“I’m afraid I’m going to die before I grow up,” shared one teen, her voice quivering. Others followed suit, uneasily admitting they too had similar fears about being killed or physically harmed.
That was really hard to hear, said Anton Gunn, referring to what he learned from a group of Tri-county teenagers who shared their personal feelings about crime in the Charleston area for a community health needs assessment (CHNA).
Gunn, MUSC Health’s chief diversity officer and executive director of community health innovation, served as MUSC’s lead representative on the CHNA advisory workgroup. He said that experience with the community youth really affected him.
“One of the stark realizations I walked away with after this initial assessment process was how prevalent violence and injury prevention were on the radar screen. We always knew that it was an issue, but to hear young adults in a focus group basically say they were afraid they wouldn’t even get a chance to grow up – that hit me hard,” he said.
He attributed it to a recent uptick in murders and violence in Charleston’s Tri-county area that has taken a toll on the mental and emotional well-being of people throughout these communities, fueling fear and frustration. High-profile crimes like the tragic murder of nine people at Mother Emanuel AME Church and the police shooting of unarmed citizen Walter Scott, not to mention 77 murders and a spate of violent crimes that took place in 2016, have many on edge.
When you think of social determinants of health, violence might not be the first thing that springs to mind. Yet research concludes that health encompasses so much more than simply the state of one’s physical condition – it also takes into consideration a number of factors such as the personal, social, economic and environmental issues that affect a person’s life. For instance, being exposed to crime, violence or social disorder, or even the perception that safety at home or in one’s neighborhood is at risk, can affect the physical, mental and emotional health of a person or even an entire community.
According to the 2016 Tri-county Community Health Needs Assessment, a joint publication recently released by MUSC Health, Roper St. Francis and the Trident United Way, violence and bodily injury ranked fifth on the list of CHNA health priorities.
While it was shocking to have that subject be so present on their minds, Gunn said, it was those types of honest and revealing comments from members of the community that were critical to putting together an accurate depiction of the Tri-county health landscape. Gunn, who has 20 years of experience conducting community health assessments, was adamant that a large swath of community members needed to be integral to the process. When the previous Charleston assessment had been conducted three years earlier, part of the strategy was to interview people who deliver health care in the community – which amounted to predominantly physicians. For Gunn, that didn’t represent a true needs assessment.
“When I came to MUSC in 2015, the first thing I asked for was our community health needs assessment. What I was shown was not a CHNA. The only people interviewed were physicians and a few school-based nurses – they didn’t speak to any grassroots community members. I thought it was woefully inaccurate to say these are the health needs of the community when you don’t ask anybody in the community what they’re concerned about in terms of their health and well-being.”
This time, the committee took the process out into the community, and the results of what they learned are, according to Gunn, a much truer reflection of health needs and realities in the Lowcountry. Since that building healthy communities is a pillar of MUSC’s Imagine 2020 strategy for the future, he believes this is one such way to get the process and discussion moving in the right direction.
MUSC Health, Roper St. Francis and the Trident United Way led the effort, and representatives began to meet last spring to devise a strategy to take a realistic snapshot of the health situation in the Tri-county region. They initiated focus groups, held community forums and conducted surveys and interviews.
What resulted was they had five times the number of people participating in the process than they did three years ago and are building what they believe will be productive partnerships. “We spent a significant amount of time talking to community members – low-income, people of color who receive health care services,” Gunn said. “We also talked to people who work in community-based settings and looked for intersections. For instance, let’s say this group runs a housing agency, and their program is focused on people who have just been evicted from their homes and need to find transitional housing. When they meet with a family, they learn nobody in the family has health insurance coverage, that their child is autistic and the father had a double bypass. They see all these health challenges, even though they’re not a health agency. That’s valuable information.”
Leveraging those insights was important to Gunn. “So we interviewed them and asked from their vantage points what was the sum of the challenges related to the health of the people coming through their doors. They gave us a tremendous amount of feedback. And when you looked at both groups – service providers and community residents – the answers they identified as their top health issues were very similar. In fact, it was very surprising to see how similar they were.”
At the first forum they conducted, 120 people representing 40 organizations attended. The participants spent three hours discussing health challenges, services and how they would work together. Rather than simply collecting information and concluding the process by submitting a report of their findings, they decided to treat the information they would collect as a starting point, so collectively, they could have a significant impact on the health of the community.
Right off the bat, people knew something different was afoot – they were encouraged. “When we finished that meeting, I had several people come up to me and say things like, ‘I’ve worked in the Tri-county region for 20 years, and I’ve been working on health issues that entire time, and never have I seen all these people and groups in one room at the same time to talk about the health needs in the Tri-county.’ There was a lot of excitement.”
There seemed to be a great deal of duplication of services, Gunn said, and the left and right hand not knowing what the other was doing. This, he added, resulted in organizations not helping other organizations achieve their goals. That, he hopes, would soon be changing.
The health issues that emerged as priorities were not a surprise at all, Gunn said. “It doesn’t take five minutes working in health care to know that mental health issues are going to be a top concern for people in the community. It’s also not going to be hard to identify that access to health services is a challenge in this community – no matter who you are.”
Access, in fact, took No. 1 on the list of priorities that need to be addressed. The CHNA highlighted that people in the community have trouble with several common access points when it comes to receiving health care services. Gunn explained, “There are the uninsured – the ‘I can’t afford to go get treatment because I don’t have coverage. Or, maybe I have coverage, but I can’t afford the copays and deductible, so I might as well not have insurance because I can’t afford to go to the doctor.’ Then there are the people who are afraid – afraid because they have immigration issues or don’t want to hear bad news. And then there are those who don’t have transportation or a doctor in their community. Access is clearly a challenge.”
Mental health issues, which landed the No. 2 spot on the list, are among the most common of all diseases and the No. 1 cause of disability in the United States, according to Healthy People 2020.
Anxiety, depression, eating disorders and attention deficit and hyperactivity disorder are common among children 13 to 18 years old. Just over 20 percent – or 1 in 5 children – according to the National Institute of Mental Health, currently has or has had a debilitating disorder in their lives. In adults, 18 percent suffer from a range of mental health issues, a statistic which does not include substance abuse disorders. The CHNA noted that alcohol or drug abuse, violent or self-destructive behavior and suicide are also considered measurable indicators of a community’s mental health.
Gunn said that MUSC Health and the other area hospitals are establishing a crisis stabilization unit for mental health as a way to provide more standardized treatment for mental health issues and keep people out of emergency rooms. It’s scheduled to open at the end of February in a temporary location near the old Charleston Memorial Hospital, and they are working collaboratively to build a facility in North Charleston.
The other roadblock Gunn said community members face is an inability to obtain preventive services for preventable diseases – No. 3 on the CHNA list. “They can’t get routine disease screenings, and they can’t get scheduled immunizations,” Gunn explained. “We can’t detect or prevent disease when people don’t have access to screenings. It can be as simple as a flu shot or as complex as an oral, cervical or prostate cancer screening.”
Gunn said because the report was basically just the beginning – the real work starts now: developing a plan to improve the health and well-being of people in the Tri-county by 2025.
MUSC Health, Roper St. Francis and Trident United Way held a meeting on Jan. 31 to kick off “Healthy Tri-county” – the new multi-sector initiative to improve health outcomes in Berkeley, Charleston and Dorchester counties – and release the CHNA report to the public. They had 127 people representing 78 organizations attend the launch, including MUSC President David Cole, M.D., FACS, and MUSC Health CEO Patrick Cawley, M.D.
Gunn said Healthy Tri-county will be an ongoing process. “We are still effectively building the plane – for where we take off and what we do. We are going to collaborate, and we are going to work for collective impact – that’s the key word. We want to be part of a collective strategy, if you will, on how we can leverage our power, our resources and what we already do to have a collective impact on health in the Tri-county region.
“The goal is,” he said, “that by the time the committee does the next CHNA, one of the top issues is no longer on the list – but we can talk about the impact we had on it.”
“The main thing is,” he continued, “now we know where our community is and what our health challenges are: Access; mental health; clinical preventive services; maternal, infant, and child health; injury and violence; and oral health make up the Top 6 list. The question is how can MUSC as an organization band together and be more integrated and collaborative to address these broad-based needs? Because again, there is a role that we all can play, if we’re really here to deliver health. How effective can we be if we don’t have a way to deliver health to the broader community – not just inside the four walls but outside of the four walls.”
Gunn shared those thoughts at a recent Charleston Regional Business Journal Power Breakfast. In his remarks, he explained how diabetes and other health conditions are costing Lowcountry employers millions of dollars in lost productivity – predominantly because of limited access to health care and a lack of preventive programs. He told them they could be part of the solution.
“If employers participate, a better job can be done to ensure these people have better access to health and do a better job. I explained that screenings, primary care, insurance coverage – all can help lower the cost. More specially, nutrition and physical activity can reverse diabetes. I told the employers that if they build a culture of health in their organizations, talk about health, encourage their people to be physically active and make it easy for them to exercise or be more active at work, they can create more productive employees and improve their health, which in the end, contributes to building a healthy community.”
Editor's Note: This is the first in a two-part series about the Tri-County Community Health Needs Assessment.