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Department of Health Services

Data Development Process

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The goal of the CHNA data development process was to gather, analyze and summarize current local data on the populations of Sonoma County, their health status and the variety of features and conditions which impact their health, healthy development and quality of life. To accomplish this, the CHNA partners collaborated to develop and utilize both primary and secondary data sources. Over the course of 6 months (April – September 2012), the partners conducted the following activities to create the 2013 Sonoma County CHNA.

A. Primary Data Collection

Key Informant Interviews with Local Experts

We recognize that we cannot improve the health of our communities alone... I feel that there is a role of everyone in creating a healthy community. Services are not going to get us out of this as evidenced by the data on mortality. We are going broke. It comes back to prevention.
Key Informant – 2012

The CHNA project partners identified a panel of 18 key informants. Key informants were selected for their expertise in a broad variety of health and health-related disciplines including hospital and primary care, public health, maternal and child health, human services, business and education. Project consultants interviewed key informants individually using a standardized set of questions designed to elicit information on the local health issues of greatest concern and perspectives on local opportunities to improve population health and/or the healthcare delivery system.

Despite the diversity of the key informant group, a number of common themes emerged from the interview process. 

These themes are:

  • The health care system is changing due to market pressures and Health Care Reform. Many key informants expressed their support for increased integration across the health care delivery system, a renewed emphasis on primary care, continued development of patient centered medical homes and adopting a population health framework to guide enhanced collaboration and system integration.
  • New financial incentives within the delivery system are key to improving health and health care. Informants believed that the Triple Aim goals of enhanced patient experience, improved health outcomes, and cost effectiveness must be supported with a system of financial incentives for health care providers at all levels.
  • Changes in composition of the health care workforce are needed. Concern was expressed about the capacity of the county’s primary care system and noted that developing and training new types of health workers (promotores, home health workers, etc.) could help expand capacity and achieve greater cost effectiveness in care delivery.
  • Sonoma County should strengthen collaboration and grass roots efforts to address community health and reduce health disparities. Reducing health disparities, particularly among children, is critical to health improvement. Respondents mentioned a number of local collaborations that focus on addressing health disparities, promote shared goals and aim to achieve collective impact in community health. They emphasized the need to continue the work of the Community Health Improvement Committee (CHIC), Health Action, the Care Transitions Project, the Healthy Eating Active Living Initiative (HEAL), and other upstream approaches now underway.
  • The impact of social determinants on health is becoming better understood as key to population health. Inequities in education, income, access to care and other socio-economic factors lead to inequalities in health status. Place-based projects like HEAL and Health Action, that focus on changing policies and practices in schools, places of employment and other community settings are seen as promising strategies to reduce disparities and promote community health.
  • Continue upstream investments that focus resources on community health and prevention. Sonoma County’s leadership has embraced the importance of making investments in the community to reduce the need for future spending for public services.
  • Sonoma County does not have the infrastructure to support its rapidly growing senior population. Sonoma County’s population is aging; seniors are living longer, becoming more frail as they age and requiring more assistance. The current senior service system is fragmented and often difficult to access. The costs, both human and financial, associated with caring for seniors in institutional settings are not sustainable. Resources and attention must go to addressing the needs of this growing and vulnerable population.

A roster of key informants and the key informant interview questions utilized in the process may be found in Appendix II.

Community Based Focus Groups
During June and July 2012, St. Joseph Health System conducted a series of targeted, community-based focus groups on behalf of the project partners. The goal of the focus group process was to gather information from residents of low-income neighborhoods on their health concerns, the challenges they face in maintaining health and their ideas on how to improve their community’s health and wellbeing. Four focus groups were held, averaging 8 participants per group. Groups were facilitated in both Spanish and English, based on group make-up. The groups were conducted in the communities of Sonoma Valley, Rohnert Park, Santa Rosa, and Cloverdale and were facilitated by St. Joseph’s staff using standardized questions approved by the CHNA partnership.

The most often mentioned community conditions that contribute positively to health were: neighborhood safety, strong relations with neighbors, community members working together on issues, access to healthy foods and family recreation opportunities.

The top health concerns identified by focus group members were: Obesity, diabetes and high blood pressure, access to drugs, local markets selling alcohol and unhealthy foods, and access to healthy foods and recreational facilities.

A copy of the focus group questions utilized in the process as well as the location and a participant profiles may be found in Appendix III.

BRFSS - A Telephone Survey of Sonoma County Residents
In the spring of 2012, St Joseph Health System contacted 1500 people (839 completed the survey) using a survey tool incorporating questions from the national Behavioral Risk Factor Surveillance System (BRFSS) survey. The Survey provided valuable information on local health status, health behaviors, experience with the local health systems and highlighted the links between social determinants, predominantly income and educational attainment, and disparities in health and health care access.

B. Secondary Data Collection


Leading Health Indicators

The health priorities identified are:

  1. Healthy eating and physical fitness. Poor nutrition and lack of physical activity are driving a national and local obesity epidemic and are contributing to increasing rates chronic disease, disability and premature mortality in Sonoma County. Low-income children and families are especially at risk when they reside in neighborhoods that offer few options to obtain healthy, nutritious food or engage safely in physical activity. Expansion of current efforts in schools and communities to improve nutrition and fitness among youth and adults can help to reduce the growing burden of disease.
  2. Gaps in access to primary care. Strong primary care systems are associated with improved health outcomes and reduced health care costs. While most Sonoma County residents have a regular source of care and can access health care when they need it, too many do not. Those who are uninsured, low-income, or are members of racial and ethnic minorities are less likely to have an ongoing source of care and more likely to defer needed care, medicines and diagnostics, often at the cost of unnecessary suffering and poor health outcomes. Increasing access to affordable, prevention-focused primary care can help to eliminate health disparities and promote health and well-being.
  3. Access to services for substance use disorders. Treatment works. Early screening, intervention and appropriate treatment for harmful substance use and addiction behaviors is critical to intervening with teens, pregnant women and others who can benefit from treatment. Unfortunately, despite increasing levels of addiction, access to substance abuse treatment in Sonoma County is severely limited for low-income individuals without healthcare coverage. Insuring timely access to culturally competent substance abuse treatment, tailored to the specific needs of those seeking help can break the cycle of addiction and benefit individuals, families and the community.
  4. Barriers to healthy aging. People over 60 now make up a larger proportion of the population of Sonoma County than ever before. As growth in this population continues, it will challenge families and communities to provide the support seniors need to stay healthy, safe, engaged and independent. Current senior service “systems” are fragmented, under-funded and often difficult for seniors and their families to understand and utilize. Low-income seniors are especially at risk for neglect, abuse and isolation. Lack of adequate, local supportive services often result in early institutionalization, poor health outcomes and reduced quality of life for many vulnerable seniors. Further development of community-based systems of services and supports for seniors can improve health outcomes and quality of life and significantly reduce costs for long-term institutional care.
  5. Access to mental health services. Many mental health problems can be effectively treated and managed with access to assessment, early detection, and links with ongoing treatment and supports. In Sonoma County, however, many low income individuals with mental health concerns do not have access to the treatment they need. Insufficient private insurance coverage for mental health services and insufficient availability of publicly-funded treatment services are significant barriers for many. Limited integration of mental health services within the health care system also leads to missed opportunities for early problem identification and prevention.
  6. Disparities in educational attainment. Educational attainment is the single greatest predictor of both income and employment status in later life and both factors are powerful determinants of health and wellbeing. In Sonoma County, Hispanics currently lag behind their White counterparts in educational attainment at all levels. Just over 6% of Whites do not have a high school diploma as compared with 45.9% of the Hispanic population. Among current students, 93.6% of White 9th - graders graduate from high school 4 years later as compared with only 64.4% of Latino students.
  7. Cardiovascular disease. Cardiovascular disease is the third leading cause of death for people ages 18-59 in Sonoma County. For residents, age 60 and older, coronary heart disease and stroke are the second and third most common cause of death, behind cancer. Major behavioral contributors to cardiovascular disease include tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol. Education and prevention efforts targeting these “lifestyle” choices and behaviors should be expanded along with continued emphasis on early detection and management of chronic disease.
  8. Adverse childhood exposure to stress (ACES). “Adverse childhood experiences (ACES),” which include a variety of ongoing conditions or events that can be categorized as recurrent childhood trauma, have been documented to lead to health and social problems, risk-taking behaviors and a shortened lifespan for the adults who survive them. ACES have been linked to a range of adverse health outcomes in adulthood, including substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature mortality. The prevalence of ACES underscores the need for additional efforts to reduce and prevent child maltreatment and associated family dysfunction and the need for further development and dissemination of trauma-focused services to treat stress-related health outcomes associated with ACES.
  9. Access to health care coverage. Insuring access to affordable, quality health care services is important to protecting both individual and population health, eliminating health disparities and promoting overall quality of life in the community. For uninsured people, the cost of both routine and emergency care can be financially devastating. Individuals without health care insurance coverage may defer needed care, diagnostics and medicines for themselves and their families and may, as a result, experience higher rates of preventable illness, suffering, disability and mortality than those who have insurance. While a significant portion of Sonoma County’s uninsured population will be eligible for more affordable health care coverage under The Affordable Care Act, financial barriers may still exist for low-wage earners who are unable to meet premium requirements. And, undocumented individuals will continue to be ineligible for publicly- funded coverage, leaving many individuals and families vulnerable.
  10. Tobacco use. Approximately one-third of all tobacco-using Americans will die prematurely from lung cancer, emphysema, cardiovascular disease and other causes related to their dependence on tobacco. Chewing tobacco is a principal contributor to oral cancers. Most smokers become addicted before the age of 19. Those who start smoking young are more likely to have difficulty quitting and more likely to develop smoking-related illness and disability. Sonoma County’s adult smoking rate does not meet the Healthy People 2020 target and is higher than the California average. Smoking rates for teens also exceeds both national and state-level benchmarks. Education programs to prevent smoking initiation among youth should be strengthened along with efforts to expand access to cessation programs for both youth and adults.
  11. Coordination and integration of local health care system. Integration of health care services may take a variety of forms, but essentially consists of the coordination of care to reduce fragmentation and unnecessary use of services, prevent avoidable conditions, and promote independence and self-care. The ability of care providers to effectively develop and use Electronic Medical Records will be critical to the coordination and integration of care. The Affordable Care Act expands health care coverage options for more Sonoma County residents. To maximize resources and provide high quality health care for newly insured patients and those already established in care, local health care services must be better coordinated and integrated with an emphasis on those most vulnerable – the aged, those living in poverty or geographic isolation and those with multiple disabilities.
  12. Disparities in oral health. Poor oral health status can threaten the health and healthy development of young children and compromise the health and well-being of adults. Low-income children suffer disproportionately from dental caries in Sonoma County.

    Low-income residents have few options for affordable oral health care and even those with insurance find access to preventive services severely limited. Fluoridated drinking water has proven to be an effective public health measure for prevention of tooth decay, yet only 3% of the public water supply in Sonoma County is fluoridated. Among the cities, only Healdsburg fluoridates its water. Stronger prevention initiatives and expanded access to prevention-focused oral health care are critical to protecting the health and wellbeing of low-income children and adults.

  13. Lung, breast, and colorectal cancer. With the exception of stomach cancer, Sonoma County’s all-cancer incidence is higher than the California rate. Research shows that routine screening for certain cancers, including breast, cervical and colorectal cancers, can increase detection at an early and often treatable stage, thereby reducing morbidity and mortality. Lung, breast, and colorectal cancer were identified as priorities because they are significant contributors to morbidity and mortality in Sonoma County and present significant opportunities for early detection through expanded education and screening.

Health Priority Profiles and Community Assets

A profile was prepared for each of the thirteen health priorities including the rationale for selecting each issue as a priority. A list of community assets per priority are identified as consideration for collaboration opportunities and to leverage efforts to address each selected issue.

Next Steps

The purpose of the Community Health Needs Assessment (CHNA) 2013-2016 is to document key information on the health and well being of Sonoma County residents. The CHNA will be used by the hospital partners to develop Community Benefit implementation strategies as required by the Affordable Care Act. The CHNA will also be made available as a resource to the broader community. It is hoped that, in this way, the CHNA be a useful resource for further communitywide health improvement efforts.