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HomeMy WebLinkAbout2001CommHealthAss.rpt Lexington Community Health Assessment: Health Priorities for the Town Submitted by the Health Assessment Advisory Committee for the Lexington Board of Health Health Assessment Advisory Committee Burt Perlmutter, M.D., Chair Wendy Heigger Bernays, PhD Martha Sheridan, M.D. James Fearnside Nancy Earsy Margaret Kennedy, M.S. Frederick Mazer, M.D. December 12, 2001 Health Assessment for the Town of Lexington: Health Priorities for the Town of Lexington Submitted by the Health Assessment Advisory Committee for the Lexington Board of Health Table of Contents EXECUTIVE SUMMARY I. INTRODUCTION II. HEALTH ASSESSMENT A. Process and Data Review B. Definition and Scope of Public Health C. Board of Health Role in Community D. Lexington’s Health Programs III. PRIORITIZATION OF KEY HEALTH CONCERNS A. Data Evaluated 1. Demographics 2. Environmental Factors 3. Disease Incidence B. Information from Community Members IV. KEY HEALTH PRIORITIES FOR LEXINGTON A. Mental Health B. Physical Exercise, Obesity, and Chronic Diseases C. Traffic and Pedestrian Safety D. Substance Abuse E. Bioterrorism and Infectious Diseases F. Senior Health G. Pesticide Usage V. RECOMMENDATIONS VI. CONCLUSION VII. REFERENCES VIII. APPENDICES 1. Data Reviewed 2. Results of Community Discussion Groups 3. Community Health Resources and Municipal Programs 4. Health Assessment Advisory Committee Information Lexington Community Health Assessment Health Priorities for the Town EXECUTIVE SUMMARY The Health Assessment Advisory Committee, appointed by the Lexington Board of Health, carried out a comprehensive analysis and evaluation of health issues and programs in the Lexington community. The goal of the assessment was to gather public health data and community concerns that could form the foundation for future planning of municipal health programs. Following the assessment, the Committee developed a set of priority health issues that the Board of Health, or other municipal agencies, may use to address now or in the future years. The assessment also gave the committee the opportunity to gather information on the many health-related programs the Town currently offers through different agencies. The assessment did not evaluate the nature or efficacy of existing health programs. The following report on the health assessment illustrates important new perspectives on municipal health programming that will be integral to planning carried out by the Board of Health and associated town agencies. The definition of "public health" extends far beyond the infectious disease and sanitation focus typically associated with the mission of a Board of Health. While traditional disease surveillance and prevention remain core public health programs for the town, our prioritization process suggests that other health concerns and influences, including behavioral and environmental factors, should be given more attention in future municipal health programming. These conclusions are supported by similar findings in other communities across the state. Mental health, substance abuse, lifestyle factors and traffic safety emerged as just a few of the priority health areas that Board of Health do not typically address, but will require support. Health programs often develop in a variety of municipal agencies, and are not necessarily connected to Board of Health efforts. In many cases, health programs develop under other agencies where they can directly serve a target audience or evolve as an integral part of a different but related program. Examples of public health services run by other departments include the Senior Health Monitor Program operated by the Council on Aging, substance abuse prevention programs run by the Lexington Public Schools, and Burn Prevention classes run by the Fire Department. The separate development and operation of such programs allows them to flourish within the optimal context and environment in terms of service delivery, planning and budgeting. However, this progression does not obviate the need for ongoing support for and engagement by the Board of Health. Collaboration between agencies administering health-related programs emerged as an important component of a comprehensive municipal public health program. Most health programs require extensive interagency work to provide communications, service delivery and financial support necessary to program success. The yearly influenza vaccination 1 Lexington Community Health Assessment clinic, for example, involves both the Health Department Staff and the Council on Aging. An environmental management program proposed for the public schools will require the involvement of the Health Department Staff, School facilities staff, and outside consultants. Emergency planning for disasters, both natural and man-made, requires input from Health, Police and Fire Departments. The Interagency Health Program Committee (IHPC), initiated by the Town Manager in 2000, and a Health & Safety Committee to address emergency planning, offers mechanisms for such needed collaboration between agencies. Public health programs form a core function of local government responsibilities that need to be evaluated continuously as the private healthcare and public health spheres evolve. The degree to which public programs support or even take the place of private healthcare services will be a major challenge for municipalities. While the public and private system interact, the distinctions between their goals and processes need to be reestablished for the public. The private healthcare system, which serves individuals, does not replace the need for solid public health initiatives that protect community health. Many residents remain unaware of the varied health programs the town currently offers, or how to navigate through the system. Other community members are not aware of the future health issues facing the town. Thus, the Board of Health and associated agencies will need to improve communications with residents and stakeholders to ensure ongoing support and development of current and future health interventions. After completing the health assessment, the committee proposes a set of priority areas on which it recommends the Board of Health and associated agencies focus over the next five to ten years. These priority areas include: Mental Health Physical Exercise, Obesity and Chronic Diseases Traffic and Pedestrian Safety Substance Abuse Senior Health Pesticide Usage The committee also suggested that the Board of Health examine several other issues for action including cancer prevention, lead paint exposure and prevention, and indoor air quality. 2 Lexington Community Health Assessment Lexington Community Health Assessment I. INTRODUCTION The following report attempts to define the key public health concerns of the people of the Town of Lexington. These priorities were assigned after an extensive information gathering and evaluation process involving committee members, state and municipal staff members, healthcare providers and other professionals, and residents of the Town. This comprehensive health assessment and evaluation process, carried out for the past 12 months (since September 2000), was designed to provide the basis for program planning and for the identification of community health concerns that the municipality should address now, and in the years to come. II. HEALTH ASSESSMENT A. Process and Data Review The Health Assessment process was carried out over the course of one year. The committee reviewed statistical data on morbidity and mortality, and behavioral and environmental factors at the state, national and local levels, as such information was available. Community discussion groups were also held to acquire information and concerns directly from residents and other members of the Lexington community. The committee used these data to evaluate the health status of the Town of Lexington from multiple perspectives. The committee reviewed the following sources of information before prioritizing the health issues that emerged. Disease and Health Status Statistics: Information was gathered from National, State and local agencies regarding specific health indicators. These data included the incidence of many cancers in Lexington and across Massachusetts, data on primary reasons for resident hospitalization, communicable disease statistics, student health information from the Lexington Schools, mortality data from State Vital Records, and other sources. The Massachusetts Community Health Information Profile (MASS CHIP) provided information on injury statistics, prenatal care and pregnancy outcomes, and other community health data. Environmental Factors: Environmental conditions that could affect health, such as the age of the housing stock, hazardous waste sites, weather patterns, water supplies, and other factors were considered. Demographic Data: Information on community socioeconomic breakdown, cultural makeup, education levels and other factors that may impact the health of the town were drawn from the Massachusetts Area Planning Council and other state sources. Resident and Community Member Concerns: Community discussion groups, held in conjunction with representatives of Mount Auburn Hospital and the Massachusetts Prevention Center in Cambridge, sought to obtain information on health concerns directly from people who live, work or participate in other ways in the Lexington community. Four community discussion groups were 3 Lexington Community Health Assessment held, drawing in representatives from the faith community, local healthcare providers, local business people, and interested citizens. Municipal Program Review: Meetings were also held with individual staff members of municipal agencies, including the Council on Aging and the Lexington Schools, to learn about existing municipal health programs and how they currently meet the needs of the community. B. Definition and Scope of Public Health In the context of the assessment process, the committee defined the term "public health" in its broadest sense to mean the wellness of the community—quality of life, access to exercise, emotional and mental health, and a safe, clean environment. The definition grew partly out of discussions with community representatives describing their concept of a “healthy community”. This broad description of public health and its mission in Lexington in turn affected the development of priorities for the town. The definition of public health as interpreted by the committee also included the core functions of the Board of Health already in place. Public health programs generally address two key influences on health status; environmental factors and lifestyle or behavioral influences. Environmental considerations typically include food, water, air and soil, and also socioeconomic status. From another perspective, environmental concerns include the many influences on health over which an individual has little or no direct control (excluding genetic make up). Lifestyle factors include the many behaviors over which an individual does have direct control, such as diet, exercise and smoking, to name a few. But environmental and behavioral influences often interconnect; for example, smoking affects indoor air quality through environmentally transmitted smoke (ETS); inappropriate disposal of household hazardous waste can affect drinking water supplies. Public health programs must target one or more facets of a health problem. In order to correct environmental conditions that affect disease status, behavioral and attitude changes may be necessary to correct the problem involved. C. Board of Health Role in the Community In the course of examining health concerns, the committee also analyzed the current role of the Board of Health in the community and its capacity to affect a broad range of health issues. Boards of Health form the governing municipal body on health issues in a community in accordance with M.G.L. Chapter 111. Typically, a Board of Health has a legal responsibility to create environmental health regulations (e.g., food safety, wastewater management), develops health promotion programs, monitors communicable diseases, and provides health screening and other individual clinical services where these programs serve the good of the public health. Programs implemented by Boards of Health aim to serve populations, rather than individual needs, and change from one municipality to the next to meet the specific needs of a given community. The concept of public health, particularly from the municipal perspective, has changed dramatically over the past 50 years. Subjects such as domestic violence and mental health were not part of the focus of a Board of Health or their staff even ten years ago. Now, new health concerns have enlarged the number of issues that affect public health, requiring additional support and action from 4 Lexington Community Health Assessment the Board of Health. In addition, the growing requirement for funding of health-related programs in agencies outside the local Board demands more involvement from the Board and other agencies in order to determine the value, reach and impact of municipal efforts on public well being. D. Overview of Lexington’s Health Programs and Resources Municipal health programs may include many different agencies in the town. The Health Department staff working for the Board of Health provides essential inspectional services and education for food establishments, pools, camps, and other organizations, develops environmental health protection programs, offers health screening and vaccinations, and creates health promotion programs. Lexington Public Schools support a strong health curriculum in the high school grades, work with Lexington Police on substance abuse programs, employ Wayside Services for crisis intervention with troubled youths, and provide guidance and counseling to students. Public school nurses offer extensive health support and protection programs to school-age children including vision, hearing and scoliosis screening, immunization information, allergy control support and other services. Lexington Police also provide domestic violence counseling and support services through the Domestic Violence Response Team. The Council on Aging provides a range of health information services specifically for the senior audience, hypertension screening, a home visiting program for frail seniors called the Senior Health Monitor Program, “meals on wheels” and others. These programs and other health resources are outlined in Appendix 3. 5 Lexington Community Health Assessment Lexington Community Health Assessment III. PRIORITIZATION OF KEY HEALTH CONCERNS The priorities described in this report reflect a lengthy and complex balancing of factors contributing to health outcomes. No single piece of datum, e.g., morbidity or mortality alone, provided the key to prioritization. Rather, a variety of factors including disease incidence, environmental concerns specific to Lexington, demographic influences, and the public’s perception of an issue were considered in terms of the way they affected the impact of a health issue on the community. Many health concerns have multiple causes, some of which may not be easily addressed through standard public health or individual intervention methods. In such cases, health concerns might not be within the purview of the Board and its associated agencies (e.g., certain inherited conditions). In other instances, a given public health problem, while clearly a priority issue, might already be addressed, or even solved, through the program of a particular agency in the town (e.g., Hepatitis B and vaccinations to prevent the disease). Finally, while a specific disease or behavior may be a health concern, its underlying cause may form the real source of the problem for the community (e.g., lung cancer is a health priority, but smoking cessation is the best way to address the problem). Or a particular pattern of behavior or environmental factor may contribute to a variety of different health issues, and may actually be the target for prioritization and intervention, rather than a specific disease. For example, high blood pressure and heart disease are associated with obesity, and all three may in and of themselves be health priorities. However, poor school lunch programs, or lack of access to exercise are also factors that contribute to these problems and offer opportunities for public health interventions. Based on the complexity of public health issues, all health concerns were prioritized within a framework from which the specific health issue could be best identified and addressed. Health concerns were evaluated and prioritized with the following equally-weighted questions: 1) Do the statistical data (if available) support this concern? 2) Is this a matter of local, statewide, or national concern? 3) Are mechanisms currently in place to address the problem? 4) Is the problem better suited to intervention on an individual, rather than public level? 5) Is the problem one that is ongoing (e.g., food safety), emerging issues (violence among schoolchildren), or a seasonal matter (e.g., West Nile encephalitis and pesticide usage). 6) Is this issue a direct, or indirect cause of disease or ill health? 7) How many persons would be affected by the particular concern? 8) Have representatives of the community expressed concern about this subject or problem, 6 Lexington Community Health Assessment regardless of its documented health impact? A. Data Evaluated Numerous data were evaluated and considered before prioritizing the key health issues for Lexington (Appendix 1, Data Reviewed). The following information formed the basis for the prioritization process. 1. Demographics In addition to specific statistics on diseases, injuries, or mortality, other broader factors influenced the prioritization process based on the long-term effects of certain factors on health outcomes. For example, the demographic profile of the town suggests potential health issues that may occur in the community based on age distribution, socioeconomic factors, cultural influences and other indicators. In Lexington, the following key demographic factors were considered in the prioritization process: Senior Population: While the aging of the population will affect the entire country, Lexington has a high proportion of persons over 65 (18%-25% by the year 2010 according to forecasts), with an 1,2 estimated 30-32% over age 55 as of the year 2000. Since health issues rise dramatically between the ages of 50 and 60, and health spending continues to grow as people age, this sector of the population will exert pressure on both private healthcare providers and many municipal services. Falls and emergency needs may increase usage of 911 emergency services and the demand for homecare visits. Housing problems, including hoarding of materials or animals in the home, and poor sanitation, can occur when elders are isolated from families and their communities, or when they are not given adequate daily care and support for daily living. The need for in-home visits for frail elders will also grow. Connection of individuals to the community, both physically and emotionally, and access to safe exercise, are key factors in maintaining wellness in older people. These emerging health issues will need to be supported through public transportation and maintenance of public roads and walkways. The incidence of chronic diseases, such as diabetes, grows rapidly within this population. Finally, seniors will increasingly need assistance in gaining access to healthcare whether it is from a private or public source. Children under 18: The fine school system in Lexington draws many young families into the town. The number of children age 19 or under according to 2000 estimates stood at 27% of the total 3 population The influx of children in turn requires a variety of health support services to ensure their well being, including school nursing services, camp safety inspections, and health protection and education within and outside the schools. As children grow, substance abuse, violence and psychological support needs become prime health matters that both the schools and the community must address. This sector of the population may also be affected by growing rates of diabetes, asthma, and other chronic conditions. Socioeconomic factors: Lexington remains an economically stable and well-off community where most residents can obtain health insurance independently or through their employer. The median household income is $67, 389 and the median family income at $76, 410 according to the 1990 45 Census information,. Most residents have private healthcare insurance; however, such coverage 7 Lexington Community Health Assessment does not replace a strong public health program that works to prevent disease and injury, and seeks to promote wellness. While a high socioeconomic status usually points to better health status, it does not guarantee it, nor does it obviate the need for solid prevention measures such as vaccinations, disease surveillance, environmental management and many others. Finally, economic status does not guarantee access to some types of healthcare (e.g., mental health benefits), particularly among the senior population. Education: The residents as a whole have a very high education level, another factor contributing to positive health outcomes. 93% of the population holds a high school degree or higher, while 56% 6 holds a Bachelor’s degree or higher according to the 1990 Census. High education levels tend to have a positive effect on health outcomes within a population. Major Ethnic Populations: The Asian population in Lexington stands at approximately 8% of the 7 total residential audience. Asian people may have specific health concerns, such as osteoporosis in women, higher rates of liver cancer, and cultural barriers that may interfere with access to both the public and private healthcare systems. Health programs must take into account any specific needs of this or other populations and design outreach efforts accordingly. 2. Environmental Factors Environmental health, taken in the broadest sense of the term, includes issues ranging from food safety and water quality to hazardous waste, pesticide usage, and housing. The Environmental Protection Agency (EPA) offers a broad definition of environmental health as “those aspects of human health, including the quality of life, that are determined by interaction with physical, chemical, biological and social factors in the environment. It also refers to the theory and practices of assessing, correcting, controlling and preventing those factors in the environment that may 8 adversely affect the health of present and future generations.” Specific geological characteristics of the town and weather patterns may also affect health within the community. Some of the key environmental factors considered in the Health Assessment included the following: Radon: Due to the geological characteristics of Middlesex County, surveys from the EPA show Lexington and other neighboring towns to be at a higher than average risk for elevated radon levels 9 in homes. Radon measurements are considered elevated above 4 picoCuries (pCi) per liter of air. The presence of radon has been correlated with increased risk for lung cancer. Building construction also has a major effect on radon levels; homes that allow little air turnover may have high radon levels due to build up within the home air space. Testing for the gas, however, is simple and inexpensive, and the problem may be remedied frequently for $1,500 or less according to the EPA. Water Quality: Water quality has a major impact on health depending on the levels of microorganisms, lead, arsenic, copper, sodium, fluoride or other trace contaminants in the water supply. Most homes in Lexington receive their water from the Quabbin Reservoir of the Massachusetts Water Resource Authority (MRWA). The water from this source is generally considered safe, but lead contaminants inside the residential piping system may contribute to higher lead levels at individual taps. The Lexington Water & Sewer Department and the Health Department provide ongoing communications to residents on this subject. 8 Lexington Community Health Assessment Other residents, however, may draw drinking water from an on-site private well due in part to rising water costs. This practice, however, may draw contaminants in the form of minerals, pesticides, herbicides, or other materials from local soils and groundwater. Private wells are protected by local regulations, but they are not tested as frequently as the public water supply, nor is the area immediately around the private well subject to the same protective regulations as public wells and other water supplies. Thus, private wells may be at risk for contamination from environmental sources. 10 Ambient Air Quality: The prevailing winds in Lexington are northerly and westerly. Thus, in order to determine possible airborne sources of contamination, it would be necessary to look for air 11 releases from these directions—not just sources within the town. In addition to these sources, vehicle exhaust from local roads and major highways (Routes 2 and 128) may contribute to air pollution in the community. Levels of air pollutants in the Middlesex County area for carbon monoxide, sulfur dioxide, and particulate matter (PM-10) were considered good, while ozone levels were considered moderate, having exceeded the 8 hour exceedance level for 4 days at the Sudbury 12 monitoring station in 1998. Soil Quality: Soil quality is an important factor in an examination of health concerns. While few if any residents derive the bulk of their food supply locally, vegetable gardens may be affected by the presence of elevated levels of lead. Lead may be a soil contaminant in gardens close to older homes, where lead paint may have contaminated the soil from painted siding on homes. High iron levels in the soil may also infiltrate home well water supplies. Schoolyards, playing fields and residential yards may contain elevated levels of contaminants such as pesticides either from direct application or from runoff from other areas. Hazardous Waste Sites: Hazardous waste sites or places where toxic materials have been disposed of illegally or accidentally spilled may contaminate the soil or the water supply. The Massachusetts Department of Environmental Protection, Bureau of Waste Site Clean Up cites 97 sites in Lexington: 23 with hazardous materials; 4 with hazardous materials and oil, and 70 with oil. The majority of the sites are of low risk under the Massachusetts Contingency plan (M.G.L. 21E). 13 However, 3 sites are rated as Tier 1B, 2 as Tier 1C, and 15 as Tier 2 sites, with those of greatest concern rated as Tier 1A. A more serious area of contamination at Hanscom Air Force Base is currently under remediation. The US EPA lists 60 facilities that handle hazardous wastes in Lexington. The Toxics Release Inventory of the United State Environmental Protection Agency 14 lists 3 facilities with toxic releases to the environment. In two cases toxic materials were released to a publicly owned water treatment works (POTW) or to a licensed hazardous materials handler at an off-site location. Lexington also participates in a regional household hazardous waste facility located on Hartwell Avenue, at the site of the former landfill. Eight collections are held each year to facilitate removal of hazardous materials found in the home from the waste stream, and to prevent contamination of the environment. No hazardous materials are deposited or stored at the site. Pesticide Usage: Pesticide usage remains a major concern of residents and should be examined given the potential effect on water resources and local ecology. Besides small truck farms in the 9 Lexington Community Health Assessment area where crops and plants are grown, and golf courses, pesticide usage is probably highest on individual home lawns and gardens, or on public recreational spaces. Pesticide usage in public buildings should also be examined. Pesticide regulation is outside the scope of authority of local Boards of Health, and may be controlled only on by Bureau of Pesticides under the Massachusetts Department of Food and Agriculture according to state law. However, municipalities may limit usage of pesticides in public places, and may carry out communications programs to spread awareness about pesticide risks. Lexington’s public school system was one of the first in Massachusetts to implement an Integrated Pest Management (IPM) program to minimize the use of pesticide agents in schools buildings. School buildings and fields, and daycare centers in the community and across the state will be required to implement this pest control approach under the Children and Families Protection Act, signed into law in 2000. Roadways, Public ways: The condition of roadways and public transportation contributes to the capacity of residents to have safe physical exercise and access to Town services and spaces. Although the safety of sidewalks and roads often vary with the seasons and traffic conditions, many of the sidewalks are continually in poor condition and in need of repair. Given the primary importance of sidewalks and public way maintenance on basic physical mobility and health, it is an issue health and related agencies in Town need to address. Recreational Facilities/Open space: Recreational facilities also contribute to physical fitness with its attendant health benefits. Fortunately, Lexington has a strong Conservation Commission dedicated to preserving open space, and public recreation facilities, which are overseen by the Town Recreation Committee and staff and maintained by the Town. The Conservation Commission owns and manages over 1,300 acres of open space, including public lands. Including parks, cemeteries and conservation land, the Town holds more than 10,000 acres of open space. Indoor Air Quality: Indoor air quality issues have been an issue in the public schools, although steps have been taken by the school system to address the problems. Indoor air quality problems can exacerbate chronic diseases like asthma and allergies, and may interfere with the learning 15,16 environment for children. Indoor air quality needs to be monitored and maintained to ensure the optimal learning environment for children in schools, and a safe working environment for public workers. For example, fumes from heavy equipment at the DPW facility at 201 Bedford St. infiltrate the space where administrative offices are located, possibly posing a hazard to workers there. Radon gas, a known carcinogen mentioned above, also contributes to poor indoor air quality. According to the US EPA, all buildings should be tested every five years and remedial action taken if levels exceed 4 pCi/L. A strong tobacco control program and local health regulations minimize levels of environmentally-transmitted smoke (ETS) in public places. Natural Disasters: Lexington is at low risk for most natural disasters. However, some parts of the town are at risk for flooding, revealed during last year’s flooding rains, and the region is at risk for an earthquake. In such instances, emergency preparedness on the part of both residents and public safety agencies, including the Board of Health, is essential to protecting the public health. Climactic variations also exacerbate weather-related disaster situations. 10 Lexington Community Health Assessment Man-Made Disasters: The events of September 11, 2001 and the subsequent threat of anthrax infection renewed concerns about bioterrorism and local preparedness for such an event. Emergency planning for biological, chemical and other disasters that may affect the population is essential to future public health planning. Coordination among town agencies including Police, Fire, Health, Schools and between State and local entities will be essential to the success of any emergency preparedness plan. Emergency Disease Epidemics: Emerging pathogens such as variant E. coli strains, vector–borne diseases such as West Nile encephalitis, and the threat of an imminent influenza pandemic have renewed concerns about infectious diseases. The threat of a potential bioterrorist attack with an agent such as the smallpox virus also reinforces the need for local preparedness to deal with a widespread disease outbreak. Enhanced surveillance of infectious diseases will be an essential part of an effective plan. However, environmental controls to contain outbreaks such as mosquito control, food safety programs and water protection will be essential to preventing outbreaks. 3. Disease Incidence Information was collected on a number of diseases or conditions, including diabetes, cancer, asthma, allergies, AIDS, sexually transmitted diseases, tuberculosis and others. Hospitalization data, including the primary ten preventable reasons for hospitalizations from Massachusetts Division of Health Care Finance and Policy, Uniform Hospital Discharge Data Set (UHDDS), and information from the Massachusetts Community Health Information Profiles (MassCHIP) were also used. Some of the key diseases or conditions noted in discussions within the committee and with the community included the following: Chronic Diseases Chronic diseases, such as asthma, arthritis, chronic obstructive pulmonary disease, and diabetes among others often have multiple environmentally-related components that may be controlled through public health measures. Air quality factors often exacerbate asthma, while chronic obstructive pulmonary disease (COPD) and smoking are linked. Such diseases are increasing within the entire population, but the incidence of many chronic diseases also will increase simply with the aging of the population. Chronic illnesses affect quality of life, and may have high 17 emotional, physical and economic costs both for individuals and the public. Asthma:The incidence of this disease has been increasing for many years; however, the causes of asthma remain largely unknown. The incidence of the disease continues to grow across the nation, with an estimated 14.9 million persons suffering from the disease, 500,000 hospitalizations 18 stemming from the illness, and 5,000 deaths each year. Certain factors may serve as "triggers" for the disease, including dust mites, allergens, pollution, and animal dander. Reports from the Lexington Public School Nurses indicate that in 1999-2000, 426 Lexington students had asthma (prevalence=7%); the number increased to 501 during the 2000-2001 school year (prevalence =8%), and 523 for the 2001-2002 year out of a total of 5981 students (prevalence=9%). The cumulative incidence (number of new cases in a given period) for the disease is 17% for the three 11 Lexington Community Health Assessment year period. Many cases in the teen years have been attributed to exercise-induced asthma, but the 19 disease may be underreported. Asthma prevalence nationwide among children 5-17 years of age 20 was reported as 130 and 135 per 1,000 children, or roughly 13%, for 1997 and 1998 respectively. Chronic Obstructive Pulmonary Disease (COPD) and Heart Disease: Data from the Massachusetts 21 Division of Health Care Finance and Policy, indicate that COPD and heart disease are two of the leading preventable hospitalizations for the Lexington area (Number 1 and Number 5 respectively). th Heart failure is the 5 among the top 30 diagnostic related groups (DRGs) for Lexington, and th22 COPD the 13. Both diseases have a high association with smoking so that tobacco control efforts and smoking cessation offer effective prevention measures for these outcomes. Lexington currently collaborates with three neighboring towns on a tobacco control program that targets retail sales of tobacco, education programs, and cessation. Diabetes: Diabetes mellitus is a chronic condition involving elevated blood sugar levels. More than 23 800,000 cases are diagnosed each year; the disease is most common among those over age 60, but rates are rising among youth. The disease contributes significantly to morbidity and mortality levels in the U.S., causing blindness, renal failure, lower extremity amputations and cardiovascular disease. It is the seventh leading cause of death in Massachusetts; approximately 244,500 adults in 2425 the State have the disease and it is the seventh leading preventable hospitalization in the state. Local data, from a Behavioral Risk Factor Survey carried out in Lexington and other nearby towns 26 do not show significant differences from that of the State. Risk factors for the disease include age (over 45 years), obesity, diet, and family history. Cancer Cancer rates are often a source of concern to residents. Surveillance on cancer rates by community is carried out by the Massachusetts Department of Public Health, Health Statistics Bureau. Each year, hospitals, laboratories and physicians report to the state Tumor Registry the different types of cancer diagnosed in communities across the State. The information collected is then compared to expected rates of each type of cancer for each community based on basic demographic information, including population age distribution (cancer occurs more frequently in older populations irrespective of lifestyle or environmental factors). From this information and the known risk factors for different types of cancer, local Boards of Health can identify rising incidence of cancer within a given town or city. However the information is not sufficient to facilitate easy identification of the various behavioral, lifestyle and environmental risk factors that might contribute to rates of different types of cancer without additional studies. The statistics generated by the Massachusetts Cancer Registry offer incidence rates by town or city at the time of diagnosis, but not according to street address. Thus it is difficult to determine the effect of the many environmental factors that contribute to cancer without identification of the residence and a health history. Tracking the possible source of cancer also becomes difficult for several other reasons: 1) A lengthy latent period of 20 years or more following exposure to a carcinogen may precede disease onset; 2) “Cancer” includes many different diagnoses characterized by uncontrolled cell proliferation, with each type of cancer initiated and promoted through different mechanisms and, 3) cancer development often involves multiple contributing factors, rather than a single source of the disease. In addition, the geographic 12 Lexington Community Health Assessment borders of the town do not confine any disease to the town; a full analysis of the problem necessarily may involve cases from one or more different neighboring municipalities. Reports of cancer incidence in Lexington point to statistically significant higher than expected rates 27 of prostate cancer (19% above levels expected for the local population. The Massachusetts Department of Public Health has indicated that the apparent elevation in figures for prostate cancer in towns like Lexington are due to increased screening, especially after age 40. At this time neither the Lexington Board of Health nor the State have identified a regional or local factor to account for this significant difference in disease incidence. For most other types of cancer, Lexington rates were at or below (8% for total cancers) predicted rates for Massachusetts. Many residents have voiced concern about breast cancer rates in the town However, the Standard Incidence Ratio (SIR), which measures the increase in specific types of cancers over baseline or expected levels for a given community, showed breast cancer rates in Lexington for the 1994-1998 period to exceed levels predicted for the community by 15% (observed/expected = 174/151 cases). According to the Massachusetts Department of Public Health, this number was not considered to be statistically significant, i.e., the increased number of cases might be due to chance or other factors such as residential turnover. Mental and Emotional Diseases While no local data could be obtained on mental health information for the general population, data for the adolescent high school population were obtained from the Centers for Disease Control 28 Behavioral Risk Factor Survey (BRFS) carried out in Lexington High School in 1995 and 1999. These reports illustrated the emotional status and behaviors of the high school age population. Information from the community discussion groups revealed that concerns about mental health and support services are emerging as a major concern for residents. Residents and other community members voiced concerns about access to care and the limitations of existing programs to support mental health. Nationally, mental health disorders affect nearly 40 million persons between the ages of 15 and 54 years, and include conditions such as anxiety, post-traumatic stress, mood disorders, depression, and schizophrenia. Preventive interventions may require a mix of programs 29 to address the many factors contributing to such diseases. B. Information from Community Members In order to ascertain the real concerns of residents and others in the Lexington community—outside of the disease data and priorities set by the State and Board of Health—the committee sponsored four community discussion groups in the Town Office Building. Marcia Lazar, Director of Community Health for Mount Auburn Hospital, facilitated the four sessions. Representatives from many sectors of the town, including all residents, parents, the faith community, business people, civic organizations, support groups and other organizations were invited to attend the meetings. The goal of the meetings was to determine how the public viewed health matters in Lexington, and their expectations of the municipality and its role in addressing these problems. 13 Lexington Community Health Assessment A variety of issues were raised during the discussion groups, including mental health issues (particularly in the schools), substance abuse in the community, obesity and lack of physical fitness, and roadway safety. A synopsis of the results of the community discussion groups may be found in Appendix 2. The first question offered to each group, “What is a Healthy Community?”, served to define the basis on which to evaluate the health status of the community as perceived by a community member. The profile of health concerns generated from the community discussion groups reveals the value of the sessions. While many of the concerns fell within the traditional scope of Boards of Health, many did not, suggesting the need to expand the focus of municipal activities and support for health programs. In addition, the information from the community discussion group sessions reinforced the preliminary findings of the Health Assessment Committee after the initial data review. Many social, lifestyle and behavioral concerns emerged from the session, while infectious disease and environmental concerns were of lower priority for the different groups. 14 Lexington Community Health Assessment Lexington Community Health Assessment IV. KEY HEALTH PRIORITIES FOR LEXINGTON The following list of priority health concerns includes a discussion of the key affected populations, and the main issues that make them key concerns for the town. The resulting priorities reflect the combined input of the many information sources used. Included is a discussion of possible interventions that may contribute to the prevention or mitigation of specific health issues Historically, the Lexington Board of Health has not been involved directly in many issues that in years past were considered social or psychological problems, rather than health concerns. However, the prioritization process revealed such health matters to be among the most important ones facing the town. Communities often associate Board of Health efforts strictly with inspectional and infectious disease services. However, merging the broad-based environmental focus of the Board of Health with more targeted behavioral and mental health concerns will provide a new level of public health service to the community. A. Mental Health Mental health and related behavioral issues were reported repeatedly in the surveillance data, through community discussion groups, and through meetings with healthcare providers. The reasons for the repeated mention and high priority given to mental health issues include: Mental illness can have a profound effect not only on the patient but also on the mental status of the people with whom they live, and failure to address the problem can have a long-lasting effect on numerous people. But access to services to help mental health problems remain very restricted. Mental health intervention services, if at all available, are limited in most health insurance programs, often to ten or fewer office visits, and are inaccessible for those with no private health insurance. Even after a clear diagnosis of a mental condition, persons with mental illness including depression, bipolar disease, suicidal tendencies, and other related behaviors may not have access to or may not take advantage of mental health programs. While school programs do attempt to intervene with children at risk, there are limited public systems or services that can adequately address these matters in adults. Interviews with the staff of Lahey Lexington by members of the Health Department in 2001 indicate that many individuals, particularly the elderly, do not receive complete care for mental and emotional problems due to gaps within the healthcare system. A Behavioral Risk Factor Survey in 1999 illustrated the existence of mental illness, 30 particularly depression and suicidal tendencies, among high school age students. The 1999 survey of Lexington High School students indicated that 24% of students surveyed had seriously considered suicide, while 12% reported that they had actually attempted suicide. Of the students queried, 26% had either been threatened or injured with a weapon at school, or had been in a fight, suggesting that problems with violence should be addressed. 15 Lexington Community Health Assessment Demographic factors including the growing number of elders in the population, suggest that many individuals in the community may eventually be at risk for depression, isolation from the community, and mental disorders associated with aging. According to hospital discharge data collected by the Massachusetts Department of Public th Health, Division of Health Care Finance and Policy, psychoses (DRG 430) is the 6 of the top thirty diagnostic related groups (DRGs) for Lexington, with 76 cases for FY 99. 31 (Rate=304/100,000). People affected by mental illness frequently have problems with activities of daily living (ADLs); conditions in their homes may become unsafe and unsanitary, posing a hazard to themselves and their families. Such conditions place increasing pressure on Health Department resources, and frequently cause workplace hazards for public safety staff. Messages from the community discussion groups suggested that there is need for counseling parents on child development, especially from birth to age five that may have a major impact on future development. Overworked and frequently absent parents often cannot or do not provide the necessary interaction with their child to ensure their future emotional health. “The Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda” notes that “The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly 32 created to take care of them.” The report also notes that, in the U.S., “one in ten children and adolescents suffer from mental illness severe enough to cause some level of impairment… but only “one in five such children receive specialty mental health services.” Recent information from the Lexington Domestic Violence Response Team indicates that many of the domestic violence calls to the Police Department are for child-against-parent 33 violence. These data, and the views expressed by citizens in community discussion groups, state that mental health issues should be studied and addressed by the municipal health programs in the future. B. Physical Exercise, Obesity and Chronic Disease Recent reports confirm that physical activity can protect against many health concerns, including 34 being overweight. Activity has been shown to have a protective effect for coronary heart disease, hypertension, non-insulin-dependent diabetes mellitus, osteoporosis, and colon cancer. Exercise 35 may also reduce feelings of depression and anxiety . To combat obesity, the 1996 National Heart, Lung, and Blood Institute’s clinical guidelines and the federal dietary guidelines for Americans recommend at least 30 minutes of physical activity per day for all adults. Maintaining a healthy body weight or body mass index (BMI), engaging in physical exercise regularly, and following a healthy diet are some of the major means of preventing a range of both physical and mental health problems. However, most adults and children do not engage in physical 16 Lexington Community Health Assessment 36 activity sufficient to show benefits in terms of overall health and disease prevention. Promotion of the behaviors contributing to a healthy lifestyle may prevent the disability and financial costs stemming from a wide range of serious illnesses and chronic diseases. Physical exercise, and related health issues such as obesity and chronic illnesses should be a focus of the town public health program for the following reasons: Due to time and safety constraints, students and adults tend to use vehicles to travel to school and work—even when their destinations are less than one mile away. School diets are high in fat and sugar; snacks available through vending machines are often poor in nutritional value Busy schedules prevent people from maintaining lifestyles that facilitate weight control At least one half of adults are considered overweight Diabetes is on the rise among increasingly younger people, while diseases that may be prevented by exercise and weight control-- heart disease, stroke, chronic diseases such as arthritis and circulatory problems--remain among the top causes of death and disability in the nation and locally. Data from the Health Care Finance Administration illustrates that ththth diabetes was the 7 (1998), 8 (1997) and 10, (1999) cause of preventable hospitalization 37 among Lexington residents. This disease may rise dramatically in Lexington as the population ages, since people over the age of 45, irrespective of health status, are at increased risk for the disease. Inactivity and weight gain contribute significantly to Type 2 or adult onset diabetes. The disease is predicted to rise 76% among persons in their 30s according to researchers; much of this increase will be attributed to obesity. The longer a 38 person has the disease, the greater the chance for debilitating complications. Heart disease, another major preventable condition, and some chronic diseases may be delayed or prevented by simple lifestyle changes. Obesity, stemming from poor diet and lack of exercise, plagues the nation as a whole. The long-term effects of being overweight contribute to considerable costs to the individual and the community in the form of disability, higher insurance rates, and lost work time. Obesity, lack of exercise and poor diet can contribute to diabetes, hypertension, heart disease, circulatory issues, and many other poor health outcomes. Obesity among the U.S. population has reached epidemic proportions. State and national averages point to a growing level of obesity in the population overall. About one half of adults in the US and 39 in Massachusetts are now considered overweight. Data from the local Community Health Network Association (CHNA), which includes the Lexington area “shows 82% of people participated in leisure time activity in the past month—this 40 percentage is significantly higher than the state average of 75.3% in BRFSS studies.” However, lifestyle and behavioral factors, including busy schedules, often prevent adequate exercise for many sectors of the population. Poor sidewalks and pedestrian hazards also prevent children and the elderly from engaging in activities that contribute to good health. While the town has many resources in favor of promoting exercise—open space, many recreational facilities, and a public bike path—other environmental factors may help augment existing exercise levels. 17 Lexington Community Health Assessment Enhancing physical exercise may be one of the top means of preventing a range of poor health outcomes in the population. Additional complementary programs that make dietary changes for the young easy and healthy food accessible, enhance public ways and conservation areas in terms of accessibility, and help persons with physical challenges to incorporate physical activity into their lifestyle will all contribute to the health of the community. C. Traffic/Pedestrian Safety Reduction of pollution levels and increased resident physical activity levels depend on more pedestrian traffic and greater usage of public transportation. However, the condition of the roads and sidewalks may create hazards for both drivers and pedestrians. Again, this problem will continue to grow as an older population dependent on a limited public transportation system must negotiate the local road and walkways. Concerns about traffic safety include the following: Poor conditions in roadways Limited sidewalks, many in need of repair or obstructed, and often not cleared in winter Increased traffic on roadways Limited mobility of older persons Use of bikes, skates and scooters, particularly by children, in high traffic areas Limited public transportation system, difficult to access for some persons, especially seniors Need for greater crosswalk availability and visibility Road rage While not usually considered a health issue in the past, the physical condition of the local environment may have a direct effect on injury rates from both traffic and pedestrian causes, and affects health indirectly by facilitating physical exercise for all sectors of the population. By addressing these safety issues, we will also directly address the obesity and exercise dilemma in the community. D. Substance Abuse Substance abuse remains a major issue in the town across all age groups, and especially among adolescents as they experiment with using alcohol, "Ecstasy,” marijuana and other drugs. Despite many efforts to reduce substance abuse of all forms, it remains a problem among all age groups. Middle aged persons and the elderly may suffer from mild to high levels of alcoholism that make them prone to traffic accidents, unintentional injuries, and increased complications from diabetes. Even moderate alcohol use may have an effect on emotional health and may contribute to violence in the home. 41 A 1999 Behavioral Risk Factor Survey report supports concerns about adolescent substance usage. The survey indicates that 36% of high school students surveyed had used alcohol in the past thirty days, 23% had used marijuana in the past thirty days, with 15% smoking the drug 1-9 times, while 7% had tried controlled substances such as cocaine, crack or steroids at least once. 18 Lexington Community Health Assessment Contributors to the community discussion groups cited concerns about tacit parental support of alcohol use in minors and their ignorance of children abusing various drugs. Seniors may also be affected by polypharmacy—taking multiple drugs that may have dangerous synergistic or antagonistic effects. The Community Health Information Profile for Lexington noted that 119 people were admitted to DPH funded treatment programs in 1998, while 69 alcohol and drug-related 42 hospital discharges occurred in 1997. While the counts were well below the State crude rate for these indicators, they suggest that substance abuse remains a significant problem in the town. Tobacco use continues as a problem among young people in Lexington, where usage continues despite a strong tobacco control program. In 1999, 50% of high school students reported trying cigarettes, while 9% continued to smoke regularly. Substance abuse problems are not new in any community, and programs are in place particularly in the school system to combat some of these problems. However, efforts against substance abuse must be continued—and continually evaluated—to protect vulnerable populations and other residents from misuse of drugs, alcohol, and tobacco, and their attendant emotional, physical and financial cost to the community. E. Bioterrorism and Infectious Diseases Recent bioterrorist attacks with the spore-forming anthrax bacteria point to the need for local emergency preparedness and community awareness regarding infectious disease outbreaks. In addition to the possibility of a bioterrorist event, other infectious diseases have emerged and continue to threaten the public health, including E. coli infections, West Nile encephalitis, and food-borne illnesses to name a few. State and federal health officials also indicate that a worldwide outbreak of influenza may occur soon, and may cause widespread illness and fatalities. Rising antibiotic resistance among various bacterial strains and the lack of a vaccine for many diseases increases the need for local preparation and service. Outbreaks of infectious disease, whether from E. coli in hamburger or anthrax from a bioterrorist attack, emerged as another key priority for the Town. Surveillance of infectious diseases must be improved to identify and address an outbreak or attack quickly effectively. F. Senior Health Seniors have a significant number of health issues that emerge solely from advancing age, but are also due to decreased exercise, poor diet, substance abuse, and isolation from society and support. These illnesses and contributing factors that may contribute to poor health outcomes include: Untreated depression and mental illness Polypharmacy, or taking multiple drugs that may interact with negative side effects Isolation from support, families and community, such that health prevention and protection 19 Lexington Community Health Assessment measures are not taken, injuries become more common, mental status deteriorates Susceptibility to influenza and related complications such as pneumonia Poor access to transportation and community services Lack of understanding of or access to the healthcare system This growing sector of the community will be faced with decreased support in the form of home health visits (limited under the 1996 Omnibus Act that decreased Medicare B payments), less support from immediate family members who may live far away or be unable to offer help, and increased isolation in their homes. The changes in the social and healthcare systems harm many individuals, and the increasing needs of this population for municipal programs will probably strain town resources. The growing demand for emergency services, including intervention by the Health Department regarding living conditions, and growing reliance on existing services (e.g., the Senior Health Monitor program run by the Council on Aging, “Meals on Wheels”), and the use of 911 services illustrate the extent of this rapidly emerging problem. G. Pesticide Usage Boards of Health cannot regulate pesticide usage under Federal and State law; however, other actions may be taken to reduce pesticides in the environment including user awareness and reduced application on public lands. Pesticides are used in three key areas: Municipal usage for mosquito control, public building maintenance, pool disinfection and parks and fields control (herbicides and pesticides). Home/residential usage for lawn and garden maintenance and home pest control (termites, ants). Farm usage for fields and crop growing The use of pesticides, herbicides, and fertilizers contributes to the overall toxic load of the environment and deposits breakdown products and nitrates into the ground and surface waters. Given Lexington's hydrological placement at the top of three watersheds (Charles River basin, Shawsheen and Boston Harbor), where ground water and runoff here fill municipal wells elsewhere, the town has an obligation to protect groundwater. Locally, pesticide, herbicide and fertilizer usage may affect private wells, used increasingly for domestic purposes. In addition, extensive pesticide and herbicide usage may affect the environment and human health in other ways, depending on their composition and fate in the environment. Regardless of toxicity, pesticides should be used judiciously to prevent long-term threats to the environment and human health. For many years, the Lexington Public Schools have used the Integrated Pest Management (IPM) approach to pesticide usage in school buildings. This model should be examined for application elsewhere in other public buildings and public spaces such as the Battle Green. 20 Lexington Community Health Assessment Lexington Community Health Assessment ADDITIONAL HEALTH PRIORITIES V. The priorities listed above do not replace existing ones for the Board of Health or other municipal agencies. Rather, the prioritization process aimed to determine which health issues, if any, required additional support or focus both from the Board and the entire community. Many other health issues continue to be of concern for the community, and will require ongoing efforts by local government. Such health issues of concern include the following: Cancer Prevention Prostate Cancer: The higher than predicted incidence of prostate cancer will require ongoing surveillance by the Board of Health and the State to identify potential environmental or lifestyle factors that might contribute to the incidence of this disease in Lexington. Breast Cancer: The growing concerns about breast cancer in the community warrant ongoing efforts to inform residents about the disease, risk factors and new findings about the disease. Regardless of statistics from the cancer registry, this disease should be treated as a key area of concern based on residential concerns about its incidence. Other types of Cancer: The public often views cancer as a single disease, when the term actually designates multiple diseases with different etiologies. Since many cancers result from lifestyle issues, rather than chemical exposure, efforts should be made to emphasize the link between individual habits and cancer. The effect of diet and personal behaviors on certain types 43 of cancer (e.g., lung and bladder) has been well documented. It is estimated that 25% of all cancers might be prevented by diet alone, and another 30% prevented through elimination of tobacco usage. In addition, the Board should improve communications to the community about environmental factors (e.g., radon in homes) that may contribute to cancer risk. The aging of the population will also be a factor contributing to increased incidence of may types of cancer; thus, communications and support mechanisms should be analyzed to address this health concern. Finally, cancer remains a particularly frightening disease in the public’s mind, and is often attributed to environmental factors not in control of the average citizen. Communication and information programs may help dispel many of the myths and fears surrounding the disease, and encourage risk-decreasing behaviors and increased screening for different types of cancer. Lead paint: While Lexington has very few cases of lead paint poisoning among children, the age of many buildings in the town increases the potential risk of lead ingestion and contamination of the environment. The removal of exterior lead paint can cause significant production and dispersion of lead-containing dust when outdoor surfaces are sanded, or when paint chips fall to the ground. While painting contractors are required to contain such contamination under State law, local regulations passed by the Board of Health permit local control of situations in which paint removal may harm the community. To prevent long term contamination of the environment, and to protect 21 Lexington Community Health Assessment children and adults who may be harmed by lead, effort should be made to spread awareness about this issue throughout the community. Indoor Air Quality: Poor indoor air quality may contribute to a range of health problems. In particular, air quality issues may be contributing to the high prevalence of asthma rates in Lexington and across the country. In our local schools, where such problems have been identified, such conditions may interfere with learning as well. Despite attempts to rectify such problems in the town, the issue remains of great concern to residents, parents and employees in town alike. Air testing, renovations, and other corrective measures may result in considerable costs to the town. As a result, the Town or Board of Health should develop a clear policy as to how such problems should be handled so that indoor air quality problems are addressed effectively. 22 Lexington Community Health Assessment Lexington Community Health Assessment VI. RECOMMENDATIONS The committee recommends that the Board and its associated agencies consider the following measures to address the priority health issues identified above. Mental Health Public health programs seldom address mental health issues, with the exception of substance abuse interventions. The private, rather than public health system typically addresses depression, suicidality and other psychoses where individual care may be taken. Public agencies, such as schools, usually take on the role of identifying potential cases and referring them to the appropriate agencies in State government or a private provider. Lexington public schools, for example, offer crisis management for youths at risk through a contract provider. Developing programs directed at mental health issues will require extensive analysis of the extent of the problem in Lexington. The already strong program in place in the public schools, and recent efforts by the Council on Aging to address depression in elders, will provide needed information on mental health issues in the town. Mechanisms for addressing mental health concerns directly, offering communications programs and other interventions may be created after such an evaluation. We recommend that the Board of Health or the Town Manager charge a committee representing stakeholders, municipal agencies and concerned citizens with the task of evaluating mental health concerns in the town and making specific recommendations as to action the Board of Health and other agencies may take. Physical Exercise, Obesity and Chronic Diseases General physical fitness leads to a variety of health benefits, while its converse generates a range of detrimental health outcomes. Diabetes, obesity, stroke, accidental injuries, osteoporosis and a host of other conditions may be prevented through basic lifestyle changes. Changing lifestyles, however, requires more work than basic health promotion. Programs to change poor health behaviors must attempt to integrate good habits into everyday schedules. The Board of Health should examine and encourage opportunities among all age groups for increased exercise. Promotional programs such as a “walk to school or work” program should be planned and coordinated with the public schools, Parent Teacher Association, and Board of Health. Substance Abuse Substance abuse remains a highly complex issue that cannot be resolved through a single program or approach. This health issue is often a symptom of larger health issues facing an individual, family or the community itself. The Board of Health should work with agencies in Town that currently work to address this issue in order to evaluate the problem, assist key agencies working on substance abuse (i.e., the School system), and provide, where possible, possible interventions.. 23 Lexington Community Health Assessment Senior Health The Board of Health should work with the Council on Aging to evaluate the major health issues facing the elderly today, and to design cooperative intervention programs to help seniors. This step will help augment existing programs and may take advantage of State supportive services such as the Minuteman Homecare Services currently provided to seniors. In addition, steps should be taken to educate physicians and families about the problem of polypharmacy. Efforts on substance abuse should also be coordinated with existing programs run by the Police Department and School Department. The Board of Health should also research and implement where possible intervention programs for other adults and children that are preventative in design rather than remedial. Pesticide Usage The Board of Health should examine programs carried out by other towns, such as Wellesley and Marblehead, designed to minimize pesticide usage in the community. In addition, pesticide usage by businesses, residents and public agencies should be examined to determine the extent of pesticide and herbicide application. Finally, a communications program to help decrease such usage should be developed. However, local Boards of Health cannot regulate residential use of pesticides however. 24 Lexington Community Health Assessment Lexington Community Health Assessment VII. CONCLUSION The list of priorities above offers a broad plan of action for the Board of Health and its associated municipal agencies to address. While these recommendations ask for a new focus in specific areas of public health, they do not attempt to eliminate or convey a lack of concern for ongoing efforts of the Board of Health in the many areas it currently targets. Rather, we have attempted to offer priorities that engage the efforts of the entire public and private health community, and health programs that may have a major preventative effect on some of the most critical conditions facing communities like Lexington today. While many strong health programs and resources serve the community today, the health assessment offers an opportunity to identify new issues in the community and can provide valuable information for those running health programs. The assessment process should be ongoing, rather than a single study, and should provide the basis for more extensive analysis and program development in the future. 25 Lexington Community Health Assessment Lexington Community Health Assessment VIII. REFERENCES 1 Lexington Community Profile. Metropolitan Area Planning Council. Population Age Group Forecasts. October, 1998. 2 Population Projections: Lexington Town. MISER, University of Massachusetts, Amherst. July 1999. 3 Population Projections: Lexington Town. MISER. University of Massachusetts, Amherst. July 1999. 4 Community Profiles Lexington, Middlesex County. Dept. of Housing and Community Development. July 2000. www.communityhealth.hrsa.gov 5 1990 US Census Data. Database C90STF3A. Lexington CDP. July 26, 2000. 6 Community Profiles-Lexington. Middlesex County. Department of Housing and Community Development. July 2000. http://www.communityhealth.hrsa.gov 7 Population Projections: Lexington Town. MISER. University of Massachusetts, Amherst. July 1999. 8 Goldman L, Apelberg B, Koduru S, Ward C, Sorian R. Healthy from the Start: Why America Needs a Better System to Track and Understand Birth Defects and the Environment. Baltimore, MD: The Pew Environmental Health Commission, 1999. 9 Indoor Air Quality (IAQ)-EPA Map of Radon Zones-Massachusetts. January 9, 2002. http://www.epa.gov/iaq/rdon/zonemap/zmapp21.html. 10 National Oceanic and Atmospheric Agency: http://www.noaa.gov 11 Massachusetts Department of Environmental Protection, Air Assessment Branch, Aerometric Information Retrieval System. 1998. 12 Massachusetts Department of Environmental Protection. 13 Massachusetts Department of Environmental Protection, Bureau of Waste Site Clean Up: Site/Reportable Release Look Up. September 9, 2000. 14 United States Environmental Protection Agency, Envirofacts Warehouse, Toxics Release Inventory Query for Lexington, September 9, 2000. 15 US Environmental Protection Agency. “The Inside Story: A Guide to Indoor Air Quality”. Office of Air and Fadiation. September, 1993. 16 IAQ Tools for Schools. Managing Asthma in the School Environment. US Environmental Protection Agency. Indoor Environments Division, Office of Air and Radiation. April 2000. 17 Centers for Disease Control, National Center for Health Statistics. Healthy People 2000. p. 238. October, 2001. 18 Centers for Disease Control, National Center for Health Statistics, Healthy People 2000. p. 238. October 2001. 19 Lexington Public Schools. Jane Franks, R.N. Personal Communication. 2000. 20 Trends in Asthma Morbidity and Mortality. American Lung Association. p.2. January 2001. http://www.lunusa.org/data/asthma/asthmach_1.html 21 Top Ten Preventable Hospitalizations for Lexington, Uniform Hospital Discharge Data set (UHDDS), Health . Systems Measurement and Improvement Group, Massachusetts Division of Health Care Finance and Policy. 1998 22 Top 30 DRGs for Lexington Residents, FY 99, Division of Health Care Finance and Policy, Case Mix Data. October 16, 2000. 23 Centers for Disease Control and Prevention, National Center for Health Statistics. Healthy People 2000. p. 238. October 2001. 24 The Burden of Diabetes in Massachusetts 1993-1995. Massachusetts Department of Public Health, Bureau of Family and Community Health, Diabetes Control Program. p.1. July 1999. 25 Top 30 DRGs for Lexington Residents, FY 99, Division of Health Care Finance and Policy, Case Mix Data October 16, 2000. 26 Behavioral Risk Factor Survey, Health Risks and Preventative Behaviors (1994-1999), Greater Woburn/Concord/Littleton CHNA, March 2001. 27 Massachusetts Department of Public Health. Bureau of Health Statistics, Research and Evaluation. Cancer Incidence in Massachusetts 1994-1998: City and Town Supplement. p. 167. October 2001. 28 Northeastern University’s Center for Criminal Justice Policy Research. An Overview of the 1999 Lexington High 26 Lexington Community Health Assessment School Survey. Comparisons between the 1995 & 1999 Youth Risks Behavior Survey Presented. March 1, 2000. 29 Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000. P. 127. October 2001. 30 Northeastern University’s Center for Criminal Justice Policy Research. An Overview of the 1999 Lexington High School Survey. Comparisons between the 1995 & 1999 Youth Risks Behavior Survey Presented. March 1, 2000. 31 Top Thirty Diagnostic Related Groups (DRGs) for Lexington, Data from the Massachusetts Department of Public Health, Division of Health Care Finance and Policy. 1999. 32 The Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. September 18, 2000. http://www.surgeongeneral.gov/ch/childreport.htm. 33 Colleen Dunbar, Lexington Police and Stephanie Scogland, Domestic Violence Response Team, personal communication. October 2001. 34 Prevalence of Leisure-Time Physical Activity Among Overweight Adults—United States, 1998. Morbidity and Mortality Weekly Report. 49(15): 326-330. April 21, 2000. 35 “Physical Activity and Health. A report of the Surgeon General.” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1996. 36 Centers for Disease Prevention and Control, National Center for Health Statistics. Healthy People 2000. p. 65. October 2001. 37 Top Ten Preventable Hospitalizations in Lexington, Massachusetts Department of Public Health, Healthcare Finance and Policy, 1999. 38 The Burden of Diabetes in Massachusetts 1993-1995. Diabetes Control Program, Massachusetts Department of Public Health, Bureau of Family and Community Health. July 1999. 39 Massachusetts Public Health Association. “The Health of Our Children: Who’s Paying Attention?” p. 2. 2000. 40 Health Risks and Preventative Behaviors. Results from the Behavioral Risk Factor Surveillance System (1994-1999). Greater Woburn/Concord/Littleton CHNA. March 2001. 41 Northeastern University Center for Criminal Justice. “An Overview of the 1999 Lexington High School Survey. Comparisons between 1995 and 1999 Youth Risks Behavior Survey Presented. March 1, 2000. 42 Massachusetts Department of Public Health. Massachusetts Community Health Information Profile. CHNA (a) Health Status Indicators Report for Lexington. September 28, 2000. 43 Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000. p. 228. October 2001. 27 Lexington Community Health Assessment Appendix 1. Results of Community Discussion Groups Community discussion groups, facilitated by Marcia Lazar, Director of Community Health, Mount Auburn Healthcare, were held in late April-early May of 2001. Community representatives from many different civic and spiritual organizations, the healthcare community, business representatives and residents themselves were invited to the groups. Thirty people attended one of the four discussion groups held, representing the health community (8), environmental concerns (2), mental/psychiatric (4), spiritual leaders (2), and 14 residents who voiced their concerns as parents and as members of civic organizations, and members of town government. Representatives were asked to first define a healthy community, then to voice their concerns about specific health issues. Lastly, they were asked to point out attributes of the town that might contribute to a health community. 1. What are the Key Health Concerns for Lexington? Key issues that arose at the community discussion groups, not in order of priority, included: Disintegration of the family and pressure on the family unit, combined with disconnection from the community and extended family was cited repeatedly throughout the discussions. Lack of parental communication with children and stress were noted as contributing factors to substance abuse, mental health problems, risky behaviors among teens and other health issues. Violence among youth was also cited as an issue. Senior concerns stood out repeatedly, especially concerns about isolated seniors maintaining independence within their homes but losing contact with and access to the community. Pedestrian safety and access to transportation were also brought up several times. Mental heath in general, including depression, suicidal tendencies, stress and other concerns were noted as problems in themselves, and also as contributing factors to risky behaviors (piercing, tattooing, sex) and substance abuse. Treatment of the mentally ill in the community was also of concern. Substance abuse itself was brought up at some, but not all of the meetings. Drinking in particular was discussed as one of the key problems among adolescents, along with use of “designer” drugs, and teen smoking. Obesity and related health issues, including diabetes, were discussed repeatedly as major factors that affected children in the community. Lack of opportunity for exercise, and poor nutritional options in the school menus were cited as contributing factors. Pedestrian safety was cited repeatedly, along with traffic safety as a related problem. Poor road conditions, lack of or poor sidewalks, and other unsafe conditions make access and exercise difficult for many residents. Other Health Concerns Voice at Discussion Groups: Pesticide Usage,especially in schools and on town land Indoor air quality, especially in schools School security Noise pollution Tree loss Violence, especially between parent and child Feral animals Academic stress among students No place for youth to congregate Lice among children 2. What is Your Definition of a Health Community ? The first question each discussion group was asked was “What Constitutes a Health Community”. Each group gave a variety of answers, including the following definitions: Clean air, water, soil Safe traffic, pedestrian safety Low infant mortality Waste disposal Education for all Healthcare access Food safety Tobacco control Privacy No discrimination 3. What are Lexington’s Health Assets? Health education in school program Full time nurses in schools Concerned, vocal population Open space Resources for recreation Educated population Strong responsive police department Adult daycare center Healthy religious communication Lexington Education Foundation Strong schools Health care institutions nearby High income and education levels among residents Excellent Fire Dept and Library Strong service organizations (Lions, Rotary) Limited industry/hazardous materials Skilled nursing facilities Reduced ETS (environmentally transmitted smoke) in schools Safe restaurants Appendix 2. Lexington Health Programs Part of the health assessment process involved a review of current health resources and services available to community members. The following outlines the current services provided by different municipal agencies and the audience(s) for whom they are provided. Clinics and Hospitals Lahey Clinic (Burlington) Lahey Lexington Mount Auburn Hospital (Cambridge) Mount Auburn Healthcare (Lexington) Emerson Hospital Winchester Hospital Beth Israel Deaconess (Pediatric) Health Stop Municipal and Public Health Services Environmental Health Services Environmental inspections (food, housing, water, air, camps, pools) Lexington Health Department Tobacco Control Minuteman Tobacco Control Animal Control Lexington Health Department Clinical Prevention Services Vaccinations (Hepatitis B for students, Influenza, Pneumococcal disease) Lexington Health Department Blood pressure screening for the general public Lexington Health Department Blood pressure screening for seniors Council on Aging Diabetes Screening Lexington Health Department Nursing visits for homebound Lexington Health Department Domestic Violence Response Team Lexington Police, Health, Schools and Human Services Senior Services Medical monitoring for frail seniors Senior Health Monitor Program through Council on Aging Senior support services Minuteman Homecare Services Student Health and Prevention Services Student evaluations and health services Public School Nurses Fire and burn safety Lexington Fire Department Counseling support for students Lexington Human Services Health Education Services Lexington Schools Service Descriptions Environmental Services The Lexington Health Department offers many services to ensure a healthy and safe environment for the community. The department carries out over 650 inspections each year on food establishments, pools, camps, water sources, housing, hazardous waste issues, nuisances and other concerns. The department works with the Massachusetts Department of Public Health and the Massachusetts Department of Environmental Protection to address these and other environmental issues including water and air pollution issues, groundwater protection, control of communicable (e.g., influenza) and vector-borne disease (e.g., West Nile encephalitis), and emergency planning for both natural and man-made disasters. Clinical Preventive Services The Lexington Health Department also offers clinical screening and vaccine prevention services through the Public Health Nurse’s Office. Current services include vaccinations for at risk groups (Influenza, Hepatitis B, and Pneumococcal Disease clinics), blood pressure screening, tuberculosis screening for high risk groups, and diabetes screening. The Department also collaborates with local private healthcare providers such as Mount Auburn Healthcare to bring these and other services, such as osteoporosis screening, to the community. Nursing visits to the homebound are also offered on a limited basis. Domestic Violence Support Services Domestic violence persists as a major problem in many communities, not only as a source of morbidity and mortality for women, but as a threat to the elderly, children and even parents. The Police Department collaborates with other town agencies (including the Schools, Council on Aging, and Health Dept.) to provide support services to victims of domestic violence. Senior Services Health Promotion The Council on Aging offers numerous lectures and support groups on the many health issues affecting seniors, including cancer, osteoporosis, chronic diseases and healthcare access. Nursing Services The Council on Aging provides basic medical monitoring services to frail, homebound elders in Lexington. Approximately 80 seniors receive this service each year. The program is funded through the municipal budget. Minuteman Senior Services A State-run agency, Minuteman Senior Services offers a range of support services including “Meals on Wheels”, Protective Services in accordance with the 1983 Elder Abuse Law, memory disorder assessments, home health services, a dementia day program, and other programs through a network of contracted providers. The Minuteman Senior Services program is supported by the Massachusetts Office of Elder Affairs. Youth Services School Health Nurses Program Basic screening and prevention services are provided to all students at the Public Schools through one full-time nurse at each school. School nurses carry out a variety of services including physicals, vision and hearing checks, scoliosis checks, dental protection programs, and pediculosis (lice) checks. Health Education Services The Comprehensive Health Education Program teaches students to avoid problems such as substance abuse and contagious diseases, and to understand and demonstrate the responsibility they share as individuals, family members and citizens to act in ways that enhance health for themselves and their families. The program focuses on three core concepts: health literacy, healthy self-management, and health promotion and advocacy. The Coordinator of Health Education at the public schools works to coordinate efforts among a variety of key programs (Health Education, Physical Education, Health Services, Food and Nutrition Services, Counseling, Psychological and Social Services, Parent/Community Involvement). Health education is provided at the elementary, middle school, and high school levels. Health Protection Advisory Committee The Health Protection Advisory Committee develops plans and guidance for a variety of school health programs. This committee is supported by funds from the Department of Education. Fire Prevention The Fire Department carries out classes for elementary school children on fire prevention and burn safety. The program is grant-funded. Emergency Services Emergency 911 Services are provided through the Fire Department. The Fire Chief is also in charge of emergency response and preparedness for man-made and natural disasters. Appendix 3. Health Assessment Advisory Committee The purpose of the Health Assessment Advisory Committee will be to assist the Board of Health in gathering and evaluating information on the health status of the community, as part of a comprehensive community health assessment. The Health Advisory Committee will form one component of the overall assessment process, which will also include focus groups, the Board of Health, town staff evaluations, and possibly surveys of residents. The members of the Health Assessment Advisory committee will include residents of Lexington with professional expertise or interest in a range of health perspectives, and will contribute to the assessment process through the following steps: Offer input as residents and as experts in their specific health specialties on the health status of the town and their recommendations as to actions/programs the town should implement to improve the public health. Work with the Interagency Health Program Evaluation Committee, which will be composed of Town staff members, to evaluate current health-related programs in the town and Lexington's "healthcare budget". Provide input to the Board of Health on the health assessment process The work of this committee will be connected to that of the town's Interagency Health Committee. The committee will begin work late in August or early September, and will meet approximately once or twice a month for 2-4 months, depending on the progress of the committee. Individual members may also work with the Health Division staff to address specific health issues. Members, Health Assessment Advisory Committee Martha Sheridan, M.D. 34 Lawrence Lane Email: jasper@massmed.org Lexington, MA 02421 (781) 863-0518 Nancy Earsey 32 Parker St. Lexington, MA 02421 Nancy@Earsy.com (781) 862-8293 Wendy Heigger Bernays 67 Grant St. whb@bu.edu Lexington, MA 02420 (781) 861-6463 (617) 638-7724 James Fearnside 19 Vinebrook Road jim_fearnside@juno.com Lexington, MA 02421 862-2696 Burt Perlmutter, M.D., Chair 8 Carnegie Place Lexington, MA 02420 bmpr@massmed.org 862-9253 Beeper: 781-945-6424 Dr. Fred Mazer 87 Dewey Road Lexington, MA 861-8639 862-6210 (Lahey) Margaret Kennedy 33 Forest St. Lexington, MA 02421 861-7850 makpak1231@yahoo.com