COMMUNITY HEALTH ASSESSMENT Ho-Chunk...
Transcript of COMMUNITY HEALTH ASSESSMENT Ho-Chunk...
COMMUNITY HEALTH ASSESSMENT
Ho-Chunk Nation December 2013
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Table of Contents
I. Acknowledgements.............................................................................................................. 3
II. List of Figures, Tables and Charts .......................................................................................... 4
III. Introduction ........................................................................................................................ 5
IV. Methodology ....................................................................................................................... 5
V. Demographics ...................................................................................................................... 7
VI. Indicators of Health ............................................................................................................. 9
Health Outcomes ........................................................................................................... 9
Maternal and Child Health (MCH) (NATALITY) ............................................................... 11
Immunization .............................................................................................................. 12
Diabetes ...................................................................................................................... 12
Health Status ............................................................................................................... 13
VII. County Health Rankings Model........................................................................................... 14
Physical Environment ................................................................................................... 15
Social and Economic Factors ......................................................................................... 16
Health Behaviors.......................................................................................................... 17
VIII. Summary of Data ............................................................................................................... 21
IX. Identified Health Needs ..................................................................................................... 22
X. Strengths and Challenges of Conducting a Community Health Assessment .......................... 23
XI. Next Steps ......................................................................................................................... 23
XII. Community Stakeholders and Resources ............................................................................ 24
XIII. APENDIX A: Additional Data ............................................................................................... 25
XIV. APENDEX B: Individual and Household Survey Results ........................................................ 27
XV. APENDIX C: PHAB Standards & Measures Comparison (Version 1.0) .................................... 27
XVI. References ......................................................................................................................... 28
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I. ACKNOWLEDGEMENTS The Ho-Chunk Nation Community Health Assessment Survey would not have been possible without the
assistance of several employees, community members, and partnering agencies. The Ho-Chunk
Nation Department of Health would like to thank the Community Health Assessment Team who worked
diligently in developing the Community Health Assessment Survey questionnaire. Team members
included: Ruth Puent, Community Health Representative Supervisor; Carol Rollins, Environmental
Health Director; Louise Voss, Community Health Educator; Marilyn Yellowbird, Community Health
Nursing Supervisor; Denise Dodson, Nutrition Supervisor; Karena Thundercloud, Diabetes Project
Coordinator; Kathleen Clemons, Exercise Physiologist; Tyler Doyle, Health Information Systems staff;
Christie Becker, Contract Health staff; Julie Abbott-Jones, Behavioral Health Director; and Nancy
Rybski, Quality Improvement Supervisor. Under the coordination of the Community Health
Representative Program and Environmental Health program, a number of Health Department staff also
contributed their time at community events to gather important data. The leadership of Alec
Thundercloud MD, Health Executive Director, guided the assessment process from start to finish.
We would also like to take the opportunity to thank Christine Hovell, Jackson County Public Health,
Samantha Lucas, Great Lakes Epidemiologist, Megan Porter, Great Lakes Epidemiologist, and Karen
Maddox RN, MSN, MPH, PNP, Associate Professor Emerita UWEC who facilitated the development of
the Community Health Assessment Survey, under the guidance of Kristin Hill, Director of Great Lakes
Epidemiology Center. The final efforts of Joan Greendeer-Lee, Health Information Systems Director
and Ruth Puent, Community Health Representative Supervisor should be applauded for compiling the
final survey results and organizing responses by area. A special thank you to Lindsay Menard, MPH,
who completed the final Community Health Assessment document.
SPECIAL ACKNOWLEDGEMENTS
The Ho-Chunk Health Department would also like to extend a special thank you to all of the community
members who provided wonderful insight and participated in each community event. It is their input
that will help shape the future programming of the Health Department. Pinigigi! Finally, we would like to
thank all Ho-Chunk Nation Health Department programs and associated staff for participating in each
Community Health Assessment Survey event. During these community gatherings staff provided food,
information on current programs, and assisted Tribal members with completing the assessment
surveys. The information gathered by the community health assessment survey will be vital to the
Health Department as it seeks to provide quality, relevant health care to Tribal members.
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II. LIST OF FIGURES, TABLES, AND CHARTS
Figure 1: Ho-Chunk Nation Legislative Districts ........................................................................................................... 5
Figure 2: County Health Rankings Model .................................................................................................................. 14
Table 1: Race Distribution ........................................................................................................................................... 7
Table 2: Age and Sex Distribution ............................................................................................................................... 8
Table 3: Death from Specific Causes ......................................................................................................................... 10
Table 4: Infant Birth Weights .................................................................................................................................... 11
Table 5: Prenatal Care Received by Women in the Ho-Chunk CHDSA ........................................................................ 11
Table 6: Women that Smoked During Pregnancy ...................................................................................................... 11
Chart 1: Age Distribution of Survey Respondents ....................................................................................................... 9
Chart 2: Respondents Diagnosed with Negative Health Outcomes ........................................................................... 10
Chart 3: Body Mass Index ......................................................................................................................................... 12
Chart 4: Blood Pressure ............................................................................................................................................ 13
Chart 5: Glycemic Control ......................................................................................................................................... 13
Chart 6: Distribution of Reported Health Status ........................................................................................................ 13
Chart 7: Health Risks Survey Respondents are Most Concerned About in Their Homes ............................................ 15
Chart 8: Annual Household Income of Survey Respondents ...................................................................................... 16
Chart 9: Percent of Survey Respondents that are High School Graduate or Have GED .............................................. 16
Chart 10: Distribution of Survey Respondents that are Current Smokers .................................................................. 17
Chart 11: Former Smokers-Time Since Quitting ........................................................................................................ 17
Chart 12: Current Smokers Interested in Cessation Classes ....................................................................................... 17
Chart 13: Days per Week Survey Respondents Exercise (Excludes Work Activities) .................................................. 18
Chart 14: Reasons for Not Being More Physically Active for all Respondents ............................................................ 18
Chart 15: Percent of Times Fast Food Was Consumed ............................................................................................... 19
Chart 16: Patient Visits for Mental Health Services ................................................................................................... 19
Chart 17: Clients Served by Mental Health Services .................................................................................................. 20
Chart 18: Clients Referred to In-Treatment Services ................................................................................................. 20
Chart 19: Health Insurance Distribution of Survey Respondents ............................................................................... 25
Chart 20: Locations Respondents Seek Care at When Sick ........................................................................................ 25
Chart 21: Frequency of Seat Belt Use While Riding in the Car ................................................................................... 26
Chart 22: Helmet Use of Respondents ...................................................................................................................... 26
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III. INTRODUCTION
Community health assessments (CHA) are a vital and important step in improving the health of
communities. Community health assessments identify the health needs of a community by
surveying residents to determine their perceived health status of the community as well as to seek
input on their own perceived health status. The purpose of this CHA is to:
1. Assess the needs of the community
2. Identify the top health needs of the community
3. Identify stakeholders and resources available to address the greatest health needs of
the community
IV. METHODOLOGY1
In 2011, the Ho-Chunk Health Department
created two surveys (individual surveys
and household surveys) with the support
of Great Lakes Inter-Tribal Epidemiology
Center (GLITEC) staff while the Ho-Chunk
Health Director oversaw the entire
process. It is important to note the survey
was approved by the Ho-Chunk
Institutional Review Board (IRB).
Approximately 625 individuals were
surveyed while 202 households were
surveyed. All individuals and households
surveyed lived in three defined geographic
areas or legislative districts (Figure 1).
Data is reported by overall responses and
then broken down by the Ho-Chunk
representative districts, known as Area 1,
Area 2, and Area 3.
This map shows four of the five Ho-Chunk Nation tribal voting
districts. The 5th district includes members who lives any place
in the world outside the State of Wisconsin.
Figure 11: Ho-Chunk Nation Legislative Districts
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It is important to note that data was not compiled from Areas 4 and 5 as these areas are not in Ho-
Chunk’s Contract Health Service Delivery Area (CHSDA). Respondents were asked several
different questions to determine how socioeconomic factors, the effectiveness and efficiency of the
healthcare system, health behaviors, and access to services all influenced the health of tribal
members. Also, survey respondents were asked to answer questions regarding the perceived
health needs of the community and potential programs/services to develop and implement in the
future to help improve the health of community members.
The sample was a convenience sample; Ho-Chunk adults over 18 years of age who answered the
survey and lived near one of the six tribal community buildings where health staff conducted the
surveys. Each survey was self-administered, using pen and paper. It was filled out at community
meetings where a meal was provided. All adults completed a survey about their individual health.
In addition, one adult from each household in which at least one minor resided was asked to fill out
a household survey. This adult answered questions about all minors living in the household. Ho-
Chunk employees staffing the events carefully distributed the household surveys so that each
household would only be represented once.
There were 827 surveys in the sample. The data was hand-entered into excel; every tenth entry
was compared to the original paper survey to check for accuracy. Data were analyzed using SAS
software.
These data have limitations. The survey utilized convenience methods; data were self-reported. In
some cases, the questions used non-standard wording and/or response options, limiting
comparability to other populations. For the household survey, data were reported by an adult in the
household, not the minor; no formal mechanism existed to ensure that each child was included
only once.
The results of the survey were collected, analyzed, and developed into a CHA. The CHA will then
be utilized by leaders of the Ho-Chunk Nation Health Department to develop a Community Health
Improvement Plan (CHIP) which will be used to move strategies and interventions forward to
reduce the health needs identified in this assessment.
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V. DEMOGRAPHICS
Understanding the demographics of a population begins to frame the health of the community.
Three important factors used to identify and analyze the health needs of a community are race,
age, and sex distribution.
Ho-Chunk Nation has tribal members spread throughout the state of Wisconsin. Ho-Chunk Nation
cannot be defined by one geographic location. As stated earlier, data for the CHA was gathered at
one of six tribal community buildings and at several community meetings during 2011. As National
and State data are not available for tribes at the reservation geographic level the data provided for
comparison of Areas 1, 2, and 3 in the demographics section includes the population of Ho-
Chunk’s CHSDA. Therefore race, age, and sex distribution data incorporate data from the
following counties2:
Area 1: Clark, Eau Claire, Jackson
Area 2: Columbia, Crawford, Dane, La Crosse, Monroe, Sauk, Vernon and Houston
County in Minnesota
Area 3: Adams, Juneau, Marathon, Shawano, and Wood
Table 13-19
: Race Distribution, Areas 1, 2, 3 and All Races in Wisconsin*, 2010
Race Area 1 Area 2 Area 3 Wisconsin
American Indian/Alaska Native 1,916 3,912 4,996 54,559
Asian/Pacific Islander 3,536 29,236 8,907 131,152
Black 1,354 29,049 2,567 359,249
White 143,542 737,902 275,234 4,920,637
Some other race 1,436 14,989 2,636 135,879
Two or more races 2,091 16,549 3,960 104,537
Total 153,875 831,637 298,300 5,706,013
*Including Houston County, MN Based on Ho-Chunk’s CHSDA, the most populous area is Area 2 which includes the counties of
Columbia, Crawford, Dane, La Crosse, Monroe, Sauk, Vernon, and Houston (Minnesota). Even
though Area 2 has the most residents, Area 3 has the highest number of American Indians/Alaska
Natives living within its counties. In Wisconsin the majority of citizens are white (86%) and this
trend is also found in areas 1, 2, and 3. Overall, less than .1% of residents living in all 16 counties
of the CHSDA are American Indian/Alaska Natives.3-19
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Age and sex distribution also provide valuable information on the health outcomes witnessed in
populations. For example, if the majority of the population consists of people over the age of 65
the health outcomes and health needs reported will more than likely be different than those
reported if the majority of the population was between the ages of 20 and 40. Ho-Chunk’s CHSDA
have approximately an even sex distribution; although, men tend to outnumber women in the
majority of age ranges. Furthermore, it can be concluded the majority of residents (~81%) in the 3
service areas are aged 1 to 59 which is similar to the state of Wisconsin.3-19
Table 23-19
: Age and Sex Distribution, Areas 1, 2, 3 and All Ages in Wisconsin*, 2010
Age
Area 1 Area 2 Area 3 Wisconsin
Male Female Male Female Male Female Male Female
20 to 24 9.8% 10.0% 8.6% 8.5% 5.3% 4.9% 7.0% 6.6%
25 to 29 7.3% 6.3% 8.0% 7.4% 6.0% 5.7% 6.7% 6.4%
30 to 34 6.2% 5.4% 7.0% 6.5% 5.8% 5.3% 6.3% 6.0%
35 to 39 5.6% 5.3% 6.4% 6.1% 6.1% 5.7% 6.2% 6.0%
40 to 44 6.1% 5.6% 6.7% 6.4% 6.9% 6.6% 6.8% 6.6%
45 to 49 6.9% 6.7% 7.3% 7.3% 8.2% 7.7% 7.7% 7.7%
50 to 54 6.9% 6.7% 7.3% 7.3% 8.0% 7.9% 7.7% 7.6%
55 to 59 6.3% 6.4% 6.7% 6.7% 7.2% 7.0% 6.8% 6.7%
60 to 64 5.4% 5.4% 5.4% 5.4% 5.9% 6.1% 5.5% 5.5%
65 to 69 3.9% 3.9% 3.6% 3.8% 4.7% 5.0% 3.9% 4.1%
70 to 74 2.7% 3.2% 2.5% 2.8% 3.6% 3.9% 2.9% 3.2%
75 to 79 2.3% 2.8% 1.9% 2.4% 2.7% 3.2% 2.2% 2.8%
80 to 84 1.7% 2.4% 1.4% 2.1% 2.0% 2.8% 1.7% 2.4%
>85 1.7% 3.0% 1.2% 2.6% 1.6% 3.3% 1.3% 2.8% *Including Houston County, MN
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Surveying
individuals at a
variety of ages
helps gauge the
health status and
health needs of a
community
rather than if the
population was
close in age as it
allows for more
diverse
responses.
Survey
respondents ranged in age from 18 to older than 85 years old. In Areas 1, 2, and 3 the majority of
individuals surveyed were between the ages of 25 and 64. Less than 5% of respondents were
over the age of 85.1
VI. INDICATORS OF HEALTH
HEALTH OUTCOMES The health of a population is often measured by mortality (length of life) and morbidity (quality of
life) rates. It is difficult to quantify and define health; therefore, these two indicators have long
been used as the primary instruments to determine the health of a community. Other leading
indicators used to define the health of a community are infant mortality and birth weights.
Furthermore, immunization data and diabetes data provide extra insight on other important health
measures impacting the health of Ho-Chunk Tribal members.
0
5
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25
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18-24 25-34 35-44 45-54 55-64 64-75 75-85 >85
Pe
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Age
Age Distribution of Survey Respondents
Area 1
Area 2
Area 3
All Respondents
Chart 11: Age Distribution of Survey Respondents
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Tribal members reported the top six negative health outcomes experienced in the population are
high blood pressure, diabetes type 2, alcohol/drug dependency, high cholesterol, arthritis, asthma,
and cancer. Additionally, data gathered from the Wisconsin Bureau of Health Information indicated
heart disease and
cancer were the main
causes of mortality
(Table 3).2 In 2009,
the leading cause of
American
Indian/Alaska Native
deaths nationwide
were heart disease,
cancer, and injuries
(unintentional
injuries).20 The trends
identified in the overall
population of
American
Indians/Alaska
Natives in the United
States coincide with
the results of the community health survey. The majority of these negative health outcomes are
chronic conditions; preventative programs and services can be used to reduce the number of
adverse health outcomes reported by Ho-Chunk Tribal members.
Chart 21: Respondents Diagnosed with Negative Health Outcomes
Table 32: Death from Specific Causes
0
50
100
150
200
250
Ast
hm
a
Dia
be
tes
Typ
e 1
Dia
be
tes
Typ
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Hea
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ttac
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Hea
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ise
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loo
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ress
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Hig
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ho
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ero
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isea
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reat
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rob
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epe
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of
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Respondents Diagnosed with Negtative Health Outcomes
All Respondents
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MATERNAL AND CHILD HEALTH (MCH) (NATALITY)
Infant birth rates and prenatal
care received by mothers during
pregnancy are two additional
indicators to use when
determining the health of a
community. If infants are born
with low birth weights they are
more susceptible to negative
health outcomes such as
respiratory illness, lung disease,
and vision and hearing problems.
Low birth weight is defined as a newborn weight of lower than 2,500 grams.21 Data from the
Wisconsin Bureau of Health Information indicated that from 2000-2009, 77.4% of American
Indians/Alaska Natives infants born in the Ho-Chunk CHDSA were born in the average birth weight
category compared to 82.4% of all races in Wisconsin.2 Furthermore, only 5.6% of American
Indian/Alaska Natives born in the Ho-Chunk service area were born with low birth weight.2 Over
70% of American Indian/Alaska Native women in the Ho-Chunk CHDSA sought prenatal care from
2000-2009 in their first trimester while 65.1% did not smoke during pregnancy.2 Although some
MCH data appears promising, it is important to note 77.4% of infants born with average birth rates
is an unexpected finding and does not reflect pregnant women seeking prenatal care in the third
trimester (5.6%) and the number of women still smoking during pregnancy (33.9%).2
Table 62: American Indian/Alaska Native
Women that Smoked During Pregnancy
Table 52: Prenatal Care Received by
Women in the Ho-Chunk CHDSA
Table 42: Infant Birth Weights
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IMMUNIZATION DATA
Ensuring populations are immunized is one of the best ways to prevent the transmission of
communicable diseases. Immunizing infants and children is a primary preventive measure a
community can take to assure the health of its residents. A goal of the Ho-Chunk Health
Department is to ensure approximately 80% of Ho-Chunk children residing in the Ho-Chunk tribal
jurisdiction area and are turning 24 months of age complete 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3
Hepatitis B, 1 Varicella, and 4 Pneumococcal Conjugate immunizations.22 In 2011, 77.6 % of Ho-
Chunk children received their required immunizations; in 2012, 77.1% of Ho-Chunk children were
immunized.22 Healthy People 2020 established a goal of immunizing 90% of children aged 19 to
35 months with effective vaccination coverage levels for universally recommended vaccinations.32
DIABETES
Diabetes is another leading
health indicator to use when
determining the health of a
population. Diabetes Type 2 is
a common negative health
outcome. Several factors
influence the onset and
diagnosis of diabetes including
but not limited to predisposition,
weight, blood pressure,
genetics, and activity levels.
The Ho-Chunk Diabetes audit indicated that from 2008-2011 approximately 70% of CHDSA
diabetic patients were obese; tribal diabetic patient’s body mass index (BMI) was also found to be
greater than 30.0.2 In order to better control and treat diabetes it is recommended that diabetic
patients have a normal BMI reading (less than 25.0).2 Additionally, it is recommended blood
pressure levels read <120/<70 for diabetic patients.2 Unfortunately, 25%-35% of diabetic patients
in the Ho-Chunk CHDSA had blood pressure levels greater than the recommended value (Chart
4).2 Managing blood-sugar levels is also important for tribal diabetic patients; approximately one-
third of diabetic patients had blood-sugar levels equal to or less than the recommended goal for
the HbA1c test (Chart 5).2 Target goals established in Healthy People 2020 for diabetic patients
whose blood pressure is under control and have a HbA1c value less than 7% are 57.0% and
58.9% respectively.32
Table 6: Smoking During Pregnancy
Chart 32: Body Mass Index (BMI)
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HEALTH STATUS
Survey respondents had the opportunity to report their health status as either being poor, fair,
good, very good, or excellent. Approximately 40% of people in all three service areas reported
having good health and over 25% of all respondents reported having very good health.1
Approximately 5%-18% of all respondents reported having fair or poor health1 compared to 13.6%
of Native Americans/Alaska Natives in the nation in 20111,23. In order to reduce negative health
outcomes and increase productivity and happiness in the community it is crucial to have healthy
residents. According to the data, the majority of residents believe they are in good health; a
successful finding for health department staff and policy makers alike.
0 10 20 30 40 50
Excellent
Very Good
Good
Fair
Poor
Percent of Respondents Self
Re
po
rte
d H
eal
th S
tatu
s
Distribution of Self Reported Health Status of Survey Respondents
All Respondents
Area 3
Area 2
Area 1
Chart 61: Distribution of Reported Health Status
Chart 42: Blood Pressure Chart 5
2: Glycemic Control
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VII. COUNTY HEALTH
RANKINGS MODEL
Healthcare and public health
professionals
have defined health by death
and disease rates for decades.
In recent years however, new
ways of defining and
categorizing health have been
adopted. The Wisconsin
Population Health Institute and
the Robert Wood Johnson
Foundation developed a new
model, The County Health
Rankings Model, to help define
what impacts individual health
and health outcomes.
According to the model, the
physical environment, social and
economic factors, clinical care,
and health behaviors all
influence health outcomes. The model indicates that 10% of health is determined by physical
environments, 40% is impacted by social and economic factors, 20% clinical care, and 30% health
behaviors.24 Therefore, it is important to assess how income levels, educational attainment, the
places people live, work, and socialize, and individual behavior all impact the health of Ho-Chunk
Tribal members. It is essential to note the methods of measurement used to calculate the County
Health Rankings do not incorporate Ho-Chunk Tribal members as Wisconsin Data Systems have
certain restrictions including but not limited to being able to identify Native Americans by tribe (C.
Rollins, personal communication, November 20, 2013).
Figure 224
: County Health Rankings Model
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PHYSICAL ENVIRONMENT
According to survey respondents, the three biggest health risks tribal members are concerned
about in their households are slips and falls, mold, and the quality of their drinking water.
Approximately 10% of all respondents are concerned about slips and falls and mold while 18% of
all respondents are concerned about the quality of their drinking. Across Areas 1, 2, and 3 there
are no significant differences noticed. Overwhelmingly, approximately 45% of respondents in
Areas 1, 2, and 3 have no environmental concerns.
0
10
20
30
40
50
60
Allerginsthat
triggerAsthma
Slips andFalls
CarbonMonoxide
Gas
Radon Gas TheQuality of
MyDrinkingWater
Mold None
Pe
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nt
of
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spo
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ts
Health Risks Survey Respondents are Most Concerned About in their Homes
Area 1
Area 2
Area 3
All Respondents
Chart 71: Health Risks Survey Respondents are Most Concerned About in their Homes
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05
101520253035
Pe
rce
nt
of
Re
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nd
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Annual Household Income
Annual Household Income of Survey Respondents
Area 1
Area 2
Area 3
All Respondents
SOCIAL AND ECONONMIC FACTORS
Income levels, educational background, employment rates, family and social support, and
community safety are all variables that significantly influence health outcomes. Survey
respondents across all three areas reported household incomes to be less than $10,000 and more
than $75,000 dollars.1 In Wisconsin, the average household income from 2007-2011 was
$66,693.25 Overall, approximately 83% of all survey respondents make less than the average
household income of Wisconsin residents.1 Ho-Chunk members earning less than the average
household income are at a greater risk of reporting negative health outcomes such as heart
disease, high blood pressure, diabetes, obesity, etc.
Education is also another leading indicator of the health of communities. According to Ho-Chunk
Tribal members taking the community health survey, 68% are high school graduates or have their
GED. Whereas in Wisconsin, 85.4% of residents 25 years
of age or older are high school graduates or have their
GED.26 With that, approximately half of all Wisconsin
residents have some form of post-secondary education
compared to only 22% of tribal members.1,26 This
difference influences the health outcomes reported by Ho-
Chunk Tribal members significantly. Research has shown
people with higher levels of education are more likely to be
healthier than those with less education. Healthy People
2020 set a goal of having 97.9% of 18 to 24 years
complete high school in the coming decade.32
73.45
62.69 67.94
68.07
Percent of Survey Respondents that are High School Graduates or have
their GED
Area 1
Area 2
Area 3
Chart 81: Annual Household Income of Survey Respondents
Chart 91: Percent of Survey Respondents that are
High School Graduates or have their GED
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HEALTH BEHAVIORS
Health behaviors, according
to the Robert Wood Johnson
Foundation and the
Wisconsin Population Health
Institute, account for 30% of
morbidity and mortality
rates.24 Many interventions,
programs, and services in
public health are currently
focused on changing
individual behavior.
Smoking, excess drinking, unhealthy eating, lack of exercise, and other human behaviors impact
the health outcomes of individuals and populations. For example, smoking is a known cause of
lung cancer and cardiovascular disease. The three figures on this page highlight the smoking
behaviors of survey respondents. In areas 1, 2, and 3 approximately 50% of tribal members
reported being a current smoker; whereas in 2011, approximately 21% of all Wisconsin adults
currently smoked cigarettes.1,27 The traditional use of tobacco is a common practice among tribal
members. In future assessments it will be important to be strategic when developing questions
regarding traditional use of tobacco products as
010203040506070
Pe
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nt
of
Cu
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Smo
kers
Distribution of Survey Respondents that are Current Smokers
Yes
No
Only for CeremonialPurposes
Healthy People 2020 Target , 12.0%32
0
10
20
30
40
50
60
70
Pe
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Smo
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Former Smokers-Time Since Quitting
Less Than a Year
1 to <3 Years
3 to <5 Years
5 Years or Greater
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Current Smokers Interested in Cessation Classes
Yes
No
Chart 101: Distribution of Survey Respondents that are Current Smokers
Figure #: Facilities Respondents Seek Care at When Sick
Chart 111: Former Smokers: Time Since Quitting
Chart 121: Current Smokers Interested in Cessation
Classes
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survey results may help develop more effective prevention programs (P. Thunder, personal
communication, November 20, 2013). Although the percent of current smokers is high, 50% of former
smokers that have quit smoking have been non-smokers for over 5 years.1 Reducing smoking
rates has been a goal
of public health
advocates for
decades. A primary
intervention used to
reduce the number of
smokers is the use of
cessation programs.
Unfortunately,
smoking cessation
programs may not be
the most successful
intervention to
implement throughout
the community as
over 60% of current
smokers are not
interested in
cessation classes
(Chart 12).1
Another important
health behavior
impacting the health
of community
members is the
amount of time
residents spend
exercising. Exercise
is vital in maintaining
a healthy weight and dealing with stress. Therefore, it is important Ho-Chunk Tribal members get
41.5
36.96
20.16
17.19 52.37
14.03
20.16
6.32
15.42
10.08
13.24 17.79
Reasons for Not Being More Physically Active for All Respondents
Lack of Time Due to Work/School
Lack of Time Due to FamilyObligationsLack of Facilities or Programs
Lack of Support from Family/Friends
Lack of Self-Discipline or Willpower
Fear of Injury
Distance I Have to Travel to Exercise
No Safe Place to Exercise
Long-Term Illness
Injury or Disability
I Do Not Know How to Start aFitness ProgramCost
0
5
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30
35
40
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erc
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Days per Week
Days per Week Survey Respondents Excercised (excludes work activities)
Area 1
Area 2
Area 3
All Respondents
Healhty People 2020 Target, 47.9% of adults will meet Federal pysical activity guidelines of engaging in 75 minutes of activity twice a week32
Chart 141: Reasons for Not Being More Physically Active for All Respondents
Chart 131: Days per Week Survey Respondents Exercise (Excludes Work Activities)
19 | P a g e
adequate exercise. It is recommended by the Centers for Disease Control and Prevention (CDC)
that adults spend about seventy-five minutes, two days a week exercising to improve their health.28
Based on the community health survey results, 35%-40% of tribal members in Areas 1, 2, and 3 do
not regularly exercise (Chart 14).1 Those that do exercise regularly, exercise 1-3 days a week.1
The biggest barriers stopping
survey respondents from
exercising are the lack of
self-discipline or willpower
(52.37%), lack of time due to
work/school (41.5%), and
lack of time due to family
obligations (36.96%).1 It is
important to note survey
respondents were allowed to
select multiple reasons for
not being more physically
active (Chart 14).
Additionally, the number of times eating at various fast food restaurants also contributes to the
health of tribal members. Over half (56.98%) of survey respondents indicated eating at fast food
restaurants 1 to 5 times in the previous month.1 Fast food restaurants tend to serve unhealthier
foods high in calories, cholesterol, and fat. Educational campaigns developed by the Ho-Chunk
Health Department should focus on teaching
and encouraging tribal members to select
healthier items such as wraps, salads, and
fruit.
Another variable impacting the health
outcomes of Ho-Chunk Tribal members are
behavioral health conditions such as
depression, anxiety, schizophrenia, post-
traumatic stress disorder, and alcohol and
other drug addictions. From 2010 through
2012 patient visits for mental health services
4.98
56.98 15.45
4.49
3.82 1
1.5
11.79
Percent of Times Fast Food was Consumed (Last 30 Days) of All
Respondents
0
1 to 5
6 to 10
11 to 15
16 to 20
21 to 25
26 to 30
Don't Know/Not Sure
Chart 1629
: Patient Visits for Mental Health Services
Chart 151: Percent of Times Fast Food was Consumed
400
500
600
700
800
900
2010 2011 2012
Nu
mb
er
of
Pat
ien
t V
isit
s
Year
Patient Visits for Mental Health Services
# ofPatientVisits
20 | P a g e
doubled; there were approximately 450 patient visits in 2010 compared to over 800 in 2012.29 With
an increase in patient visits there was also an increase in the number of patients served. In 2010
the Ho-Chunk Health Department served approximately 1200 clients in the Behavioral Health
Department while in 2012 about 2000 clients were served.29 The trend for both patient visits and
clients served increased over
the past three years
indicating the need for
behavioral health support is
growing. A trend worth noting
is the decrease in clients
referred to in-treatment
services. In 2010,
approximately 180 clients
were referred to in-treatment
services compared to 80 in
2012.29 It is important to note the Ho-Chunk Tribal data may represent duplicated clients (P.
Thunder, personal communication, December 4, 2013). In Wisconsin, among adults with serious
psychological distress it is reported approximately half (49%) received mental health treatment or
medication in 2007.30 Furthermore, frequent mental distress was more prevalent among American
Indians (14%) compared to whites (8%) in Wisconsin.30 Healthy People 2020 has a goal of
assuring 64.6% of adults aged 18 years and older with serious mental illness receive treatment by
2020.32
Chart 1829
: Clients Referred to In-Treatment Services
1000
1500
2000
2500
2009 2010 2011 2012Nu
mb
er
of
Clie
nts
Se
rve
d
Year
Clients Served for Mental Health Services
# of Clients Served
0
50
100
150
200
2010 2011 2012
Nu
mb
er
of
Pat
ien
ts R
efe
rre
d t
o In
-P
atie
nt
Tre
atm
en
t
Year
Clients Referred to In-Treatment Services
# of Clients Referred to In-Treatment Services
Chart 1729
: Clients Served for Mental Health Services
21 | P a g e
VIII. SUMMARY OF DATA
The responses collected for the Ho-Chunk community health assessment were vast (625 individual
surveys and 202 household surveys) and produced an abundant amount of data. The majority of
individuals surveyed were between the ages of 25 and 64 while less than 5% of respondents were over
the age of 85.1 Community Health Service Delivery Area (CHSDA) 3 (Adams, Juneau, Marathon,
Shawano, and Wood Counties) has the highest number of American Indians/Alaska Natives living
within its counties.3-19
Morbidity and mortality rates are two of the leading indicators used to define the health of a population.
From the data presented and analyzed, the two leading causes of death from 2000-2009 in the Ho-
Chunk Nation are heart disease and cancer.2 Furthermore, the survey results aided in the identification
of the top negative health outcomes (high blood pressure, diabetes type 2, alcohol/drug dependency,
high cholesterol, arthritis, and cancer) experienced by tribal members along with how low infant birth
weights and diabetes affect the health of community members.1,2,22
Even though high rates of disease
exist throughout the community, approximately 40% of people in all three service areas reported having
good health and over 25% of all respondents reported having very good health.1
In assessing the variables that determine the health of a person or a community it is important to
include social, economic, and physical environment factors. Health is determined by more than
individual health behaviors and clinical care. According to the County Health Rankings Model from the
Robert Wood Johnson Foundation and the Wisconsin Population Health Institute, 10% of health
outcomes can be attributed to the physical environment, 40% to social and economic factors, 30% to
individual health behaviors, and 20% to clinical care.24
Ho-Chunk Tribal members (10-18%) are most concerned about slips and falls, the quality of drinking
water, and mold adversely influencing their health in their homes.1 Overall, 83% of all survey
respondents make less than the average household income of Wisconsin residents. Education is also
another leading indicator of the health of communities.1,25
According to Ho-Chunk Tribal members
taking the community health survey, 68% are high school graduates or have their GED.1 When
compared to the state of Wisconsin, 85.4% of adults aged 25 or older are high school graduates or
have their GED.26
Individual health behaviors such as smoking, alcohol consumption, exercising, and
wearing seat belts also influence the health of communities. Approximately 50% of tribal members
reported being a current smoker and 40% stated not participating in regularly exercise.1
In addressing the greatest health needs of the community, it will be important for Ho-Chunk Health
Department staff, community residents, and stakeholders to consider how income and education levels
influence the health of tribal members.
22 | P a g e
IX. IDENTIFIED HEALTH NEEDS
A way of determining the health needs of Ho-Chunk Tribal members is to identify the most
diagnosed health outcomes. The survey results indicate Ho-Chunk Tribal members suffer from six
main health problems:
1) High Blood Pressure (210 respondents)
2) Diabetes Type 2 (143 respondents)
3) Alcohol/Drug Dependency (118 respondents)
4) High Cholesterol (114 respondents)
5) Arthritis (92 respondents)
6) Cancer (50 respondents)
The Public Health Accreditation Committee reviewed the community survey questions and results.
The areas selected as the top health needs seemed to be mostly represented in either question or
answer form. Selecting the health needs of tribal members in this manner was a tangible way for
the committee to organize such a large amount of information into a more useable form (P.
Thunder, personal communication, December 4, 2013).
It will be important for the Community Health Improvement Plan (CHIP) to identify and implement
interventions, policies, programs, and services aimed at reducing the health needs listed above.
When developing ways to reduce the negative health outcomes it will be crucial for community
members to incorporate interventions aimed at addressing the social determinants of health.
Social, economic, and physical environmental factors influence health outcomes as much, if not
more, than individual behaviors and clinical care.24
23 | P a g e
X. STRENGTHS AND CHALLENGES OF CONDUCTING A COMMUNITY HEALTH ASSESSMENT Conducting a community health needs survey and facilitating community meetings are complex
and complicated tasks. Organizing the data gathered, analyzing the data, and developing a
community health needs assessment are also very difficult activities. Throughout the entire
process many strengths and challenges were identified.
A strength of conducting this community health assessment was the opportunity to reach out to
community members and seek their feedback on health programs without any political undertones.
Community members appeared to enjoy participating in the community conversations and
appreciated the chance to provide input. Additionally, staff members were able to connect with
communities and have conversations about the health and needs of tribal members in the CHSDA
regions. Another strength of this process was the chance to foster relationships with existing
community partners and develop new relationships with key stakeholders not previously involved
in this process.
With the many strengths of the community health assessment process, challenges arose, too. It
was difficult to locate and find national and state-wide data to use for comparison with the results
of the Ho-Chunk community health survey. With that, it was also difficult to bring together local
data in a tangible and meaningful way. Additionally, it was difficult to reach more of the targeted
population as tribal members are spread across a wide geographic area. Furthermore, since the
time the assessment process began, a tribal community assessment tool has been developed and
it is believed this tool would have helped the process move forward in a more organized manner.
Moreover, a GLITEC epidemiologist helped formulate the survey questions; some of the questions
did not provide the information needed. In this respect, a dialogue with the community would have
been preferable. Finally, one of the hardest challenges was moving forward in the process after
the survey data was collected, gathered, and grouped (Rollins, C. & Thunder, P., personal
communications, November 20, 2013).
XI. NEXT STEPS In late 2013 and early 2014, the Public Health Accreditation Committee will develop a Community
Health Improvement Plan (CHIP) to address the biggest health needs facing Ho Chunk Tribal
members. Ho-Chunk staff will identify focus areas and then solicit feedback from community
members. The CHIP will be written and ready for implementation in early 2014.
24 | P a g e
XII. COMMUNITY STAKEHOLDERS AND RESOURCES
A. Ho-Chunk Nation Social Services including Youth Services and the Tribal Aging
Unit
B. Ho-Chunk Nation Housing
C. Ho-Chunk Nation Community Development Agency
D. Jackson County Health and Human Services
E. Black River Falls Memorial Hospital
F. Ho-Chunk Nation Emergency Management
G. Jackson County Emergency Management
H. WI Department of Health Services
I. Western Regional DHS Office
J. Indian Health Service
K. Institute for Wisconsin Health, Inc
L. Ho-Chunk Nation Education Department including Head Start
M. Jackson County Child Death Review Team
N. Ho-Chunk Nation Tribal Police
25 | P a g e
XIII. APPENDIX A:
ADDITIONAL DATA
Ho-Chunk residents
completing the survey are
insured by two primary
providers: employers
(47.26%) and
IHS/Contract Health
Service (44.61%).1 In the
County Health Rankings
Model, clinical care only
accounts for 20% of
health outcomes24. The
majority of community
members surveyed are
covered by two reliable
sources; therefore, residents have access to more affordable healthcare than if they were
uninsured. The
clinical care tribal
members have
access to is
important in
preventing,
diagnosing, and
controlling the
diseases faced
by the
population. Less
than 10% of all
survey
respondents
reported having
01020304050607080
Ho-ChunkTribalHealthCenterClinic
OtherTribalHealth
Care Clinic
Non-TribalHealth
Care Clinic
UrgentCare
HospitalEmergency
Room
Never goto any
place whenI'm sick or
needhealthadvice
Pe
rce
nt
of
Re
spo
nd
en
ts
Location
Locations Respondents Seek Care at When Sick
Area 1
Area 2
Area 3
All Respondents
Chart 191: Health Insurance Distribution of Survey Respondents
Chart 201: Locations Respondents Seek Care At When Sick
05
101520253035404550
Pe
rcen
t o
f R
esp
on
den
ts
Type of Health Insurance
Health Insurance Distribution of Survey Respondents
Area 1
Area 2
Area 3
All Respondents
26 | P a g e
no health care coverage at all (Chart 19).1 It is also important to note the IHS/Contract Health
Service coverage is more of a last resort payer for Ho-Chunk Tribal members rather than a primary
insurance provider (P. Thunder, personal communication, December 4, 2013).
As noted in Chart 20, when Ho-Chunk Tribal members seek coverage 75% of respondents
receive care at the Ho-Chunk Tribal Health Care Center.1 The management of chronic diseases
among tribal members has been a focus area of the Ho- Chunk Nation Health Department (C.
Rollins, personal communication,
November 20, 2013). A primary
prevention measure is regular
preventive care. Most tribal
members (70%) had a routine
check-up within the past year.1
Routine physicals and seeking
care by primary physicians
allows residents to form trusting
relationships with their providers
while also accessing more
affordable services. Primary
care is significantly less
expensive than emergency
department care. Also,
routine check-ups allow
survey respondents
to manage their care more
effectively which ultimately
impacts their health in a
positive way.
Other behaviors potentially
impacting the health
outcomes of tribal members
are adverse childhood
effects, the prevalence of
binge drinking, using a seat belt in a car, riding in a vehicle with a drunk driver, wearing a helmet,
Chart 211: Frequency of Seat Belt Use While Riding in the Car
0
20
40
60
80
100
Pe
rce
nt
of
Re
spo
nd
en
ts
Frequency of Seat Belt Use While Riding in the Car
Survey Respondents Use of Seat Belts in Car
Area 1
Area 2
Area 3
All Respondents
Healthy People 2020, Target, 92% for drivers and right-front seat pasengers32
01020304050607080
Nu
mb
er
of
Re
spo
nd
en
ts
Area
Respondents Reporting Wearing a Helmet
Bicycle
All-Terrain Vehicle
Motorcycle
Snowmobile
Healthy People 2020, Target 74 % for motorcycle operators & passangers32
Chart 221: Helmet Use of Respondents
27 | P a g e
etc. Approximately 75% of survey respondents (Chart 21) stated they always wear a seat belt
while driving in the car and approximately 25% of respondents reported wearing a helmet while
biking, using an all-terrain vehicle, motorcycling, and snowmobiling (Chart 22)1. Participating in
healthy behaviors helps reduce the risk of injury and lowers the rate of preventable injuries in the
community.
XIV. APPENDIX B: Individual and Household Survey Results
The results of the Individual and Household Surveys are available by request from the Ho-Chunk
Nation Health Department.
XV. APENDIX C: PUBLIC HEALTH ACCREDITATION BOARD Standards & Measures Comparison (Version 1.0)31
The Public Health Accreditation Board (PHAB) developed domains, standards, and measures for
State, Local, and Tribal health departments to meet in order to obtain voluntary national
accreditation. Striving to meet the standards and measures set forth by PHAB helps ensure a
health department is providing effective, efficient, and quality services. Domain 1, standard 1, and
measure 2 requires tribal health departments to complete a health assessment. In order to be in
compliance with the standards and measures tribal health departments must complete a
community health assessment and include the majority of components outlined in the measure:
A. Data and information from various sources contributed to the community health
assessment and how the data were obtained
B. A description of the demographics of the population
C. A general description of health issues and specific descriptions of population groups
with particular health issues
D. A description of contributing causes of community health issues
E. A description of existing community or Tribal assets or resources to address health
issues
The preceding Ho-Chunk Nation community health assessment encompasses the majority of the
required components. Data collected did not necessarily focus on specific population groups with
particular health issues as tribal members can be considered a low-income and minority
population. Furthermore, existing community and Tribal assets or resources can be elaborated
upon in more detail in future assessments and in the Community Health Improvement Plan.
28 | P a g e
XVI. REFERENCES
1 Ho-Chunk Nation Department of Health. (2013). Executive Summary of the 2011 Community Health Assessment
Survey. 2
Great Lakes Inter-Tribal Epidemiology Center. (2012). Ho-Chunk Community Health Profile. Great Lakes Inter-Tribal
Council, Inc. 2012.
3 United States Census Bureau. (2010). Adams County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
4 United States Census Bureau. (2010). Clark County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
5 United States Census Bureau. (2010). Columbia County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
6 United States Census Bureau. (2010). Crawford County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
7 United States Census Bureau. (2010). Dane County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
8 United States Census Bureau. (2010). Eau Claire County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
9 United States Census Bureau. (2010). Houston County MN 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
10 United States Census Bureau. (2010). Jackson County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
11 United States Census Bureau. (2010). Juneau County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
12 United States Census Bureau. (2010). La Crosse County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
13 United States Census Bureau. (2010). Marathon County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
14 United States Census Bureau. (2010). Monroe County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
15 United States Census Bureau. (2010). Sauk County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
16 United States Census Bureau. (2010). Shawno County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
17 United States Census Bureau. (2010). Vernon County WI 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
18 United States Census Bureau. (2010). Wisconsin 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
19 United States Census Bureau. (2010). Wood County 2010 Demographic Profile. Retrieved from
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
20 Heron, M. (2012, Oct 26). National Vital Statistics Reports Deaths: Leading Causes for 2009. Retrieved from
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_07.pdf
29 | P a g e
21 World Health Organization. (2013). Health status statistics: Morbidity. Retrieved from
http://www.who.int/healthinfo/statistics/indlowbirthweight/en/
22 Ho-Chunk Nation Department of Health. (2013). Immunization Program Data.
23 Centers for Disease Control and Prevention National Center for Health Statistics. (2012). Summary Health Statistics
for the U.S. Population: National Health Interview Survey, 2011. Retrieved from
http://www.cdc.gov/nchs/data/series/sr_10/sr10_255.pdf
24 University of Wisconsin Population Health Institute, Robert Wood Johnson Foundation. (2013). County Health
Rankings. Retrieved from http://www.countyhealthrankings.org/our-approach
25 United States Census Bureau. (2012). Selected Economic Characteristics: 2007-2011 American Community Survey
5-Year Estimates. Retrieved from
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_11_5YR_DP03
26 United States Census Bureau. (2012). Selected Social Characteristics in the United States: 2007-2011 American
Community Survey 5-Year Estimates. Retrieved from
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_11_5YR_DP02
27 Wisconsin Department of Health Services Wisconsin Tobacco Prevention Control Program. (2012). Tobacco Fact
Sheet. Retrieved from http://www.dhs.wisconsin.gov/publications/p4/p43073.pdf
28 Centers for Disease Control and Prevention. (2011). How Much Physical Activity Do Adults Need? Retrieved from
http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html
29 Ho-Chunk Nation Department of Health. (2013). Activity Report for Mental Health Program.
30 Wisconsin Department of Health Services. (2010). Mental Health (Focus Area Profile). Retrieved from
http://www.dhs.wisconsin.gov/hw2020/pdf/mentalhealth.pdf
31 Public Health Accreditation Board. (2011). Standards & Measures. Retrieved from http://www.phaboard.org/wp-
content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf
32 U.S. Department of Health and Human Services. (2013). Healthy People 2020: Topics and Objectives. Retrieved from
http://healthypeople.gov/2020/topicsobjectives2020/default.aspx