Community Health Status Assessment Navajo County, Arizona Conducted in collaboration with the Navajo County Public Health Services District & Health Research Alliance Arizona at Northern Arizona University January 2010 Kelly A. Harris, MA Robert T. Trotter, PhD Northern Arizona University Community Health Status Assessment Navajo County, Arizona January 2010 Conducted in collaboration with the Navajo County Public Health Services District & Health Research Alliance Arizona at Northern Arizona University Robert T. Trotter, PhD Kelly A. Harris, MA Contacts Navajo County Public Health Services District Contact: Andrea Tsatoke, MPH, Community Outreach Specialist, Andrea.Tsatoke@Navajocountyaz.gov Health Research Alliance Arizona, Northern Arizona University Contact: Kelly Harris, MA, Program and Education Coordinator, Kelly.Harris@nau.edu Navajo County Community Health Status Assessment 1 Acknowledgements The successful production of this Community Health Status Assessment (CHSA) involved a collaborative effort. Each person that assisted with the completion of the assessment played a key role in its successful completion. I want to personally thank Tara Hoffmann, Douglas Distefano, and Andrea Merrihew, three anthropology graduate students who worked diligently on this assessment. Robert T. Trotter, PhD (Chair and Regents’ Professor in Anthropology) oversaw the project progress and provided feedback on the assessment content throughout the process. His expert opinions and direction ensured a well composed set of data that provides a window into the lives and health status of the residents of Navajo County. Tara Hoffmann created the bar graphs, line graphs and maps distributed throughout the assessment in addition to formatting the document into In-Design. Douglas Distefano and Andrea Merrihew dedicated many hours to creating tables to capture the trend and comparison data for the CHSA assessment. Andrea Tsatoke, MPH, Community Outreach Specialist, Navajo County Public Health Services District provided support throughout the assessment process from the planning and organization, data collection, and analysis. I would also like to acknowledge the Navajo County Mobilizing for Action through Planning and Partnerships (MAPP) Subcommittee members for their guidance throughout the entire process. Dr. Wade Kartchner, MD, MPH, Director Navajo County Public Health Services District offered his leadership and support in improving the quality of health care data to raise the health status of Navajo County residents. The Mobilizing Action through Planning and Partnerships (MAPP) subcommittee guides and oversees the MAPP process, and is broadly representative of the community and the local public health system. Geri Hongeva, Multimedia designer created the cover art for the assessment. Completing this assessment within the project timeline would not have been possible without this team. If you have questions about the assessment please feel free to contact me, Kelly.Harris@nau.edu. Kelly Harris, MA Program and Education Coordinator Health Research Alliance Arizona Evaluation Coordinator Native American Cancer Research Partnership Department of Anthropology Northern Arizona University 2 Navajo County Community Health Status Assessment Contents Contacts.........................................................................................................................1 Acknowledgements.......................................................................................................2 Introduction...................................................................................................................4 Core Health Status Indicators.......................................................................................6 Category One - Demographic Characteristics..........................................................8 Category Two - Socioeconomic Characteristics.......................................................14 Category Three - Health Resource Availability.........................................................25 Category Four - Quality of Life...................................................................................37 Category Five - Behavioral Risk Factors .................................................................45 Category Six - Environmental Health Indicators .....................................................59 Category Seven - Social and Mental Health .............................................................68 Category Eight - Maternal and Child Health ............................................................72 Category Nine - Death, Illness and Injury ................................................................82 Category Ten - Communicable Diseases .................................................................93 Category Eleven: Sentinel Events ..........................................................................104 Appendix A ................................................................................................................108 References ................................................................................................................115 Navajo County Community Health Status Assessment 3 Introduction The MAPP Process: The Navajo County Public Health Services District made a unanimous decision to develop a strategic community health plan based on the National Association of County and City Health Officials (NACCHO) Mobilizing for Action through Planning and Partnerships (MAPP) Process. According to the NACCHO website MAPP is a community-driven strategic planning tool for improving community health. The Community Health Status Assessment (CHSA) is the third of four assessments and in the third phase of the six phases of the MAPP process. The primary method for the assessment was secondary data collection and analysis. The data collection process began in August of 2009 and continued throughout the assessment period (December 2009). The Navajo County MAPP subcommittee provided feedback to identify any additional indicators from the “extended indicator list” (as defined by MAPP) that were directly relevant to Navajo County. We planned approximately one week per indicator (11 total indicators, each with multiple sub-categories). Each indicator required additional research to identify the data needed to accurately examine the sub-categories. When there was additional data that related to the core The CHSA focuses on 11 health status indica- indicators we included it to provide the most detors as defined by the NACCHO MAPP process. tailed information about health status in Navajo The health indicators include: demographic char- County. acteristics, socioeconomic characteristics, health resource availability, quality of life, behavioral risk The data included in the assessment targets a factors, environmental health, social and mental five year span from 2004 through 2008. When data health, maternal and child health, death, illness was available from 2009 it was included. Howevand injury, communicable disease, and sentinel er, the assessment is being finalized in December events. For more information on the MAPP pro- of 2009 so any 2009 data is not from the full year. cess please see http://www.naccho.org/topics/in- When the most recent data was not available but frastructure/mapp/Phase3CHSA.cfm. other years (ranging from the late 1990s through 2003) were we included those data sets. Older CHSA Purpose: data sets were recommended as an area for fuThe purpose of the CHSA is to gather and ana- ture research in the CHSA. lyze information regarding the health status of Navajo County residents. Ultimately the CHSA will Limitations: provide additional data for the stakeholders in the One of the largest limitations for this assessNavajo County local public health system to de- ment was the time constraint. The project time velop a strategic plan. The CHSA provides a way line was approximately six months. Data collecto measure the health status of Navajo County tion, organization, and analysis took a significant residents as well as identifying trends in compari- amount of time. During three months of the projson to peer communities, state data, and national ect period three graduate assistants devoted apdata. proximately 40 hours a week creating data tables and making phone calls when necessary to collect Approach: more recent data sets. The Project Coordinator, This health assessment is the result of a part- Kelly Harris, MA spent between 8 and 25 hours a nership between the Navajo County Public Health week throughout the 6 month period writing, colServices District and the Health Research Alliance lecting and organizing data for Graduate AssisArizona (HRAA) office situated within Northern Ar- tants. izona University. The CHSA assessment process was reviewed and approved by the Northern AriSecondary data collection posed several probzona University Institutional Review Board (IRB) lems. Not all of the data sets matched the time prior to data collection. period from 2004 through 2008 that we were try4 Navajo County Community Health Status Assessment Introduction ing to cover in the assessment. In order to collect trend data we used some data sets that were older than 2004 to help provide a broader span of time which enables the identification of trends in the health status of residents of Navajo County. Not all available data sets included the preferred data for each indicator (demographic data, trend data or data from multiple years etc.). All data sources are cited in the back of this assessment. Those interested in additional information on any topic included in the CHSA may want to retrieve the actual data source in order to retrieve additional information that was not included in the assessment due to time constraints. Protection Agency (EPA), Arizona Department of Environmental Quality (ADEQ), School districts, and many other individuals. For the complete list of sources please see the references cited at the end of the assessment. Limitations associated with specific data sets are mentioned within the indicator as the data is presented. However, data from the Behavioral Risk Factor Surveillance System (BRFSS) is included throughout the entire assessment, which is why we chose to explain the limitations of the BRFSS data set herein. The information recorded in the BRFSS is recorded directly by the respondent, making a margin for error based on self-reporting. The BRFSS survey is a telephone survey. In Navajo County, Arizona, this may be problematic as a large portion of the population residing in the county may not have access to a phone. The questionnaire was provided both in English and Spanish, which could pose an issue in Navajo County where over 40% of the population is Native American, and a language barrier may exist. Unlisted phone numbers are included in the random dialing method used for the BRFSS. In 2008 the survey method began to include the use of cell phones to contact respondents. Prior to 2008 all phone surveys for the BRFSS were conducted on land-lines. Countless sources were used to create this health status assessment including data sets from the Arizona and U.S. Departments of Health and Human Services, Centers for Disease Control and Prevention(CDC) statistical databases, the U.S. Census, in addition to county-level reports, personal communication with representatives from Indian Health Services (IHS), Environmental Navajo County Community Health Status Assessment 5 Core Health Status Indicators 1) Demographic Characteristics 5) Behavioral Risk Factors Demographic characteristics include measures of total population as well as percent of total population by age group, gender, race and ethnicity, where these populations and subpopulations are located, and the rate of change in population density over time, due to births, deaths and migration patterns. Risk factors in this category include behaviors which are believed to cause, or to be contributing factors to, injuries, disease, and death during youth and adolescence and significant morbidity and mortality in later life. 6) Environmental Health Factors 2) Socioeconomic Characteristics The physical environment directly impacts health and quality of life. Clean air and water, Socioeconomic characteristics include mea- as well as safely prepared food, are essential to sures that have been shown to affect health sta- physical health. Exposure to environmental subtus, such as income, education, and employment, stances such as lead or hazardous waste increasand the proportion of the population represented es risk for preventable disease. Unintentional by various levels of these variables. home, workplace, or recreational injuries affect all age groups and may result in premature disability 3) Health Resource Availability or mortality. This domain represents factors associated with health system capacity, which may include both the number of licensed and credentialed health personnel and the physical capacity of health facilities. In addition, the category of health resources includes measures of access, utilization, cost and quality of health care and prevention services. Service delivery patterns and roles of public and private sectors as payers and/or providers may also be relevant. 4) Quality of Life Quality of Life (QOL) is a construct that “connotes an overall sense of well-being when applied to an individual” and a “supportive environment when applied to a community” (Moriarty, 1996). While some dimensions of QOL can be quantified using indicators research has shown to be related to determinants of health and community-well being, other valid dimensions of QOL include perceptions of community residents about aspects of their neighborhoods and communities that either enhance or diminish their quality of life. 7) Social and Mental Health This category represents social and mental factors and conditions which directly or indirectly influence overall health status and individual and community quality of life. Mental health conditions and overall psychological well-being and safety may be influenced by substance abuse and violence within the home and within the community. 8) Maternal and Child Health One of the most significant areas for monitoring and comparison relates to the health of a vulnerable population: infants and children. This category focuses on birth data and outcomes as well as mortality data for infants and children. Because maternal care is correlated with birth outcomes, measures of maternal access to, and/or utilization of, care is included. Number of births to teen mothers is a critical indicator of increased risk for both mother and child. 9) Death Illness and Injury Health status in a community is measured in terms of mortality (rates of death within a popu- 6 Navajo County Community Health Status Assessment Core Health Status Indicators lation) and morbidity (rates of the incidence and prevalence of disease). Mortality may be represented by crude rates or age-adjusted rates (AAM); by degree of premature death (Years of Productive Life Lost or YPLL); and by cause (disease - cancer and non-cancer or injury - intentional, unintentional). Morbidity may be represented by age-adjusted (AA) incidence of cancer and chronic disease. 10) Communicable Diseases Measures within this category include diseases which are usually transmitted through person-toperson contact or shared use of contaminated instruments / materials. Many of these diseases can be prevented through a high level of vaccine coverage of vulnerable populations, or though the use of protective measures, such as condoms for the prevention of sexually-transmitted diseases. 11) Sentinel Events Sentinel events are those cases of unnecessary disease, disability, or untimely death that could be avoided if appropriate and timely medical care or preventive services were provided. These include vaccine-preventable illness, late stage cancer diagnosis, and unexpected syndromes or infections. Sentinel events may alert the community to health system problems such as inadequate vaccine coverage, lack of primary care and/or screening, a bioterrorist event, or the introduction of globally transmitted infections. Navajo County Community Health Status Assessment 7 Category One - Demographic Characteristics Definition of Indicator Demographic characteristics include measures of total population as well as percent of total population by age group, gender, race and ethnicity, where these populations and subpopulations are located, and the rate of change in population density over time, due to births, deaths and migration patterns. 281,421,906 (2000) to 304,059,724 (2008), with a net change of 22,637,818 (7%). Between 2000 and 2004 Navajo County experienced a total population change of 20.7 (per 1,000) total population change including residual1. The natural increase in population was 8.9 (per 1,000). The birth rate was 16.1 (per 1,000) while the death rate was 7.2 (per 1,000). The net migration2 in Navajo County during that period was 12 (per 1,000). Between 2007 and 2008 Navajo County experienced a total population change of 1,678 (actual). There were 2,089 births and 839 deaths. The net migration was 378. Trends Between 2000 and 2008, the population of Navajo County experienced a 14% growth, while population in the state of Arizona grew 21% and population in the US grew 7% in the same period. Navajo County has the second highest percentage of Native American population in the US (43.97%), and is home to three Native American Table 1.0 Demographic Information for Navajo County tribes and their associated reservation land, cov- Overall Demographic Information in Navajo ering approximately 40% of the county. County, AZ from 2000-2008 2000 2008 Population Population Comments on Net Change in Population: Navajo County experienced a 14% growth in population between 2000 and 2008. The Arizona population grew from 5,130,632 in 2000 to 6,500,180 in 2008. This is a 1,369,548 (21%) net change in population in 8 years. In comparison to the total US population which grew from Net Change Population Density 11 people/ square mile US Census Bureau, Community Health Status Indicators (CHSI) 2008; Estimates of Average Annual Rates of the Components of Population Change for Counties of Arizona, US Census Bureau, Population Division (2005) (2009); 97,470 112,757 15,287 Table 1.1 Projected Population Growth in Navajo County Year Total Reservation Total Hopi Total Navajo Nation Total White Mountain Apache Total Non-Reservation Current (2009) 50,352 5,812 32,095 12,446 70,239 2010 51,147 5,812 32,677 12,658 72,025 2015 54,992 5,812 35,495 13,685 80,679 2020 58,492 5,812 38,060 14,620 88,553 2025 61,555 5,812 40,305 15,438 95,445 2030 64,216 5,812 42,255 16,149 101,431 1 The total population change includes a residual. The residual represents the change in population that cannot be attributed to any specific demographic component. (State & County terms & Definitions http://www.census.gov/ popest/topics/terms/states.html 2 Net migration includes internal and international migration. 8 Navajo County Community Health Status Assessment Category 1 - Demographic Characteristics Table 1.2 Demographic Profile: Age and Sex Total Population Age Group Under 5 5 to 9 years 10 to 14 years 15 to 19 years Navajo County Total Population 109,130 Arizona Total Population 6,152,175 Navajo County Arizona Total Percent Total Number Male Female 7.8% 4,785 7.9% 7.6% 4,542 7.2% 7.4% 4,544 9.9% 4,592 7.3% 9.5% 9.4% Total Percent Male Female 8.0% 7.7% 7.2% 7.2% 7.1% 9.1% 7.1% 7.4% 6.9% 9.7% 9.0% 6.9% 7.1% 6.6% 6.8% 7.2% 6.4% 7.9% 7.1% 7.8% 20 to 24 years 7.7% 3,682 7.9% 7.5% 25 to 29 years 7.0% 3,698 7.6% 6.5% 3,180 5.2% 5.3% 6.9% 7.2% 6.7% 3,199 6.4% 6.3% 6.9% 7.1% 6.7% 3,276 5.9% 5.8% 6.9% 7.0% 6.8% 3,669 6.6% 6.7% 6.8% 6.8% 6.9% 3,498 5.4% 6.3% 6.1% 5.9% 6.3% 3,358 5.2% 6.1% 5.5% 5.3% 5.8% 2,750 4.2% 4.3% 4.6% 4.4% 4.9% 2,207 3.5% 3.2% 3.6% 3.4% 3.8% 1,620 2.9% 3.8% 2.9% 2.7% 3.1% 1,145 1.9% 2.2% 2.8% 2.6% 3.0% 792 1.4% 1.8% 2.0% 1.6% 2.3% 665 1.0% 1.1% 1.5% 1.1% 1.9% 30 to 34 years 35 to 39 years 40 to 44 years 45 to 49 years 50 to 54 years 55 to 59 years 60 to 64 years 65 to 69 years 70 to 74 years 75 to 79 years 80 to 84 years 85 years and over 5.2% 6.4% 5.8% 6.6% 5.9% 5.6% 4.3% 3.3% 3.4% 2.1% 1.6% 1.1% 7.5% US Census (American Community Survey 2005-2007 data), Navajo County Asset Inventory (2008, data for total number of people by age, data from “Arizona Sub-county ESRI Census Defined Place Data Proportions”), Total population numbers for the county and the state are a three year estimate. Navajo County Community Health Status Assessment 9 Category 1 - Demographic Characteristics Figure 1.3. Demographic comparison between Arizona and Navajo County: Females by Age Data from Figure 1.3 above, US Census (American Community Survey 2005-2007 data), Navajo County Asset Inventory (2008, data for total number of people by age, data from “Arizona Sub-county ESRI Census Defined Place Data Proportions”), Total population numbers for the county and the state are a three year estimate. 10 Navajo County Community Health Status Assessment Category 1 - Demographic Characteristics Figure 1.4. Demographic Comparisons between Arizona and Navajo County: Males by Age Data from Figure 1.4 above, US Census (American Community Survey 2005-2007 data), Navajo County Asset Inventory (2008, data for total number of people by age, data from “Arizona Sub-county ESRI Census Defined Place Data Proportions”), Total population numbers for the county and the state are a three year estimate Figure 1.5. Demographic Comparisons between Arizona and Navajo County: Males by Age Data from table 1.3 above, US Census (American Community Survey 2005-2007 data), Navajo County Asset Inventory (2008, data for total number of people by age, data from “Arizona Sub-county ESRI Navajo County Community Health Status Assessment 11 Category 1 - Demographic Characteristics Trends and Disparities The US Census Bureau News reported that America is becoming more racially and ethically diverse. Of all the counties in the United States with a minimum population of 100,000 Navajo County, American Indians made up the highest percentage of the total population of the county (second to Los Angeles County, California, with the largest Native American Population in the country) (US Census Bureau, Public Information Office (2009) . Navajo County is home to three Native American tribes and associated reservation land. The Hopi, Navajo, and White Mountain Apache reservations span a significant part of the county. The total population of the county is approximately 112,757 (2008) and 49,583 are American Indians or Alaska Natives (Table 1.7). Table 1.7 Racial Distribution: Navajo County, Arizona (2005-2007) State Caucasian & Navajo County Arizona African American American Indian/ Alaska Native Asian Pacific Islander Other Race Hispanic or Latino** Multi-Race (2 or more) 4,701,013 210,069 276,132 144,389 8,878 661,797 1,785,737 149,897 50,233 1,151 49,583 131 82 4,888 8,011 2,436 Winslow 5,102 (49.77%) 593 (5.78%) 2,350 (22.92%) 132 (1.29%) 10 (.09%) 1,595 (15.56%) 3,422 (33%) 471 (4.60%) Holbrook 3,275 (57.47%) 129 (2.29%) 1,335 (23.64%) 77 (1.36%) 1 (.02%) 546 (9.67%) 1,521 (27%) 313 (5.55%) Snowflake 4,804 (85.73%) 28 (.49%) 379 (6.77%) 28 (.49%) 4 (.07%) 228 (4.07%) 605 (11%) 132 (2.36%) Taylor 3,874 (86.39%) 37 (.83%) 257 (5.73%) 7 (.16%) 4 (.08%) 186 (4.14%) 585 (13%) 120 (2.68%) 10,796 (87.07) 46 (.37%) 447 (3.60%) 102 (.82%) 12 (.10%) 684 (5.52%) 1,741 (14%) 313 (2.53%) PinetopLakeside 4,159 (86.68%) 62 (1.29%) 103 (2.15%) 26 (.55%) 1 (.02%) 317 (6.60%) 747 (16%) 130 (2.70%) HeberOvergaard 3,383 (93.76%) 2 (.06%) 78 (2.15%) 8 (.22%) 5 (.14%) 77 (2.13%) 295 (8%) 55 (1.52%) Hon-Dah McNary 32 (8.06%) 11 (2.77%) 326 (82.12%) 0 (.00%) 0 (.00%) 14 (3.53%) 48 (12%) 14 (3.53%) Cibecue 34 (2.05%) 2 (.12%) 1,600 (96.27%) 3 (.18%) 0 (.00%) 4 (.24%) 31 (2%) 19 (1.14%) Whiteriver 187 (2.94%) 2 (.03%) 6,035 (94.99%) 2 (.03%) 0 (.00%) 28 (.44%) 134 (2%) 99 (1.56%) Navajo County Show Low Navajo County Community Asset Inventory 2008 source: Arizona Sub-county population projections distributed by ESRI Census Defined Place Data Proportions, US Census Bureau American Community Survey 2005-2007. ** Please note the percentages for the Hispanic/Latino population include the Hispanic/Latino percentage of the total population in that area. Please note data for Navajo Nation and Hopi (within Navajo County) were unavailable. 12 Navajo County Community Health Status Assessment Category 1 - Demographic Characteristics Navajo County Navajo Nation Hopi Tribe White Mountain Apache Indian Reservation Other Indian Reservations Figure 1.8 Racial Distribution between Navajo County and Arizona The non-reservation areas in Navajo County with the highest concentration of American Indians or Alaska Natives include Winslow (22.92%) and Holbrook (23.64%). Note that the Hispanic and Latino populations in Winslow and Holbrook include a significant proportion of the overall population (33% and 27%, respectively). The percentage of Native Americans and Alaska Natives in Arizona is 4% while the percentage of Native Americans and Alaska Natives in Navajo County is significantly higher, 43% of the total population in Navajo County. Navajo County Community Health Status Assessment 13 Category Two - Socioeconomic Characteristics Definition of Category Socioeconomic characteristics include measures that have been shown to affect health status, such as income, education, and employment, and the proportion of the population represented by various levels of these variables. Unemployment The table below (2.0), Unemployment by region includes data from the regions in Navajo County with the largest labor forces, the Navajo County average unemployment rate for that year and the Arizona unemployment rates. Trends Between 2004 and 2009, the unemployment rate in Navajo County grew 57.14% while the unemployment rate in the state of Arizona grew 63.26%. Nevertheless, the poverty level in Navajo County between 2005 and 2007 is 1.5 to 2 times higher than the state level, a trend confirmed by the median average income for the same period shows similar data ($37,660 for Navajo County, $46,913 for Arizona, and $50,303 for the US). Navajo County has a multilingual, non-immigrant population, a fact that could contribute to the impact of language barriers in healthcare since 39.9% of the population over 5 years old speaks a language other than English at home (versus 25.9% in the state of Arizona). Comparison of the rate of births to unmarried mothers between Navajo County and the state of Arizona shows considerably higher numbers in Navajo County. Due to the current state of the economy (recession) we thought it was important to include 2009 rates even though they do not capture all rates for 2009 (unemployment rates for 2009 data cover the calendar year period from January to July). Table (2.0) includes the unemployment rates for tribal areas within Navajo County. The large percent change between 2004 and 2009 may be distorted by the drop in the economy beginning in 2008 and worsening in 2009. The percent change for all regions in table 2.0 reflects an increase in unemployment rates, there were no decreases in unemployment. Table 2.0 Region 2004 Unemployment Rate 2009 Unemployment Rate Percent Change from 2004 to 2009 Winslow 3.8% 6.2% 63.15% Show Low 4.0% 6.5% 62.5% Holbrook 5.4% 8.7% 61.11% Pine Top-Lakeside 4.4% 7.2% 63.63% Kayenta 13.8% 21.0% 52.17% Taylor 3.8% 6.1% 60.52% Snowflake 4.6% 7.4% 60.87% Heber-Overgaard 2.1% 3.4% 61.90% 8.4% 13.2% 57.14% Percent change is approximate change. Arizona, State and County data from Bureau of Labor Statistics www.bls.gov 2004, 2009 Special Unemployment Report. Navajo County 14 Navajo County Community Health Status Assessment Category 2 - Socioeconomic Characteristics Table 2.1 Unemployment in Tribal Regions in Navajo County Tribal Area Unemployment 2004 Unemployment 2009 Percent Change 2004 to 2009 *Navajo Nation 16.0% 20.6% 28.75% *Hopi Tribe 12.5% 18.8% 50.4% White Mountain Apache Indian 15.7% Reservation 23.5% 49.68% Arizona Native American Reservations in Arizona 15.7% 22.2% 41.40% Navajo County 8.4% 13.2% 57.14% Arizona 4.9% 8.0% 63.26% Arizona Department of Economic Security, Arizona Workforce information www.workforce.az.gov (2000, 2004, 2009 Special Unemployment Report)1 * An asterisk indicates the unemployment rates include reservation and off-reservation trust land. The unemployment rate for Caucasians in Navajo County (2005-2007 average) was 6.2% in comparison with 20.8% for American Indian and Alaska Natives and 10.0% for people of Hispanic or Latino origin (Employee Status, 2005-2007 American Community Survey). A study conducted in 2008 through the Center for Competitiveness and Prosperity Research at W.P. Carey School of Business at Arizona State University examined the economy of Navajo Nation within Navajo County, Arizona. The study concluded that in 2004 the total unemployment of Navajo Nation (in Navajo County) was “very low 109 per 1,000 residents, approxi- Arizona.Workforce.gov (2004, 2005, 2006, 2007, 2008 & 2009). Figure 2.2 Unemployment Trends: Navajo County, Arizona, and Arizona Native American Reservation. Arizona. Workforce.gov (2004, 2005, 2006, 2007, 2008 & 2009) mately 75 percent less than the national and state averages” (Economy of Navajo Nation in Navajo County, ASU and the Arizona Department of Commerce 2008). Analysis of Unemployment According to the Bureau of Labor Statistics (BLS), unemployment is defined as, people who are jobless, looking for jobs or available to work. Workers that are expecting to be recalled from a temporary layoff are considered unemployed as Arizona.Workforce.gov (2004, 2005, 2006, 2007, 2008 & 2009) Figure 2.3 Unemployment Trends: Navajo Nation, Hopi Tribe, and White Mountain Apache Indian Reservation Arizona.Workforce.gov (2004, 2005, 2006, 2007, 2008 & 2009) Navajo County Community Health Status Assessment 15 Category 2 - Socioeconomic Characteristics well. Furthermore, part-time and temporary work, as well as regular full-time, year round employment are included in the employed population. Figure 2.2 suggests that the unemployment rates for Arizona, Navajo County, and the Native American reservations in the county has only increased. When in reality the unemployment rates (across In order to gain Local Area Unemployment Sta- the board) decreased from 2004 to mid-2007. In tistics (LAUS) program generates monthly and an- order to show the change that occurred each year nual employment/unemployment and labor force we created these line graphs (Figures 2.2 and data for states and counties. Labor force data is 2.3). The overall trends (Arizona, Navajo County derived by surveys from the U.S. Census Bureau. and Native American reservations in the County) Counties are grouped into a number of geograph- are similar. However, Navajo County and the Naic areas and the U.S. Census Bureau selects a tive American Reservations in the county have percentage (sample) of homes to represent the considerably higher unemployment rates when population of each county and state. The survey compared to Arizona unemployment rates during is conducted through interviews by visiting house- that period. holds and conducting telephone interviews (70% via telephone). Figure 2.3 illustrates the trends in unemployment for the three Native American Reservations To reduce variability, the survey reflects a sam- in Navajo County. Trends on the Native American ple with different demographic, personal and so- reservations are similar to those illustrated above cioeconomic characteristics of the current popu- in Figure 2.2, however there are slight differences lation survey. The sample of household used to among the tribes. The White Mountain Apache Indetermine unemployment statistics vary from dian Reservation has the highest unemployment month to month (US Department of Labor. Bureau of the three tribes with Navajo Nation the second of Labor Statistics, Overview, 2009). highest for unemployment. On a national level, the rate of unemployment for Native Americans living Figures 2.2 and 2.3 were created to show the on reservation land is more than two times as high actual changes in unemployment year by year as the US rate (Harvard Project on American In(between 2004 and 2009). The percent change dian Economic Development: A Data Book of Soin Figure 2.2 is distorted by the increased unem- cioeconomic Change between the 1990 and 2000 ployment in between 2007 and 2009 with the cur- Censuses). rent state of the economy. The percent change in Table 2.4 Percent Below Poverty Level (2004-2007) Core Indicators 2005-2007 Navajo County 2005-2007 Arizona Averages Total (106,760, total population for whom poverty status is 24.4% determined) 14.2% Children (under 18 years) 33% 20% Less than a high school graduate 38.7% 23.7% High school graduate 20.3% 12.4% Some college, associate’s degree 13.6% 7.9% Bachelor’s degree or higher 1.6% 4.0% Educational Attainment American Fact finder: American Community Survey 2004-2007. 16 Navajo County Community Health Status Assessment Category 2 - Socioeconomic Characteristics Poverty Analysis The Office of Management and Budget’s (OMB) Statistical Policy Directive 14 of the Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty. If a family’s total income is less than the family’s threshold, then that family and every individual in it is considered in poverty. The official poverty thresholds do not vary geographically, but they are updated for inflation using Consumer Price Index (CPI-U). The official poverty definition uses money income before taxes and does not include capital gains or non cash benefits (such as public housing, Medicaid, and food stamps). The percentage of people (or families) who are below poverty equals the “poverty rate” (U.S. Census Bureau, Housing and Household Economic Statistics Division). “Ratio of income to poverty” classifies people and families as being in poverty if their income is less than their poverty threshold. If their income is less than half their poverty threshold, they are below 50% of poverty; less than the threshold itself, they are in poverty (below 100% of poverty); less than 1.25 times the threshold, below 125% of poverty, and so on. The greater the ratio of income to poverty, the more people fall under the category, because higher ratios include more people with higher incomes (U.S. Census Bureau, Housing and Household Economic Statistics Division). Table 2.4 shows a direct correlation between educational attainment and poverty status. Navajo County’s percentage below poverty level for those with less than a high school diploma is 38.7% this is a 15% increase over the state poverty level. In According to the U.S. Census Bureau, Housing 2008, 44.7% of people in Navajo County were living at and Household Economic Statistics Division the or below 200% of the poverty level (Northern Arizona Percentages of the poverty level are referred to as “Ratio of income to poverty”. Table 2.5 $40,386 $40,288 $45,292 $35,305 $15,866 $20,729 $25,519 <$50K 61% 61% 55% 61% 59% 54% 63% 91% 90% 85% >$50K 27% 28% 33% 30% 32% 36% 31% 9% 5% 13% >$100K 13% 11% 12% 10% 9% 11% 6% 0% 5% 2% Cibecue Taylor Winslow Community Asset Report, Navajo County, Conducted by Northern Arizona University, 2008 Whiteriver $44,999 Hon-Dah McNary HeberOvergaard $40,325 Show Low $35,351 Snowflake Median Income Income Level Holbrook Pine TopLakeside Median Household Income (2008) Table 2.6 Median Household Income: Navajo County, Arizona, and United States Median Average Income Navajo County Arizona United States $37, 660 $46,914 $50,303 Sources: U.S. Census Bureau, 2005-2007 American Community Survey (Navajo County Average); US Census Bureau, Current Population Survey, Annual Social and Economic Supplements, 2008 (Arizona and United States Navajo County Community Health Status Assessment 17 Category 2 - Socioeconomic Characteristics Council of Governments, Poverty Awareness and Special Populations Action Workshop, 2009). Homeless The 2008 annual report, “Governor’s InteragenNavajo County poverty level (24.4%) is 1.5 to 2 cy and Community Council on Homelessness” times the Arizona average (14.2%) thus poverty is conducted by Arizona Department of Economic an issue in Navajo County that affects health sta- Security (DES) uses the Arizona Temporary Astus. According to the US Census Bureau Histori- sistance for Needy Families (TANF) definition of cal Poverty Tables (www.census.gov/hhes/www/ homelessness: poverty/histpov, accessed 10/14/09) the US poverty rate in 2006 was 296,450 (number of all peoAccording to the McKinney-Vento Act, ple living below poverty in thousands) or 12.3%. 42 U.S. Code §11301, et seq. (1994), a person is considered homeless who lacks a fixed, regular, and adequate Drop Out Rates night-time residence and has a primary The dropout rate in Navajo County (6.3%, or night-time residency that is: a super759 students) is relatively high in comparison to vised publicly or privately operated shelthe state dropout rates (4.2%, or 21,750) (based ter designed to provide temporary living on 2006-2007 data, Arizona Department of Eduaccommodations, such as congregate cation). The U.S. dropout rate for 2006 was 9.3% shelters, transitional housing, or weland dropped to 8.7% in 2007. Dropout rates for fare hotels; an institution that provides males are relatively higher than the female rates a temporary residence for individuals in relation to the overall U.S. rates. In 2006 male intended to be institutionalized; or a dropout rates were 10.3% while female rates were public or private place not designed for, 8.3%. In 2007 dropout rates in the U.S. for males or ordinarily used as, a regular sleepdropped to 9.8% (still higher than the national aving accommodation for human beings, erage) while dropout rates for females were 7.7% such as street sidewalks, abandoned (Digest of Education Statistics, National Center buildings, parks, and subway tunnels. for Education Statistics, table 109, Percentage of high school dropouts among persons 16 through In 2009 there are a large number of school aged 24, 2006-2007, accessed 10/14/09, nces.ed.gov/ children and youth who are eligible for the McKinprograms/digest). ney-Vento support in Navajo County. McKinneyVento provides funding to state and local educational agencies (LEAs) in addition to the American Table 2.7 Homelessness in Arizona & Navajo County 2007 Group/population Arizona Navajo County 2008 Arizona Unaccompanied Youth 44 0 Not available Not available Children in Families 155 0 707 0 Individual Men 1,212 0 2,750 Not available Individual Women 292 2 504 Not available Serious Mental Illness & Sub- Not available stance Abuse Not available 408 2 Serious Mental Illness Not available 2,139 6 Not available Homelessness Rates, Tracy L. Wareing, Current Status of Homelessness in Arizona 2008 18 Navajo County Navajo County Community Health Status Assessment Category 2 - Socioeconomic Characteristics Recovery and Reinvestment Act of 2009 to address the educational and related needs of some of the most vulnerable members of our society – homeless children and youth – during a time of economic crisis in the United States (US Department of Education, American Recovery and Reinvestment Act of 2009). The number of school aged children in Navajo County (Kindergarten through 12th grade) who are eligible for McKinney-Vento funding is 295. McKinney-Vento federal regulations require that schools remove barriers to enrollment, attendance, and other barriers to ensure success in the public school system and promote stability for children and youth who are experiencing instability in their housing. Non-English Speaking Persons 60.1% of Navajo County residents speak English at home while 4.7% of Navajo County residents speak Spanish at home (68% of these people speak English very well). 0.7% of residents speak other Indo-European language at home (of these 90% also speak English very well). 0.2% of Navajo County residents speak Asian or Pacific Island language at home (of those 52% speak English very well). 34.3% of residents speak another language at home and 57% speak English very well (Citydata.com). Normally an indicator looking at non-English speaking populations is usually directed at immigrant populations. In the case of Navajo County Table 2.8 Unmarried Mothers Navajo County Number Ratio** Year Arizona Number Ratio** 2005 1,080 56.8 40,993 42.8 2006 1,092 58.2 44,746 43.9 2007 1,165 Not available Not available Not available 2008 1,145 58.9 44,728 45.1 Arizona Advanced Vital Statistics, 2005-2008 ** Indicates that the ratio is per 100 births. Table 2.9 Migrant and Seasonal Farm Worker Estimates Region MSFW farm worker estimates Migrant farm workers Non-farm workers Seasonal in migrant farm workers households Non-farm workers in seasonal households Navajo County 59 34 25 29 21 Arizona 67,704 39,913 27,791 26,940 20,728 Larson. Migrant and Seasonal Farm Worker Enumeration Profiles Study, Arizona, 2008 (data adapted The issue of homelessness in Navajo County may be dealt with effectively within each community more so than is usually the case, because the homeless rates are quite low (see table 2.7). However, there is a good deal of missing data and an assessment of homelessness in the county is recommended. it is important to consider the implications for a multilingual population that is not made up of immigrants (43% of the population in the county is Native American). There are often language barriers that can affect health care. In comparison with the state where 25.9% of those over age 5 speak a language other than English at home, 39.9% of Navajo County residents speak a language other than English at home. Navajo County Community Health Status Assessment 19 Category 2 - Socioeconomic Characteristics Single/Unmarried Parents The occurrence of births to unmarried mothers is considerably higher in Navajo County over a four year span. In Navajo County there is an average (between 2005 and 2008) of 14 more births (per 100) to unmarried mothers in comparison to Arizona. Table 2.8 below provides additional data comparing the number of unmarried mothers in Navajo County with the number of unmarried mothers in the state during the period between 2005 and 2008. partment of Labor, NAWS, 2005). Undocumented MSFW are not guaranteed the same rights as working American Citizens, such as minimum wage. According to the National Agricultural Workers Survey (2005), the educational level of MSFWs averages about six years and 56% have less than twelve years of education. Other common social, cultural, economic and political factors that affect the vulnerability of MSFW include; poverty, frequent mobility, low literacy, language and cultural barriers, and logistic barriers to social services Migrant Populations Migrant and Seasonal Farm workers (MSFWs) and health care that is cost-effective. For examare defined as, an individual whose principal em- ple, few MSFW have sick leave or insurance so ployment (51% of time) is in agriculture on a sea- they tend to prolong seeking health care services sonal basis, who has been so employed within the to avoid job loss. Thus often times they rely on last twenty-four months (Larson. Migrant and Sea- emergency department services for care. sonal Farm Worker Enumeration Profiles Study, Arizona, 20081). A migrant farm worker is slight- Additional Considerations for Migrant ly different, establishes for the purposes of such Populations Table 2.9 above identifies the number of MSFW employment a temporary abode (US Code, Public as they are defined in the traditional sense. Health Services Act, “Migrant Work”). Ranch hands are arguably a second population Although the projected numbers of MSFWs may in the county that are in fact migrant workers and be relatively low (approximately 110 total people in are not included in the migrant population counts. the county, including farm workers and MSFW) in Navajo County should consider examining the comparison to other regions in the state, there are prevalence and presence of smokejumpers and particular health related vulnerabilities for these ranch hands in their counts of migrant workers, as populations (Larson 2008). Working and hous- these groups have an important role in the county. ing conditions are often unsanitary making these workers more vulnerable to health conditions. Poverty is high for MSFWs as more than half of individual farm workers earn less than $7,500 a year while almost seventy five percent of farm worker families earn less than $10,000 a year (US Department of Labor, NAWS, 2005 ). Poverty rates in some cases may be related to citizenship; an estimated 52% of farm workers are not citizens or legal residents of the United States2 (US De1 Limitations in the scope of this study include the use of secondary data analysis through database information, and individuals. Data was collected from a five year period (1998-2002) from the AZ-MSFW EPS, as found in the National Agricultural Workers Survey (NAWS) Public Access Database. 2 However, other sources indicate that a majority of MSFW are indeed legal residents or U.S. citizens. 20 Table 2.10 Navajo County Community Health Status Assessment Category 2 - Socioeconomic Characteristics Uninsured Arizona has one of the highest rates of uninsured citizens in the nation (Arizona Hospital and Health Care Association, 2007). In 2007 Arizona ranked 6th in the nation for the number of uninsured children (Robert Wood Johnson, 2007). According to the Arizona Hospital and Healthcare Association, the average for children (under the age of19) in Arizona who were uninsured and were at or below 200% of the poverty level was 11.2% compared to a national rate of 6.8% for uninsured children (UA Census Bureau, Current Population Survey, 2007-2009 Annual Social and Economic Supplements). Uninsured children are less likely to receive medical care for ear infections, iron deficiency anemia, which if left untreated may affect language development and ultimate success in life (Emergency Department Visits 2006). In the 2000 census, 23% of Navajo County residents were uninsured (citydata.com, 2000). Navajo County Community Health Status Assessment 21 Category 2 - Socioeconomic Characteristics Number of Uninsured in Arizona (2006) Arizona United States Age Range Number Percent Age Range Number Percent Under 18 282,000 15.9% Under 18 8,872,090 11.3% 19-64 938,820 24.5% 19-64 36,098,690 19.7% Total 0-64 1,220,820 21.8% Total 0-64 44,970,780 17.2% Navajo County (2006) Data Sponsored By: U.S. Census Bureau and the Centers for Disease Control and Prevention; Data Source: SAHIE//State and County by Demographic and Income Characteristics/2006 (See table 2.11 below for more data based on income levels) Arizona (2006-2007) and United States (2007) Sources: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2007 and 2008 Current Population Survey (CPS: Annual Social and Economic Supplements). Table 2.11 Number of Uninsured in Navajo County (2006) Number Uninsured Number in a Demographic Group for all Income Levels* % Uninsured for Number in a Demographic Group for all Income Levels* Under 19 3,613 34,351 10.5% 18-64 9,956 63,836 15.6% Age Total Under 65 14,257 96,394 14.8% Navajo County Data Sponsored By: U.S. Census Bureau and the Centers for Disease Control and Prevention; Data Source: SAHIE//State and County by Demographic and Income Characteristics/2006.* The number in a demographic group is the number of people in the poverty universe in that age, sex, and race/Hispanic origin group. Table 2.12 Number of Uninsured Based on Sex Uninsured Based on Sex (0-64) Region Navajo County Arizona United States Male Female Number Percent Number Percent 5,408 17.5% 4,548 13.8% Total Number*: 30,861 Total Number*: 32,976 654,230 566,590 53.6% 46.4% Total Number: 1,220,820 Total Number: 1,220,820 24,247,040 20,723,740 53.9% 46.1% Total Number: 44,970,780 Total Number: 44,970,780 [Navajo County (2006) Data Sponsored By: U.S. Census Bureau and the Centers for Disease Control and Prevention; Data Source: SAHIE//State and County by Demographic and Income Characteristics/2006. Only ages 18-64 available.] * Total numbers specific to sex for Navajo County (# out of total males/ # out of total females) [Arizona (2006-2007) and United States (2007) Data Sources: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2007 and 2008 Current Population Survey (CPS: Annual Social and Economic Supplements) Ages 0-64.] 22 Navajo County Community Health Status Assessment Category 2 - Socioeconomic Characteristics Figure 2.13 Arizona Health Insurance Coverage Adapted from: US Department of Commerce and Statistics Administration, US Census Bureau, 2009 Figure 2.14 Arizona Health Insurance Coverage Adapted from: US Department of Commerce and Statistics Administration, US Census Bureau, 2009 Navajo County Community Health Status Assessment 23 Category 2 - Socioeconomic Characteristics Data on Insurance Portability Indian Health Services (IHS) Although Navajo County has a considerably low rate (13.9 to 17.7%) of uninsured residents (relative the state) approximately 43% of the county includes Native American reservation land. Figures 2.13 and 2.14 above illustrate the percent of uninsured in Navajo County. Indian Health Services (IHS), United States Public Health Services is the principle federal health care provider of services and advocacy to American Indians and Alaska Natives; it is not an entitlement program nor is it an insurance program or established benefits (www.rho. arizona.edu/resources/dataline/tribal%health). The coverage for Native American populations is relatively strong. However there are issues with health coverage portability for Native American populations off the reservation. Personal communication with Environmental Health Services, Winslow Indian Health Care Center, (October 1, 2009) revealed that medical services for Native American populations (in locations other than the facility they frequent in the region they live in) off the reservation is complicated dependant on the status of the individual, close economic ties, student status, and if the individual has third party payer. Thus, coverage for Native American populations who travel off of the reservation and receive care (outside the normal facility where they get care) may not be as secure as it is on the reservation. Additional sources explain that services that a facility is unable to provide may be provided through Contract Health Services (CHS). CHS services are those that IHS staff or a facility can not provide and payments can be authorized to another provider under a strict set of guidelines� (Indian Health Services Coverage, Rural Health Office, UA www.rho. arizona.edu). Many Indian people who move away from their home reservation are not eligible for CHS as they are moving away from the CHSA (Contract Health Service Area) where they have eligibility, urgent care needs may be met (defined by the local service unit). 24 Navajo County Community Health Status Assessment Category Three - Health Resource Availability Definition of Category This domain represents factors associated with health system capacity, which may include both the number of licensed and credentialed health personnel and the physical capacity of health facilities. In addition, the category of health resources includes measures of access, utilization, cost and quality of health care and prevention services. Service delivery patterns and roles of public and private sectors as payers and/or providers may also be relevant. AHCCCS enrolls most eligible persons with acute care health plans and long term care program contractors. The health plans assume responsibility for the provision of all acute care covered services to enrolled recipients (Chapter 1, Introduction to AHCCCS http://www.azahcccs.gov/commercial/ Downloads/FFSProviderManual/FFS_Chap01Introduction.pdf). The total Arizona Health Care Cost Containment System (AHCCCS) population in Navajo County is 41,197 (AHCCCS population highlights, 2009). Between 2008 and 2009 the AHCCCS population grew 12% in Navajo County (Arizona Cost Containment System http://www.ahcccs.state.az.us). Trends In general, the number of health professionals in Navajo County is lower than the average for the state of Arizona and the US; numbers are especially low for registered nurses and psychologists. Some healthcare areas like dental care are covered at similar or superior levels than the state of Arizona, other healthcare areas (e.g. specialist care, mental health, and counseling services) are perceived by the residents as very difficult to access in Navajo County. Per Capita Health Care Spending for Medicare Beneficiaries (Medicare adjusted average per capita cost) The AHCCCS population (including KidsCare) as of July 1, 2009 was 1,275,109 (AHCCCS population highlights, 2009). Primary Care Providers Per 100,000 people in Navajo County there are 49.8 primary care physicians (HRSA Area Resource Files, 2005). The number of registered nurses in Navajo County is 589, or 529 RNs per 100,000 people, in comparison with the Arizona ratio of 681 per 100,000 people and the national average 825 per 100,000 people (Arizona Hospital and Healthcare Association; Arizona Healthcare Workforce Data Center, 2007). Arizona Health Care Cost Containment System AHCCCS The Arizona Health Care Cost Containment System was implemented on October 1, 1982, as the nation’s first statewide indigent health care program designed to provide services to eligible persons primarily through a prepaid managed care system. Operating as a demonstration project under the federal Medicaid program, AHCCCS receives federal, state and county funds to operate, plus some monies from Arizona’s tobacco tax. Table 3.1 Kayenta Lakeside Pinetop- Polacca Second Mesa Show Low Snowflake Taylor Whiteriver Winslow Number of Licensed Medical Doctors Holbrook Provider Type Cibecue Number of Licensed Medical Doctors in Navajo County (2009) 1 5 2 19 5 4 1 47 5 1 16 19 Data from 2009 Arizona Medical Doctor database, Arizona Medical Board Directory Navajo County Community Health Status Assessment 25 Category 3 - Health Resource Availability The rate per total population (CHSI Report, Navajo County Community Assets) of Dentists per 100,000 of the population is 24 (approximately 4,000 patients per dentist) (HRSA Area Resource Files, 2005). Table 3.1 provides data on the number of licensed Medical Doctors (MD’s) in Navajo County. The numbers reflect those MDs who are licensed, not necessarily practicing in the area. gists) working through Indian Health Services (IHS) on the three reservations in Navajo County. Unfortunately, the data does not match the specific “trend” years (2004-2008) we are examining in this assessment. These data are useful for understanding where there are gaps in provider coverage for IHS facilities for Navajo Nation, the Hopi Tribe, and the White Mountain Apache Tribe (relative to Navajo County). We recommend that IHS Health Care Providers (On-Reservation) a more recent examination of the number of IHS Tables 3.2 through 3.6 offer data on several providers in the tribal regions of Navajo County be types of health care providers (Nurses, Dentists, conducted. Medical Doctors, Social Workers, and PsycholoTable 3.2 Number of Dentists: Indian Health Services (IHS) (1997-2001) Region Number in 1998 Navajo Service Area Number in 1999 Number in 2000 Number in 2001 Chinle Service Unit 6 5 6 5 Fort Defiance Service Unit 3 4 4 4 Kayenta Service Unit 4 5 3 2 Navajo Area IHS 3 1 1 1 Tuba City Service Unit 8 5 8 8 Winslow Service Unit 5 4 4 5 Hopi Service Unit 3 3 5 5 Whiteriver Service Area 3 3 4 4 Arizona Total IHS 56 53 62 60 Rural Health Office, University of Arizona Table 3.3 Oral Health Professionals, Licensed or Certified (2005) Snowflake Winslow Holbrook Show Low Taylor HeberOvergaard Navajo County Arizona Dentists 4 2 3 6 Not Available 1 30 2,870 Dental Hygienists 7 1 Not Available 7 1 2 26 2,299 Denturists Not Available Not Available Not Available Not Available Not Available Not Available Not Available 10 AHCCCS Dentists Not Available Not Available Not Available Not Available Not Available Not Available 26 840 Dentist Type Arizona Department of Health Services, Community Oral Health Profiles, 2005 26 Navajo County Community Health Status Assessment Category 3 - Health Resource Availability According to the White Mountain Head Start 2007 health screening among children from the White Mountain Apache Tribe, 79% of children screened (ages 3-5 years) had active dental disease. Only 82% of these children received treatment (The White Mountain Apache Tribe Regional Partnership Council Funding Plan, Overview of the three year strategic Plan, July 1, 2009 through June 30, 2012). We recommend future research on access to dental care, barriers to care, and causes of poor dental health including samples from across Navajo County including Native American populations and non-Native populations, among others. According to the White Mountain Head Start 2007 health screening among children from the White Mountain Apache Tribe, 79% of children screened (ages 3-5 years) had active dental disease. Only 82% of these children received treatment (The White Mountain Apache Tribe Regional Partnership Council Funding Plan, Overview of the three year strategic Plan, July 1, 2009 through June 30, 2012). We recommend future research on access to dental care, barriers to care, and causes of poor dental health including samples from across Navajo County including Native American populations and non-Native populations, among others. Table 3.4 Access To Care/Dental Utilization- Visits to a Dentist/Clinic (2005) Elementary School Grades K-3 Navajo County Arizona within past year 60% 54% one or more years 29% 27% never 9% 16% within past year Not Available 79.5% five or more years Not Available 1.7% never Not Available 3.1% within past year Not Available 76.2% five or more years Not Available 3.4% never Not Available 2.6% within past year 63.8% 67.3% five or more years 11.2% 8.8% never 1.2% 0.7% within past year 70.4% 71.2% five or more years 11.5% 13.4% never 0.0% 0.5% Total Population 97,470 5,130,632 Middle School Grades 6-8 High School Grades 9-12 Adults 18-64 Older Adults 65+ years Arizona Department of Health Services, Community Oral Health Profiles, 2005 Navajo County Community Health Status Assessment 27 Category 3 - Health Resource Availability Table 3.5 Oral Health Indicators; Dental Health Status (2005) Infants 6 months to 24 months Navajo County Arizona with decay experience 6% 5% with untreated tooth decay 6% 5% with urgent treatment needs 2% 3% with decay experience 40% 37% with untreated tooth decay 33% 33% with urgent treatment needs 5% 4% with decay experience 71% 62% with untreated tooth decay 51% 40% with urgent treatment needs 19% 9% with dental sealants (8 years) 33% 28% with decay experience Not Available 65% with untreated tooth decay Not Available 32% with urgent treatment needs Not Available 5% with dental sealants Not Available 16% 52.5% 63.5% with untreated tooth decay Not Available 41% with moderate to severe loose teeth Not Available 15% with no molars for chewing Not Available 11% with dental pain/infection Not Available 14% with complete tooth loss (65-74 years) 9% 13.7% Total Population 97,470 5,130,632 Toddlers 2-4 years Children 6-8 years Adolescents 11-13 years Adults 35-44 years never lost a tooth due to disease Older Adults 60+ years Arizona Department of Health Services, Community Oral Health Profiles, 2005 28 Navajo County Community Health Status Assessment Category 3 - Health Resource Availability Table 3.6 Number of Medical Doctors (MD) & Doctor of Osteopathic Medicine (DO): Indian Health Services (IHS) (1997-2001) Region Number in 1998 Navajo Service Area Number in 1999 Number in 2000 Number in 2001 Chinle Service Unit 53 37 34 38 Fort Defiance Service Unit 18 17 21 21 Kayenta Service Unit 17 17 17 16 Navajo Area IHS 4 4 4 4 Tuba City Service Unit 46 49 51 48 Winslow Service Unit 10 12 11 11 Hopi Service Unit 9 11 12 11 Whiteriver Service Area 18 18 20 19 Arizona Total IHS 302 314 318 336 Number in 2000 Number in 2001 Rural Health Office, University of Arizona Table 3.7 Social Workers: Indian Health Services (IHS) (1997-2001) Region Navajo Service Area Number in 1998 Number in 1999 Chinle Service Unit 2 2 2 2 Fort Defiance Service Unit 2 3 3 4 Kayenta Service Unit 2 2 2 2 Navajo Area IHS 0 0 0 0 Tuba City Service Unit 2 2 2 3 Winslow Service Unit 1 1 1 1 Hopi Service Unit 2 1 2 2 Whiteriver Service Area 4 4 4 4 Arizona Total IHS 24 30 34 36 Rural Health Office, University of Arizona Navajo County Community Health Status Assessment 29 Category 3 - Health Resource Availability Table 3.8 Psychologists: Indian Health Services (IHS) (1997-2001) Region Navajo Service Area Number in 1998 Number in 1999 Number in 2000 Number in 2001 Chinle Service Unit 1 2 2 2 Fort Defiance Service Unit 0 0 0 1 Kayenta Service Unit 0 0 0 0 Navajo Area IHS 0 0 0 0 Tuba City Service Unit 0 0 0 0 Winslow Service Unit 0 0 0 0 Hopi Service Unit 0 0 0 0 Whiteriver Service Area 1 1 0 0 Arizona Total IHS 3 4 5 9 Rural Health Office, University of Arizona Table 3.9 Hospital Beds in Navajo County Hospital Number of Number of specialty (acute care) beds beds Occupancy Rate per total population Number of available inpatient beds Winslow Memorial Hospital 25 0 13 (average per day of 32,000) 25* 81 12 (ICU) 14 (OB/GYN) 42 (Med/Surgery) 20 (Postpartum) 7 (LDR) Not available Not available 42 14 (ER) 5 (OB/GYN) 24 (Med Surg) Not available 25 Hopi Health Care Center 15 0 4 4 Winslow Indian Health Care Center 8 1 (OB/GYN) 7 (Urgent Care) Not available 0 (Outpatient only) Summit Health Care Regional Medical Center Whiteriver IHS Hospital (Hospital website search/phone calls to the facility were made September-October 2009) (* All acute care beds can become inpatient beds in the swing bed Medicaid program when needed) (N/A describes information that was Not Available at the time of the Community Health Status Assessment) 30 Navajo County Community Health Status Assessment Category 3 - Health Resource Availability Table 3.10 Community Health Centers in Navajo County Clinic Population Served North Country Healthcare All populations Show Low Veterans Affairs Health Care Clinic Eligible veteran populations Show Low Medical Clinic All populations Summit Healthcare All populations Women’s Choice Pregnancy Clinic Women StatClinix, PLC All populations North Country Healthcare All populations Petrified Forest Medical Center, Inc. All populations Winslow North Country Healthcare All populations Snowflake Snowflake Medical Center All populations Kayenta Kayenta Health Center Native populations only Chilchinbeto Canyonlands Community Health Care Chilchinbeto Clinic All populations Heber-Overgaard Summit Healthcare Community Clinic All populations Piñon Piñon Health Center All populations Location Show Low Holbrook Source: AZDHS The number of psychologists on the reservations is alarmingly low. An assessment to identify the current numbers of providers on the reservation and the need for psychologists may be a worthwhile endeavor. Navajo County Community Health Status Assessment 31 Category 3 - Health Resource Availability Table 3.11 ● ● ● Kayenta Public Health Service (PHS) Indian Health Services ● Tohenasshai Shelter/ Kayenta DV Task Force ● Kayenta Kayenta Outpatient Treatment Center White Mountain Safe House ● Polacca Hopi Behavioral Health & Social Services Program ● Hopi Health Center: PHS Indian Health Services ● Hopi Guidance Center: Keams Canyon ● White Mountain Counseling ● Community Counseling Centers (CCC): Show Low Outpatient Clinic ● Show Low ● Apache Tribal Behavioral Health Services (ABHS) ● ● Winslow ● --- National Sexual Assault Hotline: RAINN --- National 24 Hour Domestic Violence Hotline ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● Winslow Guidance Associates Northern Arizona Regional Behavioral Health Authority (NARBHA) Navajo County** ● ● Community Counseling Centers (CCC): Winslow Outpatient Clinic Flagstaff ● ● Rainbow Center Winslow Indian Health Care Center ● ● Pineview Behavioral Health Center Big Brothers and Big Sisters of Northeastern Arizona Whiteriver ● ● ● Pinetop Second Mesa ● Community Mental Health Agencies Addiction Recovery: Dual Diagnosis ● Sexual Assault Hotlines Mental Health Evaluation Addiction Recovery: Methadone Maintenance Community Counseling Centers (CCC): Holbrook Outpatient Clinic Mental Health Hotlines Adolescent/Youth Counseling Spouse/Domestic Partner Abuse Counseling Psychiatric Medication Services Holbrook Psychiatric Medication Services Services Addiction Recovery: Substance Abuse Treatment Programs Facility Name Addiction Recovery: Substance Abuse Counseling Location Individual Counseling Mental Health Facilities in Navajo County ● ● ● ● ● ● ● **NARBHA is located in Flagstaff, Arizona (Coconino County) but also serves Navajo County(Northern Arizona Regional Behavioral Health Authority, network of care, accessed 9/28/09 www.narbha.org) 32 Navajo County Community Health Status Assessment Category 3 - Health Resource Availability Chichenbeto Piñon 39 miles Heber- Figure 3.12 Community Health Centers and Hospitals in Navajo County Mental Health According to Healthy Arizona 2010, approximately 20% of the US population is affected by mental illness during a given year. Of all mental illnesses, depression is the most common. In Arizona, the 1997 suicide mortality rate among adolescents 15-19 years old was 23.7 per 100,000 (the second highest rate in the US). Another area of concern for Arizona is the elderly (ages 75-79) who ranked third in the nation in 1997 for suicide (Arizona Division of Public Health Services, Healthy Arizona 2010 Strategic Plan) Accessed on 9/28/09, http://www.azdhs.gov/phs/healthyaz2010/strtgc.htm). Navajo County Community Health Status Assessment 33 Category 3 - Health Resource Availability Strategies for Healthy Arizona 2010 to decrease the occurrence of depression among Arizona residents include improvement of diagnosis and treatment, better integration of behavioral and public health and boarding awareness of depressive illness among primary care providers (Arizona Division of Public Health Services, Healthy Arizona 2010 Strategic Plan) Accessed on 9/28/09, http:// www.azdhs.gov/phs/healthyaz2010/strtgc.htm). Health Care Access The Community Themes and Strengths Assessment (CTSA) conducted by the MAPP subcommittee asked the question, “How easy or difficult is it for you to receive these types of health care?” The top five responses indicating that it is very difficult to receive care (in Navajo County). Survey findings showed that 30.5% of respondents stated that specialist care was very difficult to receive, 21.8% of respondents said mental health care was very difficult to access, 21.3% stated there are not enough medical providers, and 20.3% said that counseling services were very difficult to receive in the County. On the other hand, 19.3% of survey respondents said eye care was very easy to access, 18.4% of respondents said that dental care was very easy to access, 18.4% said that emergency care was very easy to access in Navajo County, general health care was also reported to be very easy to access, while 10.4% of respondents stated that pediatric care is very easy to access (Community Themes and Assets, Navajo County Public Health District, Survey results, PowerPoint summary of findings. 2009). Local Health Department Full-time Equivalent Employees (FTEs) The Navajo County Health Department has 42 full time employees (August 2009, personal communication). Total Operating Budget of Local Health Department Navajo County Health Services District total fiscal year 2010 operating budget $6,838,248.58 (August 2009, personal communication). Table 3.13 Healthcare Access, Navajo County Year Do not have healthcare coverage 2004 11,444 17.8% 15,929 24.7% 10,630 16.5% 2005 15,709 25.1% 17,589 28.1% 8,257 13.2% Frequency Frequency Percent Could not see a doctor because of cost Frequency Percent 2006 15,306 20.9% Not available Not available 11,698 16% 2007 19,468 25.9% Not available Not available 12,714 16.9% BRFSS data, 2004-2007 34 Percent Do not have a personal healthcare provider Navajo County Community Health Status Assessment Category 3 - Health Resource Availability Table 3.14 Care for the Elderly in Navajo County Navajo County Airports Airport Paved/Unpaved Runway Length Type of Runway Holbrook 6698 x 75 3200 x 120 Paved Gravel/Dirt Show Low 3937 x 60 7200 x 100 Paved Paved Taylor 7000 x 75 Paved Whiteriver 6350 x 75 Paved Winslow 7499 x 150 7100 x 150 Paved Definitions (Source: Arizona Administrative Code, Title 9, Chapter 10, Article 1) • • Low Use Airports Heber-Overgaard 3420 x 50 Paved Kayenta 7140 x 75 Rough/rutted/ loose rock Polacca/Keams Canyon 4200 x 50 Paved No airports in Navajo County have towers. If an emergency occurs, the FAA will provide a provisional tower, just as they did in Show Low for the Rodeo fire. Helicopters can land anywhere. There are no active military airports in Navajo County (Personal Communication, MAPP Subcommittee Table 3.15 • Assisted living center or “center” means an assisted living facility that provides resident rooms or residential units to eleven or more residents. Assisted living facility means a residential care institution, including adult foster care, that provides or contracts to provide supervisory care services, personal care services or directed care services on a continuing basis. Assisted living home or “home” means an assisted living facility that provides resident rooms to ten or fewer residents. Nursing Care Facility: ‘Nursing care institution’ means a health care institution providing inpatient beds or resident beds and nursing services to persons who need nursing services on a continuing basis but who do not require hospital care or direct daily care from a physician. Senior Care Facility Availability in Navajo County Facility Total number of beds Number of available beds Aspen Pond Assisted Living 114 (apartments)*† 63 (apartments)* 30 0 Webb’s Adult Care Home 20 1 Tall Pines Care and Rehab, Inc. 100 40 Winslow Campus of Care 120 24 Home Health Agencies Summit Healthcare Home Health 179 (patients) Not applicable Hospice Hospice Compassus 7 Not available Category Assisted Living Facilities Carriage House on West Garden Lane Nursing Homes * 60 apartments awaiting Arizona State License as of 09/2009. † One to two persons per apartment. (Phone calls to facilities made September 2009). Hospice data from www.amenityhospice.com, accessed 12/16/09 Navajo County Community Health Status Assessment 35 Category 3 - Health Resource Availability Home Health Agency: ‘Home health agency’ means an agency or organization, or a subdivision of such an agency or organization, which meets all of the following requirements: a. b. c. Is primarily engaged in providing skilled nursing services and other therapeutic services. Has policies, established by a group of professional personnel, associated with the agency or organization, including one or more physicians and one or more registered professional nurses, to govern the services referred to in subdivision (a), which it provides, and provides for supervision of such services by a physician or registered professional nurse. Maintains clinical records on all patients. It is recommended to conduct an assessment on the number senior care facilities in Navajo County for Navajo Nation, Hopi Tribe, and the White Mountain Apache Tribe. There are a number of Community Health Representatives (CHR) who work on the reservations. A survey of how many work directly with elderly populations is also recommended. 36 Navajo County Community Health Status Assessment Category Four - Quality of Life Satisfaction with Life Definition of Category: Quality of Life (QOL) is a construct that “connotes an overall sense of well-being when applied to an individual” and a “supportive environment when applied to a community” (Moriarty, 1996). While some dimensions of QOL can be quantified using indicators research has shown to be related to determinants of health and community-well being, other valid dimensions of QOL include perceptions of community residents about aspects of their neighborhoods and communities that either enhance or diminish their quality of life. Proportion of Adults Satisfied with the Health Care System in the Community The proportion of adults satisfied with the health care system data was not recovered. However, the 2008 CTSA collected similar data. The percentage of adults who reported fair or poor health in Navajo County was 16.5%. This is slightly lower than the median for all U.S. counties (17.1%). Proportion of Parents Involved in Parent Teacher Type Organizations For a detailed table with parent teacher orgaTrends During 2008, Navajo County data about satis- nization involvement by school in Navajo County, faction with the healthcare system in the commu- please see Appendix A. nity showed satisfaction levels. Eligibility for DES There are a total of 79 schools in Navajo Coun(Department of Economic Security) Childcare programs has dropped in Navajo County, creating ty (elementary, middle and high schools). Aplonger waiting lists for child care in addition to oth- proximately 45% of these schools have an active er child care issues. The alarmingly low number Parent Teacher Association (PTA) the 2009-2010 of psychologists presented in the previous indica- school years. tor, there is no data on outreach programs to the physically, mentally, or psychologically challenged in Navajo County. Table 4.0 Satisfaction With Life: Navajo County, Arizona (2005-2007) Frequency Percent 41.1 1,355 2.3 125 0.2 227 0.4 59,522 100.0 33,319 47.5 31,219 44.5 3,241 4.6 1,385 2.0 915 1.3 70,080 100.0 34,296 48.2 34,776 48.9 976 1.4 1,082 1.5 Not Available Not Available 71,130 100.0 Percent Frequency 24,441 Percent 56.1 Percent Frequency Total Percent DK/NS 33,374 BRFSS Reports, 2005-2007 Frequency Very Dissatisfied Frequency 2005 2006 2007 Dissatisfied Percent Years Satisfied Frequency Very Satisfied Navajo County Community Health Status Assessment 37 Category 4 - Quality of Life Figure 4.1 Location of Head Start Centers in Navajo County* * Does not include Navajo Nation, Hopi Reservation, and White Mountain Apache Head Start Centers 38 Navajo County Community Health Status Assessment Category 4 - Quality of Life Involvement in parent teacher organizations ranges from 0.60% to 11.32% (percent of parents involved in parent teacher organizations1). The Snowflake Intermediate School located in Snowflake, Arizona is an outlier, with 35.63% involvement in the parent volunteers (Primary data collection, phone calls to all schools in Navajo County, between October and November 2009). DES Child Care for Low Income Families The percentage of DES (Department of Economic Security) eligible applicants has dropped. Once a parent is off of DES, it is hard to get back on DES. There is a scholarship for kids offered previously through First Things First that was dropped through DES. If the family is new to the scholarship, it takes 6 months to be approved. Table 4.2 Number of Openings in Head Start Facilities for Low Income Families (October – December 2009) Facility Location Number of Openings Head Start Winslow 141 Head Start Show Low 96 Head Start Snowflake 38 Head Start Pinetop-Lakeside 38 AI/AN Head Start, Hopi Tribe Polacca 0 (Waiting List) AI/AN Head Start, Hopi Tribe Hotevilla 0 (Waiting List) AI/AN Head Start, Hopi Tribe Second Mesa 0 (Waiting List) AI/AN Head Start, Hopi Tribe Kykotsmovi 0 (Waiting List) AI/AN Head Start, White Mountain Apache Cibecue 0 (Waiting List) AI/AN Head Start, White Mountain Apache Whiteriver 0 (Waiting List) Navajo Head Start Center Kayenta Unknown Navajo Head Start Center Winslow Unknown The numbers above were collected via phone calls to the facilities in August 2009 and December 2009 (personal communication). * There are 11 separate in-home facilities that take low income clients (http://www. nacog.org/hs/components.htm). The list of Head Start locations for native American/Alaska Natives was retrieved from http://eclkc.ohs.acf.hhs.gov/hslc/HeadStartOffices Child Care for Low Income Families Head Start is a federal program for preschool children from low-income families. Children who participate in Head Start are eligible to receive a number of additional resources including free dental and medical care and healthy meals. Table 4.2 provides an overview of the number of openings for low income families (accessed 10/14/09, www. nacog.org). 1 Percent of parent involvement derived by dividing the number of involved parents by the total number of students enrolled at each school. This included primary data collection through the Health Research Alliance Arizona Northern Arizona University (NAU) office (Personal communication via phone calls, and written requests when asked, data collected between October-November 2009). Problems developed when the scholarship runs out then the parents are in a bind. Many parents are not working because of the current state of the economy. Several DES certified childcare providers raised the issue that community health is suffering because parents are not qualified for DES services. There are very few jobs that pay enough to afford day care. To be eligible for DES services (such as child care reimbursement) parents must either be working or going to school2. Please see Table 4.3 for a detailed list of DES certified child care providers in the county (names and contact information acquired from local DES childcare of2 Eligibility for DES child care reimbursement requires that the parent is working at least 20 hours every week (this includes full time students). Navajo County Community Health Status Assessment 39 Category 4 - Quality of Life fices in Navajo County, and accompanying phone The Hopi Childcare Program provides high calls to identify capacity, number of openings, and quality childcare to Hopi families whose work or wait lists, calls made in October 2009). educational pursuits require them to be away from the home. Traditionally childcare has been integral Childcare on the Reservations (In Navajo to Hopi community life through parents, extended County) family and other community members. In recent On the Navajo Nation, childcare for low-in- years there has been an increase in single parent come families is provided by the Navajo Head families, families with two working parents, makStart program, which is one of the largest Head ing the demand for childcare based within commuStart organizations in the United States. NHS is nity (as previously mentioned) too great. The Hopi funded to provide services to 4,013 children aged Tribe has responded by creating the Hopi Child 3 to 5 years enrolled at 206 Head Start centers Care Program (HCCP) in 1993. Primary services and Home Base programs. 60 children aged 0 to are focused on working families, parents attend3 and expectant mothers are enrolled in 5 Early ing school and participants in the Temporary AsHead Start Centers (accessed 02/8/2010, www. sistance to Needy Families (TANF) program. Durnnheadstart.org). ing the first year of the program in-home care was offered for 114 children (birth to age 5). In 2001 In addition to NHS, There is childcare provided a facility was secured near the tribal government through “relative providers” on Navajo Nation but offices to build a child care facility. The program these are not certified childcare providers (Per- currently has 56 certified in-home care providers sonal Communication, Stacey Apodaca, DES, Of- and requires “training or certification in first aid, fice of Childcare Administration, Winslow, Arizona, CPR, nutrition, food handling, child development, 12/16/09). According to “Indian Country Today” in health and safety, communicable diseases, and March 2009 the Navajo Nation received $2.6 mil- recognizing negligence and abuse”. The program lion from the Arizona program, First Things First3, also encourages and supports employees profesfor the development of culturally relative early sional development in obtaining certification and childcare and education for children aged 0 to 5 enrolling in 2 and 4 year degree programs (The years. The funds will be used to “increase cul- Harvard Project on American Indian Economic turally-responsive quality early care and education Development, JFK School of Government, Harin childcare centers, help home-based childcare vard University, Honoring Nations: 2006 Honoree, providers across Navajo nation become licensed, The Hopi Child Program, The Hopi Tribe, www. increase the number of well-trained childcare edu- hks.harvard.edu, accessed 12/17/09). cation professionals with educational assistance and scholarships to pursue degrees”. The proThe White Mountain Apache Tribe adminisgram will provide services to about 12,000 Navajo ters Head Start (100 children receive full-day, children. Each chapter house is in need of child year-round services through the White Mouncare centers. In the Navajo program children will tain Apache head Start/Child Care Partnership) learn to speak in the Navajo language (March and Child Care and Development Funds (CCDF) 19, 2009, accessed 12/16/09 www.indiancoun- grants (serves about 400 children a year through trytoday.com/national/southwest/41310777.html). a center-based care and a certificate program that DES currently does not provide formal childcare allows families to choose from a range of care assistance on the Navajo Reservation as DES has options in the community). In 1994 a community no jurisdiction. needs assessment showed that parents would benefit from full day care for their children. As a result the Head Start program and the Childcare program combined forces to provide tribal mem3 First Things First is a non-profit organization that bers with child care (U.S. Department of Health oversees the use of state taxes from tobacco sales. 40 Navajo County Community Health Status Assessment Category 4 - Quality of Life Table 4.3 Arizona Department of Economic Security (DES) Certified Child Care Facilities & Preschools (October 2009) Location Total Capacity Number of Openings Wait List Tracy Ison Family Child Care Show Low 10 2 0 Kidz Town Day Care Show Low 75 10 11 Ehmke’s Child Haven Show Low 100 50 0 Little Bears Den Show Low 8 0 0 Dragonfly Preschool Show Low 46 24 0 Miss Dinah’s Show Low 49 15 0 Tiny Treasures Group Show Low 10 0 0 Jamie Kulish Show Low 6 4 0 Judy Watson Show Low 6 0 0 Patricia Guevara Show Low 6 1 0 Discovery Zone Learning Lakeside Not available Not available Not available One Step Ahead Preschool Lakeside 93 45 0 Tender Times Child Care Lakeside 25 15 0 Chagahache Day Care Whiteriver 100 0 100 Alchesay Beginnings Whiteriver 102 0 40 Christine Bonn Overgaard 6 2 0 Kathryn Forge Overgarrd 6 4 0 Andrea Rogers Snowflake 4 1 0 Carousel Day Care Snowflake 57 35 0 Holbrook Educational Day Care Holbrook 46 (15 on DES) 10 10 (on DES) Tommy Young Holbrook 6 0 2 Aruna Kothari Winslow 6 4 0 Josephine Chavez Winslow No info available -- -- Katherine Echoles Winslow 4 per shift (2 shifts) 0 0 Angela Thomas Winslow 6 0 0 Lena Nelson Winslow 4 2 0 Pooh’s Playhouse Winslow 49: 32 kids on DES & first step 17 0 Mary’s Little Lambs Winslow 26 13 0 Mini’s Group Home Winslow 10 4 0 Facility Show Low Lakeside Whiteriver Overgaard Snowflake Holbrook Winslow 4 0 Melissa Salazur Winslow 14 (10 kids per shift.(3 shifts) Facilities identified through the DES childcare website https://egov.azdes.gov. Current DES childcare provider lists were faxed from the Office of Childcare Administration (phone calls made to each facility to obtain data made between October 1 and October 25, 2009) Navajo County Community Health Status Assessment 41 Category 4 - Quality of Life and Human Services, Administration for Children assessment of resources and outreach to the and Families, Tribal Child Care Technical Assis- physically and mentally challenged. tance Center (TriTAC) Effective Program Strategies, White Mountain Apache, http://nccic.acf.hhs. gov accessed 12/17/09). Households without Piped Water or Electricity Number of Neighborhood Crime Watch Areas The Navajo County Sheriff’s Office has several categories of volunteer support. Auxiliary has five units throughout the county. The Sheriff’s Auxiliary Volunteers (SAV) patrol and assist with the neighborhood watch program. The SAV program started in 1990 and now includes over 30 members. The members participate in a six week training program which includes self-defense training, defensive driving, report writing, officer safety, and gang identification (September 23,2005, AzJournal.com, www.policevolunteers.org/newsletter). Civic Organizations/Association Members per 1,000 of the Population Data for this indicator was not available. Navajo County may want to consider conducting a needs assessment to collect data on what civic organizations exist in the county. Number of Registered Voters See Table 4.4 for the number of registered voters in Navajo County from 2004 through 2009. Outreach to the physically and mentally or psychologically challenged Unfortunately there is no compiled data on outreach to physically or psychology challenged peoples in Navajo County. Table 3.11 identifies facilities and organizations that provide behavioral health care to Navajo County residents. The data in Table 3.11 may prove useful in a future needs Navajo Nation No data is available for homes without piped water or electricity on non-reservation lands in Navajo County. According to the United States Environmental Protection Agency (USEPA) Region 9, approximately 40% of residents on the Navajo Nation lack piped water. Of the fifty chapters in Navajo Nation, 17 are fully or partially located within Navajo County. Table 4.5 summarizes the data for households without piped water for those chapters located within Navajo County. Hopi Reservation On the Hopi Reservation, data is available for each village regarding utility services to individual households. These data stem from village surveys conducted between 2006 and 2009. The data provide the most recent estimates of homes without utilities (Table 4.6). According to Peter Mitchell, Environmental Engineer for Indian Health Services, homes without piped water or sewer likely do not have electricity, but may operate off of generators (Peter Mitchell, personal communication, 2009). White Mountain Apache On the White Mountain Apache Reservation, nearly all homes have piped water, sewer, and electrical utilities (Rick Rivers, personal communication, 2009). Table 4.4 Percent of Registered Voters, Navajo County, AZ (2004-2009) Year 2004 2005 2006 2007 2008 2009 Number of Registered Voters 47,858 55,304 52,974 57,992 52,729 59,951 (Personal communication, Navajo County Recorder, September 23,2009) 42 Navajo County Community Health Status Assessment Category 4 - Quality of Life TB No data were available for tuberculosis rates in Navajo County. Navajo County Medical Reserve Corps The Navajo County Medical Reserve Corps provides the structure needed to set up medical and non medical personnel in response to an emergency (www.navajocountymrc.com). For example, during the H1N1 outbreak, between October 27, 2009 and November 4, 2009 Navajo County was able to offer some support (Medical Reserve) to other areas in need. Volunteer health professionals allow the Arizona Department of Health Services (ADHS), local health departments and emergency management to swiftly identify and utilize health care volunteers. In order to have an effective emergency response plan and system in Arizona, the region must be able to properly disperse volunteer health professional who have proper skills to care for people in need of services (www.azdhs.gov/volunteer). Navajo County currently (fall 2009) has a number of health volunteers available including five clinical social workers, two marriage and family counselors, two mental health counselors, one pharmacist, twenty-four registered nurses, and one veterinarian. The current numbers of health volunteers have the ability to meet the local public health need. To find the closest provider call the Public Health Help Line at 532-6057 or visit the Navajo County Medical Reserve Corps web site www.navajocountymrc.com Health Alerts tab (2009 H1N1 Health Volunteer Activity Report). Navajo County Community Health Status Assessment 43 Category 4 - Quality of Life Table 4.5. Navajo Reservation Chapters without Piped Water* CHAPTER No Water IHS Total Census Total Percent Forest Lake 165 194 293 85% Hardrock 73 305 592 24% Dilkon 166 403 806 41% Pinon 139 890 1097 16% Teesto 145 247 429 59% Whippoorwill 4 250 492 2% Whitecone 132 332 589 40% Shonto 155 236 1084 66% Black Mesa 63 185 240 34% Chilchinbeto 120 360 520 33% Dennehotso 231 496 670 47% Inscription House 47 317 447 15% Jeddito 277 339 604 82% Kayenta 221 1168 2108 19% Low Mountain 4 119 380 3% Oljiato 220 482 953 46% Steamboat 59 123 790 48% Tachee/Blue Gap 0 352 722 0% * Some chapters are only partially located in Navajo County. Source: Navajo Nation Department of Water Resources (2008) Table 4.6 Hopi Village Households without Piped Water or Sewer Village Total Homes No Piped water No Sewer No Water or Sewer Data last updated Bacavi 158 0 8 48 2007 Hotelvilla 205 0 0 0 --- Kykotsmovi 287 0 6 7 2007 Mishongovi 124 4 10 64 2009 Lower Moenkopi 46 approx. 26 --- --- 2009 Upper Moenkopi 343 0 4 6 2009 Old Oraibi 55 50-52 50-52 50-52 --- Sipaulovi 87 18 2009 Spider Mound 28 0 0 0 --- Polacca 508 --- --- 25 2006 Shungopavi 287 --- --- 62 2006 Sources: Indian Health Services WSTARS (2009) and Upper Village of Moenkopi (2009). 44 Navajo County Community Health Status Assessment Category Five - Behavioral Risk Factors Definition of Category Risk factors in this category include behaviors which are believed to cause, or to be contributing factors to, injuries, disease, and death during youth and adolescence and significant morbidity and mortality in later life. lower than the Arizona levels (9.2% and 12.7% versus 14.4% for Arizona) but much higher than national levels (7.2%). Among adults, the percentage of people who have at least one drink every day of the week has increased significantly (2.6% in 2006 versus 6.7% in 2007). Other behavioral risk factors include smoking (13.3% in Navajo County versus 1.9% in Arizona) and being overTrends High school students in Navajo County have weight. In Navajo County, 53.3% of the population higher levels of drug use and abuse when com- exercises regularly, compared to 35.9% in Arizona pared to Arizona state levels, especially regarding and 37.3% in the US. The two most risky behavthe use of marijuana and methamphetamines by iors identified include not wearing a seatbelt when 10th and 12th graders. Cocaine use levels are driving and having unprotected sex. Table 5.0 Alcohol, Tobacco and other Drug Use (ATOD) Use and Abuse among Youth (2008) Lifetime Use** Substance Tobacco (Cigarettes) Arizona Navajo County Apache County Grade 8 Grade 10 Grade 12 Grade 8 Grade 10 Grade 12 Grade 8 Grade 10 Grade 12 25.9% 39.9% 50.8% 33.5% 49.1% 57.1% 46% Not available Not available 17.1% 25.7% 28.7% 18.4% 26.3% 32.1% 22.3% Not available Not available 16.2% 32.5% 43.1% 27% 42.5% 55.7% 44% Not available Not available 14.3% 12.6% 9.2% 14% 14% 8% 15.8% Not available Not available 12.2% 20.5% 24.6% 13.4% 22.3% 29.4% 19.2% Not available Not available 1.2% 2.4% 4.0% 1.3% 6.3% 7.7% 2.3% Not available Not available 2.7% 6.8% 11.2% 2.5% 9.2% 12.7% 4.9% Not available Not available 47.8% 66.2% 74.8% 45.9% 61.2% 72.9% 40.7% Not available Not available Illegal Drugs Prescription Drugs Marijuana Inhalants Prescription Pain Relievers Methamphetamines Cocaine Alcohol* *Alcohol has been categorized as an illegal substance because all survey participants are under the legal drinking age. **Lifetime use is a measure of the percentage of students who tried the particular substance at least once in their lifetime and is used to show the percentage of students who have has an experience with a particular substance. Arizona Youth Survey 2008 Navajo County Community Health Status Assessment 45 Category 5 - Behavioral Risk Factors Table 5.1 Alcohol, Tobacco and other Drug Use (ATOD) Use and Abuse among Youth (2008) 30-Day Use** Substance Tobacco (Cigarettes) Arizona Grade 8 Grade 10 Navajo County Apache County Grade 12 Grade 8 Grade 10 Grade 12 Grade 8 Grade 10 Grade 12 8.7% 16.6% 23.9% 13.3% 18.9% 23.9% 12.7% Not available Not available Prescription Drugs 8.6% 12.2% 13.1% 9.6% 12.5% 16.1% 14.0% Not available Not available Marijuana 7.6% 15.1% 18.7% 13.5% 20.5% 23.0% 22.0% Not available Not available Inhalants 5.4% 3.0% 1.6% 4.6% 2.7% 1.5% 4.1% Not available Not available Prescription Pain Relievers 6.0% 9.4% 10.5% 6.5% 10.7% 13.5% 12.5% Not available Not available Methamphetamines 0.4% 0.6% 0.8% 0.4% 1.2% 0.8% 1.1% Not available Not available Cocaine 1.0% 2.2% 3.2% 0.8% 3.4% 4% 1.9% Not available Not available Alcohol* 23.2% 37.7% 46.8% 24.0% 32.3% 39.3% 16.0% Not available Not available Illegal Drugs *Alcohol has been categorized as an illegal substance because all survey participants are under the legal drinking age. **30-day use is a measure of the percentage of students who used the substance at least once in the 30 days prior to taking the survey. It provides a more sensitive indicator of the level of current use of the substance. Arizona Youth Survey 2008 General Risk: Binge Drinking Among Youth in Arizona For each of the following, look at risk by percent Binge Drinking is defined in the Arizona Youth of total population, by subgroups: age, gender, Survey as having five or more drinks in a row durrace, ethnicity, income, education (as appropriate ing the two weeks prior to the survey. to describe prevalence and to design appropriate subgroup interventions). According to the Arizona Youth Survey 14% of 8th graders reported binge drinking at least once in Behavioral Risk Factor: Substance Use and their lives, compared to 22% of 10th graders who Abuse reported binge drinking (2008, Arizona Youth SurThe Arizona Youth Survey contains data from vey, p. 10-11). High school seniors reported binge 2004, 2006, and 2008 for youth in the state of drinking at least once in their lives at 30% (2008, Arizona. The data was also collected and com- Arizona Youth Survey p. 13). In 2008 16% of 8th plied by County. The characteristics of the youth graders in Navajo County reported binge drinking population surveyed are as follows; 47.4% male, while 22% of 10th graders reported binge drinking. 52.6% female; 39% Native American, 43.6% Twenty-six percent of high school seniors reported White, 13.2% Hispanic, 2.5% African American, binge drinking at least once in their lives. 1.0% Asian, and .7% Pacific Islander (2008, Arizona Youth Survey). 46 Navajo County Community Health Status Assessment Category 5 - Behavioral Risk Factors National data provided by the Youth Risk Behavior Surveillance System (YRBSS) indicates that in 2007 26% of youth in the United States reported episodic heavy drinking1 while 30.4% of Arizona youth reported episodic heavy drinking during that time (Comparison Between Arizona Students and U.S. Students, YRBSS, 2007). Trends in Drug Use in Navajo County Among Youth Methamphetamine use among high school seniors in Navajo County is twice the rate of the state (4%) (Table 5.1). Marijuana use among high school seniors in Navajo County is 13% higher than the state rate (Table 5.1). 12th graders) has decreased from approximately 16% in 2001 to about 14% in 2006. Lifetime prevalence of Marijuana use among all American Indian populations (7th-12th graders) has also decreased from approximately 70% in 2001 to 57% in 2006 (Tri-Ethic Center, Colorado State University, American Drug and Alcohol Survey ADAS2). The decreased use of inhalants among Native American youth may be, in part, attributed to information Native communities received from the ADAS about the prevalence of these substances and the dissemination of targeted anti-inhalant messages (Tri-Ethic Center, Colorado State University). Cocaine Use among Youth In 2007, lifetime cocaine3 use among ArizoAccording to the Tri-Ethic Center, Colorado na youth (9th-12th graders in public and private State University, Lifetime prevalence of inhalant schools) was 14.4% nearly twice the United States use among all Native American Populations (7th- average of 7.2%, putting Arizona youth at greater Figure 5.2 Bar Graph Grade 8: 30-day ATOD Use (2004, 2006, 2008) 1 Episodic heavy drinking refers to having five or more drinks of alcohol in a row within a couple of hours on at least one day during the 30 days leading up to the survey (Comparison Between Arizona Students and U.S. Students, YRBSS, 2007) 2 The ADAS survey is administered to over 70,000 American Indian students in reservation schools and communities since 1974, funded by the National Institutes of Health (NIH), #R01DA003371. 3 Cocaine indicates any form of the substance including powder, crack or freebase. Navajo County Community Health Status Assessment 47 Category 5 - Behavioral Risk Factors Figure 5.3 Bar Graph Grade 10: 30-day AOTD Use (2004, 2006, 2008) Figure 5.4 Bar Graph Grade 12: 30-day ATOD Use (2004, 2006, 2008) 48 Navajo County Community Health Status Assessment Category 5 - Behavioral Risk Factors Drinking Among Adults in Arizona Two categories were considered for adults drinking habits in Navajo County; the number of drinks consumed in a week and a month, and binge drinking among adults in Navajo County. In 2006, 1.6% of respondents (BRFSS, 2006) had at least one alcoholic beverage seven days a week while 9% of respondents had at least one alcoholic beverage one day a week. In 2007, 6.7% of Data for 30 day use of cocaine among youth in respondents (BRFSS, 2007) had at least one alcothe United States is 3.3% (grades 9-12, public and holic beverage seven days a week while 14.3% of private schools, YRBSS Overview 2007, CDC) respondents had at least one alcoholic beverage while 30 day use of cocaine in Navajo County was one day a week. This is a significant increase in 3.4 (9th graders) and 4% (12th graders) (Arizona one year (almost double) in drinking among adults Youth Survey, 2008). in Navajo County seven days a week. risk (2007 National Youth Risk Behavior Survey Overview, CDC, YRBSS). Although cocaine use among youth in Navajo County (9.2% for 10th graders and 12.7% for 12th graders) is lower than the Arizona rates (14.4%), levels of lifetime use are still much higher than national levels (7.2%) (Table 5.1 above, Arizona Youth Survey, Lifetime AOTD Use, 2008). Prescription Drug Use and Abuse among Youth Prescription drug use (non-medical) among youth is increasing among teens; nationwide prescription drug usage among teens is only second to marijuana use. The availability of these drugs may contribute to this problem. In addition to increased use of prescription drugs among teens there is also an increase in mixing prescription drugs and alcohol, or other substances (Dr. Jane Maxwell, National Institute on Drug Abuse (NIDA), www.UniversityTexas.edu/features, Generation Rx? Increased Prescription Drug Use by teens recent national drug trends). Over the period of a month (2006, BRFSS) 2.9% of adults reported having at least one alcoholic beverage fifteen days in the month while 6% reported having at least one drink thirty days in a month. Six percent of adults reported consuming at least one drink thirty days a month in 2006. During 2007 2.7% of adult respondents reported having at least one beverage fifteen days in a month, while 2.3% reported drinking at least one drink a day thirty days in a month (BRFSS). Binge Drinking Among Adults in Navajo County Trend data indicates there is a small amount of change (from 2003 to 2005) in binge drinking According to the NIDA Info Facts 15.4% of 12th among adult populations. However approximately graders (nationally) reported using a prescrip- 12% of the population surveyed in the Behavioral tion drug non-medically in the past year. Vicodin Risk Factor Surveillance System (BRFSS) are was reported to be abused at ‘unacceptably” high considered to be at-risk for binge drinking (see levels (www.drugabuse.gov, NIDA, National Insti- Table 5.6). tutes of Health, US Department of Health and Human Services, 2008). 30-day use of prescription In 2005, binge drinking risk comparisons beth drugs among 12 graders in Navajo County was tween males and females in Navajo County reported in the Arizona Youth Survey (2008) at a showed that 10.9% of males were considered atrate of 16.1%, considerably higher than the 13.1% risk for binge drinking compared to 1.6% for feArizona rate for 12th graders. Specific data on the males (Table 5.7 and 5.8, BRFSS data). use of prescription pain relievers use among youth showed similar trends in Navajo county. ApproxiBetween 9.0% and 10.9% of males in Navajo mately 13.5% of Navajo County 12th graders re- County are at risk for heavy drinking (see table 5.7). ported 30-day use of prescription pain relievers, Approximately 1.1% to 4.1% of females are at risk higher than the state rates (10.5%) (Arizona Youth for heavy drinking (see table 5.6). Risk for heavy Survey, 2008). drinking is clearly a higher risk for males in Navajo Navajo County Community Health Status Assessment 49 Category 5 - Behavioral Risk Factors Table 5.5 During the past 30 days, how many days per week or per month did you have at least one alcoholic beverage? (Navajo County (2007) Year Number of Drinks Frequency Percent 1 day per week, had at least one drink 2,228 9.0 2 days per week, had at least one drink 2,699 10.9 3 days per week, had at least one drink 315 1.3 4 days per week, had at least one drink 1,618 6.5 5 days per week, had at least one drink 292 1.2 6 days per week, had at least one drink 195 0.8 7 days per week, had at least one drink 389 1.6 1 day in the month, had at least one drink 5,664 22.8 2 days in the month, had at least one drink 3,660 14.7 3 days in the month, had at least one drink 3,138 12.6 4 days in the month, had at least one drink 1,193 4.8 5 days in the month, had at least one drink 613 2.5 6 days in the month, had at least one drink 414 1.7 7 days in the month, had at least one drink 105 0.4 10 days in the month, had at least one drink 442 1.8 15 days in the month, had at least one drink 732 2.9 30 days in the month, had at least one drink 683 0.6 Don’t Know/Not Sure 289 1.2 Refused 158 0.6 24,826 100.0 In a Week 2006 Totals 50 In a Month Navajo County Community Health Status Assessment Category 5 - Behavioral Risk Factors County (BRFSS Navajo County Data, 2003, 2004, 2005). Alcohol and Drug use was identified in the 2008 Community Themes and Strengths Assessment (CTSA) as the top two most important health problems among Navajo County residents, 56.9% and 40.5 respectively (N=1,084). In addition the CTSA also cited alcohol abuse (73.1%) and drug abuse (58.9%) as the most risky behaviors among Navajo County residents (N=1,078) (CTSA, 2008, PowerPoint). Exercise A considerably large portion of respondents in the BRFSS (26.7%) reported being physically inactive. Approximately 73.3% of respondents reported participating in a physical activity, although only 53.3% of survey respondents exercised at the recommended activity level of 20 minutes or more on 3 or more days per week. Navajo County rates are higher than the state and national reported exercising 20 minutes or more 35.9% and 37.3%, respectively (ADHS, Division of Public Health Services 2007). Table 5.6 Binge Drinking Risk Factors (Navajo County, AZ) 2003-2005 Year 2003 Not At Risk At Risk Don’t Know/Not Sure/ Refused Total Frequency Percent Frequency Percent Frequency Percent Frequency Percent 57,836 87.9 7,939 12.1 Not Available Not Available 65,775 100.0 2004 56,078 87.1 7,961 12.4 350 0.5 64,388 100.0 2005 54,344 86.8 7,915 12.6 350 0.6 62,609 100.0 * CDC, BRFSS Navajo County (2003-2005) Table 5.7 Heavy Drinking Among Men Risk Factor: Navajo County, AZ (2003-2005) Year Not At Risk At Risk Don’t Know/ Not Sure/ Refused Total Frequency Percent Frequency Percent Frequency Percent Frequency Percent 2003 28,709 89.4 2,892 9.0 511 1.6 32,111 100.0 2004 25,448 89.0 2,629 9.2 508 1.8 28,585 100.0 2005 25,807 89.1 3,148 10.9 Not Available Not Available 28,955 100.0 * CDC, BRFSS Navajo County (2003-2005) Table 5.8 Heavy Drinking Among Females Risk Factor: Navajo County, AZ (2003-2005) Year Not At Risk At Risk Don’t Know/ Not Sure/ Refused Total Frequency Percent Frequency Percent Frequency Percent Frequency Percent 2003 33,306 98.9 358 1.1 Not Available Not Available 33,664 100.0 2004 34,321 95.9 1,482 4.1 Not Available Not Available 35,803 100.0 2005 32,061 95.3 546 1.6 1,047 3.1 33,653 100.0 *CDC, BRFSS Navajo County (2003-2005) Navajo County Community Health Status Assessment 51 Category 5 - Behavioral Risk Factors Obesity According to the 2000 Behavioral Risk Factor Survey 46.7% of older adults in Navajo County are classified as overweight or obese by national health standards; however only 20.0% of respondents reported current attempts at losing weight (CDC, BRFSS, Navajo County data 2000). (The White Mountain Apache Tribe Regional Partnership Council Funding Plan, Overview of the three year strategic Plan, July 1, 2009 through June 30, 2012). According to the 2008 Community Themes and Strengths Assessment (CTSA) 29.1% of respondents reported being overweight, 16.4% reported lack of exercise, and 16.1% reported poor eating habits as the most risky behaviors among Navajo County residents. Nutrition Being overweight or obese, poor dietary habits, little or no physical activity, and tobacco use are all associated with an increase in health problems. Over half of the respondents in Navajo County (53.3%) reported that they did not consume the recommended 5 or more servings of fruits and vegetables a day. According to Healthy Arizona 2010 approximately 75.4% of individuals living in Arizona eat few fruits and vegetables (ADHS, Healthy Aging 2010. Health Status of Older Adults. Accessed 20 October, 2009). In 2005 only 23.7% of Arizona adults consumed five or more fruits or vegetables a day, while 76.3% Table 5.9 Exercise Last 30 Days, Adults (2003-2007) Yes Year Frequency No Percent Frequency Don’t Know/ Not Sure/ Refused Percent Frequency Percent Total Frequency Percent 2003 49,256 74.9 16,391 24.9 128 0.2 65,775 100.0 2004 51,608 80.2 12,504 19.4 276 0.4 64,388 100.0 2005 45,489 72.7 16,516 26.4 604 1.0 62,609 100.0 2006 57,892 79.1 14,864 20.3 417 0.6 73,173 100.0 2007 59,460 79.0 15,836 21.0 Not Available Not Available 75,296 100.0 *CDC, BRFSS, Navajo County (2003-2007) Table 5.10 Youth Trends in Physical Activity (2003, 2005, 2007) Behavioral Risk Factors 2003 2005 2007 Met recommended levels of physical activity Not available 35.8% (physically active total of at least 60 minutes per day on 5 or more days the week before the survey) (National data) 34.7% Attended physical education classes (on 1 or more days in a week when they were in school) (National Data) 55.7% 54.2% 53.6% Attended physical education classes daily (5 days a week when in school) (National Data) 28.4% 33.0% 30.3% * Did not attend physical education classes daily (Arizona data) Not available Not available 73.1% (CDC, National Youth Behavioral Risk Survey (YRBSS) 2003, 2005, 2007) 52 Navajo County Community Health Status Assessment Category 5 - Behavioral Risk Factors of adults consume less than the recommended five per day (CDC, BRFSS, Prevalence and Trend Data, Arizona, 2005). In 2007 28.3% of Arizona adults reported eating five or more fruits or vegetables in a day while 71.7% of adults did not consume the recommended daily servings of fruit and vegetables (CDC, BRFSS, Prevalence and Trend Data, Arizona, 2007). Nutrition (as measured by fruit and vegetable intake) in Navajo County is poor in relation to overall state rates. Table 5.11 Risk Factor for Overweight or Obese Not At Risk Year 2003 Don’t Know/ Not Sure/ Refused At Risk Total Frequency Percent Frequency Percent Frequency Percent Frequency Percent 19,174 29.2 43,909 66.8 2,692 4.1 65,775 100.0 2004 24,433 37.9 38,891 60.4 1,064 1.7 64,388 100.0 2005 21,203 33.7 38,697 61.8 2,809 4.5 62,609 100.0 *CDC, RFSS, Navajo County (2003-2005) Table 5.12 Body Mass Index: Three Levels Category Year Neither Overweight nor Obese Frequency Percent Frequency Percent Frequency Percent Frequency Percent Frequency Percent 2003 19,173 29.2 26,562 40.4 17,346 26.4 2,692 4.1 65,775 100.0 Overweight Obese Don’t Know/ Not Sure/ Refused Total 2004 24,433 37.9 26,461 41.1 12,430 19.3 1,064 1.7 64,388 100.0 2005 21,103 33.7 16,278 26.0 22,419 35.8 2,809 4.5 62,609 100.0 * CDC, BRFSS, Navajo County (2003-2005) Navajo County Community Health Status Assessment 53 Category 5 - Behavioral Risk Factors Table 5.13 State Indicator Report on Fruits and Vegetables, 2009 Fruit and Vegetable Consumption (%) Adults Adults eating 2+ fruits a day Adults eating 3+ vegetables a day Adults eating both 2+ fruit and 3+ vegetables a day Adolescents Arizona 32.8% 30.4% 16.1% United States 32.8% 27.4% 14.0% Adolescents eating 2+ fruits a day 27.1% 32.2% Adolescents eating 3+ vegetables a day 11.0% 13.2% Adolescents eating both 2+ and 3+ vegetables a day 7.4% 9.5% State Indicator Report on Fruits and Vegetables, 2009. Center for Disease Control; Department of Health and Human Services, 2009. Web. . 2007 BRFSS, 2007 YRBSS 54 Navajo County Community Health Status Assessment Category 5 - Behavioral Risk Factors Behavioral Health Risk Factors among Respondents Age 65 and Older Table 5.14 Risk Factors Among Respondents Age 65 and Older Navajo County Arizona United States Normal Weight 43.3% 46.8% 42.5% Overweight 46.7% 35.1% 36.7% Obese 0.0% 17.0% 16.8% Unknown 10.0% 1.1% 4.0% Less than once a day or never 0.0% 1.4% 3.3% 1 to less than 3 times per day 23.3% 16.8% 21.9% 3 to less than 5 times per day 30.0% 38.8% 43.3% 5 or more times per day 46.7% 42.9% 31.5% Physically inactive 26.7% 37.5% 37.0% Less than recommended activity 20.0% 26.6% 25.7% Meets recommended activity level 53.3% 35.9% 37.3% Current smoker, smoke everyday 6.7% 7.4% 7.9% Current smoker, smoke some days 13.3% 1.9% 2.1% Former smoker 43.3% 41.3% 37.4% Never smoked 36.7% 48.7% 52.1% Don’t know/ Refused question 0.0% 0.6% 0.5% Risk Factors Weight Group Daily Servings of Fruits and Vegetables Activity Level/ Exercise Smoking Status Report on the Health Status of Older Adults, Navajo County, Arizona, AZHS, Healthy Aging 2010 (2002) 1 Based on Body Mass Index, BMI<25.0 normal weight, BMI _ 25.0 and < 30.0 overweight, BMI _ 30.0 obese 2 Recommended activity is exercise 3 or more days per week for 20 minutes or more Navajo County Community Health Status Assessment 55 Category 5 - Behavioral Risk Factors Seatbelt Use in Navajo County According to the 2008 CTSA 10.8% of respondents reported not using seatbelts as one of the most risky behaviors in Navajo County. Table 5.15 Child Restraint Usage in Arizona, 2004-2008 (Children under five years old) Year 2004 2005 2006 2007 2008 Severity of Injury Percent of Restraint Used Percent of No Restraint Percent Unknown No Injury 89.79% 63.79% 75.92% Possible Injury 6.36% 13.87% 9.19% Injury 2.92% 19.88% 8.27% Fatality 0.03% 0.62% 0.18% Unknown 0.90% 1.85% 6.43% TOTALS 100.00% 100.00% 100.00% No Injury 89.52% 65.40% 58.21% Possible Injury 6.35% 10.90% 5.04% Injury 2.91% 17.99% 5.91% Fatality 0.02% 0.52% 0.14% Unknown 1.19% 5.19% 30.69% TOTALS 100.00% 100.00% 100.00% No Injury 89.82% 66.98% 76.40% Possible Injury 6.26% 14.49% 4.84% Injury 2.70% 15.68% 6.77% Fatality 0.05% 1.66% 0.77% Unknown 1.17% 1.19% 11.22% TOTALS 100.00% 100.00% 100.00% No Injury 89.93% 68.12% 74.12% Unknown Injury 1.13% 0.51% 9.43% Possible Injury 6.31% 11.83% 11.40% Non-Incapacitating 2.20% Injury 11.57% 4.17% Incapacitating Injury 0.35% 6.94% 0.44% Fatal Injury 0.08% 1.03% 0.44% TOTALS 100.00% 100.00% 100.00% No Injury 89.62% 72.11% 75.39% Unknown Injury 1.30% 2.04% 11.63% Possible Injury 6.54% 11.56% 7.83% Non-Incapacitating 2.08% Injury 11.22% 3.80% Incapacitating Injury 0.44% 2.38% 0.89% Fatal Injury 0.03% 0.68% 0.45% TOTALS 100.00% 100.00% 100.00% Information Source from: Arizona Department of Transportation, Motor Vehicle Crash Facts (2004-2008). [http://www.azdot.gov/mvd/Statistics/crash/index.asp] 56 Navajo County Community Health Status Assessment Category 5 - Behavioral Risk Factors Table 5.16 Driver Restraint Usage in Arizona, 2004-2008 Year 2004 2005 2006 2007 Severity of Injury Percent of Restraint Used Percent of No Restraint Percent Unknown No Injury 81.47% 50.93% 36.57% Possible Injury 10.72% 12.04% 5.60% Injury 6.82% 30.96% 8.03% Fatality 0.10% 3.35% 0.35% Unknown 0.89% 2.72% 49.45% TOTALS 100.00% 100.00% 100.00% No Injury 82.20% 49.60% 34.98% Possible Injury 10.02% 11.67% 5.31% Injury 6.62% 29.81% 7.63% Fatality 0.10% 3.22% 0.40% Unknown 1.06% 5.70% 51.69% TOTALS 100.00% 100.00% 100.00% No Injury 82.61% 47.32% 34.83% Possible Injury 10.00% 12.11% 5.33% Injury 6.19% 28.99% 7.00% Fatality 0.11% 3.90% 0.32% Unknown 1.09% 7.69% 52.53% TOTALS 100.00% 100.00% 100.00% No Injury 82.99% 48.05% 36.38% Unknown Injury 1.09% 7.35% 51.68% Possible Injury 9.70% 11.53% 4.96% In- 5.07% 19.23% 4.84% Incapacitating Injury 1.06% 10.24% 1.90% Fatal Injury 0.10% 3.61% 0.24% TOTALS 100.00% 100.00% 100.00% No Injury 83.05% 49.19% 39.74% Unknown Injury 1.14% 6.32% 47.81% Non-Incapacitating jury Possible Injury 2008 9.53% 11.65% 5.43% In- 5.14% 19.33% 4.79% Incapacitating Injury 1.04% 10.14% 1.94% Fatal Injury 0.11% 3.37% 0.29% TOTALS 100.00% 100.00% 100.00% Non-Incapacitating jury Information Source From: Arizona Department of Transportation, Motor Vehicle Crash Facts (2004-2008). [http://www.azdot.gov/mvd/Statistics/crash/index.asp] Navajo County Community Health Status Assessment 57 Category 5 - Behavioral Risk Factors Table 5.17 How Often Do You Use Seatbelts in a Car? (Navajo County, 2006) Indicator Frequency Percent Always 48,842 69.1% Nearly Always 14,245 20.1% Sometimes 3,557 5.0% Seldom 1,767 2.5% Never 457 0.6% DK/NS 1,844 2.6% TOTAL 70,712 100.0% Information Source From: Arizona Behavioral Risk Factor Surveillance System Questionnaire, 2006. Women’s Health Screening Bike Helmet Data According to the CDC Navajo County ComThere was no data available on bicycle helmet munity Health Status Report (2008), women 18 use within Navajo County. and over in Navajo County who get regular PapSmears is 75.9%. The percent of women in NaCondom Use The YRBSS Comparison between Arizona and vajo County who get a regular Mammography U.S. students indicated that Arizona youth who (women age 50 and over) is 70.8% (CDC Navajo are sexually active are at greater risk for unintend- County Community Health Status Report, 2008). ed pregnancies and Sexually Transmitted Diseases (STDs) including HIV infection. According to Healthy Arizona 2010 (ADHS, 2000) about one half of all new HIV infections in the United States are among people under age 25, and are infected through sexual behavior. Using a condom correctly and consistently can help prevent unintended pregnancy and STD’s (ADHS, Healthy Arizona 2010, 2000). The U.S. percent of sexually active youth who reported not using a condom during last sexual intercourse was 38.5% in comparison to 44.5% of Arizona youth (CDC, YRBSS, Comparison between Arizona Students and US Students, 2007). According to the 2008 CTSA 16.6% of respondents reported unsafe sex and not using birth control (7.4%) were some of the most risky activities among Navajo County residents. 58 Navajo County Community Health Status Assessment Category Six - Environmental Health Indicators Definition of Category The physical environment directly impacts health and quality of life. Clean air and water, as well as safely prepared food, are essential to physical health. Exposure to environmental substances such as lead or hazardous waste increases risk for preventable disease. Unintentional home, workplace, or recreational injuries affect all age groups and may result in premature disability or mortality. Trends A comprehensive assessment of water quality in Navajo must consider the areas of the county that are part of the three Native American reservations that exist within the county. The measurements for off reservation water show stable levels. Air quality in Navajo County meets national standards, and with 550 homes at risk for lead poisoning, the county holds the 5th place among other Arizona counties. Water Quality (Off-Reservation) Arizona Department of Environmental Quality (ADEQ) is charged with monitoring lakes, streams, and groundwater throughout the state to gather information which is used to determine if water is safe to drink, swim in, suitable for irrigation, and adequate to support aquatic life. The ADEQ conducts ambient water monitoring to comply with the Clean Water Act (CWA) to protect human and aquatic life (The Water Quality of the Little Colorado River Watershed, Fiscal year 2007 data, prepared by the Arizona Department of Environmental Quality, March 2009, Publication number OFR 09-11). The Little Colorado watershed is located in northeastern Arizona and approximately 50% of the watershed is on Native American Reservations. However the sample sites used for the ADEQ reports are all located on non-reservation land. Most streams (9 out of 10) were reported to be “stable”. Approximately 67% of macro inverFood Safety tebrate samples violated the bio-criteria standard According to Healthy Arizona 2010, “Food for coldwater streams. The main culprit was the borne illness imposes a burden on public health crayfish, a known biological stressor in the Little and contributes to the cost of health care” (2000, Colorado River Basin (The Water Quality of the Healthy Arizona 2010, Environmental Health). Little Colorado River Watershed, Fiscal year 2007 The number of food borne illness complaints in data, prepared by the Arizona Department of EnNavajo County is low (see Table 6.0). vironmental Quality, March 2009, publication number OFR 09-11). Table 6.0 According to the 2008 ADEQ non-point source annual report, sediments, metals, and nutrients are the most common sources of pollution for Year Number of Food-borne Illness Complaints Arizona streams Non-point sources like grazing 2004 Not reported and agriculture are the primary cause of stream 2005 0 impairment. “Streams in Arizona are especially 2006 34 vulnerable to sedimentation due to climatic condi2007 5 tions, recent forest fires, as well as past and current unsuitable land management practices which 2008 3 Data from Food Safety and Environmental Services, resulted in less vegetative cover.” Some of the efBureau of Epidemiology and Disease Control, Office of fects of unstable streams include abnormal floodEnvironmental Health (2004-2008) ing of agricultural and urban lands, the alteration of stream channel structure, and lowering of the Rodeo-Chediski Fire Public Health Assessment, Argroundwater table (ADEQ, Arizona, EQR 0803 izona Department of Health Services, Navajo County, 2008). Arizona, Office of Environmental Health 2003 Number of Food-borne Illness Complaints in Navajo County (2004-2008) Navajo County Community Health Status Assessment 59 Category 6 - Environmental Health Indicators In order to better access the water quality of Navajo County it is important to consider the water quality on each Native American reservation in the county as the tribes control water on their land. Please note that the following data are in relation to the entire tribal area, some of which exists outside of Navajo County lines. There are multiple areas at high-risk for forest fires in Navajo County. Forest fires can negatively impact water resources in a number of ways thus presenting a risk to water quality for those residents. The Rodeo-Chediski fire in 2002 is a case in point. The Rodeo-Chediski fire was the largest forest fire in Arizona history. State-regulated systems sent out boil water advisories to increase water quality that was compromised by the fire. Twenty-two communities were affected by the fire. The affected communities were grouped by the degree of damage sustained (please see Table 6.1) (Rodeo-Chediski Fire Public Health Assessment, Arizona Department of Health Services, Navajo County, Arizona, Office of Environmental Health 2003). Table 6.1 thority (NTUA). Approximately 40%1 of the reservation does not have running water, forcing residents to haul water. An assessment of individual small farms on the reservation (15 acres and less) showed that it does not have a large impact on water. However, the collective impact includes fallow areas because of drought or an inability to get water to areas can cause sediment and nutrient loading from fertilizers and pesticides. Uranium (mining and milling in the 1940s and 1950s) has had some effect (low-level radiation) on groundwater. The affected areas (including Shiprock, Tuba City, Mexican Water, and Cane Valley) are in the process of being cleaned up. (Water Quality for the 21st Century, New Mexico water resources Arvin Trujillo, Division of Natural Resources, Navajo Nation). Hopi Tribe Water Quality Surface water on the Hopi reservation consists primarily of intermittent or ephemeral streams. Limited data was available on water quality for the Hopi Tribe. Between 1992 and 1993 the Hopi Tribe accessed 18 springs and revealed that in several springs had one or more cases where they Communities and Degree of Fire Damage (Rodeo-Chediski Fire) 2002 Communities Effected Degree of Damage Pinedale, Linden, Timberline Acres, Clay Springs, Heber, Overgaard, and Alpine Communities were evacuated, suffered severe loss of homes and community infrastructure Show Low, Pine Top-Lakeside, Hon-Dah, Forest Lakes, and McNary Communities that were evacuated but not directly damaged by the fire Payson, Eager, Snowflake-Taylor, Holbrook, and Winslow Host communities that mobilized to provide shelter and support to evacuees Rodeo-Chediski Fire Public Health Assessment, Arizona Department of Health Services, Navajo County, Arizona, Office of Environmental Health 2003 Navajo Nation Water Quality exceeded the allowances of nitrate, selenium, total There are two primary departments on Navajo coli-form, and or fecal coli-form. Overall, ground Nation involved with water quality; The Depart- water quality is good on the Hopi reservation. The ment of Water Resources (which is under the De- N-aquifer provides excellent drinking water to a The percent of residents without running water in partment of Natural Resources) and Navajo Nation 1 some chapters is estimated to be as high as 90% without Environmental Protection Agency. Approximately running water (Water Quality for the 21st Century, New 60% of water systems within Navajo Nation are Mexico water resources Arvin Trujillo, Division of Natural under the authority of the Navajo Tribal Utility Au- Resources, Navajo Nation). 60 Navajo County Community Health Status Assessment Category 6 - Environmental Health Indicators majority of the Hopi villages. Mining actives off of the reservation are the largest threat to the Naquifer, from the impacts of abandoned uranium tailings in Tuba City. (The Hopi Tribe Water Recourses Program, Philip Tuwaletstiwa, The Hopi Tribe 1994, www.epa.gov/owow/305B/94report/ hopi.pdf). Statistics the number of (nonfatal) occupational injuries and illnesses requiring days away from work decreased between 2006 and 2007. The median Number of days away from work for all cases of injury and illness was 7 days in 2007. This average remains unchanged from 2004 (see Table 6.6 below for trend data on the number of cases per year in Arizona). (Bureau of Labor Statistics, White Mountain Apache Water Quality News: United States Department of Labor, NonThe White Mountain Apache Indian Reser- fatal occupational Injuries and Illness Requiring vation includes twenty-six cold water lakes and Days Away from Work, Washington, D.C. 20212, over 400 miles of streams. The primary source of 2008). drinking water on the reservation is the Coconino aquifer. In 1994 the White Mountain Apache Tribe National data for worker demographic characbegan their water quality program. As part of the teristics include gender, age, race, or ethic origin. tribe’s water quality development initiatives, a wa- Workers who were 20 to 24 years old suffered the ter quality database was developed in order to en- most work related injuries and illnesses (134 cassure reliable, easy, and secure access to all of the es per 1,000) a decline from 2006 (Bureau of Lawater quality data collected throughout the years. bor Statistics, News: United States Department of The Rodeo-Chediski fire had a significant impact Labor, Nonfatal occupational Injuries and Illness on water quality as a result of the fire which de- Requiring Days Away from Work, Washington, stroyed almost 275,000 acres. The fire caused D.C. 20212, 2008). Arizona workers age 20-24 winter stream flow to drastically increase causing suffered work related injuries and illnesses at a flooding and turbidity wiping out wetland vegeta- rate of 10 cases per 1,000 in 2006) see Table 6.7 tion. An effort to replant vegetation took place to below (Bureau of Labor Statistics, Fatal Occupamitigate the negative impact from the fire (US En- tional Injuries by Demographic Characteristic, Arivironmental Protection Agency, Pacific Southwest zona, www.bls.gov, (2004-2008). Region 9, Water Division, Water Pollution ConMales typically suffer more work related injutrol Program, EPA-909-K-06-001, 2006 accessed 10/29/09 from http://www.epa.gov/region09/water/ ries/illnesses than women due to the type of intribal/pdf/tribal-water-quality-accomplishments. dustry that men tend to work in industries/jobs with pdf). higher incidence rates (Bureau of Labor Statistics, News: United States Department of Labor, NonAir Quality fatal occupational Injuries and Illness Requiring According to the Community Health Status Re- Days Away from Work, Washington, D.C. 20212, port from CDC (CSA, FIPS CODE 04-017, 2008) 2008). This is true in Arizona where the rate of Navajo County meets all Environmental Protec- cases for men from 77 per 1,000 in 2004 to 84 per tion Agency (EPA) National Air Quality standards 1,000 in 2007) is much worse than rates of injury for Carbon Monoxide, Nitrogen Dioxide, Sulfur Di- for women ranging from 6 per 1,000 in 2005 to 13 oxide, Ozone, Particulate Matter, and Lead (EPA per 1,000 in 2007 (see Table 6.7 below) (Bureau of AIRSData, 2006). Labor Statistics, Fatal Occupational Injuries by Demographic Characteristic, Arizona, www.bls.gov, Workplace Hazards (2004-2008). Musculoskeletal disorders (MSD’s)2 MSD’s are often referred to as ergonomic injuries There was no data available at the County level 2 that affect the connective tissues of the body (Bureau of for workplace hazards. There is however a good Labor Statistics, News: United States Department of Labor, deal of data collected at both the state and naNonfatal occupational Injuries and Illness Requiring Days tional levels. According to the Bureau of Labor Away from Work, Washington, D.C. 20212, 2008). Navajo County Community Health Status Assessment 61 Category 6 - Environmental Health Indicators account for 29% of all workplace injuries nationally in 2007 (Bureau of Labor Statistics, News: United States Department of Labor, Nonfatal occupational Injuries and Illness Requiring Days Away from Work, Washington, D.C. 20212, 2008). levels of lead. Arizona ranks 41st (11,000 homes) in the nation regarding number of housing units with a high risk of lead hazards while New York state ranks number one with 430,000 units (Scorecard, EPA, 2009). Lead Exposure The most widespread environmental health problem children face today is lead poisoning (Centers for Disease Control and Prevention: Lead, CDC’s National Surveillance Data, 2009). Children ages 6 years and under are at the highest risk of being exposed which can lead to poisoning (Arizona Department of Health Services, Lead Poisoning Prevention Program, 2009). About 1 in 22 children have high levels of lead in their blood, according to the Centers for Disease Control and Prevention (National Head Start Association, Lead Poisoning Prevention, 2009, accessed 10/29/10). National reports showed that 163 children had contracted lead poisoning (>10ug/dL) in 2001. Lead-based paint in older homes (built before 1960) continues to be a significant source of lead poisoning for children in Arizona (Arizona Department of Health Services. Office of Environmental Health, Childhood Lead Poisoning, 2009 Childhood Lead Poisoning Targeted Screening Plan). High risk occupations for adults that can result in increased lead exposure include: manufacturing or recycling of storage batteries, metals, and ammunition; mining and smelting; radiator and automotive repair; soldering and welding; production of PVC plastic, crystal, ceramics, and glass; remodeling and demolition of older housing and structures; and indoor/outdoor shooting ranges (Arizona Department of Health Services, Lead Poisoning Prevention Program, 2009). Navajo County ranks 5th (550 homes) in the state of Arizona for number of housing units with a high level of lead hazards3 while Maricopa County ranks 1st in the state with (3,800 homes) for high 3 Number of housing units with a high risk of lead hazards: This indicator estimates the percent of housing units in an area with a high risk of lead hazards. It is calculated by dividing the number of housing units with high risk of lead hazards by the total number of occupied housing units (EPA, Scorecard, 2009). 62 Navajo County Community Health Status Assessment Category 6 - Environmental Health Indicators Fluoridated Water Table 6.2 Water Fluoridation Statistics (2002, 2004, 2006) Year 2002 2004 2006 Region Percent of US PopPersons receiving ulation*** Receiving fluoridated water Fluoridated Water Persons served by Community Water Systems (CWS) National Rank United States 67.4* 172,209,735 255,443,289 - Arizona 55.4 2,737,028 4,944,156 38 United States 68.7 180,632,481 262,690,043 - Arizona** 55.8 2,890,016 5,183,216 38 United States 69.2 184,028,038 265,794,252 - Arizona** 56.1 3,147,245 5,611,581 38 Department of Health and Human Services. Centers for Disease Control and Prevention- Community Water Fluoridation * Estimate has changed from that previously reported due to new methodology or correction of a rounding error. ** Changed over time are due in part to improvements in WFRS data for CWS with naturally occurring fluoride concentrations. *** Percent of US Population on Public Water Systems Navajo County Community Health Status Assessment 63 Category 6 - Environmental Health Indicators Figure 6.3 64 Navajo County Community Health Status Assessment Category 6 - Environmental Health Indicators Table 6.4 Numbers of Occupational Injuries and Illnesses in All Industries in Arizona (Including State and Local Government) (2004, 2005, 2006, 2007) Year Average Annual Employment (in thousands) Total Recordable Cases (in thousands) Cases with Days away from Work, Job, Transfer, or Restriction (in thousands) 2004 2,295.1 87.1 41.8 2005 2,389.9 97.0 47.3 2006 2,521.1 99.4 49.6 2007 2,580.9 4.6 2.2 Includes all industries except farms with less than 11 employees Bureau of Labor Statistics, Injuries, Illnesses and Fatalities, www.bls.gov, (2004-2007) Navajo County Community Health Status Assessment 65 Category 6 - Environmental Health Indicators Table 6.5 Fatal Occupational Injuries and Demographic Characteristics, Arizona (2004-2008) Selected Characteristics Years 2004 2005 2006 2007 2008* 84 99 112 97 86 Wage and Salary 78 94 106 90 78 Self Employed 6 5 6 7 8 Men 77 93 98 84 81 Women 7 6 14 13 5 Under 16 0 0 0 0 0 16-17 0 0 0 0 0 18-19 0 3 3 0 0 20-24 5 6 10 10 5 25-34 24 18 21 15 16 35-44 17 25 27 24 25 45-54 16 27 31 25 20 55-64 15 13 11 12 13 65 and older 5 4 9 9 7 White, non-Hispanic 53 50 57 62 52 Black or African American, non-Hispanic 0 4 0 5 0 Hispanic or Latino 25 36 36 26 27 American Indian or Alaskan Native 0 7 6 0 0 Asian 0 0 0 0 0 Native Hawaiian 0 0 0 0 0 Multiple races 0 0 9 0 0 Total Employee Status Sex Age Race or Ethnic Origin * 2008 data are preliminary numbers Bureau of Labor Statistics, Fatal Occupational Injuries by Demographic Characteristic, Arizona, www.bls.gov, (2004-2008) 66 Navajo County Community Health Status Assessment Category 6 - Environmental Health Indicators Rabies in Animals Navajo county has low incidences with rabies in animals. Any rabies cases in Navajo County were found in bat populations. Bat populations across the state equal the highest number of cases statewide. Table 6.6 Lab Confirmed Rabies Positive Animals (2005-2009) Year 2005 2006 2007 2008 2009 01/01/2009 to 10/26/2009 County/State Infected Animals Total Submitted Tested Navajo County 0 0 10 9 Arizona Bat (84), Skunk (67), Fox (12), Other 169 (6) 2551 2481 Navajo County Bat (2) 23 22 Arizona Bat (96), Skunk (16), Fox (22), Other 140 (6) 2594 2499 Navajo County Bat (1) 30 30 Arizona Bat (115), Skunk (13), Fox (24), Other 159 (7) 2534 2476 Navajo County 0 14 14 Arizona Bat (89), Skunk (51), Fox (21), Other (15) 176 7 bobcats 2758 2688 Navajo County Not Available Not Available Not Available Arizona Bat (61), Skunk (94), Fox (45), Other 221 (12) Not Available Not Available 2 1 0 Not Available Arizona Department of Health: Rabies in Arizona. Vector Bourne and Zoonotic Disease, accessed 10/28/09 http:// www.azdhs.gov/phs/oids/vector/rabies/stats.htm Navajo County Community Health Status Assessment 67 Category Seven - Social and Mental Health Definition of Category This category represents social and mental factors and conditions which directly or indirectly influence overall health status and individual and community quality of life. Mental health conditions and overall psychological well-being and safety may be influenced by substance abuse and violence within the home and within the community. Trends Homicides and suicides rates for men in Navajo County are higher than for women, which is consistent with a nationwide trend. In 2008, domestic violence and child abuse and neglect were the most important health problem among Navajo County residents, between 2004 and 2008 there was an increase in the cases for both problems. The alcohol induced mortality rate for males in the county is nearly twice the rate for females, which is consistent with Arizona trends. Homicide Rate The homicide rate is considerably higher (triple the rate for women in most cases) for men then for women both in Navajo County and Arizona (see Table 7.2). There is a similar trend for suicide rates ranging from two to five times higher for males in both Navajo County and the state (see Table 7.3). Table 7.0 Number of Days in the Past 30 Days that Mental Health was Not Good, Navajo County (2003-2007) Years 2003 Percent Frequency Percent Frequency Percent Frequency Percent 2007 Frequency 2006 Percent 2005 Frequency Number of Days 2004 1 403 0.6% 4,107 6.4% 929 1.5% 1,224 1.7% 5,319 7.1% 2 5,211 7.9% 3,855 6.0% 2,291 3.7% 5,375 7.3% 5,897 7.8% 3 2,144 3.3% 1,436 2.2% 542 0.9% 2,699 3.7% 4,802 6.4% 4 613 0.9% 546 0.8% 1,850 3.0% 1,943 2.7% 1,260 1.7% 5 2,352 3.6% 3,238 5.0% 2,580 4.1% 1,649 2.3% 2,938 3.9% 10 1,068 1.6% 1,333 2.1% 851 1.4% 2,740 3.7% 2,762 3.7% 15 4,029 6.1% 751 1.2% 670 1.1% 1,332 1.8% 1,523 2.0% 20 2,112 3.2% 763 1.2% 1,041 1.7% 1,011 1.4% 129 0.2% 30 4,073 6.2% 3,423 5.3% 2,821 4.5% 5,130 7.0% 3,883 5.2% DK/NS 1,853 2.8% 1,399 2.2% 1,365 2.2% 4,390 6.0% 1,414 1.9% None 37,289 56.7% 41,274 64.1% 44,515 71.1% 44,146 60.3% 40,600 53.9% Total 65,775 Not Available* 64,388 Not Available* 62,609 Not Available* 73,173 Not Available* 75,296 Not Available* The Following question was asked in the 2007 BRFSS “Thinking of your mental health which includes: stress, depression, and problems with emotions, how many days during the last 30 days was your mental health not good” (BRFSS 2007). DK/NS means that a respondent Did not know or was not sure * Percents do not equal 100 in this table because not all responses were used. There were years where the responses (in number of days) given created different output. For the purpose of this assessment we included the responses (in number of days) that were uniform across all of the years (2003-2007) (Health Status and Vital Statistics by County of Residence; 2003-2007). 68 Navajo County Community Health Status Assessment Category 7 - Social and Mental Health Between 2004 and 2008, the number of cases for both domestic violence and child abuse increase. It is also important to note that when the numbers for domestic violence decrease slightly, the numbers for child abuse and neglect increase slightly (see Table 7.1). According to the 2008 CTSA, domestic violence (18.8%) and child abuse and neglect (17.8%) were cited as the most important health problems among Navajo County residents (N= 1,084). Table 7.1 Cases of Domestic Violence and Child Abuse, Navajo County (2004-2008) Year Domestic Violence Child Abuse/Neglect* 2004 54 8 2005 84 18 2006 88 15 2007 77 21 2008 88 15 Homicide Rate Table 7.2 Homicide Rate (2005-2008) Year Arizona Navajo County Male Female Male Female 2005 425 78 8 2 2006 430 95 11 2 2007 381 103 13 1 2008 364 84 6 2 Advanced Vital Statistics by County of Residence (2005-2008) Actual number of homicides Suicide Rate Table 7.3 Suicide Rate (2005-2008) Year Arizona Navajo County Male Female Male Female 2005 723 192 18 6 2006 743 205 23 5 2007 773 213 16 2 2008 693 183 11 3 Advanced Vital Statistics by County of Residence (2005-2008) Navajo County Community Health Status Assessment 69 Category 7 - Social and Mental Health Table 7.4 Year Total Male Total Female 2008 Female Male Total Male Total 2007 Female 2006 Female 2005 Male Age of Victim Persons Injured in Motor Vehicle Crashes in Arizona (2005-2008) 0-4 797 765 1,564 743 687 1,432 686 726 1,412 604 589 1,193 05-09 1,014 960 1,947 891 947 1,840 874 918 1, 792 705 735 1,441 10-14 1,216 1,314 2,531 1,148 1,211 2,366 1,102 1,117 2,222 954 922 1,876 15-19 4,378 4,961 9,342 4,346 4,853 9,204 3,987 4,526 8,514 3,271 3,792 7,065 20-24 5,031 4,857 9,896 4,864 4,768 9,620 4,652 4,405 9,058 3,638 3,780 7,418 25-34 6,809 6,707 13,524 6,327 6,415 12,757 6,029 6,278 12,309 5,007 5,339 10,346 35-44 5,191 5,491 10,687 5,173 5,447 10,626 4,858 5,125 9,984 4,045 4,339 8,384 45-54 4,192 4,592 8,797 4,178 4,571 8,753 4,089 4,649 8,739 3,567 4,001 7,568 55-64 2,608 3,077 5,687 2,608 3,151 5,764 2,649 3,089 5,738 2,438 2,809 5,247 65-74 1,267 1,580 2,848 1,256 1,502 2,760 1,259 1,461 2,720 1,218 1,380 2,598 75 + 1,334 1,445 2,809 916 1,230 2,149 891 1,132 2,023 828 1,003 1,831 Other 267 343 634 685 534 1,303 616 528 1,194 492 488 1,042 Total 23,104 36,092 70,293 33,117 35,316 68,574 31,692 33,954 65,705 26.767 29,177 56,009 Actual number of Suicides Arizona Motor Vehicle Crash Facts (2005-2008) * Male and female numbers do not equal the total number provided as there were causes listed in the original data set where the victim’s sex was unknown. Table 7.5 Motor Vehicle Deaths (2005-2008) Year Motor Vehicle Accidents Resulting in Death 2005 2006 2007 Arizona Navajo County Arizona Navajo County Arizona Navajo County Arizona Navajo County 1,137 54 1,220 50 1,035 60 874 43 Advanced Vital Statistics by County of Residence (2005-2008) 70 2008 Navajo County Community Health Status Assessment Category 7 - Social and Mental Health Drug Related Mortality Rate Table 7.6 Drug and Alcohol Related Mortality Rate (2005-2008) Navajo County Female Male Female 492 307 8 7 568 335 8 7 590 350 2 7 321 202 Alcohol Induced Deaths 18 12 481 174 26 13 462 175 19 11 523 189 20 8 514 203 Male Male 4 Male Female 3 Male Male Arizona Female Arizona Female Navajo County Arizona 2008 Male Navajo County 2007 Drug Induced Deaths Male Female Cause of Death Arizona Female Navajo County 2006 Female 2005 Advanced Vital Statistics, Arizona (2005-2008) Navajo County Community Health Status Assessment 71 Category Eight - Maternal and Child Health US (for child mortality, compare the US rate of 19 per 100,000 with the Navajo County rate of 50.8 per 100,000). According to the 2008 Navajo County Community Themes and Strengths Assessment (CTSA), teen pregnancy rates were identified as one of the most important health problems in Navajo County. Definition of Category One of the most significant areas for monitoring and comparison relates to the health of a vulnerable population: infants and children. This category focuses on birth data and outcomes as well as mortality data for infants and children. Because maternal care is correlated with birth outcomes, measures of maternal access to, and/or utilization of, care is included. Number of births to teen mothers is a critical indicator of increased risk for both mother and child. Infant Mortality Infant mortality rates in Navajo County started to increase at a rate almost double (10.9) the state rate (6.8) in 2007. In 2008 the infant mortality rate in Navajo County (8.7) remained slightly higher Trends Infant mortality rate for Navajo County almost than the state rate (6.3) (see Table 8.0 below for doubles the Arizona state rate in 2007 (10.9 vs. details). 6.8), for 2008, the Navajo County rate has decreased, but remains over the state levels (8.7 Inadequate Prenatal Care Navajo County has high rates of women receivvs. 6.3). The rate of women receiving inadequate prenatal care also doubles the Arizona state rate, ing inadequate prenatal care. Rates for Navajo and probably relates to low weight birth rates and County almost double the state numbers. Rates neonatal mortality, both slightly higher in Navajo ranging from 10.9% to 12.4% present a crisis in County than in Arizona. Post-natal and child mor- prenatal care for women in the county (see Table tality rates are significantly higher in Navajo Coun- 8.1). This is an issue worth examining in future ty when compared to the rates for Arizona or the research. Table 8.0 Infant Mortality (2005-2008) Years 2005 Infant Deaths 2006 2007 2008 Arizona Navajo County Arizona Navajo County Arizona Navajo County Arizona Navajo County Infant Deaths 653 17 642 9 701 22 625 17 Infant Mortality Rate Per 1,000 Births 8.9 6.8 6.3 4.8 6.8 10.9 6.3 8.7 Advanced Vital Statistics by County of Residence (2005-2008) Table 8.1 Women Receiving Inadequate Prenatal Care (2004-2007) Years Inadequate Care (Percent) 2004 2005 2006 2007 Arizona Navajo County Arizona Navajo County Arizona Navajo County Arizona Navajo County 7.4% 12.0% 6.5% 10.9% 6.4% 11.2% 6.0% 12.4% Kids Count, Data Center- Arizona Inadequate care refers to women reporting 0-4 visits to a prenatal care provider during pregnancy 72 Navajo County Community Health Status Assessment Category 8 - Maternal and Child Health Births to Adolescents Table 8.2 Births to Adolescents (2005-2008) Years 2005 2006 2007 2008 Pregnancies to Females 19 and Younger Births to Females 19 and Younger Number/Rate Arizona Navajo County Arizona Navajo County Number 13,898 356 11,933 343 Rate 32.7% 33.1% 28.1% 31.9% Number 14,918 325 12,916 311 Rate 34.1% 30.0% 29.6% 28.7% Number 15,038 355 12,972 341 Rate 34.4% 33.7% 29.7% 32.3% Number 14,047 381 12,161 364 Rate 31.6% 36.3% 27.4% 34.7% Advanced Vital Statistics by County of Residence (2005-2008) Pregnancies are determined by the sum of live births, fetal deaths, and abortions. Rate is per 1,000 females 19 or younger Adolescent Pregnancy Rate Table 8.3 Adolescent Pregnancy Rate: Mother’s Age Group, Race/Ethnicity (2005-2008) <15 2005 2006 2007 2008 17 1 137 3 8 0 21 2 1 0 1 0 Navajo County Total Arizona Navajo County Other/ Unknown Arizona Navajo County Asian or Pacific Islander Arizona Navajo County American Indian or Alaskan Native Arizona Navajo County Black or African American Arizona Navajo County Hispanic or Latino Arizona Age Group Navajo County Years Arizona White nonHispanic 185 6 15-17 711 18 2,721 11 199 1 478 91 28 0 42 0 4,179 121 18-19 2,016 47 4,330 22 362 0 705 144 67 2 89 1 7,569 216 <15 19 1 123 0 7 0 19 2 1 0 1 0 170 3 15-17 852 22 2,923 15 187 0 403 82 28 0 30 1 4,450 120 18-19 2,338 45 4,692 16 407 1 767 124 63 1 29 1 8,296 188 <15 26 0 115 0 12 0 26 2 0 0 1 0 180 2 15-17 779 19 2,892 8 195 2 445 88 31 0 19 0 4,361 117 18-19 2,295 50 4,775 26 414 0 814 143 72 0 61 3 8,431 222 <15 15 0 111 0 12 0 22 7 1 0 0 0 161 7 15-17 769 18 2,724 9 203 1 408 90 26 0 21 1 4,151 119 18-19 2,209 64 4,333 25 441 1 755 146 86 2 25 0 7,849 238 Advanced Vital Statistics by County of Residence (2005-2008) Navajo County Community Health Status Assessment 73 Category 8 - Maternal and Child Health Navajo County Teen Pregnancy According to the 2008 CTSA, teenage pregnancy was cited as one of the most important health problems among Navajo County youth. The Navajo County Teen Pregnancy Program collaborates with schools, a residential treatment facility for troubled girls, the county juvenile detention center, tribal health care providers and other community organizations to present sexual health information to teenagers and their parents. The program also includes health science curriculum at Holbrook High School and the Navajo County Juvenile Restoration Center and at the Academy of Eastern Arizona. The Navajo County Teen Pregnancy Program worked with 1,426 youth (in classroom sessions), 96 parents of teens, and over 400 community outreach encounters with both teens and adults. In 2008, the Navajo County Teen Pregnancy Prevention Program conducted a pre and post survey with teens they worked with. According to this survey, 56.6% of students reported knowing much more and 21.7% reported knowing more about sexuality. 47.6% reported having much more and 20.7% reported having more clarity about their own values regarding sexual behaviors. 54.9% of respondents reported feeling much more and 23.2% reported feeling more in control of their sexual behavior. According to the survey 51.9% of students reported feeling much more in control of their decisions regarding sex. 74 Navajo County Community Health Status Assessment Category 8 - Maternal and Child Health Prenatal Care Table 8.4 Prenatal Care Navajo County (2005-2008) Year Ethnicity/Race Care 2005 American Indian or Alaska Native Asian or Pacific Islander Other or Unknown Total 336 1,530 88 187 29 78 2,248 34,784 29,279 2,642 4,271 2,421 1,056 74,453 2nd Trimester 3,782 9.111 595 1,403 299 211 15,401 3 Trimester 728 2,208 117 418 54 81 3,606 Unknown 27 28 8 14 2 11 90 No care 398 1,611 88 223 38 43 2,401 1st Trimester 37,384 31,457 2,992 4,196 2,701 569 79,299 2nd Trimester 4,357 9,481 673 1,489 323 144 16,467 3 Trimester 850 2,287 108 445 67 40 3,797 Unknown 24 26 3 11 7 7 78 No care 386 1,445 114 206 52 45 2,248 1 Trimester 36,512 32,257 3,200 4,225 2,952 537 79,683 2nd Trimester 4,429 9,751 693 1,534 337 120 16,864 3 Trimester 872 2,238 156 426 70 47 3,809 Unknown 17 40 2 17 1 6 83 No care 303 1,080 90 199 45 38 1,755 1 Trimester 36,619 31,301 3,336 4,141 2,958 383 78,738 st rd st 2008 Black or African American 1st Trimester rd 2007 Hispanic or Latino No care rd 2006 White nonHispanic 2 Trimester 4,142 8,316 705 1,520 317 94 15,084 3rd Trimester 814 1,912 161 495 105 44 3,531 Unknown 47 30 9 17 0 4 107 nd Advanced Vital Statistics by County of Residence, Arizona (2005-2008) Navajo County Community Health Status Assessment 75 Category 8 - Maternal and Child Health Low Birth Weight Table 8.5 Low Birth Weight (LBW) Births in Navajo County and Arizona (2004-2008) Year 2004 2005 2006 2007 2008 Number/Rate Navajo County Arizona Low Birth Weight Births (number) 150 6,704 Low Birth Weight Births per 100 Births (rate) 8.4 7.2 Low Birth Weight Births (number) 149 6,640 Low Birth Weight Births per 100 Births (rate) 7.8 6.9 Low Birth Weight Births (number) 152 7,266 Low Birth Weight Births per 100 Births (rate) 8.1 7.1 Low Birth Weight Births (number) 152 7,285 Low Birth Weight Births per 100 Births (rate) 7.6 7.1 Low Birth Weight Births (number) 160 7,062 Low Birth Weight Births per 100 Births (rate) 8.2 7.1 Data Source: Advance Vital Statistics by County of Residence, Arizona Department of Health Services, 20042008. 11/6/09 76 Navajo County Community Health Status Assessment Category 8 - Maternal and Child Health Payee for Births Table 8.6 Payee for Births by Ethnicity/Race (Navajo County, 2005-2008) White non-Hispanic Hispanic or Latino Black or African American American Indian or Alaska Native Asian or Other or Pacific Unknown Islander Total (Payee) AHCCCS 11,978 31,224 2,207 3,510 686 802 50,407 IHS 16 28 5 1,632 5 17 1,703 Private insurance 26,049 9,321 1,161 811 2,008 545 39.895 Self 1,062 1,310 61 82 90 51 2,656 Unknown 552 273 16 258 16 22 1,137 Total (Ethnicity/Race) 39,657 42,156 3,450 6,293 2,805 1,437 95,798 AHCCCS 13,292 32,808 2,379 3,528 705 408 53,121 IHS 20 32 8 1,717 3 8 1,788 Private insurance 27,993 10,208 1,382 905 2,313 327 43,128 Self 1,247 1,548 73 60 101 45 3,074 Unknown 461 266 22 154 14 14 931 Total (Ethnicity/Race) 43,013 44,862 3,864 6,364 3,136 803 102,042 AHCCCS 12,884 33,582 2,551 3,456 786 366 53,625 IHS 40 33 5 1,869 3 17 1,967 Private insurance 27,522 10,426 1,523 893 2,503 305 43,172 Self 1,207 1,419 67 51 103 42 2,889 Unknown 563 271 19 139 17 25 1,034 Total (Ethnicity/Race) 42,216 45,731 4,165 6,408 3,412 755 102,687 AHCCCS 14,435 31,327 2,654 3,553 795 317 52,081 IHS 58 30 9 1,768 7 12 1,884 Private insurance 26,722 9,920 1,524 839 2,487 196 41,688 Self 1,164 1,186 81 48 113 22 2,614 Unknown 546 176 33 154 23 16 948 Total (Ethnicity/Race) 41,925 42,639 4,301 6,362 3,425 3,425 99,215 Payee 2005 2006 2007 2008 Advanced Vital Statistics by County of Residence, Arizona (2005-2008) Navajo County Community Health Status Assessment 77 Category 8 - Maternal and Child Health Child Mortality Table 8.7 Top Four Leading Causes of Death Among Infants in Navajo County (2004-2008) Year 2004 2005 2006 2007 2008 Cause of Death Navajo County Arizona Certain conditions originating in the perinatal period 4 198 Congenital Malformations 2 152 SIDS 0 25 Accidents (unintentional injury) 0 19 Total, all causes* 12 622 Certain conditions originating in the perinatal period 6 293 Congenital Malformations 4 149 SIDS 0 32 Accident (unintentional injury) 3 24 Total, all causes* 17 653 Certain conditions originating in the perinatal period 3 314 Congenital Malformations 3 142 SIDS 0 37 Accident (unintentional injury) 1 17 Total, all causes* 9 642 Certain conditions originating in the perinatal period 7 328 Congenital Malformations 5 159 SIDS 2 43 Accident (unintentional injury) 0 30 Total, all causes* 22 701 Certain conditions originating in the perinatal period 5 303 Congenital Malformations 6 145 SIDS 1 21 Accident (unintentional injury) 1 19 Total, all causes* 17 625 *All causes of death include causes of death not listed in the table above. Data Source: Advance Vital Statistics by County of Residence, Arizona Department of Health Services, 2004-2008. 11/10/09. 78 Navajo County Community Health Status Assessment Category 8 - Maternal and Child Health Neonatal Mortality Table 8.8 Neonatal Mortality Rate (Per 1,000 live births) in Navajo County (2004-2008) Year Navajo County Arizona Number Rate Number Rate 2004 7 3.9 421 4.5 2005 8 4.2 424 4.4 2006 4 2.1 440 4.3 2007 10 5.0 479 4.7 2008 7 3.6 419 4.2 Data Source: Advance Vital Statistics, AZDHS, 2004-2008 11/9/09 http://www.azdhs.gov/plan/report/ahs/ ahs2008/5e.html The Neonatal mortality rate is slightly higher in Arizona than in Navajo County. In 2007 a significant increase in Neonatal mortality rates in infants surpassed the rate in Arizona. The Post-neonatal mortality rate is significantly lower in Arizona when compared to Navajo County. The post-neonatal mortality rate in Navajo County fluctuates anywhere from 2.7 to 6.0. Navajo County Community Health Status Assessment 79 Category 8 - Maternal and Child Health Table 8.9 Fetal Deaths out of Total Pregnancies in Navajo County and Arizona: By Age Group (2004-2008) Year Region Navajo County 2004 Arizona Navajo County 2005 Arizona Navajo County 2006 Arizona Navajo County 2007 Arizona Navajo County 2008 Arizona Deaths vs. Total Pregnancies Total <15 15-19 20-29 30-39 40-44 45+ Not Known Total Pregnancies 1,874 1 352 1,025 453 39 2 2 Fetal Deaths 15 0 2 4 9 0 0 0 Total Pregnancies 106,252 233 13,930 58,451 30,854 2,299 133 352 Fetal Deaths 555 1 79 253 199 19 1 3 Total Pregnancies 1,969 6 350 1,058 490 60 1 4 Fetal Deaths 15 0 2 7 6 0 0 0 Total Pregnancies 106,776 239 13,659 58,972 31,113 2,203 149 441 Fetal Deaths 532 0 73 266 170 17 2 4 Total Pregnancies 1,937 3 322 1,117 451 44 0 0 Fetal Deaths 13 0 3 5 4 1 0 0 Total Pregnancies 113,091 242 14,676 62,852 32,603 2,370 226 3 Fetal Deaths 543 3 80 255 171 26 5 3 Total Pregnancies 2,078 3 352 1,182 489 45 7 0 Fetal Deaths 15 0 1 7 6 0 1 0 Total Pregnancies 113,756 325 14,713 62,641 33,314 2,431 308 24 Fetal Deaths 583 3 84 296 180 15 3 2 Total Pregnancies 2,018 7 374 1,128 462 44 3 0 Fetal Deaths 15 0 3 6 6 0 0 0 Total Pregnancies 110,115 230 13,817 60,377 32,946 2,301 151 333 Fetal Deaths 544 2 71 273 176 18 2 2 Advance Vital Statistics by County of Residence, Arizona Department of Health Services, 2004-2008. 11/10/09. [http://www.azdhs.gov/plan/report/ahs/ahs2004/pdf/5a4.pdf] Table 8.10 Child Mortality (Number) in Navajo County (2004-2008) Age Group 2004 Navajo County Arizona 2005 Navajo County Arizona 2006 Navajo County Arizona 2007 Navajo County Arizona 2008 Navajo County Arizona 1-4 5 108 2 126 8 144 2 111 4 128 5-9 3 57 4 84 2 55 5 61 0 66 10-14 4 83 5 75 4 79 2 84 2 68 Total 12 248 11 285 14 278 9 256 6 262 Advance Vital Statistics by County of Residence, Arizona Department of Health Services, 2004-2008. 11/9/09 [http://www.azdhs.gov/plan/menu/for/deathscounty.htm] 80 Navajo County Community Health Status Assessment Category 8 - Maternal and Child Health Table 8.11 Child Mortality Rate (Per 100,000) in Navajo County (2004-2006) Year Navajo County Arizona United States Number Rate Number Rate Number Rate 2004 12 40.7 248 20.4 11,619 20 2005 11 36.4 285 22.7 11,358 20 2006 14 50.8 278 21.5 10,780 19 Advance Vital Statistics by County of Residence, Arizona Department of Health Services, 2004-2006. 11/9/09 [http://www.azdhs.gov/plan/menu/for/deathscounty. htm] Kids Count Data Center, 2004-2006. 11/9/09 [http://datacenter.kidscount.org/data/ Fetal Deaths and Child Mortality Table 8.12 Top Four Causes of Death Among Children Ages 1-14 (2004-2008) Year 2004 2005 2006 2007 2008 Cause of Death Navajo County Arizona Accidents (unintentional injury) 3 98 Malignant Neoplasm 0 22 Assault (homicide) 1 18 Congenital Malformations 2 18 Total, all causes* 12 248 Accidents (unintentional injury) 5 112 Malignant Neoplasm 0 24 Assault (homicide) 0 18 Congenital Malformations 1 23 Total, all causes* 11 285 Accidents (unintentional injury) 8 102 Malignant Neoplasm 0 17 Assault (homicide) 1 15 Congenital Malformations 0 28 Total, all causes* 14 278 Accidents (unintentional injury) 5 96 Malignant Neoplasm 0 42 Assault (homicide) 1 18 Congenital Malformations 0 13 Total, all causes* 9 256 Accidents (unintentional injury) 3 77 Malignant Neoplasm 0 30 Assault (homicide) 0 14 Congenital Malformations 0 22 Total, all causes* 6 262 Advance Vital Statistics by County of Residence, Arizona Department of Health Services, 20042008. 11/10/09. [http://www.azdhs.gov/plan/report/ahs/ahs2004/5e.htm] * Indicates all causes of death including the ones not listed in the table Navajo County Community Health Status Assessment 81 Category Nine - Death, Illness and Injury Definition of Indicator Health status in a community is measured in terms of mortality (rates of death within a population) and morbidity (rates of the incidence and prevalence of disease). Mortality may be represented by crude rates or age-adjusted rates (AAM); by degree of premature death (Years of Productive Life Lost or YPLL); and by cause (disease - cancer and non-cancer or injury - intentional, unintentional). Morbidity may be represented by age-adjusted (AA) incidence of cancer and chronic disease. gov) the self-rated health status (percent of adults who report fair of poor health) reported by Navajo County Residents was 16.5%. Navajo County residents’ self-reported health status is slightly better than the median for all Counties in the United States (17.1%) and falls within the range of peer counties (16.5%-29.4) (Data in the CHSR came from BRFSS 2000-2005). Average Number of Sick Days within the Last Month According to the CHSR the average number of unhealthy days experienced by Navajo County residents in the past month (as reported by the Trends The self-rated health status for residents of Na- NCHS Vital Statistics Reporting System, 1999vajo County is slightly higher than the median for 2003) was six days. This number is the same as US counties. In 2008, diabetes and cancer were the national average for all counties in the United considered respectively the third and fourth more States (six days) and falls within the normal range important health problems in the county. Data among peer counties (5.5 days to 8.7 days). from 2005 shows the high incidence of oral cancer Table 9.2 in Navajo County for males and females, a fact that could be related to smoking as a behavioral Average Number of Unhealthy Days in the risk factor in Navajo County. Last Month (2008) General Health Status According to the Community Health Status Report (CHSR) (CDC, 2008 communityhealth.hhs. Table 9.0 Average Number of Unhealthy Days in the Last Month Peer Counties U.S. Median Navajo County 5.5-8.7 6.0 6.0 Community Health Status Report, Navajo County, AZ (2008) Community and Person Health (Navajo County, AZ) Health Status Overall Health of Community Your Own Personal Health Very Unhealthy 4.50% 1.50% Unhealthy 21.80% 5.00% Somewhat Healthy 58.50% 40.50% Healthy 13.40% 43.80% Very Healthy 1.90% 9.30% Total Respondents 1,078 1,081 Table 9.1 Self-Rated Health Status (2008) Percent of Adults who Report Fair or Poor Health Peer Counties U.S. Median Navajo County 16.5%- 29.4% 17.1% 16.5% Community Health Status Report, Navajo County, AZ (2008) 82 Navajo County Community Health Status Assessment Category 9 - Death, Illness and Injury Table 9.3 Mortality: Total Number of Deaths (2005-2008) Years 2005 Age Groups 2006 2007 2008 Navajo County Arizona Navajo County Arizona Navajo County Arizona Navajo County Arizona Adolescents (15-19) 15 346 20 412 13 342 10 297 Young Adults (20-44) 103 3,121 126 3,258 116 3,120 101 2,829 Middle Aged (45-64) 193 8,524 180 8,618 189 8,629 203 8,899 Elderly (65+) 462 32,163 511 32,192 539 31,582 456 32,214 Total Deaths 773 44,154 837 44,480 857 43,673 770 44,239 Advance Vital Statistics by County of Residence, Arizona (2005-2008) Table 9.4 Number of Unintentional Injuries Resulting in Death (2005-2008) Years Accidents Region Navajo County Total Accidents Arizona Navajo County Transport Accidents Arizona Navajo County Motor Vehicle Accidents Arizona Other Land Transport Accidents Navajo County Arizona Sex 2005 2006 2007 2008 Male 69 68 80 65 Female 28 32 33 30 Combined 97 100 113 95 Male 1,921 2,026 1,890 1,608 Female 1,085 1,130 1,124 940 Combined 3,006 3,156 3,014 2,548 Male 39 34 46 29 Female 16 21 17 16 Combined 55 55 63 45 Male 859 913 770 704 Female 349 412 344 267 Combined 1,208 1,325 1,114 971 Male 38 30 43 28 Female 16 20 17 15 Combined 54 50 60 43 Male 801 831 710 621 Female 336 389 325 253 Combined 1,137 1,220 1,035 874 Male 0 3 2 1 Female 0 1 0 1 Combined 0 4 2 2 Male 20 34 17 28 Female 5 4 6 3 Combined 25 38 23 31 Navajo County Community Health Status Assessment 83 Category 9 - Death, Illness and Injury Number of Unintentional Injuries Resulting in Death (2005-2008) Navajo County Water, Air, Space Arizona Navajo County Non-Transport Accidents Arizona Navajo County Falls Arizona Accidental Discharge of Firearms Accidental Drowning and Submersion Accidental Expose to Smoke, Fire and Flames 84 Navajo County Arizona Navajo County Arizona Navajo County Arizona Male 1 1 1 0 Female 0 0 0 0 Combined 1 1 1 0 Male 38 48 43 55 Female 8 19 13 11 Combined 46 67 56 66 Male 30 34 34 36 Female 12 11 16 14 Combined 42 45 50 50 Male 1,062 1,113 1,120 904 Female 736 718 780 673 Combined 1,798 1,831 1,900 1,577 Male 5 7 9 9 Female 7 2 6 4 Combined 12 9 15 13 Male 308 338 329 344 Female 377 364 391 396 Combined 685 702 720 740 Male 2 0 0 0 Female 0 0 0 0 Combined 2 0 0 0 Male 10 6 12 7 Female 5 3 1 2 Combined 15 9 13 9 Male 4 0 1 3 Female 1 0 1 0 Combined 5 0 2 3 Male 63 71 65 56 Female 26 21 23 14 Combined 89 92 88 70 Male 1 5 1 4 Female 0 1 0 0 Combined 1 6 1 4 Male 36 27 18 29 Female 20 16 13 17 Combined 56 43 31 46 Navajo County Community Health Status Assessment Category 9 - Death, Illness and Injury Number of Unintentional Injuries Resulting in Death (2005-2008) Navajo County Accidental Poisoning Arizona Male 2 10 11 6 Female 2 4 6 6 Combined 4 14 17 12 Male 376 441 489 293 Female 187 205 232 138 Combined 563 646 721 431 Mortality Years of Productive Life Lost (YPLL) Premature death is measured by the number 100,000 of the population, which is 43 years more of YPLL due to death before age 75(as defined by per 100,000 of the population than the 2004. Arith the Centers for Disease Control and Prevention’s zona ranked 30 in the nation for premature death Years of potential Life Lost [YPLL-75]). For ex- with 7,930 years lost per 100,000 of the population ample the death of a 25 year old would account for (United Health Foundation, America’s Health rank50 years of productive life lost. The U.S. national ings, Premature Death, accessed 12/9/09 from http://wwwunitedhealthfoundation.net/shr2005/ average in 2005 was 7,564 years lost per components/prematuredeath.html). Table 9.5 Number of Cardiovascular Disease Cases Resulting in Death (2005-2008) Years Cause of Death Region Navajo County Major Cardiovascular Diseases Arizona Navajo County Diseases of Heart Arizona Acute Rheumatic fever and Chronic Rheumatic Heart Disease Navajo County Arizona Sex 2005 2006 2007 2008 Male 106 113 108 108 Female 84 92 98 88 Combined 190 205 206 196 Male 7,238 6,866 6,733 6,909 Female 6,908 6,624 6,462 6,222 Combined 14,146 13,490 13,195 13,131 Male 83 96 88 90 Female 56 72 64 61 Combined 139 168 152 151 Male 5,789 5,538 5,455 5,535 Female 4,990 4,824 4,692 4,517 Combined 10,779 10,362 10,147 10,052 Male 0 0 0 1 Female 1 1 0 0 Combined 1 1 0 1 Male 16 15 15 24 Female 39 42 23 33 Combined 55 57 38 57 Navajo County Community Health Status Assessment 85 Category 9 - Death, Illness and Injury Number of Cardiovascular Disease Cases Resulting in Death (2005-2008) Navajo County Hypertensive Heart Disease Arizona Hypertensive Heart and Renal Disease Navajo County Arizona Navajo County Ischemic Heart Disease Arizona Navajo County Acute Myocardial Infection Arizona Other Acute Ischemic Heart Disease Navajo County Arizona Other Forms of Chronic Ischemic Heart Disease Navajo County Arizona Atherosclerotic Cardiovascular Disease Navajo County Arizona 86 Male 3 0 2 4 Female 2 2 2 0 Combined 5 2 4 4 Male 226 256 332 322 Female 261 250 314 314 Combined 487 506 646 636 Male 0 0 0 1 Female 1 0 0 1 Combined 1 0 0 2 Male 18 13 15 22 Female 21 11 14 26 Combined 39 24 29 48 Male 65 74 61 67 Female 39 53 42 38 Combined 104 127 103 105 Male 4,509 4,202 4,005 4,225 Female 3,551 3,426 3,158 3,101 Combined 8,060 7,628 7,163 7,326 Male 22 30 26 24 Female 12 16 23 10 Combined 34 46 49 34 Male 1,117 988 891 966 Female 916 835 782 689 Combined 2,033 1,823 1,673 1,655 Male 1 2 4 3 Female 0 0 1 0 Combined 1 2 5 3 Male 26 14 21 20 Female 11 10 9 8 Combined 37 24 30 28 Male 42 42 31 40 Female 27 37 18 28 Combined 69 79 49 68 Male 3,366 3,200 3,093 3,239 Female 2,624 2,581 2,367 2,404 Combined 5,990 5,781 5,460 5,643 Male 19 13 6 12 Female 8 13 3 6 Combined 27 26 9 18 Male 1,102 1,119 1,041 1,066 Female 875 824 687 718 Combined 1,977 1,943 1,728 1,784 Navajo County Community Health Status Assessment Category 9 - Death, Illness and Injury Number of Cardiovascular Disease Cases Resulting in Death (2005-2008) All Other Forms of Chronic Ischemic Heart Disease Navajo County Arizona Navajo County Other Heart Diseases Arizona Acute and Subacute Endocarditis Navajo County Arizona Diseases of Pericardium and Acute Myocarditis Navajo County Arizona Navajo County Heart Failure Arizona Navajo County All Other Forms of Heart Failure Arizona Male 23 29 25 28 Female 19 24 15 22 Combined 42 53 40 50 Male 2,264 2,080 2,052 2,173 Female 1,749 1,757 1,680 1,686 Combined 4,013 3,837 3,732 3,859 Male 15 22 25 17 Female 13 16 20 22 Combined 28 38 45 39 Male 1,020 1,052 1,088 942 Female 1,118 1,095 1,183 1,043 Combined 2,138 2,147 2,271 1,985 Male 0 0 1 0 Female 0 0 0 1 Combined 0 0 1 1 Male 17 14 19 14 Female 6 10 14 16 Combined 23 24 33 30 Male 0 0 0 0 Female 2 0 0 0 Combined 2 0 0 0 Male 5 10 8 8 Female 11 4 7 5 Combined 16 14 15 13 Male 2 6 6 4 Female 3 4 4 7 Combined 5 10 10 11 Male 295 325 302 255 Female 431 410 357 336 Combined 726 735 659 591 Male 13 16 18 13 Female 8 12 16 14 Combined 21 28 34 27 Male 703 703 759 665 Female 670 671 805 686 Combined 1,373 1,374 1,564 1,351 Advance Vital Statistics by County of Residence, Arizona (2005-2008) Navajo County Community Health Status Assessment 87 Category 9 - Death, Illness and Injury Table 9.6 Number of Chronic Obstructive Lung Disease Cases Resulting in Death (2005-2008) Years Cause of Death Chronic Lower Respiratory Disease Region Navajo County Arizona Bronchitis, Chronic and Unspecified Navajo County Arizona Navajo County Emphysema Arizona Navajo County Asthma Arizona Other Chronic Lower Respiratory Diseases Navajo County Arizona Sex 2005 2006 2007 2008 Male 2 19 26 21 Female 0 13 12 22 Combined 2 32 38 43 Male 1,301 1,343 1,281 1,394 Female 1,477 1,428 1,370 1,502 Combined 2,778 2,771 2,651 2,896 Male 0 0 0 0 Female 0 0 0 0 Combined 0 0 0 0 Male 6 3 1 2 Female 5 5 3 5 Combined 11 8 4 7 Male 2 4 2 4 Female 3 1 4 4 Combined 5 5 6 8 Male 200 171 140 145 Female 185 178 142 113 Combined 385 349 282 258 Male 0 0 3 0 Female 1 0 0 1 Combined 1 0 3 1 Male 28 32 21 14 Female 45 41 38 33 Combined 73 73 59 47 Male 20 15 21 17 Female 10 12 8 17 Combined 30 27 29 34 Male 1,067 1,137 1,119 1,233 Female 1,242 1,204 1,187 1,351 Combined 2,309 2,341 2,306 2,584 Advance Vital Statistics by County of Residence, Arizona (2005-2008) 88 Navajo County Community Health Status Assessment Category 9 - Death, Illness and Injury Table 9.7 Cancer Death Rates (2005-2008) Years Region Navajo County 2005 Arizona Navajo County 2006 Arizona Navajo County 2007 Arizona Navajo County 2008 Arizona Sex Breast Cancer Lung Cancer Cervical Cancer Colorectal Cancer Prostate Cancer Male 0 11 0 7 10 Female 10 9 1 5 0 Combined 10 20 1 12 10 Male 7 1,461 0 490 564 Female 670 1,146 65 425 0 Combined 677 2,607 65 915 564 Male 0 20 0 4 12 Female 11 11 3 9 0 Combined 11 31 3 13 12 Male 6 1,528 0 495 522 Female 739 1,190 54 422 0 Combined 745 2,718 54 914 522 Male 0 20 0 11 16 Female 13 17 1 4 0 Combined 13 37 1 15 16 Male 6 1,443 0 535 548 Female 718 1,130 62 431 0 Combined 724 2,573 62 966 548 Male 0 20 0 8 11 Female 11 16 1 8 0 Combined 11 36 1 16 11 Male 9 1,477 0 466 568 Female 725 1,155 60 430 0 Combined 734 2,632 60 896 568 Table 9.8 Oral Cancer Rates (2005) Oral Cancer (Lip, Oral Cavity and Pharynx) Navajo County Arizona Male Rate 17.23% 11.04% Female Rate 7.25% 4.08% Male Death Rate Not Available 3.44% Female Death Rate Not Available 1.25% Proportion of cases detected at earliest stage Not Available 30.8% * Rates per 100,000 population, Arizona Department of Health Services, Office of Oral Health (2005) Navajo County Community Health Status Assessment 89 Category 9 - Death, Illness and Injury Table 9.9 Total Number of Cases of Pneumonia/Influenza Resulting in Death (2005-2008) Years Cause of Death Pneumonia and Influenza Region Navajo County Arizona Navajo County Pneumonia Arizona Navajo County Influenza Arizona Sex 2005 2006 2007 2008 Male 21 16 17 11 Female 22 13 8 11 Combined 43 29 25 22 Male 633 579 433 515 Female 647 568 442 545 Combined 1,280 1,147 875 1,060 Male 20 16 17 11 Female 21 13 8 11 Combined 41 29 25 22 Male 623 569 428 507 Female 624 560 439 534 Combined 1,247 1,129 867 1,041 Male 1 0 0 0 Female 1 0 0 0 Combined 2 0 0 0 Male 10 10 5 8 Female 23 8 3 11 Combined 33 18 8 19 Advance Vital Statistics by County of Residence, Arizona (2005-2008) 90 Navajo County Community Health Status Assessment Category 9 - Death, Illness and Injury Table 9.10 Chronic Liver Disease and Cirrhosis Resulting in Death (2005-2008) Years Cause of Death Chronic Liver Disease and cirrhosis Alcoholic Liver Disease Region Navajo County Arizona Navajo County Arizona Other Chronic Liver Disease and Cirrhosis Navajo County Arizona Sex 2005 2006 2007 2008 Male 12 12 11 13 Female 11 12 14 8 Combined 23 24 25 21 Male 498 426 481 479 Female 251 280 253 281 Combined 749 706 734 760 Male 10 9 10 10 Female 8 10 7 5 Combined 18 19 17 15 Male 305 282 309 349 Female 119 128 133 161 Combined 424 410 442 510 Male 2 3 1 3 Female 3 2 7 3 Combined 5 5 8 6 Male 193 144 172 130 Female 132 152 120 120 Combined 325 296 292 250 Advance Vital Statistics by County of Residence, Arizona (2005-2008) Table 9.11 Number of Cases of Diabetes Mellitus Resulting in Death (2005-2008) Years Cause of Death Region Navajo County Diabetes Arizona Sex 2005 2006 2007 2008 Male 19 16 23 12 Female 11 12 9 15 Combined 30 28 32 27 Male 641 632 629 625 Female 555 556 516 522 Combined 1,196 1,188 1,145 1,147 Advance Vital Statistics by County of Residence, Arizona (2005-2008) Navajo County Community Health Status Assessment 91 Category 9 - Death, Illness and Injury According to the 2008 CTSA, diabetes (35.7%) and cancer were cited as the third and fourth (respectively) most important health problems among Navajo County residents (N=1,084). Table 9.12 Stroke Rate Resulting in Death (2008) Year Navajo County Rate U.S. Rate (2003) Healthy People 2010 Target 2008 58.8% 53.0% 50.0% Community Health Status Report, CDC, Navajo County (2008) 92 Navajo County Community Health Status Assessment Category Ten - Communicable Diseases Definition of Indicator Measures within this category include diseases which are usually transmitted through person-toperson contact or shared use of contaminated instruments / materials. Many of these diseases can be prevented through a high level of vaccine coverage of vulnerable populations, or through the use of protective measures, such as condoms for the prevention of sexually-transmitted diseases. Trends Navajo County has low incidences of Hantavirus Pulmonary Syndrome (HPS), Rocky Mountain Spotted Fever (RMSF), Hepatitis A, and Syphilis. The estimated percentage of Arizona children (aged 24-35 months) who received timely vaccinations ranges from 19.8% (Meningitis Vaccine) to 72.5% (Measles, Mumps, and Rubella) dependent on the vaccination type. Chlamydia rates in Navajo County are highest among 15 to 29 year -olds, with rates higher among females. Chlamydia rates are slightly higher among females in Navajo County when compared to the state. Reported cases of Genital Herpes are nearly two times higher among males aged 20-24 in Navajo County when compared to state rates among males. Reported cases of Genital Herpes among females age 30-34 in Navajo County are considerably higher (124.8 cases per 1000,000) than the state rates (71.1 cases per 100,000). Hantavirus & RMSF (Rocky Mountain Spotted Fever) Hantavirus Pulmonary Syndrome (HPS) According to the Centers for Disease Control and Prevention (CDC), HPS is a deadly disease from rodents. Humans can contract the disease when they come into contact with infected rodents or their urine and droppings. HPS was first recognized in 1993 and has since been identified throughout the United States. Although rare, HPS is potentially deadly. Rodent control in and around the home remains the primary strategy for preventing hantavirus infection. Table 10.0 Estimated Percentages of Children Aged 24-35 Months who Received Timely Vaccinations in Arizona (2000-2002) All Doses As Recommendeda Un-weighted Same Size 4 DPT (Tetanus, Diphtheria, Pertussis)b 3 Polio (Polio)c MMR (Measles, 3 Hep B (Hepatitis 3-4 Hib (Meningitis Mumps, Rubella)d B)e Vaccine)f 1238 20.4% 44.5% 72.5% 64.5% 19.8% National Immunization Survey (2000-2002) Luman et al. (2005). Timeless of Childhood Immunizations: A State-Specific Analysis. Research and Practice. American Journal of Public Health (2008) 95(8):1367-1374. a Recommended age for routine administration approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics. And the American Academy of Family Physicians. b 4 doses of diphtheria and tetanus toxoids and acellular or whole-cell pertussis vaccine. c 3 doses of poliovirus vaccine. d 1 dose of measles –mumps-rubella vaccine. e 3 doses of hepatitis B vaccine f 3-4 doses of Haemophilus influenzae type b vaccine, as appropriate. Navajo County Community Health Status Assessment 93 Category 10 - Communicable Diseases Most Hantaviruses that cause human infections is the Sin Nombre Virus that is transmitted primarily through deer mice. Individuals are often exposed to the virus while working with dust in mouse contaminated environments. People living in rural areas are at the highest risk due to infected wild mice. Maricopa (7), Coconino (5), La Paz (1), and Pinal (1). The most vulnerable individuals are between the ages of 13-71. Sixty-three percent of infected were males and 33% were fatal. In 2008, there has been one adult female that was reported to have been infected with HPS in Arizona. The 2008 case occurred in a rural area (Arizona Department of Health Services. Bureau of Epidemiology and Between 1998 and 2007, there have been 20 Disease Service, Office of Infectious Disease Sercases of HPS in Arizona. Cases were reported in vices, Vector-Borne & Zoonotic Disease). the following counties: Apache (18), Navajo (8), Table 10.1 Have you ever had a pneumonia shot? (2003-2007) 27.4% 13,562 21.7% 15,492 21.6% 21,645 28.7% No 47,975 72.9% 43,985 68.3% 44,023 70.3% 48,256 67.2% 46,959 62.4% Don’t Know/ 2,768 Not Sure 4.2% 4,478 7.0% 5,023 8.0% 8,096 11.3% 6.692 8.9% Total 100.0% 64,388 100.0% 62,609 100.0% 71,843 100.0% 75,296 100.0% Percent Frequency 15,925 Percent 22.9% Percent 15,032 65,775 Frequency 2007 Yes BRFSS (2003-2007) Frequency 2006 Percent 2005 Frequency 2004 Percent Response Frequency Years 2003 Table 10.2 During the past 12 months, have you had a flu shot? (2003-2007) Percent Frequency Percent 19,654 29.9% 21,171 32.9% 16,970 27.1% 18,434 25.7% 36,040 47.9% No 46,010 70.0% 43,217 67.1% 45,394 72.5% 53,409 74.3% 39,255 52.1% Don’t Know/ Not Sure 111 Not Available Not 244 Available Not Available Not Available Not Available Not Available Total 65,775 100.0% 64,388 100.0% 71,843 100.0% 75,295 100.0% BRFSS (2003-2007) 94 62,608 Percent Frequency 2007 Yes 0.2% Frequency 2006 Percent 2005 Frequency 2004 Percent Response Frequency Years 2003 0.4% Navajo County Community Health Status Assessment Category 10 - Communicable Diseases Rocky Mountain Spotted Fever (RMSF) RMSF is a potentially life threatening tick-borne disease that is caused by the bacteria Rickettsia Rickettsii. During 2003 and 2004, an outbreak of RMSF occurred in the White Mountains region of eastern Arizona. The CDC collected and tested ticks, dogs, blood and human blood. Case followups resulted in the identification of a new tick vector for RMSF, called the Brown Dog Tick (Rhipicephalus Sanguineus). Seventy cases of RMSF have been reported in eastern Arizona from 2002-2008. There were cases reported in Gila, Graham, and Navajo counties. There were 17 reported cases in 2008, nine were children and ten cases were male. Reported cases ranged from the ages of 1-75 years old. Two of the reported cases were fatal (Arizona Department of Health Services. Bureau of Epidemiology and Disease Service, Office of Infectious Disease Services, Vector-Borne & Zoonotic Disease). Table 10.3 Have You Ever Had A Pneumonia Shot? (2003-2007) Years 15,925 27.4% 13,562 21.7% 15,492 21.6% 21,645 28.7% No 47,975 72.9% 43,985 68.3% 44,023 70.3% 48,256 67.2% 46,959 62.4% Don’t Know/ Not Sure 2,768 4.2% 4,478 7.0% 5,023 8.0% 8,096 11.3% 6.692 8.9% Total 65,775 100.0% 64,388 100.0% 62,609 100.0% 71,843 100.0% 75,296 100.0% Percent Frequency 22.9% Percent 15,032 Percent Frequency 2007 Yes BRFSS (2003-2007) Frequency 2006 Percent 2005 Frequency 2004 Percent Frequency 2003 Table 10.4 During the past 12 months, have you had a nasal spray vaccine (FluMist™)? (2003-2007) Percent Frequency 2007 Percent Frequency 2006 Percent Frequency 2005 Percent 2004 Frequency Percent Response Frequency Years 2003 Yes N/A N/A N/A N/A N/A N/A 195 0.3% N/A N/A No N/A N/A 64,155 99.6% 62,438 99.7% 71,649 99.7% 74,940 99.5% Don’t Know/ Not Sure N/A N/A 233 0.4% 171 0.3% N/A N/A 356 0.5% Total N/A N/A 64,388 100.0% 62,609 100.0% 71,844 100.0% 75,296 100.0% BRFSS (2003-2007) N/A indicates that the data was not available. Navajo County Community Health Status Assessment 95 Category 10 - Communicable Diseases Table 10.5 Have you ever been tested for HIV? (2003-2007) Years 13,822 26.6% 13,908 27.9% 16,020 27.2% 13,612 22.4% No 30,621 58.0% 37,582 72.2% 35,235 70.8% 41,973 71.2% 46,862 77.2% Don’t Know Not Sure 541 1.0% 645 1.2% 636 1.3% 967 1.6% 258 0.4% Refused 932 1.8% N/A N/A N/A N/A N/A N/A N/A N/A Total 52,816 100.0% 52,049 100.0% 49,779 100.0% 58,960 100.0% 60,732 100,0% Percent Frequency 39.2% Percent Percent 20,722 BRFSS (2003-2007) NA indicates that the data was not available. Frequency Frequency 2007 Percent 2006 Yes Response Frequency 2005 Percent 2004 Frequency 2003 Table 10.6 Reported Chlamydia Case Rate per 100,000 Population, Navajo County 2006-2008* Arizona Age Group Male Navajo County Female 2006 2007 2008 2006 2007 <10 11 12 3.6 27 25 10-14 24 34 19.8 221 278 15-19 1266 1476 679.2 6180 20-24 1958 2132 25-29 1198 30-34 Male 2008 Female 2006 2007 2008 2006 2007 2008 7.2 0 0 10.7 0 1 11.0 110.3 2 2 0.0 8 13 212.5 6596 3,065.3 37 26 573.9 157 155 3,174.9 937.6 6732 6418 3,014.3 27 22 906.1 156 131 3,646.2 1222 494.9 3035 3072 1,220.1 18 12 551.2 74 62 1,560.5 511 533 249.4 1253 1338 538.1 5 8 196.5 34 47 998.4 35-39 279 295 141.8 540 562 268.6 6 6 98.5 20 18 504.6 40-44 179 144 81.3 270 262 108.3 9 5 339.2 14 11 320.6 45-49 82 116 40.5 99 126 44.6 1 3 0.0 6 3 154.6 50-54 30 50 24.6 49 63 32.0 0 3 31.1 1 2 139.5 55-59 20 20 9.6 21 32 14.9 1 0 0.0 1 1 95.1 60-64 16 7 7.2 15 7 3.9 2 0 0.0 2 0 0.0 ≥65 10 13 3.2 16 11 4.1 0 11 0.0 0 0 0.0 Navajo County Case Rate= 522.7 per 100,000 population, AZ Department of Health Services, STD Control Program (2006-2008) * 2006 and 2007 list actual counts of cases. 96 Navajo County Community Health Status Assessment Category 10 - Communicable Diseases Table 10.7 Reported Gonorrhea Case Rate per 100,000 Population, Navajo County 2006-2008* Arizona Age Group Navajo County Male 2006 Female 2007 2008 2006 Male 2007 2008 2006 Female 2007 2008 <10 4 8 0.4 7 9 1.3 0 0 0.0 10-14 7 14 3.0 38 32 8.4 0 0 0.0 15-19 473 437 123.4 802 709 216.9 22 6 129.6 20-24 843 713 218.2 889 738 263.1 14 13 144.2 25-29 638 603 155.2 578 402 110.5 6 8 95.9 30-34 389 286 86.7 229 213 52.0 4 3 32.7 35-39 284 229 77.8 149 110 37.3 6 2 32.8 40-44 203 179 43.7 82 62 18.4 1 0 28.3 45-49 121 135 30.2 47 37 11.2 1 1 0.0 50-54 76 68 24.1 12 18 5.9 0 0 0.0 55-59 36 28 11.3 3 4 0.0 0 0 0.0 60-64 15 9 6.4 3 4 2.0 0 0 0.0 2006 0 1 26 23 9 4 1 2 1 0 0 0 0 2007 0 0 14 14 11 7 5 0 0 2 0 0 0 2008 11.0 58.0 281.8 180.1 100.7 62.4 94.6 0.0 51.5 0.0 0.0 0.0 0.0 ≥65 10 9 2.9 0 1 0.9 0 0 0.0 Arizona Case Rate= 52.9 per 100,000 Population. Does not include cases where gender was unknown. Arizona Department of Health Services- STD Control Program (2006-2008) * 2006 and 2007 list actual counts of cases. Table 10.8 Reported Syphilis Case Rates per 100,000 Population, Navajo County 2006-2008* Arizona Age Group Male Navajo County Female Male Female 2006 2007 2008 2006 2007 2008 2006 2007 2008 <10 0 0 2.2 1 0 3.0 0 0.0 10-14 0 1 0.0 0 2 0.4 0 0.0 15-19 17 20 10.3 26 36 13.3 0 0.0 20-24 65 108 36.9 47 66 38.9 3 0.0 25-29 104 128 58.9 50 71 33.1 1 24.0 30-34 110 135 65.8 26 70 28.3 4 0.0 35-39 102 116 62.2 42 47 21.2 1 0.0 40-44 95 137 68.2 21 30 20.2 1 28.3 45-49 70 85 48.2 15 18 8.9 0 0.0 50-54 28 27 40.5 10 11 8.4 0 0.0 55-59 19 47 16.3 9 11 8.0 0 33.8 60-64 6 15 14.3 1 4 5.2 --------------------------- 0 0.0 2006 --------------------------- 2007 0 0 1 0 0 1 0 0 0 0 0 0 0 2008 0.0 0.0 0.0 45.0 0.0 0.0 0.0 53.4 0.0 0.0 0.0 0.0 0 0.0 0.0 ≥65 12 2.6 5 4 0.9 Arizona Case Rate= 21.4 per 100,000 Population. Does not include transgendered persons. 51 cases from unknown counties were distributed based on Provider County. Arizona Department of Health Services- STD Control Program (2006-2008) * 2006 and 2007 list actual counts of cases. Navajo County Community Health Status Assessment 97 Category 10 - Communicable Diseases Table 10.9 Reported Genital Herpes Case Rates per 100,000 Population, Navajo County 2007-2008* Arizona Age Group Male 2007 Navajo County Female 2008 2007 Male 2008 2007 Female 2008 2007 2008 <10 6 2.6 9 3.6 0 21.3 1 0.0 10-14 1 0.0 10 5.3 0 0.0 0 0.0 15-19 54 13.3 136 66.8 1 0.0 3 37.6 20-24 135 47.0 258 114.2 2 82.4 5 45.0 25-29 169 50.5 228 95.6 0 24.0 2 0.0 30-34 123 28.5 153 71.1 0 0.0 2 124.8 35-39 90 30.4 145 65.0 2 32.8 4 63.1 40-44 69 25.4 81 46.3 2 56.5 2 26.7 45-49 43 17.6 72 32.1 2 0.0 1 51.5 50-54 21 13.3 56 23.7 0 31.1 3 27.9 55-59 27 10.7 31 19.6 1 33.8 2 0.0 60-64 25 19.3 20 11.7 0 0.0 1 0.0 ≥65 16 4.5 24 6.2 0 0.0 2 0.0 Arizona case rate= 28.4 per 100,000 Population. Newly reported cases do not include unknown gender. 103 cases from unknown counties were distributed based on Provider County. Arizona Department of Health Service- STD Control Program (2007-2008) *2007 lists counts of cases Table 10.10 Ever Received the Hepatitis B Vaccine* (Navajo County, 2006-2007) Responses 2006 2007 Frequency Percent Frequency Yes 27,295 38.2 28,946 38.4 Percent No 34,236 47.9 34,880 46.3 Don’t Know/ Not Sure 10,013 14.0 11,470 15.2 Refused 0 0 0 0 Total 71,544 100.0 75,296 100.0 *The Hepatitis B vaccine is completed after the third shot is given. (2006-2007) BRFSS, Arizona 98 Navajo County Community Health Status Assessment Category 10 - Communicable Diseases Table 10.11 Reported Infectious Disease Case Rates per 100,000 Population, Navajo County, 2004-2008 Case Rate Case Types 2004 2005 2006 2007 2008 Navajo Navajo Navajo Navajo Navajo Arizona Arizona Arizona Arizona Arizona County County County County County Syphilis-Total 13.0 17.1 7.3 13.1 6.2 14.9 10.4 19.3 7.0 21.4 Total Tuberculosis (TB) 3.8 4.7 0.0 4.6 2.7 5.0 4.3 4.7 2.6 3.5 Hepatitis A 0.9 4.6 1.8 3.2 1.8 2.9 0.9 2.4 1.7 1.8 Hepatitis B (acute) 7.4 5.0 7.3 6.2 6.2 6.0 0.9 2.8 3.5 2.5 Source: ADHS Health Status and Vital Statistics by County of Residence (2003-2008) Hepatitis A (United States) The Hepatitis A vaccine has been available in the U.S. since 1995. In 2006 the Advisory Committee on Immunization Practices (ACIP) recommended that the Hepatitis A vaccine become part of the routine vaccination of children in all 50 states. Risk factors for Hepatitis A include international travel (18% of all reported cases), sexual and household contact with a person infected with Hepatitis A (8% of reported cases), Males who have sex with males (MSM) (6% of reported cases), Injection-drug use (IDU) accounted for 1% of infections. Historically, Hepatitis A rates have varied cyclically with a nationwide increase every 15 years. In 2007, the lowest U.S. incidence rate ever was recorded (1.0 case per 100,000) (Department of Health and Human Services and Centers for Disease Control, MMWR, Surveillance Summaries for Viral Hepatitis, United States, 2007, May 22, 2009 Vol. 58 No.SS-3). In 2007 the incidence among males in the U.S. was 1.1 cases per 100,000 of the population compared with 0.9 cases per 100,000 of the female population. The difference in rates by sex was highest among persons aged 35-49. Rates of Hepatitis A vary historically in terms of race/ethnicity with the highest rates among American Indian Table 10.12 Are Any of These Statements True* (Regarding behaviors related to Hepatitis B) Navajo County, 2007 2007 Responses Frequency Percent Yes, at least one statement is true 3,219 4.3 No, none of these statements is true 72,076 95.7 Don’t Know/ Not Sure 0 0 Refused 0 0 Total 75,296 100.0 (2007) Behavioral Risk Factor Surveillance System (BRFSS) Questionnaire, Arizona. *Statements about behaviors relating to hepatitis B: 1).You have hemophilia and have received clotting factor concentrate 2). You have had sex with a man who has had sex with other men, even just one time 3). You have taken street drugs by needle, even just one time 4). You traded sex for money or drugs, even just one time 5). You have tested positive for HIV 6). You have had sex (even just one time) with someone who would answer “yes” to any of these statements 7). You had more than two sex partners in the past year. Navajo County Community Health Status Assessment 99 Category 10 - Communicable Diseases Table 10.13 Cases of Hepatitis C in the United States (2002-2007) Types of Cases Number of acute clinical cases reported 2002 2003 2004 2005 2006 2007 1,223 891 758 694 802 849 Estimated number of acute clinical cases2 4,800 4,500 4,200 3,400 3,200 2,800 Estimated number of new infections 29,000 28,000 26,000 21,000 19,000 17,000 1 3 Percent ever infected 1.3%-1.9% Number of persons living with chronic infections 4 2.7-3.9 million persons Annual Number of Chronic Liver Disease Deaths as- 12,000 sociated with Viral Hepatitis5 CDC, MMWR, 2008. _____________________ 1 Number of Acute Clinical Cases Reported For Hepatitis A, Hepatitis B, and hepatitis C/non-A, non-B hepatitis, the number of cases reported to the National Notifiable Disease Surveillance System (NNDSS). 2 Estimated Number of Acute Clinical Cases of New Infections Incidence estimates for Hepatitis A and Hepatitis A are derived from catalytic modeling of seroprevalence data form the Third National Health and Nutrition Examination Survey (NHANES III) applied to case studies reported to the Nationally Notifiable Disease Surveillance System (NNDSS). Incidence estimates for Hepatitis C are derived by adjusting rates from the Sentinel Counties Study of Viral Hepatitis (1982-2006) and Emerging Infection program (2007) for underreporting and asymptomatic infection. 3 Percent Ever Infected seroprevalence estimates for HAV, HBV, and HCV come from National Health and Nutrition Examination Survey HAV: Bell BP, Kruszon-Moran D, Shapiro CN et al. Hepatitis A virus infection in the United States: serologic results from the Third National Health and Nutrition Examination Survey. Vaccine 23(2005):57985806. HBV McQuillan GM, et al. Prevalence of Hepatitis B virus infection in the United States: The National Health and Nutrition and Examination Surveys, 1976 through 1994. AJPH 1999; 89(1)14-18. HCV Armstrong GL et al. The Prevalence of Hepatitis C virus infection in the United States, 1999 through 2002. Ann Int Med 2006;144:705-14. 4 Number of Persons Living with Chronic Infection HBV CDC Recommendations for Identification and public health management of persons with chronic Hepatitis B virus infection. MMWR;57(No.RR-8). HCV Armstrong GL et al. The prevalence of Hepatitis C virus in the United States, 1999 through 2002. Ann Int Med 2006;144:705-14 5 Annual Number of Chronic Liver Disease Deaths Associated with Viral Hepatitis HBV Vogt et al. Hepatitis B mortality in the United States, 1990-2004. Paper presented at 45th Annual Matting of the Infectious Disease Society of America; October 4-7, 2007; San Diego, CA. and Manos MM et al. Limitations of conventionally derived chronic liver Disease mortality rates: results of a comprehensive assessment. Hepatology 2008; 47:1150-7. HCV Wise et al. Changing trends in Hepatitis C-related mortality in the United States, 1995-2004. Hepatology 2008;1-8. 100 Navajo County Community Health Status Assessment Category 10 - Communicable Diseases and Alaska Native (AI/AN) populations andthe lowest rates among Asian and Pacific Islanders (API) populations. Rates among AI/AN have drastically decreased since 1996 (pre-1996 rates among AI/ AN populations were >60 cases per 100,000). Between 2001-2007 rates among AI/AN populations (rates became lower than or similar to those for other races (Department of Health and Human Services and Centers for Disease Control, MMWR, Surveillance Summaries for Viral Hepatitis, United States, 2007, May 22, 2009 Vol. 58 No.SS-3). (the percentage was higher among adults over the age of 45, 17%) (Department of Health and Human Services and Centers for Disease Control, MMWR, Surveillance Summaries for Viral Hepatitis, United States, 2007, May 22, 2009 Vol. 58 No.SS-3). In 2007, the Hepatitis B rates among males (1.9 cases per 100,000 of the population) was higher than the rate among females (1.2 cases per 100,000). Since 2004 the Hepatitis B rates began to plateau among all racial and ethnic populations. In 2007, the Hepatitis B rate among non-Hispanic Hepatitis B (United States) Blacks was highest (2.3 cases per 100,000 of the An estimated 43,000 new Hepatitis B infections population). (Department of Health and Human in the United States occurred in 2007 (taking into Services and Centers for Disease Control, MMWR, account asymptomatic infection and underreport- Surveillance Summaries for Viral Hepatitis, United ing from previous years). Approximately, 4,519 of States, 2007, May 22, 2009 Vol. 58 No.SS-3). these cases were acute and asymptomatic. The reported risk factors for infection include having Hepatitis C multiple sex partners (38% of reported cases), Currently no vaccine exists for Hepatitis C. In MSM (reported rate 11%), sexual contact with a 2007, as in previous years, a majority of those at person known to have Hepatitis B (6% of reported risk for Hepatitis C infection (among adults) was cases), IDU was reported by 15%, having surgery related to IDU. Hepatitis C is the most common was reported for 12% of persons with Hepatitis B blood borne illness in the United States with an Figure 10.14 . ADHS Hepatitis C Program, Data and Statistics, www.azdhs.gov/phs/iods/hepc/stats.htm, accessed 12/11/09 Navajo County Community Health Status Assessment 101 Category 10 - Communicable Diseases estimated 3.2 million chronically infected persons nationwide. In 2007, the most common risk-factor identified was IDU (48%), while 42% reported having multiple sex partners during the incubation period, 10% reported having sexual contact with another known Hepatitis C Virus (HCV) infected person and 10% were MSM. Another 20% reported having surgery (the rate was higher among persons aged >40 years, 32%). Another 2% of respondents reported occupational exposure to blood. Primary intervention strategies include screening and testing blood donors, risk-reduction counseling and screening among those at-risk for infection, and routine practice of infection control in health-care settings (Department of Health and Human Services and Centers for Disease Control, MMWR, Surveillance Summaries for Viral Hepatitis, United States, 2007, May 22, 2009 Vol. 58 No.SS-3). In 2007, 849 confirmed cases of acute Hepatitis C were reported in the U.S. (a rate of 0.3 cases per 100,000 of the population). In 2007, among persons aged 15-34 years, the male to female ratio was <1 (0.5 for persons aged 15-19 years, 0.8 for persons aged 20-24 years, and 1.0 for persons aged 25-29 years and for persons aged 30-34 years). Since 2004 the rate of Hepatitis C has plateaued among all racial/ethnic populations except for American Indians/Alaska Natives (AI/ AN), for whom rates fluctuated. In 2007, rates for AI/AN populations was 0.5 cases per 100,000 of the population. Rates for non-AI/AN populations ranged from 0.02 cases per 100,000 of the population of Asians and Pacific Islanders (API) to 0.3 cases per 100,000 of the non-Hispanic white population (Department of Health and Human Services and Centers for Disease Control, MMWR, Surveillance Summaries for Viral Hepatitis, United States, 2007, May 22, 2009 Vol. 58 No.SS-3). Figure 10.15 ADHS Hepatitis C Program, Data and Statistics, www.azdhs.gov/phs/iods/ hepc/stats.htm, accessed 12/11/09 102 Navajo County Community Health Status Assessment Category 10 - Communicable Diseases Figure 10.16 ADHS Hepatitis C Program, Data and Statistics, www.azdhs.gov/phs/iods/ hepc/stats.htm, accessed 12/11/09 The reporting Hepatitis C cases by physicians to the state did not begin until April 1997. It is estimated that approximately 100,000 people in Arizona are infected with Hepatitis C, with 85,000 infected for life. A majority of Arizonans infected with Hepatitis C are between 35-54 years of age (see Figure 10.15) (ADHS Hepatitis C Program, Data and Statistics, www.azdhs.gov/phs/iods/ hepc/stats.htm, accessed 12/11/09). Hepatitis rates by age group reached a plateau in the U.S. since 2003. In 2007, rates increase slightly among persons aged 25-35 years (.05 per 100,000 population) and those aged >40 years (.03 per 100,000 population). Rates declined in the U.S. 90% (from 5.3 cases per 100,000 in 1990 to .5 cases per 100,000 per population in 2007) among persons aged 25-39 years, the group with the highest rates, historically speaking (Department of Health and Human Services and Centers for Disease Control, MMWR, Surveillance Sum- maries for Viral Hepatitis, United States, 2007, May 22, 2009 Vol. 58 No.SS-3). Tetanus, Diphtheria, and Pertussis (Tdap) Vaccination Data for Tdap was acquired through the Surveillance data management maintained by Arizona Department of Health Services (ADHS) Infectious Disease Epidemiology Section (NETSS) and reported by the local health departments who investigate and report to the state health department. From January 2005 through December 2005 the incidence rate of Pertussis for all ages was 4.65 per 100,000 of the population. During the same time span the Tdap vaccination rate for 10-18 year-olds was 2.38% (Erhart et al. Infectious Disease Epidemiology, Arizona Immunization Program, 2005). Navajo County Community Health Status Assessment 103 Category Eleven: Sentinel Events Definition of Indicator Sentinel events are those cases of unnecessary disease, disability, or untimely death that could be avoided if appropriate and timely medical care or preventive services were provided. These include vaccine-preventable illness, late stage cancer diagnosis, and unexpected syndromes or infections. Sentinel events may alert the community to health system problems such as inadequate vaccine coverage, lack of primary care and/or screening, a bioterrorist event, or the introduction of globally transmitted infections. Trends Numbers of cases for late-stage cancer diagnosis in Navajo County between 2001 and 2006 are range from 97 cases of colorectal cancer, 142 cases of lung cancer, 97 cases of female breast cancer, 6 cases of cervical cancer, and 32 cases of prostate cancer. There were no reported occurrences of unexpected syndromes due to unusual toxins or infectious agents during the five year period this CHSA assessment covers. The only available data available on occupational injuries was in relation to the nation and the state, thus no data is available for Navajo County in that category. Late Stage Cancer Diagnosis Stages of cancer are based on the National Cancers Institute’s Surveillance, Epidemiology, and End Results (SEER) Summary Staging Manual - 2000. Table 11.1 summarizes the definitions for Early and Late Stage cancer diagnoses. Tables 11.2 and 11.3 summarize the number of cases and percent of cases of colorectal, lung, female breast, cervical, and prostate cancers for Arizona and Navajo County, respectively. Vaccine Preventable Disease Table 11.0 Vaccine Preventable Disease Rates (1997-2001) 1997 Disease Arizona Navajo County Measles 0.1% Mumps 0.7% 1998 Arizona Navajo County 0.0% 0.2% 0.0% 0.1% 1999 Arizona Navajo County 0.0% <0.1% 0.0% <0.1% 2000 2001 Arizona Navajo County Arizona Navajo County 0.0% 0.0% 0.0% <0.1% 0.0% 0.0% 0.1% 0.0% <0.1% 0.0% Rubella 0.1% 0.0% <0.1% 0.0% 0.3% 0.0% <0.1% 0.0% 0.0% 0.0% Pertussis 1.0% 3.5% 5.1% 0.0% 1.5% 0.0% 2.1% 0.0% 7.2% 1.0% University of Arizona, Rural Health Office Arizona Department of Health Services, Arizona Health and Vital Statistics (5F-2), 1997-2001 (Vaccine Preventable Diseases) Table 11.1 Definitions of Cancer Stages Stage Early SEER Summary Stage In Situ Presence of malignant cells within the cell group from which they arose Local Malignancy that is limited to the organ in which it started Regional Late Definition Distant Tumors that have extended beyond the boundaries of the organ of origin Metastasized tumor cells that have broken away from the primary tumor and spread to other areas of the body and have begun to grown in the new location Source: SEER Summary Staging Manual 2000. 104 Navajo County Community Health Status Assessment Category 11 - Sentinel Events Table 11.2 Early- Late SEER Summary Stage for All Arizona Cancer Cases 2001-2006 Primary Site Race White Non-Hispanic Colorectal Total* % of Race Case Count % of Race 6083 84.3 12810 85.0 African American 129 2.2 189 2.6 363 2.4 American Indian 68 1.2 117 1.6 224 1.5 Asian & Pacific Island 57 1.0 75 1.0 155 1.0 White Hispanic 484 8.4 717 9.9 1398 9.3 71 1.2 31 0.4 121 0.8 All Races 5790 100.0 7212 100.0 15071 100.0 White Non-Hispanic 2887 92.7 10845 89.7 18432 90.4 African American 55 1.8 298 2.5 444 2.2 American Indian 12 0.4 77 0.6 119 0.6 Asian & Pacific Island 20 0.6 103 0.9 147 0.7 White Hispanic 124 4.0 744 6.2 1175 5.8 15 0.5 29 0.2 71 0.3 3113 100.0 12096 100.0 20388 100.0 All Races White Non-Hispanic 13389 86.9 5570 82.4 20495 85.4 African American 268 1.7 188 2.8 496 2.1 American Indian 166 1.1 127 1.9 317 1.3 Asian & Pacific Island 204 1.3 84 1.2 306 1.3 White Hispanic 1193 7.7 738 10.9 2099 8.7 Unknown 180 1.2 50 0.7 293 1.2 15400 100.0 6757 100.0 24006 100.0 348 64.8 312 62.0 774 63.1 African American 8 1.5 16 3.2 28 2.3 American Indian 20 3.7 25 5.0 52 4.2 Asian & Pacific Island 10 1.9 12 2.4 27 2.2 White Hispanic All Races White Non-Hispanic Cervix Case Count 86.0 Unknown Female Breast Late Stage % of Race 4981 Unknown Lung Early Stage Case Count 138 25.7 133 26.4 322 26.3 Unknown 13 2.4 5 1.0 23 1.9 All Races 537 100.0 503 100.0 1226 100.0 11636 84.2 2347 82.8 16678 82.2 African American 405 2.9 95 3.4 572 2.8 American Indian 128 0.9 46 1.6 223 1.1 Asian & Pacific Island 88 0.6 20 0.7 130 0.6 White Hispanic 1004 7.3 281 9.9 1590 7.8 556 4.0 44 1.6 1095 5.4 13817 100.0 2833 All Races * Total includes Early Stage, Late Stage, and Unknown Stage cancers. 100.0 20288 100.0 White Non-Hispanic Prostate Unknown Navajo County Community Health Status Assessment 105 Category 11 - Sentinel Events Table 11.3 Early- Late SEER Summary Stage for All Navajo County Cancer Cases 2001-2006 Primary Site Race White Non-Hispanic African American Case Count Late Stage % of Race 46 Case Count 82.1 Total* % of Race 71 Case Count % of Race 73.2 46 82.1 1 1.8 0 0.0 1 1.8 7 12.5 18 18.6 7 12.5 2 3.6 8 8.2 2 3.6 All Races 56 100 97 100 56 100 White Non-Hispanic 17 73.9 124 87.3 17 73.9 African American 1 4.3 2 1.4 1 4.3 American Indian 3 13.0 11 7.7 3 13.0 White Hispanic 2 8.7 5 3.5 2 8.7 23 100.0 142 100.0 23 100.0 134 74.4 65 67.0 134 74.4 African American 1 0.6 1 1.0 1 0.6 American Indian 33 18.3 21 21.6 33 18.3 Asian & Pacific Islander 0 0.0 1 1.0 0 0.0 White Hispanic 11 6.1 9 9.3 11 6.1 1 0.6 0 0.0 1 0.6 180 100.0 97 100.0 180 100.0 White Non-Hispanic 6 60.0 1 16.7 6 60.0 African American 0 0.0 0 0.0 0 0.0 American Indian 2 20.0 4 66.7 2 20.0 Asian & Pacific Islander 1 10.0 0 0.0 1 10.0 White Hispanic 1 10.0 1 16.7 1 10.0 10 100.0 6 100.0 10 100.0 159 78.7 21 65.6 159 78.7 African American 2 1.0 1 3.1 2 1.0 American Indian 28 13.9 10 31.3 28 13.9 Asian & Pacific Islander 1 0.5 0 0.0 1 0.5 White Hispanic 3 1.5 0 0.0 3 1.5 Unknown 9 4.5 0 0.0 9 4.5 202 100.0 32 All Races * Total includes Early Stage, Late Stage, and Unknown Stage cancers. 100.0 202 100.0 Colorectal American Indian White Hispanic Lung All Races White Non-Hispanic Female Breast Unknown All Races Cervix All Races White Non-Hispanic Prostate 106 Early Stage Navajo County Community Health Status Assessment Category 11 - Sentinel Events Number of Deaths or age for work related injury Years of Productive Life Lost (YPLL) Premature death measures the loss of years of productive life due to death before age 75 (as defined by the Center for Disease Control and PreTable 11.4 Total Fatal Occupational Injuries (2004-2008) Years 2004 2005 2006 2007 2008 Totals (2004-2008) Arizona United Arizona States United Arizona States United Arizona States United Arizona** States United Arizona States United States 84 5,764 5,734 5,840 5,657 5,071 28,066 99 112 Bureau of Labor Statistics (2004-2008) 88 86 469 **The 2008 figures are preliminary. Final figures will be released in April 2010. vention’s YPLL-75. For example, the death of a 25 year old would account for 50 years of life lost. In 2005, the national average is 7,564 years lost per 100,000 of the population. This is 43 years per 100,000 of the population more than it was a year before (in 2004). In 2005 Arizona ranked 30th in Unexpected syndromes due to unusual toxins or infectious agents There have been no reported occurrences of unexpected syndromes in Navajo County (Don Walker, personal communication, 2009). According to Don Walker, Program Director for the Navajo County Bioterrorism Program, there have been no incidents of diseases or fatalities as a result of exposure to pollutants from trains and buses traveling through Navajo County (Don Walker, personal communication, 2009). Navajo County Community Health Status Assessment 107 Appendix A Number of Parents in Parent Teacher Organizations in Navajo County (October 2009) School Location Number of Students Number of Parents in PTA/PTO Percent of Parents in PTA/PTO Tolani Lake Elementary School Winslow 27 Not Available 0 N. AZ Academy for Career Development- Winslow School Winslow 77 46 Parent and Teacher Involvement Program (PTIP) 60% Bonnie Brennan School Winslow 170 No active Parent/Teacher Association this year (PTA) 0 School Name Winslow USD Jefferson Elementary School Winslow 370 Not Available 0 Washington School Winslow 456 No active PTA this year 0 Winslow High School Winslow 787 Not Available 0 Winslow Junior High School Winslow 439 Not Available 0 Holbrook High School Holbrook 721 10 Cite Council (General advisory board, including students) 1.38% Holbrook High School (Satellite Campus) Holbrook 583 (Students attend other schools) Not Available 0 Holbrook Junior High School Holbrook 366 10 Cite Council 2.73% Holbrook USD Hulet School Holbrook 370 7 Cite Council 1.89% Park Elementary School Holbrook 286 11 3.84% Rainbow Accommodation School Holbrook 14 (satellite campus, not official enrollment) Not Available 0 Holbrook SDA Indian School Holbrook 86 No active PTA this year 0 Living Word Christian School Holbrook 7 Not Available 0 Indian Wells Elementary School Holbrook 411 No active PTA this year 0 Tiisyaatin Residential Hall Holbrook 128 No active PTA this year 0 Highland Primary School Snowflake 516 17 Parent Teacher Student Organization (PTSO) 2.13% Navit Courses School Snowflake 399 (Students attend other schools) Not Available 0 Snowflake High School Snowflake 760 No active PTA this year 0 Snowflake Intermediate School Snowflake 350 15 Parent Teacher Student Organization (PTSO) 124 Volunteers 35.63% Snowflake 400 No active PTA this year 0 Taylor Elementary School Taylor 365 25 Volunteers helping at different times throughout the year 6.85% Taylor Intermediate School Taylor 258 20 ( PTSO) 7.75% Snowflake USD Snowflake Junior High School Taylor USD 108 Navajo County Community Health Status Assessment Appendix A Number of Parents in Parent Teacher Organizations in Navajo County (October 2009) School Name School Location Number of Students Number of Parents in PTA/PTO Percent of Parents in PTA/PTO Northern Arizona Academy for Career Development- Taylor Taylor 53 6 (PTA) 11.32% Linden Elementary School Show Low 245 No active PTA this year 0 Show Low High School Show Low 822 5-6 Volunteers helping at different times throughout the year .60%-.72% Show Low High School-Satellite Campus Show Low 56 (students attend other schools) Not Available 0 Nikolaus Homestead Elementary School Show Low 370 10-15 (PTA) 2.70-4.05% Show Low Junior High School Show Low 550 No active PTA this year 0 Show Low USD Show Low Preschool Show Low 31 Not Available 0 Show Low Primary School Show Low 458 7 (PTSO) 1.52% Snowflake High School- Satellite Campus Show Low 512 (Students attend other schools) Not Available 0 White Mountain Institute School Show Low 822 9 Cite Council (3 parents, 1 community member, 4 students, 1 teacher) 1.09% Jefferson Academy of Advancing Learning School Show Low 180 32 Parent Board & Fundraising 17.7% Renaissance Academy- John Reeder Campus School Show Low 38 Not Available 0 Sequoia Village School Show Low 200 Open Enrollment Parent/Teacher Organization (PTO) Not available American Indian Christian School Show Low 50 No active PTA this year 0 Whipple Ranch Elementary Show Low 456 9 (PTSO) 1.97% Mountain Christian School Show Low 53 30 (PTA families) 56.6% White Mountain Montessori School Pinetop 48 Policy: All parents are members 16 (Registered on a message board) 33.3% St. Anthony’s Pinetop 79 No active PTA this year 0 Lakeside 497 Pinetop Blue Ridge USD Blue Ridge High School (Navit) Blue Ridge Elementary School Blue Ridge High School (Unified) Blue Ridge Junior High School Blue Ridge Middle School Lakeside Lakeside Lakeside Lakeside 540 922 Not Available 65 ( This is a district wide PTSO, including all Blue Ridge Schools) 409 414 Not Available Not Available Not Available 24 parents involved at Blue Ridge Middle School 5.79% Heber/Overgaard USD Navajo County Community Health Status Assessment 109 Appendix A Number of Parents in Parent Teacher Organizations in Navajo County (October 2009) School Name Capps Elementary School Mogollon High School Mogollon Junior High School Mountain Meadows Primary School Location Heber Heber Heber Overgaard Number of Students Number of Parents in PTA/PTO Percent of Parents in PTA/PTO 119 No active PTA this year 0 159 No active PTA this year 0 73 No active PTA this year 0 172 >10 Parent Teacher Committee (PTC) 0.58-5.23% Whiteriver USD Cibecue Community School Cibecue 468 Not Available 0 Alchesay High School (Whiteriver) Whiteriver 710 Not Available 0 Alchesay High School (Navit) Whiteriver 438 Not Available 0 Canyon Day Junior High School Whiteriver 226 6 Parent Advisory Committee (PAC) 2.65% Cradleboard Elementary School Whiteriver 350 4 (PAC Officers, Voluntary) 1.14% Seven Mile School Whiteriver 466 Everyone is a member (PAC) Not available Whiteriver Elementary School Whiteriver 516 50 (PAC) 9.6% East Fork Mission School Lutheran Whiteriver 81 No active PTA this year 0 Hon-Dah McNary Elementary School Hon-Dah McNary 114 No active PTA this year 0 Alternative School Whiteriver Not Available 0 Not Available 0 Kayenta USD Kayenta Primary School Kayenta 408 Kayenta Intermediate School Kayenta 420 5 Cite Council 1.19% Kayenta Middle School Kayenta 447 5-10 Cite Council 1.11%-2.23% Monument Valley High School Kayenta 838 6 Cite Council 0.71% Cedar USD Jeddito School Keams Canyon 265 20 Parent Involvement Committee (PIC) 7.54% White Cone High School Keams Canyon 93 4 (PAC) 4.30% Joseph City USD Joseph City Elementary School Joseph City 272 No active PTA this year 0 Joseph City Junior & High School Joseph City 235 5 Cite Council 2.12% Pinon Elementary School Pinon 553 5 Parent Involvement Cadre (PIC) .90% Pinon Middle School Pinon 363 No active PTA this year 0 Pinon High School Pinon Not Available 0 Not Available 0 Pinon USD Navajo Reservation Greasewood Springs Community School 110 187 Navajo County Community Health Status Assessment Appendix A Number of Parents in Parent Teacher Organizations in Navajo County (October 2009) School Name Seba Dalkai Boarding School School Location Number of Students Number of Parents in PTA/PTO Percent of Parents in PTA/PTO Winslow 130 20 Parent Committee 15.3% Black Mesa Community School Pinon 52 3 Parent Committee 5.76% Fort Apachehinbeto Community School Kayenta 99 20 (PAC) 20.2% Kayenta Community School Kayenta 397 Kykotsmovi 52 75 (PTO) 144.2% Hotevilla 115 4 (PTA) 3.47% Keams Canyon 77 Not Available 0 Kykotsmovi 134 20 (PTA) 14.9% Whiteriver 210 No active PTA this year 0 No active PTA this year 0 Hopi Reservation Hopi Day School Hotevilla Bacavi Community School Keams Canyon Elementary Rocky Ridge Boarding School White Mountain Apache Reservation John F. Kennedy Day School Theodore Roosevelt School Fort Apache 100 3 (PAC) 3.0% List of schools adjusted from Navajo County Asset Report, NAU, College of Business, 2008. Phone calls and e-mails were used to collect PTA/PTO data and updated enrollment numbers (October 2009). School listings were found at The Navajo County website, Public School Districts http://www.navajocountyaz.gov/schools/distbr.aspx (accessed October 19, 2009). Additional school listings were found at The Department of the Interior, Bureau of Indian Education http://www.bie.edu/home.aspx. Navajo County Community Health Status Assessment 111 Appendix A - Section 2 Section 2 Bar Graph Grade 8: Navajo County Lifetime AOTD Use (2004, 2006, 2008) 112 Navajo County Community Health Status Assessment Appendix A - Section 3 Section 3 Bar Graph Grade 10: Navajo County Lifetime ATOD Use (2004, 2006, 2008) Navajo County Community Health Status Assessment 113 Appendix A - Section 4 Section 4 Bar Graph Grade 12: Navajo County Lifetime ATOD Use (2004, 2006, 2008) 114 Navajo County Community Health Status Assessment References Agency for Toxic Substances and Disease Registry (ATSDR). (1999). Public Health Statement for Uranium, CAS# 7440-61-1. Accessed on 16 November, 2009. http://www.atsdr.cdc.gov/toxprofiles/phs150.html Arizona Care Planning Council. (2009). Arizona Assisted Living Facilities, Nursing Homes and Home Care Services. National Care Planning Council. Centerville, UT. Retrieved from: http://www. carearizona.org/list01_az_nursing_homes.htm. 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