First and foremost, we wish to extend our thanks to the 800 local residents who were willing to share their insights and concerns on community health in the Tri-County area. Without their cooperation and patience we would not have been able to present the community concerns that are so central to this assessment. We also would like to extend a special note of thanks to the 100 individuals who attended the ten community health workshops. Their willingness to come out in the evening and share their time for the good of their communities demonstrates that residents are willing and able to address local community health issues.

We are especially grateful to the three County Public Health Directors and their staff for their assistance and support during the past eight months. Their input during the monthly project meetings was crucial to keeping the project focused on the health issues of most concern to local residents. The Public Health Directors are:

Clinton County: Jack Andrus, assisted by Laurie Williams, Health Education Unit Coordinator.
Essex County: Dorothy Madden, assisted by Linda Lazzari, Deputy Director and Nancy Fink, Public Health Educator.
Franklin County: Katrine Kretser, assisted by Sue Patterson, Public Health Educator.

Holmes & Associates also would like to extend a note of appreciation to a number of individuals at the New York State Department of Health who provided data, information, reports and other support. Most notably, Colene Byrne of the Public Health Information Group provided help on numerous occasions, supplying us with data, reports and GIS-produced maps illustrating social and health characteristics within the Tri-County area. Robert Davenport, Bureau of Dental Health, and David Shabat, Bureau of Injury Prevention, were helpful as well in compiling Tri-County data sets for use in this assessment. We also appreciate the assistance of Bill LaBarge, facilitator with the Department of Health, who met with the assessment team in Saranac Lake and helped design the community workshop process.

Margaret Terrance, Executive Director of St. Regis Mohawk Tribe Health Services, kindly provided recent reports that allowed us to summarize community health concerns of tribal members living in the vicinity of the St. Regis Mohawk reservation.

At Holmes & Associates, Sarah Granquist assisted in a wide variety of project related-tasks including database management, data entry, editing, and logistical support for the community workshops. Nadia Korths made significant contributions to the success of the ten community workshops, as did Jack Drury who helped design a public input process that contributed quantitative as well as qualitative data for this assessment. Leanne Yanni, 4th year medical student at Syracuse, also helped in designing and implementing the workshop process.

Introduction: If ranked on environmental quality, the Tri-County area would likely be classed among the areas with the cleanest air and water in New York State. When ranked on the health of its residents, however, the area often falls below the State average. Although this health assessment shows that the area faces a number of community health challenges, progress is continually being made and the area is rich in organizations, agencies, and individuals that are currently working to address specific health problems.

The goal of the Tri-County Community Health Assessment was to identify what really matters to local residents about their health and to highlight their concerns about health issues and problems in their own communities. Another goal was to provide a regional overview on the current status of various health issues identified as statewide priorities by the New York State Department of Health (NYSDOH). This Community Health Assessment is presented to the residents, businesses, organizations and health care providers of the Tri-County area as a working document for developing partnerships and strategies to address the priority community health issues.

Description of the Area: The Tri-County area of Clinton, Essex and Franklin Counties covers approximately 4,500 square miles in the northeast corner of New York State. The area shares the international border with Quebec to the north and the shoreline of Lake Champlain with Vermont to the east. Over eighty percent (83%) of the land area is classified as forestland, while another thirteen percent is farmland.

According to the 1990 census, close to 170,000 people make their home in the Tri-County area. The area is sparsely populated, with an average of 38 people per square mile. The population of the area is dispersed, with at least 116 communities of fifty or more people. The average population of a Tri-County community is 850 people, while the largest community is Plattsburgh with 21,000 residents.

The per capita income in Franklin County was 31% below the average for the United States in 1991. Similarly, median family income, household income and average wages & salaries are below the national average. Poverty, on the other hand, exceeds state and national averages. Twelve percent of children in Upstate New York were living below poverty in 1989, while in Clinton and Essex Counties the child poverty rate was 15% and in Franklin County it was 20%.

Government-related employment comprises a significantly larger proportion of total employment in the Tri-Counties than nationally. Farm employment also tends to be higher in the area. The average annual unemployment rates exceeded the 1997 New York average of 6.4 per 100 workers, with rates of 8.7% in Franklin County, 8.6% in Essex County, and 6.8% in Clinton County.

That brief description highlights some of the key characteristics of the Tri-County area that have a direct bearing on the availability and accessibility of health care to local residents. Hindering residents' ability to adopt healthier lifestyles is the area's ruralness, the prevalence of small, widely scattered communities, the lower than average incomes, and higher than average unemployment. Although not necessarily unique among rural America, the community health issues facing the Tri-County area are often very unique compared to the issues facing the more populated areas of New York State. While sharing the same goals for a healthier population, the steps to achieving those goals in the Tri-County area will necessarily require innovative actions adapted to the geographic, socioeconomic and environmental conditions existing in the area.

State & National Health Objectives: Healthy People 2000: National Health Promotion and Disease Prevention Objectives was published by the U.S. Department of Health and Human Services, Public Health Service in 1990. The document presented a national strategy for the improvement of the health of all Americans and contains 298 specific health related objectives to be achieved by year 2000. The three overriding goals of the national effort are to:

Increase the span of healthy life for Americans.

Reduce health disparities among Americans.

Achieve access to preventive services for all Americans.

Those goals served as the foundation for efforts in New York State to develop its own strategy for improving community health.

In September, 1996, the New York State Public Health Council published a document entitled Communities Working Together for a Healthier New York, Opportunities for Improving the Health of New Yorkers, recommending health objectives for New York for the next 10 years. The committee working on the project held six regional workshops throughout New York to discuss the most serious public health issues in local communities, the underlying causes of these problems and interventions that could be most effective. The goal was to focus community attention and stimulate action in areas that lead to longer, healthier lives for New Yorkers, with a special emphasis on those problems of greatest health concern to the community.

Recognizing the importance of using public input to identify the 12 health priority areas for New York State (see box), the Department of Health (NYSDOH) suggested that county health departments use a similar process to learn if those 12 statewide priorities are the major concerns in their local communities. Following that suggestion, in 1997 the Public Health Departments of Clinton, Essex and Franklin counties formed a Regional Community Partnership for the purpose of producing a joint Tri-County Community Health Assessment. Holmes & Associates of Saranac Lake and Patricia Randolph-Clark were hired to develop the assessment.

Tri-County Community' Health Assessment

The underlying causes of disease, rather than the diseases themselves are the focus of this assessment. Similar in approach to both the New York State and Federal efforts to improve the health of Americans, this local initiative has sought to capture what makes the Tri-County area unique in its quest for better health.

The overriding goal for the Tri-County Community Health Assessment is to improve the health of the people living in Clinton, Essex and Franklin counties. Specific objectives to be accomplished during the local health assessment process included:

Involving local people in the process of identifying community health priorities in their own communities.

Clearly and succinctly presenting state and national health objectives in relation to Tri-County health statistics and findings from community workshops, focus groups, surveys and interviews.

Identifying the top health priorities for the three counties that could lead to improved lives and healthier communities.

Stimulating interest and awareness of potential opportunities for various provider agencies to develop partnerships for the purposes of cost effectiveness and reduction of agency overlap or redundancy.

Producing a health assessment document that informs the public about the health characteristics of their communities and that serves as a solid foundation for a second phase of the health assessment process that involves developing health partnerships, designing interventions and evaluating progress.

The cornerstone of the eight-month project was a series of public workshops held in ten communities throughout the Tri-County area. The workshops were opportunities for local residents to be heard on what they thought were the health priorities in their community. In addition, the assessment team carried out focus groups, questionnaire surveys, interviews and presentations in thirty-six different settings. The individuals and groups contacted represented a wide variety of community interests including older residents, youth, service organizations, business owners, health care providers, uninsured families and educators. In total, over 800 local residents provided input on their community health concerns.

Local Priority Health Issues

The assessment team combined four main sources of information in an effort to determine the priority community health issues of the Tri-County area. The four sets of information were:

Top health priorities identified in the ten community health priority workshops (100 participants).

Top health priorities identified in survey work for the Tri-County Health Assessment (324 respondents).

Tri-County health measures most distant from Healthy People 2000 objectives (44 objectives compared).

Top health priorities in 1996 United Way Clinton County Needs Assessment Survey (514 households).

The four sets of information each yielded six community health priorities. The assessment team analyzed those four lists of six priority issues to identify which issues were consistently top priorities. The six priority health issues presented below reflect the community health issues presently of most concern in the Tri-County area. They are presented in order of priority along with the main local concerns for each issue.

1.Access To and Delivery of Health Care

Availability of services and providersin some areas.

Financial and health insurance issues.

Transportation, rural isolation issues.

Medicaid and welfare issues.

Decline in volunteerism, EMS concerns.

2. Substance Abuse: Alcohol & Drugs

Difficult problem to address with the easy access to alcohol and growing availability of drugs.

Causing too many automobile accidents.

Need more alternative activities for youth, difficult for small communities.

Need for better role models. Low self-esteem is a related issue.

Educating parents is a continuing need.

Lack of services, access to services and use of available services are all issues. Employers need to become involved.

3. Health & Prevention Education

Primary focus needed on nutrition and physical activity.

Need for educating teens.

Early health education.

How to access the system.

Improved availability of nutritious food and opportunities for exercise and physical activity.

4. Mental Health Needs

Lack of mental health services.

Recognizing mental health needs.

Special focus on the needs of youth, including counseling and medical needs as well as improved social and recreational opportunities.

Older residents were also identified as a population with special needs.

5. Healthy Births

Concern over high rates of teen pregnancy.

Teens need more information regarding the effects of drugs and alcohol on the unborn.

Age-appropriate sex education.

Need for increased support of pregnant teens and young mothers.

6. Tobacco Use

Need to recognize the problem.

Tobacco too available to teens.

Need for positive role models.

Improved education for teens.

Second-hand smoke in the work place is an issue in some communities.

There are obviously many other local health priorities beyond these top six, and certain communities will view other health issues as their top health concerns. However, the six priority issues presented here were consistently of highest concern throughout the Tri-County area.

In addition to identifying priority health issues for the Tri-County area, the Tri-County Community Health Assessment succeeded in putting a local face on the state-wide community health priorities. For example, during the community health workshops it became apparent that Substance Abuse is perceived as a youth issue in the Tri-County area and is viewed locally as being closely related to the availability of youth social and recreational activities. The New York State description of the substance abuse health issue was quite different. Similarly, while healthy babies are a concern throughout the state, in the Tri-County area Healthy Births was strongly interpreted by local participants as a teen sexual behavior and sex education issue.

Access to and Delivery of Health Care, the number one priority issue in the area, is a broad issue encompassing a variety of concerns. The identification of transportation as a major concern under access relates directly to the remoteness of some communities, the distance to health providers and limited public transportation options.

The full report provides additional data and local concerns for each of the top six priority issues, as well as for the other six community health issues identified as statewide priorities. Included in the Tri-County Health Assessment are health statistics on major causes of death and disease in the area. In addition, a section entitled Populations of Special Concern, highlights major concerns for five sub-populations of local residents: Native Americans, residents with disabilities, older residents, lower income families and youth.

Collaborative Partnerships

It is not the intent of the Tri-County Community Health Assessment to prescribe a treatment to "fix" the area's health problems, but rather to stimulate interest among individuals, organizations, schools, businesses, the media, etc. to develop collaborative partnerships as a strategy to address the priority health issues. As such, this document is a community resource that can be used to identify possible areas for collaboration among those interested in trying to alleviate the health problems in this rural area of New York State.

A widely respected expert on community health collaborations in New York recognizes that the most effective and beneficial collaboration for improving community health is that between medicine and public health. Working independently, the medical and public health sectors have made great strides in achieving their missions, however, continuing on separate tracks is no longer in the best interest of either. "By combining their resources and skills in various ways, professionals and organizations in the two sectors are able to achieve benefits that none of them can accomplish alone" (Lasker 1997:154).

There are numerous partnerships and collaborations presently occurring throughout the Tri-County area. It is hoped that the Tri-County Community Health Assessment will help communities build on those efforts, as well as contribute to new partnerships and collaborations.

On a regional level, five rural health care networks are currently working within the Tri-County area to enhance collaboration within the health provider system:

Eastern Adirondack Health Care Network

Adirondack Rural Health Network

Northern Adirondack-St. Lawrence Health Care Network

High Peaks EMS Task Force

North Country Behavioral Health Care Network:

The success and longevity of the rural health care networks will hinge in part on their ability to reach out beyond traditional health care providers and identify non-provider support and involvement. By continuing to involve community members, local governments, businesses, churches, schools, service organizations and others they will contribute to keeping the "community" in community health.

Next Steps

In total, over 800 local individuals, associated with over 40 organizations, agencies and communities took part in the Tri-County Community Health Assessment process. The participants identified what concerned them the most about their health and the health of their communities. This assessment conveys their interests and concerns, as well as providing background health statistics on some of the major issues. Prioritization of what appear to be the health issues of most concern in the Tri-County area is also included.

There are a number of next steps that can be taken at the State, community, and regional levels, as follows:

State Level Action

1. Develop better monitoring and data systems.

2. Dedicate the necessary resources to ensure adequate capacity at the local level.

3. Develop performance measures.

4. Establish a public health intervention clearinghouse to assist localities in sharing their experience and learning from each other.

Community Level Action

The best next step would be for a community to publicly recognizing the health issue or issues of most concern to their residents and initiate community-level action to address the problem. The area is rich in health-related organizations and support groups, as well as public health offices, hospitals, social service agencies and others that can assist local communities in their efforts.

An example of a local community action would be to organize a community group comprised of a cross-section of community member, businesses and organizations to evaluate the availability and adequacy of local recreational and social facilities. They would identify needed changes in facilities, operating hours, programs, management, etc. Such a local action could make a positive impact on a number of priority health issues, including substance abuse, prevention education, mental health, healthy births and tobacco use. It would also address the needs of youth and older residents, two populations of special concern in the area. This is only one of many possible local community actions that could easily and inexpensively begin to address local community health priorities.

Tri-County Level Action

There are a number of multi-county activities underway to help communities achieve improved health. Following are action steps that may facilitate those activities and build on previous accomplishments:

1. Convene an educational forum on developing collaborative partnerships.

2. Utilize the priorities identified in the Tri-County Community Health Assessment as the areas of focus for future partnership/collaborative efforts. Priority health concerns identified are:

1. Access to and Delivery of Health Care

2. Substance Abuse: Alcohol & Drugs

3. Health & Prevention Education

4. Mental Health Needs

5. Healthy Births

6. Tobacco Use

3. Update directories of agencies, people and institutions interested in improving community health.

4. Match health care providers with one or more of the groups identified who share similar goals and philosophy, to develop local or regional interventions for the priority health issues.

5. Identify how to regularly update the database compiled for this assessment and to develop indicators of progress in addressing Tri-County community health issues.

6. Ensure that local schools, colleges and universities maintain an active role in addressing the health needs of children, youth and young adults.

7. Work through the rural health care networks and others to coordinate health-related questionnaire surveys.

8. Coordinate efforts to compile longitudinal health data on children in the area.

It is hoped that Tri-County Community Health Assessment will foster new partnerships and collaborative relationships for implementing innovative health promotion and disease prevention programs in Essex, Clinton and Franklin Counties. These next steps can serve to maintain a focus on the community health priorities recognized throughout the Tri-County area, while at the same time supporting the goals of the many health-related agencies and organizations currently working in the area.

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