Ave., S.W., Roanoke, Va. Contact: 540-342-7561 or cccofva.org St. Francis House (food pantry) Contact: 540-342-7561 ext. 319 or cccofva.org Pregnancy Counseling Hotline Contact: 800-296-2367 or cccofva.org Central Intake – One Door Services: homeless services, housing stability and a shelter system. 339 Salem Ave., S.W., Roanoke, Va. Contact: 540-853-1163 Child Health Investment Partnership (CHIP) of Roanoke Valley Services: pairs pregnant moms, low-income children (birth to first-grade entry) and their guardians with medical services, assists with managing chronic conditions and provides developmental education, kindergarten preparation and regular child assessment and monitoring. Contact: 540-857-6993 or chiprv.org or referrals@chiprv.org Common Help website (for Virginia citizens) Services: access to applications for TANF, child care services, energy assistance (fuel, crisis and cooling), food assistance (SNAP) and medical assistance for Virginia citizens. Eligibility requirements. Contact: 855-242-8282 or commonhelp.virginia.gov Community Housing Resource Center Services: homeless services, housing stability and a shelter system. 339 Salem Ave., S.W., Roanoke, Va. Contact: 540-266-7551 Council of Community Services A central information and referral organization for homelessness prevention, HIV/ HCV prevention and care, and community building. 502 Campbell Ave., S.W., Roanoke, Va. Contact: 540-985-0131 / 800-354-3388 or councilofcommunityservices.org Cover Virginia

Services: health insurance, Medicaid, Medicare and FAMIS enrollment. Contact: 855-242-8282 (toll-free) or coverva.org Department of Social Services, Botetourt County 220 Commons Parkway, Daleville, Va. Contact: 540-591-5960 or botetourtva.gov Department of Social Services, Franklin County Services: adult protective services, child protective services, foster care and prevention, TANF and child care. 120 East Court St., Rocky Mount, Va. Services: SNAP, Medicaid and energy assistance 11161 Virgil H Goode Hwy., Rocky Mount, Va. Contact: 540-483-9247 or franklincountyva.gov Department of Social Services, Roanoke City 1510 Williamson Road, N.E., 3rd floor, Roanoke, Va. Contact: 540-853-2591 or roanokeva.gov Department of Social Services, Roanoke County 220 E. Main St., Salem, Va. Contact: 540-387-6087 or roanokecountyva.gov Department of Social Services, Salem 220 E. Main St., Salem, Va. Contact: 540-375-3039 or roanokecountyva.gov Family Services of Roanoke Valley Services: counseling, therapy and outreach for children, youth and adults; life skills training; personal affairs management; domestic violence survivor programs. 360 Campbell Ave., S.W., Roanoke, Va. Contact: 540-563-5316 or fsrv.org Feeding America Southwest Virginia (FASWVA) Services: food pantries, elderly and youth nutrition, shelter and emergency meal programs, and culinary arts training. Contact: 540-342-3011 or faswva.org F.R.E.E. Foundation Services: providing mobility rehabilitation equipment. 1489 East Main St., Salem, Va. Contact: 540-777-4929 or free-foundation.org G. Wayne Fralin Free Clinic for the Homeless Services: primary and preventive care for uninsured and homeless individuals. 321 Tazewell Ave., S.E., Roanoke, Va. Contact: 540-777-7671 Goodwill Industries of the Valleys Services: employment training for youth, adult and older citizens, computer training and education programs. Goodwill Roanoke Job Campus

2502 Melrose Ave., N.W., Ste. B, Roanoke, Va. Contact: 540-581-0620, option 1 or goodwillvalleys.com Habitat for Humanity in Roanoke Valley Services: assistance with construction or restoration of housing, housing placement, construction supplies and home furnishings. 3435 Melrose Ave., N.W., Roanoke, Va. Contact: 540-344-0747 or habitat-roanoke.org InnovAge PACE Services: provides medical services including personal care, transportation, medicines, adult day center, therapy, medical supplies, dental and vision for adults ages 55+. InnovAge PACE – Roanoke Valley 1606 Lynchburg Turnpike, Salem, Va. Contact: 540-682-3851 or mboyes@myinnovage.com Local Office on Aging (LOA) Services: care coordination and outreach, care transitions, Meals on Wheels, adult daycare, homemaker services, transportation, emergency services, options counseling, long term care ombudsman, Elder Justice Alliance and VICAP (to assist with insurance questions and needs). 4932 Frontage Road, N.W., Roanoke, Va. Contact: 540-345-0451 / 888-355-6222 Mental Health America of Roanoke Valley Services: mental illness first aid training, workshops for families and individuals, counseling, advocacy and crisis intervention for individuals with mental illness. 10 Church Ave., S.E., Ste. 300, Roanoke, Va. Contact: 540-344-0931 or mharv.org NAMI - Roanoke Valley Services: emotional support, fellowship and informational programs for parents, relatives and friends, as well as individuals with mental illness. Contact: 540-977-3470 or namiroanokevalley@gmail.com New Horizons Healthcare Services: adult and pediatric medical, behavioral health, dental and pharmacy services, and assistance enrolling in health care coverage. 3716 Melrose Ave., N.W., Roanoke, Va. Contact: 540-362-0360 Peer Recovery Center Specialists can help you apply for resources, including Medicaid, a cell phone, transportation and much more. Call for an appointment. Carilion Clinic Rehabilitation Building/Peer Recovery Center 2017 S. Jefferson St., First Floor, Roanoke, Va. Contact: 540-853-9152 Piedmont Community Services Services: daily continuum of behavioral health services, including prevention, treatment, education and support. Same-day and emergency access available.

24 Clay St., Martinsville, Va. Contact: 540-483-0582 / (888) 819-1331 Presbyterian Community Center Services: after-school program, food pantry, emergency services and utility assistance. 1228 Jamison Ave., S.E., Roanoke, Va. Contact: 540-982-2911 RADAR Transit Services: Valley Metro STAR service, CORTRAN program, the Mountain Express, Maury Express, PART and College Express. P.O. Box 13825, Roanoke, Va. Contact: 540-343-1721 / 800-964-5707 or radartransit.org RAM House Services: day shelter for homeless individuals, noon-day meals, emergency financial assistance, laundry services, employment training and job placement, clothes closet. 824 Campbell Ave., S.W., Roanoke, Va. Contact: 540-345-8850 Rescue Mission Services: emergency shelter for homeless individuals, including meals, spiritual guidance, self-sufficiency and life-stabilizing programs, substance abuse recovery programs. 402 4th St., S.E., Roanoke, Va. Contact: 540-343-7227 Roanoke City Parks and Recreation 215 Church Ave., Room 303, Roanoke, Va. Contact: 540-853-2236 or playroanoke.com Roanoke Financial Empowerment Center Services: No-cost, professional one-on-one financial counseling. Contact: 540-427-6811 or RoanokeFEC.org Roanoke Redevelopment and Housing Authority Services: housing placement, homeownership programs, employment training and job placement. 2624 Salem Turnpike N.W., Roanoke, Va. Contact: 540-983-9281 or rkehousing.org Roanoke Valley-Alleghany Region 5 Adult Education Services: adult education, GED courses and testing, ESL courses and testing. Contact: 540-853-2151 or regionfiveadulted.com Roanoke Valley Libraries Botetourt County 540-928-2900 Roanoke City 540-853-2473 Roanoke County 540-772-7507 Salem 540-375-3089

Salem City Parks and Recreation 620 Florida St., Salem, Va. Contact: 540-375-3057 or salemva.gov/departments/parks-and-recreation Salvation Army Services: New Day Center for youth ages 18-24, Pathway of Hope life-stabilizing program for families, domestic violence and human trafficking survivor programs, disaster relief, short-term family emergency/utility relief, youth fellowship and senior fellowship. 724 Dale Ave., S.E., Roanoke, Va. Contact: 540-343-5335 SARA Roanoke Services: crisis counseling, individual/group/family counseling and advocacy for sexual assault survivors. 3034 Brambleton Ave., S.W., Roanoke, Va. Contact: 540-345-7273 24-Hour Crisis Hotline 540-981-9352 Tap Into Hope/Total Action for Progress (TAP) Services: housing, employment and education for early learning, youth and adults; financial basics; support for veterans; domestic violence services; and child-parent relationship support. 302 2nd St., S.W., Roanoke, Va. Contact: 540-777-HOPE (4673) or tapintohope.org United Way of Roanoke Valley Services: early learning and childcare programs for ages 0-12, housing and life-stabilizing services for families, family health strategies, financial basics and prescription medication program. 325 Campbell Ave., S.W., Roanoke, Va. Contact: 540-777-4200 Virginia Career Works Services: job searching, training, education, career planning and unemployment. 3601 Thirlane Road, N.W., Ste. 2, Roanoke, Va. Contact: 540-613-8220 Virginia Cooperative Extension - Roanoke Services: Nutrition education, food safety, water and soil testing, agricultural support, positive youth development (4-H) and health/wellness classes. Contact: 540-772-7524 or ext.vt.edu/Roanoke Virginia Department of Health Services: clinical, community outreach, emergency preparedness and response, environmental health, family services and WIC 1502 Williamson Road, N.E., 2nd floor, Roanoke, Va. Contact: 540-283-5050 or vdh.virginia.gov/Roanoke Virginia Health Care Foundation (VHCF) Services: SignUpNow program for Medicaid and FAMIS. Contact: vhcf.org/workshops

Appendix 6: Community Health Survey Results 1. County of Residence Roanoke City Roanoke County Botetourt County Craig County Bedford County Answered Skipped

# 648 435 215 90 84 1560 0

% 41.54% 27.88% 13.78% 5.77% 5.38%

County of Residence

6% Roanoke City

15%

44%

Roanoke County Botetourt County Craig County Bedford County

29%

2. What do you think are the most important issues that affect health in our community? (Check all that apply) Overweight / obesity Mental health problems COVID-19 / Coronavirus Alcohol and illegal drug use Poor eating habits Access to affordable housing Access to healthy foods Stress Lack of exercise Tobacco use / smoking / vaping High blood pressure Prescription drug abuse Child abuse / neglect Diabetes Domestic violence Cell phone use / texting and driving / distracted driving Heart disease and stroke Social isolation Aging problems Cancers Dental problems Gang activity Transportation problems Housing problems (e.g. mold, bed bugs, lead paint) Bullying Neighborhood safety Suicide Environmental health (e.g. water quality, air quality, pesticides, etc.) Homicide Not getting “shots” to prevent disease Unsafe sex Grief Sexual assault Not using seat belts / child safety seats / helmets Teenage pregnancy Accidents in the home (ex. falls, burns, cuts) Lung disease HIV / AIDS Injuries Other (please specify) Infant death Answered Skipped

# 808 781 761 738 708 658 632 628 593 472 464 455 444 444 442 441 436 415 379 366 336 335 326 325 276 275 271 234 221 214 207 202 188 176 169 140 135 107 89 86 54 1344 216

% 60.12% 58.11% 56.62% 54.91% 52.68% 48.96% 47.02% 46.73% 44.12% 35.12% 34.52% 33.85% 33.04% 33.04% 32.89% 32.81% 32.44% 30.88% 28.20% 27.23% 25.00% 24.93% 24.26% 24.18% 20.54% 20.46% 20.16% 17.41% 16.44% 15.92% 15.40% 15.03% 13.99% 13.10% 12.57% 10.42% 10.04% 7.96% 6.62% 6.40% 4.02%

3. Which health care services are hard to get in our community? (Check all that apply) Mental health / counseling Adult dental care Alternative therapy (ex. herbal, acupuncture, massage) Substance abuse services –drug and alcohol Eldercare Dermatology Domestic violence services Medication / medical supplies Specialty care (ex. heart doctor) Family doctor Programs to stop using tobacco products Vision care Emergency room care Women’s health services Child dental care Preventive care (ex. yearly check-ups) Cancer care None Urgent care / walk in clinic X-rays / mammograms Chiropractic care Other (please specify) End of life / hospice / palliative care Family planning / birth control Physical therapy Inpatient hospital Lab work Ambulance services Immunizations Answered Skipped

# 520 467 370 346 306 252 219 213 209 208 206 201 187 173 160 155 133 129 128 123 122 121 111 96 96 86 69 63 53 1291 269

% 40.28% 36.17% 28.66% 26.80% 23.70% 19.52% 16.96% 16.50% 16.19% 16.11% 15.96% 15.57% 14.48% 13.40% 12.39% 12.01% 10.30% 9.99% 9.91% 9.53% 9.45% 9.37% 8.60% 7.44% 7.44% 6.66% 5.34% 4.88% 4.11%

4. What social / support resources are hard to get in our community? Affordable / safe housing Childcare Transportation Medical debt assistance Health insurance Employment / jobs assistance Rent / utilities assistance Healthy food Medication assistance Domestic violence assistance Legal services Banking / financial assistance Food benefits (SNAP, WIC) Education and literacy Unemployment benefits Veterans services Translation assistance / language services TANF (Temporary Assistance for Needy Families) None Other (please specify) Answered Skipped

# 654 453 425 415 384 378 374 365 336 280 270 221 194 191 191 175 171 153 91 64 1281 279

% 51.05% 35.36% 33.18% 32.40% 29.98% 29.51% 29.20% 28.49% 26.23% 21.86% 21.08% 17.25% 15.14% 14.91% 14.91% 13.66% 13.35% 11.94% 7.10% 5.00%

5. What keeps you from being healthy? (Check all that apply) Nothing keeps me from being healthy Cost Long waits for appointments Lack of evening and weekend services High co-pay Don’t know what types of services are available Other (please specify) No health Insurance Afraid to have check-ups Don’t trust doctors / clinics Location of offices Childcare No transportation Have no regular source of healthcare Can’t find providers that accept my Medicaid insurance Don’t like accepting government assistance Can’t find providers that accept my Medicare insurance Language services Answered Skipped

# 453 433 329 319 277 136 112 103 90 83 82 76 75 58 54 36 28 15 1267 293

% 35.75% 34.18% 25.97% 25.18% 21.86% 10.73% 8.84% 8.13% 7.10% 6.55% 6.47% 6.00% 5.92% 4.58% 4.26% 2.84% 2.21% 1.18%

6. Do you use medical care services?

Yes No Answered Skipped

# 1082 223 1305 255

% 82.91% 17.09%

Do you use medical care services?

17% Yes No

83%

Where do you go for medical care? (Check all that apply)

Doctor’s Office Urgent Care / Walk in Clinic Emergency Room Online / Telehealth / Virtual Visits Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) Health Department Federally Qualified Health Center (e.g. New Horizons Healthcare) Other (please specify) Salem VA Medical Center Answered Skipped

# 976 457 198 191

% 91.13% 42.67% 18.49% 17.83%

69 44 41 25 20 1071 489

6.44% 4.11% 3.83% 2.33% 1.87%

7. How long has it been since you last visited a doctor for a routine checkup? (Please check one) # Within the past year (1 to 12 months ago) 1025 Within the past 2 years (1 to 2 years ago) 183 Within the past 5 years (2 to 5 years ago) 48 5 or more years ago 34 I have never visited a doctor or other healthcare provider for a routine checkup. 8 Answered 1298 Skipped 262

% 78.97% 14.10% 3.70% 2.62% 0.62%

How long has it been since you last visited a doctor for a routine checkup? 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Within the past year (1 to 12 months ago)

Within the past 2 years (1 to 2 years ago)

Within the past 5 years (2 to 5 years ago)

5 or more years ago I have never visited a doctor or other healthcare provider for a routine checkup.

8. Do you use dental care services? Yes No Answered Skipped

# 1004 291 1295 265

% 77.53% 22.47%

Do you use dental care services?

22% Yes No

78%

Where do you go for dental care? (Check all that apply) Dentist’s office Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) Other (please specify) VWCC Dental Hygiene Program Urgent Care / Walk in Clinic Emergency Room Salem VA Medical Center Answered Skipped

# % 955 95.21% 40 26 8 7 3 2 1003 557

3.99% 2.59% 0.80% 0.70% 0.30% 0.20%

9. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. (Please check one) Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) 5 or more years ago Within the past 5 years (2 to 5 years ago) I have never visited a dentist or a dental clinic for any reason. Answered Skipped

# 866 154 154 105 7 1286 274

% 67.34% 11.98% 11.98% 8.16% 0.54%

How long has it been since you last visited a dentist or a dental clinic for any reason? 80% 70% 60% 50% 40% 30% 20% 10% 0% Within the past Within the past 2 Within the past 5 5 or more years I have never year (1 to 12 years (1 to 2 years years (2 to 5 years ago visited a dentist or months ago) ago) ago) a dental clinic for any reason.

10. Do you use mental health, alcohol abuse, or drug abuse services? Yes No Answered Skipped

# 261 1031 1292 268

% 20.20% 79.80%

Do you use mental health, alcohol abuse, or drug abuse services?

20% Yes No

80%

Where do you go for mental health alcohol abuse, or drug abuse services? (Check all that apply)

Doctor/Counselor’s Office Online / Telehealth / Virtual Visits Other (please specify) Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) Federally Qualified Health Center (e.g. New Horizons Healthcare) Emergency Room Salem VA Medical Center Urgent Care / Walk in Clinic Answered Skipped

# % 171 67.06% 82 32.16% 39 15.29% 22 16 5 3 1 255 1305

8.63% 6.27% 1.96% 1.18% 0.39%

11. How long has it been since you used mental health, alcohol abuse, or drug abuse services for any reason? (Please check one) I have never used mental health, alcohol abuse, or drug abuse services for any reason. Within the past year (1 to 12 months ago) 5 or more years ago Within the past 5 years (2 to 5 years ago) Within the past 2 years (1 to 2 years ago) Answered Skipped

# 737 264 143 74 54 1272 288

% 57.94% 20.75% 11.24% 5.82% 4.25%

How long has it been since you used mental health, alcohol abuse, or drug abuse services for any reason? 70% 60% 50% 40% 30% 20% 10% 0% Within the past year (1 to 12 months ago)

Within the past 2 years (1 to 2 years ago)

Within the past 5 years (2 to 5 years ago)

5 or more years ago

I have never used mental health, alcohol abuse, or drug abuse services for any reason.

12. Have you been told by a doctor that you have… (Check all that apply)

Depression or anxiety Obesity / overweight High blood pressure High cholesterol I have no health problems Asthma Other (please specify) High blood sugar or diabetes Mental health problems Cancer Heart disease COPD / chronic bronchitis / Emphysema Drug or alcohol problems Stroke / Cerebrovascular disease HIV / AIDS Cerebral palsy Answered Skipped

# 475 438 419 260 214 181 163 148 147 61 55

% 39.68% 36.59% 35.00% 21.72% 17.88% 15.12% 13.62% 12.36% 12.28% 5.10% 4.59%

52 40 29 2 1 1197 363

4.34% 3.34% 2.42% 0.17% 0.08%

13. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

Median: Answered Skipped

5.4 1037 523

14. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

Median: Answered Skipped

8.3 1051 509

15. During the past 30 days: (Check all that apply) I have had 5 or more alcoholic drinks (if male) or 4 or more alcoholic drinks (if female) during one occasion. I have used tobacco products (cigarettes, smokeless tobacco, e-cigarettes, etc.) I have taken prescription drugs to get high I have used marijuana I have used other illegal drugs (e.g. cocaine, heroin, ecstasy, crack, LSD, etc.) None of these Answered Skipped

205 186 4 61 8 836 1184 376

17.31% 15.71% 0.34% 5.15% 0.68% 70.61%

During the past 30 days: 80% 70% 60% 50% 40% 30% 20% 10% 0% I have had 5 or I have used tobacco I have taken more alcoholic products prescription drugs drinks (if male) or 4 (cigarettes, to get high or more alcoholic smokeless tobacco, drinks (if female) e-cigarettes, etc.) during one occasion.

I have used marijuana

I have used other illegal drugs (e.g. cocaine, heroin, ecstasy, crack, LSD, etc.)

None of these

16. Please check one of the following for each statement

I have been to the emergency room in the past 12 months. I have been to the emergency room for an injury in the past 12 months (e.g. motor vehicle crash, fall, poisoning, burn, cut, etc.). I have been a victim of domestic violence or abuse in the past 12 months. I take the medicine my doctor tells me to take to control my chronic illness. I can afford medicine needed for my health conditions. Does your community support physical activity? (e.g. parks, sidewalks, bike lanes, etc.) In the area that you live, is it easy to get affordable fresh fruits and vegetables? Have there been times in the past 12 months when you did not have enough money to buy the food that you or your family needed? Have there been times in the past 12 months when you did not have enough money to pay your rent or mortgage? Do you feel safe where you live? Answered Skipped

Yes # 222

% 18.18%

No # 957

Not applicable % # % 78.38% 42 3.44%

6.26%

1082

89.05%

4.69%

3.22%

1108

91.49%

5.28%

641 837

52.71% 69.17%

236 189

19.41% 15.62%

339 184

27.88% 15.21%

919

76.01%

253

20.93%

3.06%

893

73.74%

308

25.43%

0.83%

301

24.79%

886

72.98%

2.22%

306 1115 1228 332

25.19% 92.00%

866 93

71.28% 7.67%

43 4

3.54% 0.33%

17. Where do you get the food that you eat at home? (Check all that apply) Grocery store Take-out / fast food / restaurant Farmers’ market Home garden Dollar store Corner store / convenience store / gas station Food bank / food kitchen / food pantry Other (please specify) Back-pack or summer food programs I regularly receive food from family, friends, neighbors, or my church Community garden Meals on Wheels I do not eat at home Answered Skipped

# 1194 525 273 257 196 116 112 52 50 50 18 5 3 1224 336

% 97.55% 42.89% 22.30% 21.00% 16.01% 9.48% 9.15% 4.25% 4.08% 4.08% 1.47% 0.41% 0.25%

18. During the past 7 days, how many times did you eat fruit or vegetables? Do not count fruit juice. (Please check one) 1 – 3 times during the past 7 days 4 – 6 times during the past 7 days 2 times per day 1 time per day 3 times per day 4 or more times per day I did not eat fruits or vegetables during the past 7 days Answered Skipped

# 325 290 256 138 117 61 35 1222 338

% 26.60% 23.73% 20.95% 11.29% 9.57% 4.99% 2.86%

During the past 7 days, how many times did you eat fruit or vegetables? 30% 25% 20% 15% 10% 5% 0% I did not eat 1 – 3 times 4 – 6 times 1 time per day 2 times per day 3 times per day 4 or more fruits or during the past during the past times per day vegetables 7 days 7 days during the past 7 days

19. How connected do you feel with the community and those around you? Very connected Somewhat connected Not connected Answered Skipped

# 237 681 301 1219 341

% 19.44% 55.87% 24.69%

How connected do you feel with the community and those around you? 60% 50% 40% 30% 20% 10% 0% Very connected

Somewhat connected

Not connected

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days Answered Skipped

# 194 127 177 213 148 143 51 165 1218 342

% 15.93% 10.43% 14.53% 17.49% 12.15% 11.74% 4.19% 13.55%

In the past 7 days, on how many days were you physically active for a total of at least 30 minutes? 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 0 days

1 day

2 days

3 days

4 days

5 days

6 days

7 days

21. During the past 7 days, how many times did all, or most, of your family living in your house eat a meal together? # Never 1-2 times 3-4 times 5-6 times 7 times More than 7 times Not applicable / I live alone Answered Skipped

61 154 206 192 163 266 182 1224 336

% 4.98% 12.58% 16.83% 15.69% 13.32% 21.73% 14.87%

During the past 7 days, how many times did all, or most, of your family living in your house eat a meal together? 25% 20% 15% 10% 5% 0% Never

1-2 times

3-4 times

5-6 times

7 times

More than 7 Not times applicable / I live alone

22. Do you have reliable transportation? # Yes 1147 No 67 Answered 1214 Skipped 346

% 94.48% 5.52%

Do you have reliable transportation?

Yes No

94%

23. What type of transportation do you use typically use?

I drive Bike or walk Friends / Family drive me Public transit (i.e. bus, shuttle, similar) Other (please specify) Taxi (including Uber/LYFT) RADAR / CORTRAN Ridesharing / Carpooling

1118

91.12%

113 100 54 28

9.21% 8.15% 4.40% 2.28%

23 9 8

1.87% 0.73% 0.65%

Answered

1227

Skipped

333

What type of transportation do you use typically use? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I drive

Bike or walk

Friends / Public transit RADAR / Ridesharing / Taxi Other (please Family drive (i.e. bus, CORTRAN Carpooling (including specify) me shuttle, Uber/LYFT) similar)

24. Which of the following describes your current type of health insurance? (Check all that apply)

Employer Provided Insurance Dental Insurance Medicaid Medicare Health Savings / Spending Account Individual / Private Insurance / Market Place / Obamacare No Dental Insurance Medicare Supplement No Health Insurance Government (VA, Champus) COBRA Answered Skipped

# 701 461 183 171 158 110 95 94 70 38 10 1202 358

% 58.32% 38.35% 15.22% 14.23% 13.14% 9.15% 7.90% 7.82% 5.82% 3.16% 0.83%

25. If you have no health insurance, why don’t you have insurance? (Check all that apply) Not applicable- I have health insurance Too expensive / cost Unemployed / no job Other (please specify) I don’t understand Marketplace / Obamacare Options Not available at my job Student Answered Skipped

# 666 72 21 21

% 87.29% 9.44% 2.75% 2.75%

9 5 1 763 797

1.18% 0.66% 0.13%

26. What is your ZIP code? Zip Code 24012 24013 24014 24015 24016 24017 24018 24019 24066 24085 24090 24127 24153 24175 24179 Other Answered Skipped

# 104 64 93 106 60 94 159 105 29 24 26 47 96 33 62 120 1222 338

% 8.50% 5.20% 7.60% 8.67% 4.90% 7.70% 13.00% 8.60% 2.40% 2% 2.10% 3.80% 7.90% 2.70% 5.10% 9.80%

27. What is your age?

Average: Answered Skipped

47.8 1190 370

28. What is your gender identity?

Male Female Other In your own words: Answered Skipped

# % 223 18.52% 976 81.06% 0 0.00% 5 1204 356

0.42%

What is your gender identity? 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Male

Female

Other

In your own words:

29. What is your height, in inches?

Median: Answered Skipped

72.0 1182 378

30. What is your weight, in pounds?

Median: Answered Skipped

191.3 1157 403

Weight Status Based on Self-Reported Height and Weight 1.75%

27.93%

24.08%

46.23%

Normal

Obese

Overweight

Underweight

31. How many people live in your home (including yourself)? Number of children (0 – 17 years of age): Number of adults age 18 – 64: Number of adults age 65 or older: Answered Skipped

Median: 1.1 1.8 0.5 1180 380

32. What us your highest education level completed? # 353 322 272 222 25 15 1209 351

High school diploma/GED Bachelors Masters / PhD Associates Some high school Less than high school Answered Skipped

% 29.20% 26.63% 22.50% 18.36% 2.07% 1.24%

Education Level 35% 30% 25% 20% 15% 10% 5% 0% Less than high school

Some high school

High school diploma/GED

Associates

Bachelors

Masters / PhD

33. What is your primary language? English Spanish Other (please specify) Answered Skipped

# 1175 16 13 1204 356

% 97.59% 1.33% 1.08%

Primary Language 120% 100% 80% 60% 40% 20% 0% English

Spanish

Other (please specify)

34. With what ethnicity do you identify? (Check all that apply) White Black / African American Latino Decline to answer More than one race Asian American Indian / Alaskan Native Other (please specify) Native Hawaiian / Pacific Islander Answered Skipped

# 944 178 32 32 20 17 13 12 4 1201 359

% 78.60% 14.82% 2.66% 2.66% 1.67% 1.42% 1.08% 1.00% 0.33%

35. What is your marital status?

Married Single Divorced Widowed Domestic Partnership Answered Skipped

# 618 281 181 65 47 1192 368

% 51.85% 23.57% 15.18% 5.45% 3.94%

Marital Status 60% 50% 40% 30% 20% 10% 0% Married

Single

Divorced

Widowed

Domestic Partnership

36. What is your yearly household income? # $100,001 and above 233 $70,001 – $100,000 187 $20,001 – $30,000 127 $30,001 – $40,000 127 $50,001 – $60,000 101 $0 – $10,000 99 $40,001 – $50,000 96 $10,001 – $20,000 95 $60,001 – $70,000 81 Answered 1146 Skipped 414

% 20.33% 16.32% 11.08% 11.08% 8.81% 8.64% 8.38% 8.29% 7.07%

Yearly Household Income 25%

20%

15%

10%

0% $0 – $10,000

$10,001 – $20,001 – $30,001 – $40,001 – $50,001 – $60,001 – $70,001 – $100,001 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $100,000 and above

37. What is your current employment status? # % Full-time 763 63.58% Part-time 130 10.83% Retired 129 10.75% Unemployed 114 9.50% Homemaker 33 2.75% Self-employed 21 1.75% Student 10 0.83% Answered 1200 Skipped 360

Employment Status 70% 60% 50% 40% 30% 20% 10% 0% Full-time

Part-time

Unemployed Self-employed

Retired

Homemaker

Student

100

Appendix 7: Secondary Data from University of Missouri CARES SparkMap

101

102

103

104

105

106

107

108

109

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Appendix 8: Links to Other Assessments •

•

2019 Roanoke Valley Community Healthy Living Index, Roanoke College Center for Community Health Innovation o https://www.roanoke.edu/documents/CommunityHealthInnovation/2019RVCHLIFinalR eport.pdf COVID-19 Impact Survey, 2021 Roanoke Valley, Virginia Results Report, United Way of Roanoke Valley o https://www.uwrv.org/alice-covid-19-survey-results/ Regional Housing Market Analysis Study, Roanoke Valley-Alleghany Regional Commission o https://rvarc.org/wp-content/uploads/2021/02/RVA-Regional-Housing-Study-FINAL121520.pdf Roanoke City Plan 2040 Community Response Report (2018), City of Roanoke o https://www.roanokeva.gov/DocumentCenter/View/11666/Community-ResponseReport Roanoke Valley Local Food Plan 2020, Roanoke Valley-Alleghany Regional Commission o https://rvarc.org/wp-content/uploads/2020/09/Local-Food-Plan-2020-FINAL9.16.20.pdf

178

Appendix 9: Cancer Community Health Survey Results To better understand the specific needs of those with cancer, the Community Health Survey was filtered to show results from respondents who self-identified as having cancer. 1. County of Residence Roanoke City Roanoke County Botetourt County Salem City Bedford County Craig County Answered Skipped

# % 19 31.15% 18 29.51% 10 16.39% 6 9.84% 5 8.20% 3 4.92% 61 0

179

2. What do you think are the most important issues that affect health in our community? (Check all that apply) # % Overweight / obesity 43 70.49% COVID-19 / Coronavirus 39 63.93% Alcohol and illegal drug use 36 59.02% Poor eating habits 33 54.10% Access to healthy foods 32 52.46% Access to affordable housing 31 50.82% Lack of exercise 30 49.18% Stress 30 49.18% Mental health problems 29 47.54% Cell phone use / texting and driving / distracted driving 28 45.90% Aging problems 27 44.26% Social isolation 27 44.26% Cancers 26 42.62% Tobacco use / smoking / vaping 26 42.62% Heart disease and stroke 24 39.34% Diabetes 23 37.70% Domestic violence 23 37.70% High blood pressure 23 37.70% Dental problems 22 36.07% Prescription drug abuse 22 36.07% Not getting “shots” to prevent disease 20 32.79% Child abuse / neglect 19 31.15% Bullying 18 29.51% Housing problems (e.g. mold, bed bugs, lead paint) 18 29.51% Gang activity 17 27.87% Environmental health (e.g. water quality, air quality, pesticides, etc.) 16 26.23% Transportation problems 16 26.23% Sexual assault 13 21.31% Unsafe sex 13 21.31% Grief 12 19.67% Neighborhood safety 12 19.67% Suicide 11 18.03% Lung disease 10 16.39% Teenage pregnancy 10 16.39% Homicide 9 14.75% Not using seat belts / child safety seats / helmets 9 14.75% Accidents in the home (ex. falls, burns, cuts) 8 13.11% HIV / AIDS 7 11.48% Infant death 6 9.84% Injuries 5 8.20% 180

Other (please specify) Answered Skipped

4 61 0

6.56%

3. Which health care services are hard to get in our community? (Check all that apply) # % Mental health / counseling 25 44.64% Adult dental care 19 33.93% Substance abuse services –drug and alcohol 18 32.14% Alternative therapy (ex. herbal, acupuncture, massage) 13 23.21% Eldercare 13 23.21% Programs to stop using tobacco products 13 23.21% Cancer care 11 19.64% Family doctor 11 19.64% Domestic violence services 10 17.86% Vision care 10 17.86% Emergency room care 9 16.07% Family planning / birth control 9 16.07% Medication / medical supplies 9 16.07% Urgent care / walk in clinic 9 16.07% Child dental care 8 14.29% None 8 14.29% Specialty care (ex. heart doctor) 7 12.50% Women’s health services 7 12.50% Other (please specify) 7 12.50% End of life / hospice / palliative care 6 10.71% Immunizations 6 10.71% Preventive care (ex. yearly check-ups) 6 10.71% Dermatology 5 8.93% X-rays / mammograms 5 8.93% Inpatient hospital 4 7.14% Chiropractic care 3 5.36% Lab work 2 3.57% Physical therapy 2 3.57% Ambulance services 0 0.00% Answered 56 Skipped 5

181

4. What social / support resources are hard to get in our community? # % Affordable / safe housing 27 47.37% Childcare 19 33.33% Healthy food 18 31.58% Medication assistance 18 31.58% Transportation 17 29.82% Health insurance 16 28.07% Medical debt assistance 16 28.07% Domestic violence assistance 15 26.32% Employment / jobs assistance 13 22.81% Food benefits (SNAP, WIC) 12 21.05% Rent / utilities assistance 12 21.05% Veterans services 12 21.05% Banking / financial assistance 11 19.30% Unemployment benefits 11 19.30% Legal services 10 17.54% Education and literacy 9 15.79% TANF (Temporary Assistance for Needy Families) 9 15.79% None 8 14.04% Translation assistance / language services 6 10.53% Other (please specify) 3 5.26% Answered 57 Skipped 4

182

5. What keeps you from being healthy? (Check all that apply) # Nothing keeps me from being healthy 23 Long waits for appointments 13 Lack of evening and weekend services 12 High co-pay 11 Cost 9 Don’t know what types of services are available 6 No transportation 6 Other (please specify) 6 No health Insurance 5 Childcare 4 Location of offices 4 Can’t find providers that accept my Medicaid insurance 3 Don’t trust doctors / clinics 3 Have no regular source of healthcare 3 Can’t find providers that accept my Medicare insurance 2 Don’t like accepting government assistance 2 Afraid to have check-ups 1 Language services 1 Answered 56 Skipped 5

% 41.07% 23.21% 21.43% 19.64% 16.07% 10.71% 10.71% 10.71% 8.93% 7.14% 7.14% 5.36% 5.36% 5.36% 3.57% 3.57% 1.79% 1.79%

183

6. Do you use medical care services? Yes No Answered Skipped

# % 51 86.44% 8 13.56% 59 2

Where do you go for medical care? (Check all that apply)

Doctor’s Office Urgent Care / Walk in Clinic Emergency Room Online / Telehealth / Virtual Visits Federally Qualified Health Center (e.g. New Horizons Healthcare) Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) Health Department Salem VA Medical Center Other (please specify) Answered Skipped

# 50 21 9 9 2

% 94.34% 39.62% 16.98% 16.98% 3.77%

1 1 1 1 53 8

1.89% 1.89% 1.89% 1.89%

184

7. How long has it been since you last visited a doctor for a routine checkup? (Please check one) # % Within the past year (1 to 12 months ago) 52 85.25% Within the past 2 years (1 to 2 years ago) 7 11.48% Within the past 5 years (2 to 5 years ago) 1 1.64% 5 or more years ago 1 1.64% I have never visited a doctor or other healthcare provider for a routine checkup. 0 0.00% Answered Skipped

61 0

185

8. Do you use dental care services? Yes No Answered Skipped

# % 48 78.69% 13 21.31% 61 0

Where do you go for dental care? (Check all that apply) Dentist’s office Other (please specify) Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) Salem VA Medical Center Emergency Room Urgent Care / Walk in Clinic VWCC Dental Hygiene Program Answered Skipped

# % 44 91.67% 2 4.17% 1 1 0 0 0 48 13

2.08% 2.08% 0.00% 0.00% 0.00%

186

9. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. (Please check one) # % Within the past year (1 to 12 months ago) 42 68.85% Within the past 2 years (1 to 2 years ago) 6 9.84% Within the past 5 years (2 to 5 years ago) 7 11.48% 5 or more years ago 6 9.84% I have never visited a dentist or a dental clinic for any reason. 0 0.00% Answered 61 Skipped 0

187

10. Do you use mental health, alcohol abuse, or drug abuse services? # % Yes 6 9.84% No 55 90.16% Answered 61 Skipped 0

Where do you go for mental health alcohol abuse, or drug abuse services? (Check all that apply) # % Doctor/Counselor’s Office 4 66.67% Other (please specify) 2 33.33% Federally Qualified Health Center (e.g. New Horizons Healthcare) 1 16.67% Online / Telehealth / Virtual Visits 1 16.67% Emergency Room 0 0.00% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 0 0.00% Salem VA Medical Center 0 0.00% Urgent Care / Walk in Clinic 0 0.00% Answered 6 Skipped 55

188

11. How long has it been since you used mental health, alcohol abuse, or drug abuse services for any reason? (Please check one) # % I have never used mental health, alcohol abuse, or drug abuse services for any reason. 41 67.21% Within the past year (1 to 12 months ago) 8 13.11% 5 or more years ago 7 11.48% Within the past 5 years (2 to 5 years ago) 3 4.92% Within the past 2 years (1 to 2 years ago) 2 3.28% Answered 61 Skipped 0

189

12. Have you been told by a doctor that you have… (Check all that apply) # % Cancer 61 100.00% High blood pressure 33 54.10% Obesity / overweight 21 34.43% Depression or anxiety 20 32.79% High cholesterol 19 31.15% COPD / chronic bronchitis / Emphysema 13 21.31% High blood sugar or diabetes 13 21.31% Asthma 11 18.03% Heart disease 7 11.48% Mental health problems 5 8.20% Stroke / Cerebrovascular disease 5 8.20% Other (please specify) 4 6.56% Drug or alcohol problems 2 3.28% Cerebral palsy 0 0.00% HIV / AIDS 0 0.00% I have no health problems 0 0.00% Answered 61 Skipped 0

190

13. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? Median: Answered Skipped

6.4 52 9

14. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? Median: Answered Skipped

7.0 55 6

15. During the past 30 days: (Check all that apply) None of these I have used tobacco products (cigarettes, smokeless tobacco, e-cigarettes, etc.) I have had 5 or more alcoholic drinks (if male) or 4 or more alcoholic drinks (if female) during one occasion. I have used marijuana I have taken prescription drugs to get high I have used other illegal drugs (e.g. cocaine, heroin, ecstasy, crack, LSD, etc.) Answered Skipped

# 45 7

% 75.00% 11.67%

6 10.00% 3 5.00% 2 3.33% 1 1.67% 60 1

191

16. Please check one of the following for each statement Yes # I have been to the emergency room in the past 12 months. I have been to the emergency room for an injury in the past 12 months (e.g. motor vehicle crash, fall, poisoning, burn, cut, etc.). I have been a victim of domestic violence or abuse in the past 12 months. I take the medicine my doctor tells me to take to control my chronic illness. I can afford medicine needed for my health conditions. Does your community support physical activity? (e.g. parks, sidewalks, bike lanes, etc.) In the area that you live, is it easy to get affordable fresh fruits and vegetables? Have there been times in the past 12 months when you did not have enough money to buy the food that you or your family needed? Have there been times in the past 12 months when you did not have enough money to pay your rent or mortgage? Do you feel safe where you live? Answered Skipped

No %

10 16.39%

# Not applicable %

47 77.05%

6.56%

9.84%

51 83.61%

6.56%

1.64%

53 86.89%

11.48%

45 73.77%

8 13.11%

13.11%

46 77.97%

8 13.56%

8.47%

49 80.33%

10 16.39%

3.28%

42 70.00%

17 28.33%

1.67%

14 22.95%

46 75.41%

1.64%

12 19.67% 55 90.16% 61 0

48 78.69% 6 9.84%

1 0

1.64% 0.00%

192

17. Where do you get the food that you eat at home? (Check all that apply) Grocery store Take-out / fast food / restaurant Farmers’ market Home garden Dollar store Corner store / convenience store / gas station Food bank / food kitchen / food pantry Other (please specify) Back-pack or summer food programs I regularly receive food from family, friends, neighbors, or my church Community garden I do not eat at home Meals on Wheels Answered Skipped

# 60 22 20 16 12 8 4 3 2 2 1 0 0 61 0

% 98.36% 36.07% 32.79% 26.23% 19.67% 13.11% 6.56% 4.92% 3.28% 3.28% 1.64% 0.00% 0.00%

193

18. During the past 7 days, how many times did you eat fruit or vegetables? Do not count fruit juice. (Please check one) # % 1 – 3 times during the past 7 days 18 29.51% 4 – 6 times during the past 7 days 13 21.31% 2 times per day 10 16.39% 1 time per day 8 13.11% 3 times per day 7 11.48% 4 or more times per day 3 4.92% I did not eat fruits or vegetables during the past 7 days 2 3.28% Answered 61 Skipped 0

194

19. How connected do you feel with the community and those around you? # % Very connected 16 26.23% Somewhat connected 35 57.38% Not connected 10 16.39% Answered 61 Skipped 0

195

20. In the past 7 days, on how many days were you physically active for a total of at least 30 minutes? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard for some of the time.) # % 0 days 7 11.48% 1 day 4 6.56% 2 days 11 18.03% 3 days 5 8.20% 4 days 8 13.11% 5 days 9 14.75% 6 days 1 1.64% 7 days 16 26.23% Answered 61 Skipped 0

196

21. During the past 7 days, how many times did all, or most, of your family living in your house eat a meal together? # % Never 5 8.20% 1-2 times 7 11.48% 3-4 times 7 11.48% 5-6 times 8 13.11% 7 times 11 18.03% More than 7 times 10 16.39% Not applicable / I live alone 13 21.31% Answered 61 Skipped 0

197

22. Do you have reliable transportation?

Yes No Answered Skipped

# % 57 95.00% 3 5.00% 60 1

198

23. What type of transportation do you use typically use?

I drive Friends / Family drive me Public transit (i.e. bus, shuttle, similar) Bike or walk Taxi (including Uber/LYFT) Other (please specify) RADAR / CORTRAN Ridesharing / Carpooling Answered Skipped

# 55 4

% 90.16% 6.56%

4 3 1 1 0 0 61 0

6.56% 4.92% 1.64% 1.64% 0.00% 0.00%

199

24. Which of the following describes your current type of health insurance? (Check all that apply) # 27 25 21 11 9 8 7 4 3 3 0 59 2

Dental Insurance Employer Provided Insurance Medicare Medicaid Medicare Supplement Health Savings / Spending Account Individual / Private Insurance / Market Place / Obamacare No Dental Insurance Government (VA, Champus) No Health Insurance COBRA Answered Skipped

% 45.76% 42.37% 35.59% 18.64% 15.25% 13.56% 11.86% 6.78% 5.08% 5.08% 0.00%

25. If you have no health insurance, why don’t you have insurance? (Check all that apply)

Not applicable- I have health insurance Unemployed / no job Too expensive / cost Other (please specify) I don’t understand Marketplace / Obamacare Options Not available at my job Student Answered Skipped

# 31 2 1 1 0 0 0 35 26

% 88.57% 5.71% 2.86% 2.86% 0.00% 0.00% 0.00%

200

26. What is your ZIP code? Zip Code 24014 24015 24016 24017 24018 24019 24064 24153 Other Answered Skipped

# 4 4 3 7 6 3 3 8 21 59 2

% 6.8% 6.8% 5.1% 11.9% 10.2% 5.1% 5.1% 13.6% 35.6%

27. What is your age? Median: Answered Skipped

58 59 2

201

28. What is your gender identity?

Male Female Other In your own words: Answered Skipped

# 11 48 0 0 59 2

% 18.64% 81.36% 0.00% 0.00%

202

29. What is your height, in inches? Average: Answered Skipped

65 58 3

30. What is your weight, in pounds? Average: Answered Skipped

182.3 58 3

31. How many people live in your home (including yourself)? Number of children (0 – 17 years of age): Number of adults age 18 – 64: Number of adults age 65 or older: Answered Skipped

Average 0.725490196 1.471698113 0.645833333 57 4

203

32. What is your highest education level completed?

Associates High school diploma/GED Bachelors Masters / PhD Less than high school Some high school Answered Skipped

# 18

% 30.51%

15 25.42% 12 20.34% 12 20.34% 2 3.39% 0 0.00% 59 2

204

33. What is your primary language?

English Spanish Other (please specify) Answered Skipped

# % 59 100.00% 0 0.00% 0 0.00% 59 2

34. With what ethnicity do you identify? (Check all that apply)

White Black / African American More than one race Decline to answer Other (please specify) American Indian / Alaskan Native Asian Latino Native Hawaiian / Pacific Islander Answered Skipped

# % 48 81.36% 8 13.56% 1 1.69% 1 1.69% 1 1.69% 0 0.00% 0 0.00% 0 0.00% 0 0.00% 59 2

205

35. What is your marital status?

Married Divorced Single Widowed Domestic Partnership Answered Skipped

# % 33 55.93% 14 23.73% 7 11.86% 4 6.78% 1 1.69% 59 2

206

36. What is your yearly household income?

$100,001 and above $10,001 – $20,000 $70,001 – $100,000 $0 – $10,000 $20,001 – $30,000 $30,001 – $40,000 $40,001 – $50,000 $50,001 – $60,000 $60,001 – $70,000 Answered Skipped

# % 12 23.08% 10 19.23% 6 11.54% 4 7.69% 4 7.69% 4 7.69% 4 7.69% 4 7.69% 4 7.69% 52 9

207

37. What is your current employment status?

Full-time Retired Part-time Unemployed Homemaker Self-employed Student Answered Skipped

# % 29 49.15% 16 27.12% 7 11.86% 4 6.78% 2 3.39% 1 1.69% 0 0.00% 59 2

208