Executive Summary
Rural Pennsylvania Counts:
Columbia, Montour, Northumberland, Snyder and Union Counties

This community needs assessment of the five counties in the central Susquehanna Valley of Pennsylvania kicked off during the summer of 2009. It focused on evaluating the current status of access and barriers to use of regional health and human services and was conducted in three phases: focus groups, personal interviews with health and human service client households, and a population based survey.  All phases of the study were reviewed and approved by Geisinger Health System’s Institutional Review Board charged with human subject’s protection.

The focus groups were conducted in community settings to increase participation among participants and scheduled during the business day as well as during early evening hours to provide scheduling flexibility. Lunch or dinner was provided at each focus group.  Focus group participants were community leaders, health and human service workers and administrators, and others who have special knowledge of the needs of clients/patients in their communities.  Focus group invitees were identified by members of the ACTION Health board, through snowballing techniques in which people from the primary list (recommended by ACTION Health) recommended other participants and sent in response to an invitation extended directly to local agencies. At least one focus group was held in each county.

Table 1 Focus Group Locations

Focus group findings varied somewhat from county to county and community to community.  However, a number of findings were consistent across the region:

1. Medical care and specialty care: residents have difficulty navigating the health care system.  This includes finding appropriate health care, particularly specialty care.  Moreover, participants noted that there is limited care available for those who are uninsured or who are underinsured.
2. Dental care for area residents is limited.  Particularly problematic for low-income residents and for those who do not have dental insurance.  There are few area dentists who accept state-assistance (Medicaid/CHIPS) as a form of payment for dental care and there is no dental care for low-income adults.  Children with state-funded insurance must often receive their dental care outside of the region, necessitating travel which may be a problem for families with no dependable transportation.
3. Mental health and substance abuse treatment is limited.  There is limited availability of specialty services for substance abuse particularly.  Inpatient mental health services are limited and residents often do not know how to navigate the mental health care system.
4. There is a general agreement that area residents do not know where to go to obtain information about availability of all kinds of social and support services.  Moreover, there is only limited coordination of information and services between agencies and organizations.
5. Limited access to homeless shelters and transitional housing support.
6. Need for health and consumer education and promotion of consumer literacy, health and wellness education, parenting, and prevention programs.
7. Need for expanded public transportation.  While focus group participants acknowledged the tremendous work of the Union-Snyder Transportation Authority (USTA) and other similar transportation systems, there were general agreement that there remains a need for expanded public transportation.
8. Limited food resources.  Participants noted that food pantries are difficult to locate and may be limited in their ability to meet the increasing demands for additional food support in the community.
9. Need for affordable child care and child care for all work shifts.  There was significant concern at some focus group locations regarding the lack of 24-hour child care due to shift work required in some employment settings.
10. Services and education designed for special groups including seniors, adolescents, grandparents raising grand children, non-English-speaking seniors.  Participants noted that these demographic groups have unique needs that may not be met by ‘one-size fits all’ approaches currently in place.  The development of special programs for unique groups that reach out to these individuals may improve access.
11. Rising unemployment was noted as the economic downturn reached this area.  The central concern for focus group members was the increasing population without health insurance and a middle class that was not schooled in accessing assistance, such as food pantry and utility assistance.
12. Increase in domestic violence.  Again, in the current economic environment members expressed concerns about the increased reporting of domestic violence.  There was an expressed need for education strategies to promote stress management and other strategies for reducing interpersonal violence.
13. Reduction in tobacco use, but continued need for affordable tobacco cessation programs. Members suggested that tobacco cessation programs should be available in workplaces such as food sales environment and programs should be developed to target particular demographic groups.
14. Computer access was viewed as potentially increasing disparity.  Many use the computer to access health information, social services and other resources.  Addressing computer access may include providing training for the use of the computer to navigate health and human services.

Phase 2 – Insight interviews revealed many of the same concerns on a more personal level.  These interviews were conducted primarily to ensure that the perspectives of system users were also considered.

Phase 3 – Survey of residents of the five-county area.  This survey was mailed to 10,000 residents of the five-county region.  Some surveys were returned as the result of incorrect addresses or because the addressee was deceased. Thus, 9211 surveys were disseminated. The sample was stratified to reflect the population density of each county in the study. The final response rate was 36 percent and a total of 3308 surveys were returned during the response period.  Addresses selected for participation received a notification of selection into the study, a full survey, a reminder letter, another full survey if one had not been received and one final reminder note.  These mailings occurred over a four week period in September and October.  [1]Respondents were 18 years or older and were randomly selected using a list purchased through a contractor.

Representativeness of survey responses 

The final survey was a 21-page survey with 140 questions and an inventory of services used by individuals and household members.  The survey requested response to questions relating to:

• Basic demographic information
• Housing and community
• Computer access and utilization
• Social network
• Tobacco use and cessation history
• Alcohol use history
• Preventive health services utilization
• Health insurance
• Health care utilization and barriers to care
• Financial hardships and health
• Healthy lifestyle behaviors
• Chronic Disease
• Psychological distress and suicide
• Sources of information for health and wellness information
• Perceptions of the community
• Household and individual need for and use of human services

An important early success of this project involved the development of an undergraduate field school involving faculty from Bucknell University, Bloomsburg University, and Geisinger Center for Health Research.  Students from both universities participated in research training in survey research methodology, focus group script development and facilitation, and development and conduct of semi-structured qualitative interviews. 

The following are summary findings of note, derived from the survey:

Socioeconomic and Demographic

College aged students are underrepresented in this study.  The sample was identified through the use of telephone and utility records and most college students in the area are living on campus or use cell phones rather than landlines, while utility records are in the name of a landlord.  Most of these students remain insured by parents and/or receive health services through their university or at home.  Thus, the average age of respondents in somewhat older.

• Nearly 39% of respondents were senior citizens
• More than half of responses represent households with income of $40,000 per year or less.
• About one-third of area resident’s report that their financial circumstances are somewhat or much worse off compared to two years ago.
• While the educational levels of area residents are generally quite high due to the presence of occupations that require higher levels of education, about 1 out of 9 adults in the region do not have a high school diploma.  Those without a high school diploma have a significantly increased risk for unemployment, low income, and housing issues.
• Most residents have lived in the area for ten or more years.  About 8.2% have moved two or more times in the past two years.
• About two-thirds of households in the region have a computer in their home.  Among those with a computer, 74.0% use the computer daily.
• Senior households are the least likely to report having a computer or using a computer regularly.

Community Cohesion 

• 91% of area residents indicated that they feel safe or very safe at home.
• Senior residents are somewhat less likely to feel safe in their neighborhoods.
• Residents who do not feel safe in their neighborhood are less likely to ask for assistance such as a ride to an appointment.

Tobacco and Alcohol Use

• About 16% of area adults use tobacco products.  Two-thirds of these individuals have attempted to stop using tobacco.
• Most adults in the region have used alcohol at some time in their lives.
• About 6% of adults reported alcohol use consistent with binge drinking during the past thirty days.
• One third of those who reported drinking five or more drinks the last time alcohol was consumed had problems associated with drinking such as family or legal problems.
• Nearly 60% of these individuals believed that they had a drinking problem and nearly half of those who drank five or more drinks the last time they drank were unable to get help when sought during the past year.

Prevention and Healthy Lifestyles

Generally, there is a need for increased compliance with prevention and healthy lifestyle practices.  It appears that individuals with a chronic health condition are likely to have had many of the screening and prevention procedures that are indicated.  However, among those without a diagnosed health condition, and among those who are under age 65 years, there is a much lower rate of compliance with recommended evaluations and prevention activities.  Additionally, those who have no health insurance are less likely to have these prevention and screening procedures:

• Influenza vaccines were more likely among seniors and those with insurance.
• Less than two-thirds of adults who do not have hypertension (high blood pressure) reported a blood pressure check in the past year.
• Most young adults did not plan to get the H1N1 vaccine during the height of the influenza outbreak.
• About 37% of area adults do not exercise regularly each week.  An additional one-third exercise one to three days each week.  While the remaining 31% exercise four or more days each week.
• Most residents report walking as their usual exercise.  Thus, promoting healthy walkable communities should be an important public health agenda item for the region.
• Household income was associated with the ability to afford a healthy diet.  Nearly 7% of low income families are often or very often unable to afford a healthy diet. Households with children were more likely to report that they could not afford fresh fruits and vegetables.

Health Status 

The most prevalent chronic health conditions reported by adults included:

• High blood pressure
• Arthritis
• Diabetes
• Anxiety and depression
• Heart disease

High blood pressure is most prevalent among adults over the age of 44 years, while anxiety and depression is most prevalent among 18-44 year olds.

About 13% of respondents met criteria for serious psychological distress.  These individuals may have need for treatment for conditions such as depression or anxiety. 

Access to Health Care and Health Information 

• About 90% of area residents have a usual source of health care.  However, among those residents who do not have health insurance, nearly 41% reported that they did not have a usual source of care.
• More than 5% of area residents are unable to afford prescribed medicines often or very often.
• Uninsurance status reduces the likelihood that a resident of the area will have seen a health care provider in the past two years.
• Most area residents obtain health information from their health care provider.  However, more than 40% obtain some health information from the internet.

Community Problems

The most significant community problems noted by area residents included:

• Unemployment
• Domestic violence
• Child abuse
• Drug abuse
• Underage drinking
• Affordable childcare

Personal and Household Needs during the past year

Among the services or assistance that area residents were reported having difficulty accessing was:

• Paying for prescription medication, mental health services, dental care, and medical care.
• Finding mental health care, substance abuse treatment, dental care, medical care and childcare.
• Locating or applying for social services, food pantry and other food assistance, heating assistance, legal assistance, and adult Access. 

Conclusion

Themes across the focus groups, interviews and surveys were similar.  There is considerable work to be done by area agencies and organization.  There is a significant need for health and wellness education and support and promotion of wellness education and physical activity.  A very clear need is present in helping area residents navigate the health care and social service system.  There is no clear roadmap for area residents in locating services.  For example, there is not a listing in the phone book or on the internet for food banks.  

The greatest needs appear to be in obtaining health and dental care for low income and uninsured residents.  The problem is a multi-level problem that begins with locating providers and is closely followed by negotiating payment strategies for services.  It is unlikely that these problems can be resolved by one organization but may offer opportunities for partnership across many organizations. 

Prevention and education for substance use disorders and tobacco use is one of many issues that will require the development of strategies for reaching many different constituencies.  A frequently noted concern in the focus groups was that a minority population was not reached by existing services.  These populations included seniors, teens, immigrant populations, and others.  Education for consumer issues as well as health issues cannot be assumed to be ‘one size fits all’ and must be tailored to populations of need. 

Clearly, this summary cannot address the full range of issues that emerge in a study of this magnitude.  It will be the exciting work of area organizations to use these data to develop partnerships for meeting the needs of area residents. 

As a final note, there are many more topic areas and study findings that will be highlighted and released over the coming months. Please continue to check back on this website for additional information.